VA and Defense Health Care: More Information Needed to Determine If VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder Services
Published: 2004-09-20T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Post-traumatic stress disorder (PTSD) is caused by an extremely stressful event and can develop after the threat of death or serious injury as in military combat. Experts predict that about 15 percent of servicemembers serving in Iraq and Afghanistan will develop PTSD. Efforts by VA to inform new veterans, including Reserve and National Guard members, about the expanded availability of VA health care services could result in an increased demand for VA PTSD services. GAO identified the approaches DOD uses to identify servicemembers at risk for PTSD and examined if VA has the information it needs to determine whether it can meet an increase in demand for PTSD services. GAO visited military bases and VA facilities, reviewed relevant documents, and interviewed DOD and VA officials to determine how DOD identifies servicemembers at risk for PTSD, and what information VA has to estimate demand for VA PTSD services.
section_title: What GAO Found
paragraphs: DOD uses two approaches to identify servicemembers at risk for PTSD: the combat stress control program and the post-deployment health assessment questionnaire. The combat stress control program trains servicemembers to recognize the early onset of combat stress, which can lead to PTSD. Symptoms of combat stress and PTSD include insomnia, nightmares, and difficulties coping with relationships. To assist servicemembers in the combat theater, teams of DOD mental health professionals travel to units to reinforce the servicemembers' knowledge of combat stress symptoms and to help identify those who may be at risk for combat stress and PTSD. DOD also uses the post-deployment health assessment questionnaire to identify physical ailments and mental health issues commonly associated with deployments, including PTSD. The questionnaire includes the following four screening questions that VA and DOD mental health experts developed to identify servicemembers at risk for PTSD: Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you (1) have had any nightmares about it or thought about it when you did not want to; (2) tried hard not to think about it or went out of your way to avoid situations that remind you of it; (3) were constantly on guard, watchful, or easily startled; and/or (4) felt numb or detached from others, activities, or your surroundings? VA lacks the information it needs to determine whether it can meet an increase in demand for VA PTSD services. VA does not have a count of the total number of veterans currently receiving PTSD services at its medical facilities and Vet Centers--community-based VA facilities that offer trauma and readjustment counseling. Without this information, VA cannot estimate the number of new veterans its medical facilities and Vet Centers could treat for PTSD. VA has two reports on the number of veterans it currently treats, with each report counting different subsets of veterans receiving PTSD services. Veterans who are receiving VA PTSD services may be counted in both reports, one of the reports, or not included in either report. VA does receive demographic information from DOD, which includes home addresses of servicemembers that could help VA predict which medical facilities or Vet Centers servicemembers may access for health care. By assuming that 15 percent or more of servicemembers who have left active duty status will develop PTSD, VA could use the home zip codes of servicemembers to broadly estimate the number of servicemembers who may need VA PTSD services and identify the VA facilities located closest to their homes. However, predicting which veterans will seek VA care and at which facilities is inherently uncertain, particularly given that the symptoms of PTSD may not appear for years.

section_title: Letter
paragraphs: Mental health experts predict that because of the intensity of warfare in  Iraq and Afghanistan 15 percent or more of the servicemembers returning  from these conflicts will develop post-traumatic stress disorder (PTSD).1, 2   This rate approximates the PTSD rate for Vietnam War veterans.PTSD,  which is caused by an extremely stressful event, can develop after military  combat and exposure to the threat of death or serious injury. Symptoms of  PTSD, which may appear within months or be delayed for years after the  stressful event, include insomnia, intense anxiety, nightmares about the  event, and difficulties coping with work, family, and social relationships.  Although there is no cure for PTSD, experts believe that early identification  and treatment of PTSD symptoms may lessen the severity of the condition  and improve the overall quality of life for servicemembers and veterans. If  left untreated, PTSD can lead to substance abuse, severe depression, and  suicide.
The Department of Veterans Affairs (VA) has intensified its efforts to  inform new veterans from the Iraq and Afghanistan conflicts about the  health care services—including treatment for PTSD—it offers to eligible  veterans. These efforts, along with expanded availability of VA health care  services for Reserve and National Guard members, could result in an  increased percentage of veterans from Iraq and Afghanistan seeking PTSD  services through VA. Concerns have been raised about whether VA can  provide PTSD services for a new influx of veterans, while at the same time  continuing these services for veterans that VA currently treats for PTSD.
