DOD Health: Actions Needed to Ensure Post-Traumatic Stress Disorder and Traumatic Brain Injury Are Considered in Misconduct Separations
Published: 2017-05-16T00:00:00

Fast Facts:
PTSD and traumatic brain injury can affect the behavior of servicemembers in the Armed forces and may lead to separations for misconduct. We examined misconduct separations and found that servicemembers diagnosed with PTSD, TBI, or certain other conditions can receive an "other than honorable" discharge—making them potentially ineligible for VA health benefits.
However, not all of the military services have consistent policies in place to address the impact of these disorders on misconduct separations. We recommended that DOD direct the military services to address inconsistencies in their separation policies.

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Carl Levin and Howard P. “Buck” McKeon National Defense Authorization Act for Fiscal Year 2015 contains a provision that GAO examine the effect of PTSD, TBI, and certain other conditions on separations for misconduct. This report examines (1) the number of servicemembers separated for misconduct who were diagnosed with PTSD, TBI, or certain other conditions and were potentially ineligible for VA benefits and services; (2) the extent to which military services' policies to address the impact of PTSD and TBI on separations for misconduct are consistent with DOD's policies; (3) the extent to which Army and Marine Corps have adhered to their policies; and (4) the extent to which DOD, Army, and Marine Corps monitor adherence to the policies. GAO analyzed DOD data; reviewed applicable policies; interviewed DOD, Army, Marine Corps, Air Force, and Navy officials; visited two Army and one Marine Corps sites selected on factors such as separation rates; and reviewed a nongeneralizable sample of Army and Marine Corps servicemember misconduct separation documents.
section_title: What GAO Found
paragraphs: GAO's analysis of Department of Defense (DOD) data show that 62 percent, or 57,141 of the 91,764 servicemembers separated for misconduct from fiscal years 2011 through 2015 had been diagnosed within the 2 years prior to separation with post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), or certain other conditions that could be associated with misconduct. Specifically, 16 percent had been diagnosed with PTSD or TBI, while the other conditions, such as adjustment and alcohol-related disorders, were more common. Of the 57,141 servicemembers, 23 percent, or 13,283, received an “other than honorable” characterization of service, making them potentially ineligible for health benefits from the Department of Veterans Affairs (VA).
GAO found that the military services' policies to address the impact of PTSD and TBI on separations for misconduct are not always consistent with DOD policy. For example, contrary to DOD policy, Navy policy does not require a medical examination—or screening—for certain servicemembers being separated in lieu of trial by court-martial to assess whether a PTSD or TBI diagnosis is a mitigating factor in the misconduct charged. This type of separation occurs when a servicemember facing a trial by court-martial requests, and is approved, to be discharged administratively. In addition, GAO found that two of the four military services have TBI training polices that are inconsistent with DOD policy.
GAO also found that the Army and Marine Corps may not have adhered to their own screening, training, and counseling policies related to PTSD and TBI. For example, GAO found that 18 of the 48 nongeneralizable sample separation packets reviewed for Marine Corps servicemembers administratively separated for misconduct lacked documentation showing that the servicemember had been screened for PTSD and TBI. During interviews with Army officers, GAO found that some officers may not have received training to identify mild TBI symptoms, despite Army policy that all servicemembers should be trained. Further, GAO found instances in which both Army and Marine Corps may not have adhered to their counseling policies, which require that servicemembers, specifically prior to requesting separation in lieu of trial by court-martial, be counseled about their potential ineligibility for VA benefits and services. For 11 of the 48 separation packets included in GAO's analysis of Army servicemembers who requested separation in lieu of trial by court-martial, there was no documented evidence—or the evidence was unclear—as to whether the servicemembers received counseling.
Finally, while Army and Marine Corps have some available data on servicemembers' screenings, training, and counseling, the military services do not use these data to routinely monitor whether they are adhering to relevant policies. Federal internal control standards call for agencies to establish monitoring activities to ensure internal control systems and evaluate results. Without monitoring adherence to these policies, the military services cannot provide assurance that servicemembers with PTSD and TBI are receiving adequate consideration of their conditions as well as the services DOD has established for them.
section_title: What GAO Recommends
paragraphs: GAO is making five recommendations, including that DOD direct the Air Force and Navy to address inconsistencies in their screening and training policies and ensure that the military services monitor adherence to their screening, training, and counseling policies. DOD agreed with four of GAO's recommendations, but did not agree to address inconsistencies in training policies. GAO maintains inconsistencies should be addressed, as discussed in the report.

section_title: Letter
paragraphs: Mental health conditions and cognitive impairments such as post- traumatic stress disorder (PTSD) and traumatic brain injury (TBI) are  “signature wounds” of the conflicts in Afghanistan and Iraq, according to  the Department of Defense (DOD) and published research. PTSD, TBI,  and other mental and physical conditions can go unrecognized and  unacknowledged by the military, family members, and society in general.  Because these conditions can adversely affect servicemembers’ moods,  thoughts, and behavior, they may lead to disciplinary infractions and  subsequent separations for misconduct from the military. Misconduct  separations can result from actions and behaviors such as drug use,  insubordination, absence from the military without leave, and criminal  behavior. In some cases, servicemembers separated for misconduct are  not eligible for benefits and services from the Department of Veterans  Affairs (VA).
Congress and others have raised questions about whether  servicemembers with PTSD or TBI resulting from their military service  may be separated for misconduct without appropriate consideration of  these conditions. For example, Congress has passed a law requiring the  military services—Army, Marine Corps, Air Force, and Navy—to assess  the impact of a PTSD or TBI diagnosis before separating certain  servicemembers for misconduct under regulations prescribed by DOD.  To implement this requirement, DOD has issued policies, and each of the  military services has its own policies to address servicemember  separations for misconduct that involve PTSD or TBI. Nevertheless,  advocacy groups and media reports have described instances of  servicemembers with symptoms of PTSD and TBI being discharged for  misconduct without adequate treatment or consideration of these  symptoms. In May 2016, the Army’s Audit Agency weighed in on this  topic, finding that the Army did not have sufficient documentation to  demonstrate that it had considered whether PTSD or TBI was a mitigating  factor in certain servicemembers’ behavior prior to separating them for  misconduct.
The Carl Levin and Howard P. “Buck” McKeon National Defense  Authorization Act for Fiscal Year 2015 contains a provision that we  examine the impact of mental and physical trauma, including PTSD, TBI,  and other combat traumas, on the separation of servicemembers from the  military services for misconduct. In this report, we examine  1.  the number of servicemembers separated for misconduct in fiscal  years 2011 through 2015 who were diagnosed with PTSD, TBI, or  certain other conditions and were potentially ineligible for VA benefits  and services;  2.  the extent to which the military services’ policies to address the impact  of PTSD and TBI on the separation of servicemembers for misconduct  are consistent with DOD’s policies;  3.  the extent to which the Army and Marine Corps have adhered to their  policies to address the impact of PTSD and TBI on the separation of  servicemembers for misconduct; and  4.  the extent to which DOD, the Army, and Marine Corps monitor  adherence to policies to address the impact of PTSD and TBI on the  separation of servicemembers for misconduct.
To examine the number of servicemembers who were separated for  misconduct in fiscal years 2011 through 2015, diagnosed with PTSD, TBI,  or certain other conditions, and potentially ineligible for VA benefits and  services, we obtained data from three sources. We obtained separation  data from DOD’s Defense Manpower Data Center (DMDC), medical data  from DOD’s Defense Health Agency (DHA), and data on VA eligibility  determinations from the Veterans Benefits Administration. We limited our  analysis to active duty servicemembers, both officers and enlisted, who  were separated for misconduct from the Army, Marine Corps, Air Force,  or Navy in fiscal years 2011 through 2015. We assessed the reliability of  the DMDC, DHA, and VA data in several ways, including discussing the  reliability of the data with DOD and VA officials, performing electronic  tests of the data to identify any outliers or anomalies, reviewing relevant  documentation, and comparing the data with data from published  sources. We determined that the data were sufficiently reliable for the  purposes of our reporting objectives. For additional information about the  data analysis, see appendix I.
To examine the extent to which the military services’ policies to address  the impact of PTSD and TBI on the separation of servicemembers for  misconduct are consistent with DOD’s policies, we reviewed the military  services’ policies related to (1) assessing the impact of a PTSD or TBI  diagnosis prior to separating certain servicemembers for misconduct, (2)  training servicemembers on how to identify mild TBI symptoms in the  deployed setting, and (3) counseling servicemembers being separated for  misconduct about potential ineligibility for VA benefits and services. We  compared the extent to which the military services’ policies, as provided  by these military services, are consistent with DOD’s related policies in  the above three areas. In addition, we interviewed DOD and military  service officials regarding the policies. For this and subsequent  objectives, we focused our review on the screening and counseling of  enlisted servicemembers because they represented the vast majority (98  percent) of separations for misconduct identified in our first objective. We  focused our review of TBI training requirements on the training of officers,  consistent with our reporting objectives under the Carl Levin and Howard  P. “Buck” McKeon National Defense Authorization Act for Fiscal Year  2015.
To examine the extent to which the Army and Marine Corps have  adhered to their policies designed to address the impact of PTSD and TBI  on the separation of servicemembers for misconduct, at the national level  we reviewed separation documents contained in final personnel files for a  small, nongeneralizable sample of Army and Marine Corps enlisted  servicemembers who were separated during fiscal years 2011 through  2015. We also interviewed Army and Marine Corps headquarter  officials. In addition, we reviewed relevant documents and interviewed  officials regarding screening, training, and counseling during three site  visits. Specifically, we visited two Army installations—Fort Bragg (NC)  and Fort Sill (OK)—and one Marine Corps installation—Camp Pendleton  (CA). We selected the sites based on the number of servicemembers  separated for misconduct and geographic variation. We limited our  review to the Army and the Marine Corps for this and subsequent  objectives because of the resource intensive nature of the site visits. We  selected the Army and Marine Corps because, as of 2014, these two  military services represented over half (almost 60 percent) of all  servicemembers in the United States military forces.
To examine the extent to which DOD, the Army, and the Marine Corps  monitor adherence to policies to address the impact of PTSD and TBI on  the separation of servicemembers for misconduct, we reviewed relevant  documents and interviewed officials from DOD, the Army, and the Marine  Corps. We determined whether or to what extent they collect and monitor  data related to the military services’ adherence to screening, training, and  counseling policies. We compared these efforts to relevant standards for  internal control in the federal government.
We conducted this performance audit from August 2015 to May 2017 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: When a servicemember is charged with misconduct—such as drug use,  insubordination, absence from the military without leave, or criminal  behavior—the military can take action to separate the servicemember  through either a punitive discharge or an administrative separation. A  punitive discharge generally involves a trial by court-martial, where  charges are filed and the case is adjudicated in a military court. In  contrast, administrative separations involving misconduct charges are  handled through a nonjudicial administrative process and can include  attempts to correct and rehabilitate behavior and to counsel  servicemembers on the impact of being separated for misconduct.
subsections: section_title: Separations for Misconduct: Types and Processes
paragraphs: There are two main types of separations for misconduct for enlisted  servicemembers: administrative separations for misconduct and  administrative separations in lieu of trial by court-martial.