Servicemembers include active duty members of the Army, Marines, Air Force, and Navy  and members of the Reserves and National Guard.
Hoge, Charles W., MD et. al. “Combat Duty in Iraq and Afghanistan, Mental Health  Problems, and Barriers to Care”, The New England Journal of Medicine, 351 (2004): 13-22.
You asked that we review the Department of Defense’s (DOD) efforts to  identify servicemembers who have served in Iraq and Afghanistan and are  at risk for PTSD, and VA’s efforts to ensure that PTSD services are available  for all veterans. Specifically, we identified the approaches DOD uses to  identify servicemembers who are at risk for PTSD. We also examined if VA  has the information it needs to determine whether it can meet an increase  in demand for VA PTSD services.
To determine the approaches DOD uses to identify servicemembers who  are at risk for PTSD, we reviewed documents, interviewed DOD officials,  and visited a military installation for each of DOD’s uniform services, some  of which had large numbers of servicemembers returning from Iraq and  Afghanistan. We have reviewed how well DOD’s uniform services  implemented these approaches in previous work and did not address that  issue in this review. To determine whether VA has the information it needs  to estimate the future demand for VA PTSD services, we interviewed VA  headquarters and facility officials to discuss the number of veterans  receiving treatment for PTSD and future demand for these services in areas  of the country where large numbers of servicemembers were returning  from Iraq and Afghanistan. To obtain additional information on identifying  and treating veterans with PTSD, we interviewed VA’s PTSD experts at the  National Center for PTSD. We reviewed VA’s annual capacity reports,  which include information on the number of seriously mentally ill veterans  receiving PTSD services. We also reviewed the findings of the VA Office of  Inspector General (OIG) who is responsible for reporting to Congress on  the accuracy of VA’s capacity reports. We did not include data from VA’s  annual capacity reports because the OIG found that the data were not  sufficiently reliable. We also interviewed VA headquarters and facility  officials and DOD officials to determine what information they share about  returning servicemembers. For a complete description of our scope and  methodology, see appendix I. Our work was conducted from May through  September 2004 in accordance with generally accepted government  auditing standards.
subsections: section_title: Background
paragraphs: PTSD can develop following exposure to life-threatening events, natural  disasters, terrorist incidents, serious accidents, or violent personal assaults  like rape. PTSD is the most prevalent mental disorder arising from combat.  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. If  the symptoms of acute stress reaction or combat stress continue for more  than 1 month, PTSD is diagnosed.
PTSD services are provided in VA medical facilities and VA community  settings. VA medical facilities offer PTSD services as well as other services,  which range from complex specialty care, such as cardiac or spinal cord  injury, to primary care. VA’s community settings include more than 800  community-based outpatient clinics and 206 Vet Centers. Community- based outpatient clinics are an extension of VA’s medical facilities and  mainly provide primary care services. Vet Centers offer PTSD and family  counseling, employment services, and a range of social services to assist  veterans in readjusting from wartime military service to civilian life. Vet  Centers also function as community points of access for many returning  veterans, providing them with information and referrals to VA medical  facilities. Vet Centers were established as entities separate from VA  medical facilities to serve Vietnam veterans, who were reluctant to access  health care provided in a federal building. As a result, Vet Centers are not  located on the campuses of VA medical facilities.
VA has specialized PTSD programs that are staffed by clinicians who have  concentrated their clinical work in the area of PTSD treatment. VA  specialized PTSD programs are located in 97 VA medical facilities and  provide services on an inpatient and outpatient basis. VA PTSD services  include individual counseling, support groups, and drug therapy and can be  provided in non-specialized clinics, such as general mental health clinics.
Veterans who served in any conflict after November 11, 1998 are eligible for  VA health care services for any illness, including PTSD services, for 2 years  from the date of separation from military service, even if the condition is  not determined to be attributable to military service. This 2-year eligibility  includes those Reserve and National Guard members who have left active  duty and returned to their units. After 2 years, these veterans will be  subject to the same eligibility rules as other veterans, who generally have to  prove that a medical problem is connected to their military service or have  relatively low incomes. In July 2004, VA reported that so far 32,684 or 15  percent of veterans who have returned from service in Iraq or Afghanistan,  including Reserve and National Guard members, have accessed VA for  various health care needs.