Administrative separation for misconduct is an involuntary  separation of a servicemember who is unqualified for further military  service. Examples of the behaviors that can lead to an administrative  separation for misconduct include behaviors ranging from a pattern of  minor disciplinary infractions to the commission of a serious military or  civilian offense.
Administrative separation in lieu of trial by court-martial is when  a servicemember facing trial by court-martial voluntarily requests to be  discharged from military service, and, if approved, the separation case  is then handled through the administrative process.
The process for separating servicemembers varies slightly between the  two separation types. (See fig. 1.)
section_title: Service Characterization for Separating Servicemembers: Potential Impact on VA Benefits and Services
paragraphs: When a servicemember separates from the military, DOD characterizes  the nature of that servicemember’s military service. Administrative  separations generally result in one of three potential characterizations of  service, which determine a servicemember’s eligibility for VA benefits and  services. Specifically,  servicemembers who receive an “honorable” characterization of  service are eligible for all VA benefits and services;  servicemembers who receive a “general” characterization of service  are eligible for most VA benefits and services, with the exception of  some VA education assistance; and  servicemembers who receive an “other than honorable”  characterization of service may not be eligible for any VA benefits and  services, including health care.
According to DOD policy, servicemembers separating under either type of  administrative misconduct separation will normally receive a  characterization of service of “other than honorable,” though other  characterizations may be warranted depending on the circumstances.
section_title: Legislative and DOD Policy Requirements
paragraphs: Congress has enacted several laws and DOD has established several  additional policies governing the military services’ handling of misconduct  separations in cases involving PTSD and TBI.
Screening servicemembers prior to separation. The National Defense  Authorization Act for Fiscal Year 2010, as amended, requires each  military service to provide, under policies established by DOD, a medical  examination for certain servicemembers diagnosed with PTSD or TBI  who are facing administrative separation under conditions other than  honorable, including administrative separations in lieu of court-martial.  The purpose of the medical examination—or screening—is to assess  whether these conditions were a mitigating factor in the behavior that  resulted in the misconduct charge. The law prohibits the administrative  separation of these servicemembers under conditions other than  honorable until the results of the screening have been reviewed by  appropriate authorities responsible for the separation case, as determined  by the relevant military service.
The law’s screening requirements only apply to certain servicemembers  facing administrative separation under conditions other than honorable.  As relevant here, the law requires a screening for those servicemembers  who have been deployed overseas in support of a contingency operation  during the previous 24 months and have been diagnosed with PTSD or  TBI by one of five provider types: (1) a physician, (2) clinical psychologist,  (3) psychiatrist, (4) licensed clinical social worker, or (5) psychiatric  advanced practice registered nurse.
The list of providers eligible to diagnose PTSD and TBI is not the same as  the list of providers eligible to conduct PTSD screenings or the list of  providers eligible to conduct TBI screenings. Specifically, the statute  restricts PTSD screenings to one of four provider types—(1) a clinical  psychologist, (2) psychiatrist, (3) licensed clinical social worker, or (4)  psychiatric advanced practice registered nurse. In comparison, TBI  screenings may be performed by (1) a physician, (2) clinical psychologist,  (3) psychiatrist, or (4) other health care professional, as appropriate. As  a result of this statutory scheme, physicians may diagnose PTSD and  TBI, and they may also perform TBI screenings. However, they may not  perform PTSD screenings.
DOD updated its separation policy first in 2010 and most recently in 2014  in response to changes in the law. Among other things, DOD required  each of the military services to issue its own guidance to implement the  new requirements within that military service.
Training on PTSD and TBI. Although not required by law, DOD has  established a policy for the management of mild TBI, also known as  concussion, in the deployed setting. The policy directs the military  services to develop and support effective training plans for  servicemembers on early detection of potential mild TBI in the deployed  setting. While DOD does not have—nor is it legally required to have— any identifiable policies that require training of PTSD-specific symptoms,  it does have a policy that requires training on combat and operational  stress reactions, which may include sleep disturbance, anger and difficulty concentrating. While combat and operational stress reactions  may overlap with PTSD symptoms, the conditions are distinct.
Counseling on potential ineligibility for VA benefits and services.  DOD has several policies related to counseling servicemembers on  aspects of DOD’s separation policy. Some counseling policies apply to all  servicemembers or to those separating under honorable or general  conditions. One is specific to separations in lieu of trial by court-martial.
DOD policy requires the military services to establish procedures for  periodically counseling all servicemembers throughout their careers  on DOD’s separation policy, including the types of separation and how  particular actions might affect a servicemember’s eligibility for VA  benefits and services.
DOD policy requires that the military services offer legal counsel to  servicemembers requesting separation in lieu of trial by court-martial  prior to the servicemember submitting his or her request to be  separated. The servicemember may refuse to meet with counsel, but  must state in the written request for separation that he or she  understands that such request may result in an “other than honorable”  characterization of service and the consequences, such as potential  loss of benefits, associated with that characterization.
section_title: Many Servicemembers Separated for Misconduct Had PTSD, TBI, or Certain Other Conditions; About a Quarter Were Potentially Ineligible for VA Benefits and Services
paragraphs: Our analysis of DOD data shows that 91,764 servicemembers were  separated for misconduct from fiscal years 2011 through 2015; of these  servicemembers, 57,141—62 percent—had been diagnosed within the 2  years prior to their separation with PTSD, TBI, or certain other conditions  that could be associated with misconduct. More specifically, 16 percent,  or 14,816 of the 91,764 servicemembers who were separated for  misconduct, had been diagnosed with PTSD or TBI. Looking at the  conditions individually, 8 percent had been diagnosed with PTSD and 11  percent had been diagnosed with TBI, while other conditions, such as  adjustment and alcohol-related disorders were more common. (See  table 1.) For additional data on prior diagnoses of servicemembers  separated for misconduct, see appendix II.
The 57,141 servicemembers who were separated for misconduct and  diagnosed within the 2 years prior to separation with PTSD, TBI, or  certain other conditions had, on average, 4 years of active military  service. Almost all, or 98 percent, were enlisted servicemembers, rather  than officers, and two-thirds had not been deployed overseas within the 2  years prior to separation. For additional data on total separations and  separations for misconduct, see appendix III.
Further, of these servicemembers, 23 percent, or 13,283, received an  “other than honorable” characterization of service, making them  potentially ineligible for VA benefits and services, including health care.  The majority—that is, 71 percent—of the servicemembers who were  separated for misconduct and diagnosed within the 2 years prior to  separation with PTSD, TBI, or certain other conditions received a  “general” characterization of service. (See fig. 2.) Within the smaller  population of servicemembers separated for misconduct and diagnosed  with PTSD or TBI, these proportions were the same—that is, 23 percent  received an “other than honorable” characterization of service and 71  percent received a “general” characterization of service.
Our analysis of VA data shows that as of June 2016, of the 13,283  servicemembers who were separated for misconduct with an “other than  honorable” characterization and diagnosed with one of the conditions we  reviewed, 87 percent had not submitted a claim to VA for benefits and  services or completed VA’s determination process. Twelve percent  submitted a claim and were determined eligible for at least some VA  benefits and services, including health care, while the remaining 1  percent submitted a claim and were determined ineligible for all VA  benefits and services. For additional data on the characterizations of  service for servicemembers separated for misconduct and previously  diagnosed with PTSD, TBI, or certain other conditions, see appendix IV.
section_title: Some Military Services’ Screening and Training Policies Related to PTSD and TBI Are Inconsistent with DOD Policy
paragraphs: We found two of the four military services’ policies are inconsistent with  DOD policies related to screening servicemembers for PTSD and TBI  prior to separation and training servicemembers on the early detection of  mild TBI symptoms in the deployed setting. In contrast, we found that the  counseling policies for all four military services are consistent with DOD  policy. (See appendix V for more information on the individual policies  that the Army, Marine Corps, Air Force, and Navy identified as  implementing applicable DOD policy requirements.)
Screening servicemembers prior to separation. We found that the  Marine Corps’ screening policies are consistent with DOD’s screening  policies, the Army’s policy is consistent but set to expire March 31, 2018,  and the Air Force’s and Navy’s screening policies are not consistent with  DOD policy. (See fig. 3.) For the purposes of this review, we compared  the military services’ screening policies to DOD’s policy governing  screenings for certain servicemembers deployed overseas in support of a  contingency operation during the previous 24 months. Our assessment  was based on the following requirements set forth in DOD’s screening  policy, which align with applicable statutory requirements:  1.  do the military services’ screening policies apply to servicemembers  diagnosed with PTSD or TBI by a physician, clinical psychologist,  psychiatrist, licensed clinical social worker, or psychiatric advanced  practice registered nurse;  2.  do the military services’ screening policies apply to servicemembers  facing administrative separation under conditions other than  honorable, including those separating in lieu of trial by court-martial;  and  3.  do the military services’ screening policies identify an appropriate  official to review the results of the screening before deciding whether  the servicemember’s service was “other than honorable?”
We did not assess the military services’ consistency with DOD’s  screening policy regarding the types of providers eligible to perform  screenings because at the time of our review, DOD’s policy was  inconsistent with the law in one respect. In particular, DOD’s policy  permitted physicians to conduct PTSD screenings, whereas the law only  authorizes clinical psychologists, psychiatrists, licensed clinical social  workers, and psychiatric advanced practice registered nurses to do so.  DOD officials stated that they would take steps to correct this issue, which  they did on February 27, 2017 by publishing a revised policy that  removed physicians from the list of providers who can conduct PTSD  screenings.
Specifically we found that:
The Marine Corps’ screening policy not only meets, but exceeds, key  DOD policy requirements. In particular, the Marine Corps’ screening  policy requires screenings for servicemembers who have been  previously diagnosed with PTSD or TBI or who allege its effects,  regardless of the characterization of their service or whether they  served overseas in support of a contingency operation.
In April 2017, the Army reissued its temporary policy requiring  separation authorities to ensure screenings for servicemembers  diagnosed with PTSD or TBI, consistent with DOD policy. The policy  applies to servicemembers deployed overseas in support of a  contingency operation during the previous 24 months and who are  facing administrative separation under conditions other than  honorable, including those separating in lieu of trial by court-martial.  While this policy is consistent with DOD’s screening policy, it is set to  expire on March 31, 2018, and the Army’s permanent separation  regulation has not yet been updated to reflect DOD’s screening  requirements under the statute, as amended.