DOD and VA have formed a Seamless Transition Task Force with the goal  of meeting the needs of servicemembers returning from Iraq and  Afghanistan who will eventually become veterans and may seek health care  from VA. To achieve this goal, DOD and VA plan to improve the sharing of  information, including individual health information, between the two  departments in order to enhance VA’s outreach efforts to identify and serve  returning servicemembers, including Reserve and National Guard  members, in need of VA health care services. Since April 2003, VA requires  that every returning servicemember from the Iraq and Afghanistan conflicts  who needs health care services receive priority consideration for VA health  care appointments.
section_title: DOD Uses Two Approaches to Identify Servicemembers At Risk for PTSD
paragraphs: DOD uses two approaches to identify servicemembers who may be at risk  of developing PTSD: the combat stress control program and the post- deployment health assessment questionnaire. DOD’s combat stress control  program identifies servicemembers at risk for PTSD by training all  servicemembers to identify the early onset of combat stress, which if left  untreated, could lead to PTSD. DOD uses the post-deployment health  assessment questionnaire to screen servicemembers for physical ailments  and mental health issues commonly associated with deployments,  including PTSD. The questionnaire contains four screening questions that  were developed jointly by DOD and VA mental health experts to identify  servicemembers at risk for PTSD.
subsections: section_title: DOD Trains Servicemembers to Identify Symptoms That Could Lead to PTSD
paragraphs: DOD’s combat stress control program identifies servicemembers at risk for  PTSD by training all servicemembers to identify the early onset of combat  stress symptoms, which if left untreated, could lead to PTSD. The program  is based on the principle of promptly identifying servicemembers with  symptoms of combat stress in a combat theater, with the goal of treating  and returning them to duty. This principle is consistent with the views of  PTSD experts, who believe that early identification and treatment of  combat stress symptoms may reduce the risk of PTSD. To assist  servicemembers in the combat theater, teams of DOD mental health  professionals travel to units to reinforce the servicemembers’ knowledge of  combat stress symptoms and to help identify those who may be at risk for  combat stress or PTSD. The teams may include psychiatrists,  psychologists, social workers, nurses, mental health technicians, and  chaplains. DOD requires that the effectiveness of the combat stress control  program be monitored on an annual basis.
section_title: DOD Uses the Post- Deployment Questionnaire to Identify Servicemembers At Risk for PTSD
paragraphs: DOD generally uses the post-deployment health assessment questionnaire,  DD 2796, to identify servicemembers at risk for PTSD following  deployment outside of the United States. (See app. II for a copy of the DD  2796.) DOD requires certain servicemembers deployed to locations outside  of the United States to complete a DD 2796 within 30 days before leaving a  deployment location or within 5 days after returning to the United States.This applies to all servicemembers returning from a combat theater,  including Reserve and National Guard members.
The DD 2796 is a questionnaire used to determine the presence of any  physical ailments and mental health issues commonly associated with  deployments, any special medications taken during deployment, and  possible environmental or occupational exposures. The DD 2796 includes  the following four screening questions that VA and DOD mental health  experts developed to identify servicemembers at risk for PTSD:  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?
Once completed, the DD 2796 must be initially reviewed by a DOD health  care provider, which could range from a physician to a medic or  corpsman. Figure 1 illustrates DOD’s process for completion and review  of the DD 2796. The form is then reviewed, completed, and signed by a  health care provider, who can be a physician, physician assistant, nurse  practitioner, or an independent duty medical technician or corpsman. This  health care provider reviews the completed DD 2796 to identify any “yes”  responses to the screening questions—including questions related to  PTSD—that may indicate a need for further medical evaluation. The review  is to take place in a face-to-face interview with the servicemember and be  conducted either on an individual basis, as we observed at the Army’s Fort  Lewis in Washington, or in a group setting, as we found at the Marine  Corps’ Camp Lejeune in North Carolina. If a servicemember answers “yes”  to a PTSD question, the health care provider is instructed to gather  additional information from the servicemember and use clinical judgment  to determine if the servicemember should be referred for further medical  evaluation to a physician, physician’s assistant, nurse, or an independent duty medical technician.To document completion of the DD 2796, DOD  requires that the questionnaire be placed in the servicemember’s  permanent medical record and a copy sent to the Army Medical  Surveillance Activity, which maintains a database of all servicemembers’  completed health assessment questionnaires.