The Air Force’s screening policy, which is set to expire no later than  June 2017, is inconsistent with DOD’s policy in two respects. First, the  screening requirement under DOD’s policy extends to  servicemembers who request separation in lieu of trial by court- martial, whereas the Air Force’s policy excludes this group. An Air  Force official told us that PTSD and TBI screenings are, in fact, given  to this group because separating servicemembers are required to be  asked about PTSD and TBI symptoms as part of their physical prior to  separation. However, a separation physical does not meet the  requirements of a PTSD or TBI screening for the purpose of  determining whether the condition is a possible mitigating factor in the  separation characterization of servicemembers who request  separation in lieu of trial by court-martial, as required by DOD policy.  Second, DOD policy requires that any qualifying servicemember who  is diagnosed with PTSD or TBI by one of five specified provider types,  including a licensed clinical social worker or psychiatric advanced  practice registered nurse, must receive a screening to determine  whether the condition is a potentially mitigating factor in the conduct in  question. However, Air Force policy does not require such a screening  unless the diagnosis is made by a doctoral-level provider, thereby not  recognizing diagnoses made by licensed clinical social workers and  psychiatric advanced practice registered nurses. An Air Force official  told us that the intent of the policy is to ensure that diagnoses made  by these providers are reviewed and confirmed by doctoral-level  providers. However, imposing such a condition on the diagnoses  made by these provider types is inconsistent with DOD policy, which  recognizes that their diagnoses are sufficient to trigger the screening  requirement.
Similar to the Air Force, the Navy’s screening policy excludes  servicemembers who request separation in lieu of trial by court-martial  and is likewise inconsistent with DOD’s screening policy. This is  because the Navy’s separation policy only requires screenings prior to  involuntary separations, whereas the Navy elsewhere defines a  separation in lieu of trial by court-martial as a voluntary separation.  While the Navy, like the Air Force, requires all servicemembers to  undergo a separation physical that includes questions about PTSD  and TBI, such a procedure does not meet the requirement of a  screening for the purpose of assessing whether the condition is a  mitigating factor in the misconduct charged in the separation case.
Our review did not evaluate whether the inconsistencies we identified had  an impact on any individual servicemember who may have been entitled  to a screening. However, unless the military services rectify these  inconsistences, DOD is at risk that some servicemembers may be  deprived of a required screening for PTSD or TBI or may not have the  results of a screening taken into account as a possible mitigating factor in  their misconduct, as required by DOD policy.
Some of the inconsistencies in military service screening policies appear  to have existed since DOD updated its screening policy in 2014 in  response to various statutory amendments enacted in 2013. For example,  neither the Navy nor Air Force have updated their policies to expressly  require PTSD or TBI screenings for servicemembers requesting  separation in lieu of trial by court-martial for the purpose of determining  whether the condition is a mitigating factor in the servicemember’s  separation characterization. While each military service has released at  least one policy update to correspond with other updates made by DOD  in 2014, none of the Navy or Air Force updates pertain to  servicemembers requesting separation in lieu of trial by court-martial.
Training on PTSD and TBI. We found that two of the four military  services’ TBI training policies are inconsistent with DOD policy. (See table  2.) DOD policy requires the military services to develop effective training  plans for all servicemembers on the early detection of potential  concussion or mild TBI in the deployed setting. As previously noted,  DOD does not have a specific policy that requires training on how to  identify the symptoms of PTSD.
We found that the Army’s temporary policy and the Marine Corps’ policy  are consistent with DOD’s policy requiring that all servicemembers be  trained on how to identify mild TBI symptoms in the deployed setting, but  the Air Force’s and the Navy’s policies are not. Specifically we found  that:  the Air Force training policy incorporates DOD’s policy by reference  and assigns responsibility to an Air Force component to develop  training plans. However, as of April 2017, Air Force officials had not  identified whether this component had issued such training plans.
While the Navy’s TBI policy requires that training be provided to  certain health providers assigned to military treatment facilities, the  policy does not extend to all servicemembers in the deployed setting,  consistent with DOD’s policy.
Because of these inconsistencies, Air Force and Navy increase their risk  that some servicemembers, including officers, may not be getting trained  on how to identify symptoms of mild TBI in the deployed setting.
Counseling on potential ineligibility for VA benefits and services. All  four military services have policies that require all servicemembers to be  counseled about their eligibility for VA benefits and services at multiple  points in their career, with additional counseling requirements for  servicemembers who are requesting separation in lieu of trial by court- martial. This is consistent with DOD policy. All four military services  established periodic counseling policies, including a requirement for  servicemembers to be briefed on eligibility for VA benefits and services at  least twice in the first year of service. All four military services also  established policies requiring that servicemembers who are considering  separating in lieu of trial by court-martial be offered legal counsel who,  among other things, advises the servicemember on his or her potential  ineligibility for VA benefits and services as a result of an “other than  honorable” characterization of service.
section_title: Army and Marine Corps May Not Have Adhered to Their Own Policies Related to PTSD and TBI Screening, Training, and Counseling
paragraphs: In our review of separation documents and interviews with installation- level Army and Marine Corps officials we found that the Army and Marine  Corps may not have adhered to their own screening, training, and  counseling policies.
Screening servicemembers prior to separation. Our review of the  Army and Marine Corps implementation of screening policies identified  instances in which servicemembers may not always have been screened  for PTSD and TBI and that screening results may not have been reviewed  by the appropriate officials as required by the military services’ policies.
In our review of separation packets for Army servicemembers, we found  the following:  In 2010, the Army issued a policy requiring PTSD and TBI screening  for servicemembers administratively separated for misconduct who  meet certain requirements. In our review of 46 separation packets  for Army servicemembers separated for administrative misconduct  from fiscal years 2011 to 2015, we did not find screening  documentation in 16 packets, and in 1 of the packets the  documentation was unclear.
In October 2013, the Army updated its policy to require screenings for  servicemembers separating in lieu of trial by court-martial. In our  review of 7 separation packets for Army servicemembers separated in  lieu of trial by court-martial after the policy update to the end of fiscal  year 2015, we did not find screening documentation in 5 of the  packets.
In addition, the Army’s October 2013 update required the separation  authority to review the screenings prior to making a final separation  decision. In our review of 21 separation packets for Army  servicemembers who were administratively separated for misconduct  or in lieu of trial by court-martial after the policy update to the end of  fiscal year 2015, we did not find documentation of review by the  separation authority in 4 of the packets, and in 5 of the packets the  documentation was unclear. As a result, PTSD or TBI may not have  been identified as a possible mitigating factor in the separation.
In our review of separation packets for Marine Corps servicemembers, we  found the following:
Of those Marine Corps servicemembers who were administratively  separated for misconduct from fiscal years 2011 to 2015, screening  documentation was missing for 18 of the 48 separation packets we  reviewed and in 2 packets the documentation was unclear. As such,  it is unclear whether these Marine Corps servicemembers were  screened for PTSD and TBI as required under DOD policy.
In addition, 19 of the 48 separation packets we reviewed did not have  documented evidence that the appropriate official reviewed the  screening prior to separation, and in 1 packet the documentation was  unclear. As such, we cannot be certain that these Marine Corps  servicemembers’ screening results were reviewed by the appropriate  official prior to the servicemembers being separated.
While the absence of documentation does not prove that screenings and  review by appropriate officials did not occur, it does suggest that Army  and Marine Corps policies may not have been followed.
In interviews with Army and Marine Corps installation-level defense  counsel who represent servicemembers, some additional concerns  regarding the PTSD and TBI screenings were mentioned. For example,  Marine Corps defense counsel raised concerns that screenings might be  occurring after key separation recommendations are being made and that  the tools used to determine whether servicemembers have either  condition should have a more comprehensive exam for PTSD and TBI.  During our review of separation packets we found one instance in which a  screening did not occur before a board was convened; however, the  board members did discuss PTSD during the proceedings. In addition,  Army and Marine Corps defense counsel raised concerns that providers  might be pressured by commanders to clear servicemembers.
Training on PTSD and TBI. During our Army and Marine Corps  installation interviews, we found that some Army officers who should have  received training on how to identify symptoms of TBI may not have;  further, installation-level officials for both the Army and the Marine Corps  could not produce documentation for officers who had received the  training. During our site visits to the Army installations, noncommissioned  officers, in particular, told us that they did not receive specific training on  how to identify symptoms for TBI. In contrast, commissioned officers were  more likely to recall that they had received the training, often citing the  officer leadership courses as the way they received the information.  When we asked officials at both Army and Marine Corps installations for  documentation of training, officials said that while they have sign-in  sheets for the servicemembers who participate in the training, they do not  maintain them or other documentation, such as training logs, at the  installations because they are not required to do so.
Officers at one of the Army and the Marine Corps installations we visited  said that other efforts—beyond training courses—to build awareness of  PTSD and TBI have been helpful. In particular, they said that a DOD- wide initiative to have a mental health provider “embedded” in the units  has been beneficial in helping them to identify these symptoms in the  servicemembers under their command. The officers added that  discussing a servicemember’s behavior with a mental health provider  often resulted in a medical referral instead of initiating the process for  separating a servicemember for misconduct.
Counseling on potential ineligibility for VA benefits and services. We  found instances in which both the Army and the Marine Corps may not  have adhered to their own counseling policies, specifically prior to  servicemembers’ request for separation in lieu of trial by court-martial. In  11 of the 48 packets included in our analysis of Army servicemembers  who requested separation in lieu of trial by court-martial, we found that  there was no documented evidence or the evidence was unclear as to  whether the servicemembers were counseled on their potential ineligibility  for VA benefits and services. Similarly, with respect to the Marine Corps, 4 of the 15 packets we reviewed for servicemembers who  requested separation in lieu of trial by court-martial were missing  documented evidence that the servicemembers were made aware of their  potential ineligibility for VA benefits and services. As such, we cannot be  certain these servicemembers were counseled on potential ineligibility for  VA benefits and services as required.
Army and Marine Corps installation-level defense counsel said that if a  servicemember elects to meet with legal counsel prior to requesting  separation in lieu of trial by court-martial, counsel reviews how receiving  an “other than honorable” characterization can affect the  servicemember’s eligibility for VA benefits and services as part of the  counseling. Officials from both military services also stated that  servicemembers are counseled on how their characterization of service  could affect their eligibility for VA benefits and services as part of their  initial training. Moreover, installation-level officials said that commanders  at multiple levels discuss the impact of certain characterizations on  eligibility for VA benefits and services as part of their misconduct  counseling with servicemembers. Marine Corps officials said that early  counseling is done through one-on-one conversations, and in many cases  only once the formal separation is about to begin do the counseling  sessions become documented. However, as previously reported, we  cannot be certain that counseling policies for separations in lieu of trial by  court-martial were always implemented as required based on the results  of our packet review.
section_title: DOD, Army, and Marine Corps Do Not Routinely Monitor Adherence to Policies to Address the Impact of PTSD and TBI on Servicemembers
paragraphs: DOD does not routinely monitor the military services’ adherence to  policies for screening servicemembers for PTSD and TBI prior to  separating them for misconduct, training officers on how to identify  symptoms of TBI in the deployed setting, and counseling servicemembers  on eligibility for VA benefits and services. According to DOD officials, the  expectation is that the military services are responsible for monitoring  adherence to these polices. While both Army and Marine Corps have  some data available that could make it possible for them to monitor  whether their screening, training, and counseling policies are being  adhered to as required, the two military services are not routinely using  these data to do so because of limited resources in some instances,  according to an official. Federal internal control standards call for  agencies to establish activities to monitor internal control systems and  evaluate results. Without monitoring adherence to these policies, the  military services cannot provide assurance that certain servicemembers  are screened for PTSD and TBI prior to separation; all servicemembers,  including officers at all levels, are trained on how to identify symptoms of  mild TBI in the deployed setting; and servicemembers are counseled  about VA benefits and services during the separation process.