The National Defense Authorization Act for Fiscal Year 1998 required DOD  to establish a quality assurance program to ensure, among other things,  that post-deployment mental health assessments are completed for  servicemembers who are deployed outside of the United States.  Completion of the DD 2796 is tracked as part of this quality assurance  program. DOD delegated responsibility for developing procedures for the  required quality assurance program to each of its uniform services. The  uniform services have given unit commanders the responsibility to ensure  completion of the DD 2796 by all servicemembers under their command. To  ensure the DD 2796 is completed, one DOD official we interviewed told us  that servicemembers would not be granted leave to go home until the DD  2796 was completed. Another official told us that Reserve and National  Guard members would not be given their active duty discharge paperwork  until the DD 2796 was completed.
section_title: VA Lacks Information Needed to Determine Whether It Can Meet an Increase in Demand for PTSD Services
paragraphs: VA does not have all the information it needs to determine whether it can  meet an increase in demand for VA PTSD services. VA does not have a  count of the total number of veterans currently receiving PTSD services at  its medical facilities and Vet Centers. Without this information, VA cannot  estimate the number of veterans its medical facilities and Vet Centers could  treat for PTSD. VA could use demographic information it receives from  DOD to broadly estimate the number of servicemembers who may access  VA health care, including PTSD services. By assuming that 15 percent or  more of returning servicemembers will develop PTSD, VA could use the  demographic information to broadly estimate demand for PTSD services.  However, predicting which veterans will seek VA care and at which  facilities is inherently uncertain, particularly given that the symptoms of  PTSD may not appear for years.
subsections: section_title: VA Does Not Have Information on the Total Number of Veterans Currently Receiving PTSD Services
paragraphs: VA does not have a count of the total number of veterans currently  receiving PTSD services at its medical facilities and Vet Centers. Without  this information, VA cannot estimate the number of additional veterans its  facilities could treat for PTSD. On August 27, 2004, a Northeast Program  Evaluation Center (NEPEC) official told us that a count of the total number  of veterans with a diagnosis of PTSD who receive VA services at medical  facilities could be obtained from VA’s existing database. However, this  database does not include Vet Centers’ information because this  information is kept separate from the medical facilities’ data.
VA publishes two reports that contain information on some of the veterans  receiving PTSD services at its medical facilities.  Neither report includes all  veterans receiving PTSD services at VA medical facilities and Vet Centers.  VA’s annual capacity report, which is required by law, provides data on  VA’s most vulnerable populations, such as veterans with spinal cord  injuries, blind veterans, and seriously mentally ill veterans with PTSD.  The NEPEC annual report mainly provides data on veterans with a primary  diagnosis of PTSD. VA has not developed a methodology that would allow  it to count the number of veterans receiving PTSD services at its medical  facilities and Vet Centers.
The PTSD data used in VA’s annual capacity report and the data used in  NEPEC’s annual report are drawn from different—though not mutually  exclusive—subgroups of veterans receiving PTSD services at VA’s medical  facilities. VA developed criteria that allow it to determine which veterans  should be included in each subgroup. VA’s criteria, which differ in each  report, are based on the type and frequency of mental health services  provided to veterans with PTSD at its medical facilities. (See Figure 2 for  the veterans included in each of VA’s annual reports.)
Veterans who are receiving VA PTSD services may be counted in both  reports, only counted in the NEPEC report, or not included in either report.  For example, a veteran who is seriously mentally ill and has a primary  diagnosis of PTSD is counted in both reports. On the other hand, a veteran  who has a primary diagnosis of PTSD but is not defined as seriously  mentally ill is counted in the NEPEC report but not in the capacity report.  Finally, a veteran who is receiving PTSD services only at a Vet Center is not  counted in either report.