Screening servicemembers prior to separation. Neither the Army nor  the Marine Corps routinely monitors whether its screening policies related  to PTSD and TBI are adhered to. According to an Army headquarters  official, it is the responsibility of commanders and staff judge advocates at  each Army installation to review a servicemember’s separation material  and make sure that the required screening documents are included  before final separation decisions are made. Such documents can indicate  whether or not servicemembers have been screened for PTSD or TBI.  However, the official added that the Army does not have a systematic  method for monitoring whether certain servicemembers are being  screened. As previously discussed, we found that screening documents  were not always included in the Army separation packets that we  reviewed.
Recent Army audits have found that the Army did not have sufficient  documentation to demonstrate that it was always considering whether  PTSD or TBI was a mitigating factor in servicemembers’ behavior prior to  separating them for misconduct. Specifically, the Army Audit Agency  conducted two audits that reviewed separation and medical records of  servicemembers who had been separated with a characterization of  service of “other than honorable” and had been deployed and diagnosed  with PTSD or TBI within 24 months of their separation for the period of  November 1, 2009 through July 31, 2015. The Army Audit Agency found  that not all of the separation packets it reviewed had documentation  showing that screening for PTSD and TBI had occurred prior to the  servicemember’s separation for misconduct.
While the Army does not have a systematic method for monitoring, it does  have data available that could be used to routinely monitor whether  screening is occurring. Specifically, the Army has access to  servicemembers’ medical records and could review the medical records  of certain servicemembers being separated for misconduct to determine if  they had been previously diagnosed with PTSD or TBI and therefore  should be screened. According to Army officials, Army Behavioral Health  System of Care personnel are building an electronic program that will  create an automated record of all screenings. Officials added that this  electronic program is expected to be completed in fiscal year 2017.
In the case of the Marine Corps, officials recognize that monitoring is  necessary; however, an official told us that the Marine Corps does not  have sufficient data to routinely monitor whether screenings are  occurring. The officials told us the Marine Corps was exploring options for  analyzing separation and medical data to see whether separating  servicemembers had been screened for PTSD and TBI. The officials  explained that the Marine Corps has a new electronic system that allows  commanders at the installation level to input real time information about  an administrative separation, which can be viewed by officials at Marine  Corps headquarters. The officials stated that this system could be used to  help identify separation issues, such as unaccounted for screenings prior  to a servicemember being separated. However, one of the officials told us  that the Marine Corps installations are only using the electronic system in  forty percent of separation cases. Furthermore, the official stated that  medical personnel would be required to review medical records of certain  servicemembers to determine if they had been diagnosed with PTSD or  TBI, but the Marine Corps does not have the resources to hire this  personnel.
Training on PTSD and TBI. Although Army and Marine Corps officials  told us they collect data about the training provided as part of the TBI  programs, they do not use these data to routinely monitor adherence with  their training policies. As previously discussed, Army and Marine Corps  officials told us they collect attendance for the servicemembers, including  officers, who participate in the trainings. However, according to officials,  these data are not used to identify officers who may not have received  training or to routinely monitor whether the Army and Marine Corps are  adhering to DOD’s policy that all servicemembers receive training on how  to identify mild TBI symptoms in the deployed setting. Because DOD  does not have a policy requiring PTSD training, and the military services  have not developed such policies on their own, there is no policy for the  DOD and the military services to monitor adherence against.
Counseling servicemembers about VA benefits and services. While  Army and Marine Corps collect some data about the counseling provided  to servicemembers, the two military services do not routinely use these  data to ensure adherence with their counseling policies. For example,  Marine Corps headquarters officials told us that they collect attendance  records for the Marine Corps’ 90-day personnel readiness training, which  includes counseling on VA benefits and services, but the data collected  are not reviewed to ensure that servicemembers have received the  required counseling. For the counseling that is provided to  servicemembers being separated in lieu of trial by court-martial, Army and  Marine Corps officials told us that documentation of this counseling  should be included in each servicemember’s separation packet. However,  officials from both military services told us that servicemembers’  separation packets are not reviewed by officials at the military services’  headquarters to ensure that counseling is occurring. Similar to how the  PTSD and TBI screening documents are reviewed, officials explained that  military staff at the installations should review the separation material to  make sure that the counseling documents are included. For example, an  Army headquarters official told us that the Army relies on staff judge  advocates at the installations to review servicemembers’ separation  material and make sure that the required counseling documents are  included prior to a final separation decision. However, as previously  noted, in our review of a sample of Army and Marine Corps separation  packets, we found that counseling documents were not always present  and therefore could not confirm that the counseling had occurred.