Furthermore, both the VA OIG and VA’s Committee on Care of Veterans  with Serious Mental Illness have found inaccuracies in the data used in VA’s  annual capacity report.For example, OIG found inconsistencies in the  PTSD program data reported by some VA medical facilities. OIG found that  some medical facilities reported having active PTSD programs, although  the facilities reported having no staff assigned to these programs.  Additionally, the Committee on Care of Veterans with Serious Mental  Illness, commenting on VA’s fiscal year 2002 capacity report, stated the data  VA continues to use for reporting information on specialized programs are  inaccurate and recommended changes in future reporting.22, 23 VA agreed  with OIG that the data were inaccurate and is continuing to make changes  to improve the accuracy of the data in its annual capacity report. VA’s fiscal  year 2003 capacity report to Congress is currently undergoing review by  OIG, which informed us that VA has not incorporated all of the changes  necessary for OIG to certify that the report is accurate. OIG further stated  that it will continue to oversee this process.
section_title: VA Has Information to Broadly Estimate Future Demand for PTSD Services
paragraphs: The Committee on Care of Severely Chronically Mentally Ill Veterans assesses VA’s  capability to meet the rehabilitation and treatment needs of such veterans. See 38 U.S.C. §  7321. The Committee, established within VA, is generally referred to as the Committee on  Care of Veterans with Serious Mental Illness.
Department of Veterans Affairs, Capacity Report Fiscal Year 2002 (Washington, D.C.:   May 2003). predict the facilities or Vet Centers that could experience an increase in  demand for care. By assuming that 15 percent or more of returning  servicemembers will eventually develop PTSD, based on the predictions of  mental health experts, VA could use the demographic information to  broadly estimate the number of returning servicemembers who may need  VA PTSD services and the VA facilities located closest to servicemembers’  homes. However, predicting which veterans will seek VA care and at which  facilities is inherently uncertain, particularly given that the symptoms of  PTSD may not appear for years.
VA headquarters received demographic information from DOD in  September 2003; however, during our review we found that VA had not  shared this information with its facilities. On July 21, 2004, VA provided this  information to its medical facilities for planning future services for  veterans returning from the Iraq and Afghanistan conflicts. However, VA  did not provide the demographic information to Vet Centers. Officials at  seven VA medical facilities told us that while the demographic information  VA receives from DOD has limitations, it is the best national data currently  available and would help them plan for new veterans seeking VA PTSD  services.
Officials at six of the seven VA medical facilities we visited explained that  while they are now able to keep up with the current number of veterans  seeking PTSD services, they may not be able to meet an increase in demand  for these services.  In addition, some of the officials expressed concern  about their ability to meet an increase in demand for VA PTSD services  from servicemembers returning from Iraq and Afghanistan based on DOD’s  demographic information. Officials are concerned because facilities have  been directed by VA to give veterans of the Iraq and Afghanistan conflicts  priority appointments for health care services, including PTSD service. As a  result, VA medical facility officials estimate that follow-up appointments  for veterans currently receiving care for PTSD may be delayed. VA officials  estimate the delay may be up to 90 days. Veterans of the Iraq and  Afghanistan conflicts will not be given priority appointments over veterans  who have a service-connected disability and are currently receiving  services.
section_title: Conclusions
paragraphs: While the VA OIG continues to oversee VA’s efforts to improve the accuracy  of data in the capacity reports, VA does not have a report that counts all  veterans receiving VA PTSD services. Although VA can use DOD’s  demographic information to broadly estimate demand for VA PTSD  services, VA does not know the number of veterans it now treats for PTSD  at its medical facilities and Vet Centers. As a result, VA will be unable to  estimate its capacity for treating additional veterans who choose to seek  VA’s PTSD services, and therefore, unable to plan for an increase in demand  for these services.
section_title: Recommendation for Executive Action
paragraphs: To help VA estimate the number of additional veterans it could treat for  PTSD and to plan for the future demand for VA PTSD services from  additional veterans seeking these services, we recommend that the  Secretary of Veterans Affairs direct the Under Secretary for Health to  determine the total number of veterans receiving VA PTSD services and  provide facility-specific information to VA medical facilities and Vet  Centers.
section_title: Agency Comments
paragraphs: In commenting on a draft of this report, VA concurred with our  recommendation and acknowledged that more coordinated efforts are  needed to improve its existing PTSD data. VA stated that it plans to  aggregate, at the national level, the number of veterans receiving PTSD  services at VA medical facilities and Vet Centers. We believe VA should  provide these data to both its medical facilities and Vet Centers so they  have the information needed to plan for future demand for PTSD services.   In addition, VA provided two points of clarification. First, VA stated that it  is in the process of developing a mental health strategic plan that will  project demand by major diagnoses and identify where projected demand  may exceed resource availability. VA stated that future revisions to the  mental health strategic plan would include Vet Center data. Second, VA  stated that it would seek additional information from DOD on  servicemembers who have served in Iraq and Afghanistan to improve its  provision of health care services to these new veterans. VA’s written  comments are reprinted in appendix III. DOD concurred with the findings  and conclusions in this report and provided technical comments, which we  incorporated as appropriate. DOD’s written comments are reprinted in  appendix IV.
As agreed with your office, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days after its  date. We will then send copies of this report to the Secretary of Veterans  Affairs and other interested parties. We also will make copies available to  others upon request. In addition, the report will be available at no charge at  the GAO Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please call me at  (202) 512-7101. Another contact and key contributors are listed in   appendix V.
section_title: Scope and Methodology
paragraphs: To determine the approaches DOD uses to identify servicemembers who  are at risk for PTSD, we reviewed directives on screening servicemembers  deployed to locations outside of the United States, interviewed DOD  officials, and visited a military installation for each of DOD’s uniformed  services. At each of the military installations, we discussed with officials  the steps taken by each of the uniformed services to implement DOD’s  approaches, particularly the steps involved in completing the post- deployment health assessment questionnaire, DD 2796, as it relates to  PTSD. How well the uniformed services implemented DOD’s approaches  were reported in other GAO reports. The uniformed services included in  our review were Army, Marines, Air Force, and Navy. We did not include  the Coast Guard in this review because few Coast Guard servicemembers  are involved in the Iraq and Afghanistan conflicts. The military installations  visited were: Fort Lewis Army Base and Madigan Army Medical Center in  Washington, Seymour Johnson Air Force Base in North Carolina, Camp  Lejeune Marine Base and the Naval Hospital Camp Lejeune in North  Carolina, and the Naval Medical Center San Diego in California. We also  asked DOD officials whether they provide information to VA that could  help VA plan how to meet the demand for VA PTSD services from  servicemembers returning from the Iraq and Afghanistan conflicts.
To determine whether VA has the information it needs to determine  whether it can meet an increase in demand for PTSD services, we  interviewed PTSD experts from the National Center for PTSD established  within VA and members of the Under Secretary for Health’s Special  Committee on PTSD. We also visited three divisions of the National Center  for PTSD: the Executive Division in White River Junction, Vermont; the  Education Division in Palo Alto, California; and NEPEC in West Haven,  Connecticut to review the Center’s reports on specialized PTSD programs.
We also reviewed VA’s fiscal year 2001 and 2002 annual reports on VA’s  capacity to provide services to special populations, including veterans with  PTSD, and NEPEC’s annual reports on specialized PTSD programs to  determine the criteria VA uses to count the number of veterans receiving  VA PTSD services. We reviewed the findings of VA’s Committee on Care of  Veterans with Serious Mental Illness and the VA OIG, who have reported on  the accuracy of VA’s annual capacity report to Congress on the number of  veterans receiving specialized services, including PTSD services. We  interviewed officials from each of these groups to clarify their findings. We  did not include data from the annual capacity reports because the OIG  reported that the data were not sufficiently reliable. We also interviewed  the director of NEPEC to discuss the information included in NEPEC’s  annual reports.
To determine whether VA facilities have the information needed to  determine whether they can meet an increase in demand for PTSD  services, we interviewed officials at 7 VA medical facilities, and 15 Vet  Centers located near the medical facilities to discuss the number of  veterans currently receiving VA PTSD services and the impact that an  increase in demand would have on these services. We also discussed DOD’s  demographic information with four of the seven medical facilities we  visited. We contacted VA medical facilities located in Palo Alto and San  Diego in California; Durham and Fayetteville in North Carolina; White River  Junction, Vermont; West Haven, Connecticut; and Seattle, Washington. We  also contacted Vet Centers located in Vista, San Diego, and San Jose in  California; Raleigh, Charlotte, Greenville, Greensboro, and Fayetteville in  North Carolina; South Burlington and White River Junction in Vermont;  Hartford, Norwich, and New Haven in Connecticut; and Seattle and  Tacoma in Washington.
Our work was conducted from May through September 2004 in accordance  with generally accepted government auditing standards.
section_title: Department of Defense Post-Deployment Health Assessment Questionnaire DD-2796
paragraphs: Authority:  10 U.S.C. 136 Chapter 55.  1074f, 3013, 5013, 8013 and E.O. 9397 Principal Purpose:  To assess your state of health after deployment outside the United States in support of military operations and to assist military healthcare providers in identifying and providing present and future medical care to you.
Routine Use:  To other Federal and State agencies and civilian healthcare providers, as necessary, in order to provide necessary medical care and treatment.
Disclosure:  (Military personnal and DoD civilian Employees Only) Voluntary.  If not provided, healthcare WILL BE furnished, but comprehensive care may not be possible.
INSTRUCTIONS:  Please read each question completely and carefully before marking your selections.  Provide a response                              for each question.  If you do not understand a question, ask the administrator.
Today's Date (dd/mm/yyyy)
DOB (dd/mm/yyyy)
Date of arrival in theater (dd/mm/yyyy)
Date of departure from theater (dd/mm/yyyy)
Asia (Other)
To what areas were you mainly deployed: (mark all that apply - list where/date arrived)
Occupational specialty during this deployment (MOS, NEC or AFSC)
subsections: section_title: Please answer all questions in relation to THIS deployment
paragraphs: 1.  Did your health change during this deployment?
4.  Did you receive any vaccinations just before       or during this deployment?
Smallpox (leaves a scar on the arm)
subsections: section_title: 3. Did you have to spend one or more nights in a hospital as a patient during this deployment?
paragraphs: 5.  Did you take any of the following medications      during this deployment? (mark all that apply)
PB (pyridostigmine bromide) nerve agent pill Pills to stay awake, such as dexedrine 6.  Do you have any of these symptoms now or did you develop them anytime during this deployment?
section_title: 7. Did you see anyone wounded, killed or dead during this deployment?
paragraphs: 10. Are you currently interested in receiving help for a stress,       emotional, alcohol or family problem? (mark all that apply)
11. Over the LAST 2 WEEKS, how often have you        been bothered by any of the following problems?
8.  Were you engaged in direct combat where you discharged      your weapon?
Little interest or pleasure in doing things air  )
section_title: 9. During this deployment, did you ever feel that you were in great danger of being killed?
paragraphs: DD FORM 2796, APR 2003 12. Have you ever had any experience that was so       frightening, horrible, or upsetting that, IN THE       PAST MONTH, you ....
15. On how many days did you wear       your MOPP over garments?
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?
16. How many times did you put on       your gas mask because of alerts and       NOT because of exercises?
Were constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities, or your surroundings?
17. Were you in or did you enter or closely inspect any       destroyed military vehicles?
13. Are you having thoughts or concerns that ...
18. Do you think you were exposed to any chemical,        biological, or radiological warfare agents during this       deployment?
You may have serious conflicts with your spouse, family members, or close friends?
You might hurt or lose control with someone?
section_title: 14. While you were deployed, were you exposed to:
paragraphs: (mark all that apply)
DEET insect repellent applied to skin Environmental pesticides (like area fogging)
Smoke from burning trash or feces Vehicle or truck exhaust fumes Fog oils (smoke screen)
Depleted Uranium (If yes, explain)
section_title: Post-Deployment Health Care Provider Review, Interview, and Assessment
section_title: After my interview/exam of the service member and review of this form, there is a need for further evaluation as indicated below. (More than one may be noted for patients with multiple problems. Further documentation of the problem evaluation to be placed in the service member's medical record.)
paragraphs: Date (dd/mm/yyyy)
section_title: End of Health Review
section_title: Comments from the Department of Veterans Affairs
section_title: Comments from the Department of Defense
section_title: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above Mary Ann Curran, Linda Diggs,  Martha Fisher, Krister Friday, and Marion Slachta made key contributions  to this report.
section_title: Related GAO Products
paragraphs: Defense Health Care:  DOD Needs to Improve Force Health Protection and  Surveillance Processes. GAO-04-158T, Washington, D.C.:  October 16, 2003.
Defense Health Care:  Quality Assurance Process Needed to Improve  Force Health Protection and Surveillance. GAO-03-1041, Washington, D.C.:   September 19, 2003.
Disabled Veterans’ Care: Better Data and More Accountability Needed to  Adequately Assess Care. GAO/HEHS-00-57, Washington, D.C.:  April 21,  2000.
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