section_title: Conclusions
paragraphs: DOD’s policies and the policies of the four military services—Army,  Marine Corps, Air Force, and Navy—are intended to ensure that PTSD  and TBI are appropriately considered before a servicemember is  separated for misconduct. However, we found that Air Force and Navy’s  pre-separation screening and training policies are inconsistent with DOD  policy. Furthermore, we found that the Army and Marine Corps may not  always be adhering to their own policies and that monitoring of the  policies—which could include a review of documentation, data analyses,  or other oversight mechanisms—by DOD, Army, and Marine Corps is  limited. While we did not review whether the Air Force or Navy adhered to  or monitored their policies, we identified inconsistencies between their  policies and DOD’s policies. As a result of policy inconsistencies and  limited monitoring, DOD has little assurance that certain servicemembers  diagnosed with PTSD or TBI receive the required screening and  counseling prior to being separated for misconduct and that all  servicemembers, including officers, have been trained on how to identify  symptoms of mild TBI in the deployed setting. Unless the policy  inconsistencies are resolved and routine monitoring is undertaken to  ensure adherence, the risk increases that servicemembers may be  inappropriately separated for misconduct without adequate consideration  of these conditions’ effects on behavior, separation characterization, or  eligibility for VA benefits and services.
section_title: Recommendations for Executive Action
paragraphs: To increase its assurance that PTSD and TBI are appropriately  considered prior to separating certain servicemembers from the military  for misconduct, the Secretary of Defense should take the following five  actions:  Direct the Air Force and Navy to address inconsistencies with DOD policy  in their policies related to  screening certain servicemembers, including servicemembers  separating in lieu of trial by court-martial, for PTSD and TBI and  reviewing the results prior to separation for misconduct; and  training servicemembers, including officers, on how to identify mild  TBI symptoms in the deployed setting.
Ensure that the military services routinely monitor adherence to policies  related to  screening certain servicemembers for PTSD and TBI prior to  separation for misconduct;  training servicemembers, including officers, on how to identify mild  TBI symptoms in the deployed setting; and  counseling about VA benefits and services during the process of  separating certain servicemembers for misconduct.
section_title: Agency Comments and Our Evaluation
paragraphs: DOD and VA reviewed a draft of this report. DOD provided general  comments, which are reprinted in appendix VI, and technical comments,  which we incorporated as appropriate. VA did not provide written  comments on this report, but the department indicated that it will continue  to raise awareness of PTSD and TBI programs available to veterans,  including veterans with a less than honorable discharge.
In its comments, DOD concurred with four of our five recommendations.  Specifically, DOD agreed with our recommendation to direct the Air Force  and the Navy to address inconsistencies in their policies related to  screening certain servicemembers for PTSD and TBI and reviewing the  results prior to separation for misconduct. DOD also agreed with our  recommendations to ensure that the military services routinely monitor  adherence to policies related to screening certain servicemembers for  PTSD and TBI prior to separation for misconduct; counseling  servicemembers about VA benefits and services during the separation  process; and training servicemembers, including officers, on how to  identify mild TBI symptoms. On this last monitoring recommendation  related to training, based on additional information from DOD we revised  the language of the original recommendation to clarify that the military  services should monitor the training provided to servicemembers on how  to identify mild TBI symptoms in the deployed setting.
DOD did not concur with our recommendation that it direct the Air Force  and the Navy to address inconsistencies between their policies and  DOD’s policy related to training servicemembers on how to identify mild  TBI symptoms. In its comments, DOD said that because our  recommendation did not specify that training to identify mild TBI  symptoms was in the deployed setting, we were in effect creating new  policy. We have revised the language in our recommendation to clarify  this point. However, this clarification does not obviate the need for our  recommendation because the inconsistencies we identified in the Air  Force and Navy policies were material to their mild TBI training  requirements in deployed settings. In particular, the Air Force provided no  documentation of the training plans it was responsible for developing,  while the Navy’s mild TBI training requirement only applied to certain  health providers.
DOD also raised four concerns about our data analysis. First, DOD raised  concern that data from DOD’s Defense Manpower Data Center (DMDC)  on the total number of separations were lower than Army and Marine  Corps data. We obtained our data from DMDC, and over the course of  our audit assessed the reliability of the data provided in several ways,  including comparing it with published sources and discussing the data  with officials from the military services and DMDC. Differences between  DMDC’s and the military services’ data were reviewed and, where  necessary, explanations were identified and noted. The discrepancy in  total number of separations noted in DOD’s comments stems largely from  differences in which servicemembers were included. In their analyses of  total separations, the Army and the Marine Corps included  servicemembers who separated from active duty and transferred directly  to National Guard or Reserve duty, whereas the data provided by DMDC  that we used for our analysis excluded these servicemembers. We  excluded these servicemembers because our review focuses on  servicemembers separating to civilian life. In response to DOD’s concern,  we clarified this exclusion in the report. Further, these military services  confirmed that DMDC’s misconduct separations data—the data on which  our findings are based—are consistent with their data.
Second, DOD raised concern that the number of servicemembers we  report as having been diagnosed with PTSD or TBI—14,816—is  inaccurate because of double counting. We disagree. As stated in the  report, collectively, about 16 percent, or 14,816, of the 91,764  servicemembers who were separated for misconduct had been  diagnosed with PTSD or TBI. As we explain in footnote 28, this proportion  is lower than the sum of the proportion diagnosed with PTSD (8 percent)  and the proportion diagnosed with TBI (11 percent) because some  servicemembers had been diagnosed with both conditions. However, in  response to DOD’s concern, we made additional clarifications in the  report.
Third, DOD expressed concern about some of the conditions included in  our group of conditions other than PTSD and TBI that could be  associated with misconduct. As described in our methodology, we  developed our list of conditions through conversations with DOD and  mental health professionals and reviews of relevant publications. We  ultimately selected conditions that could potentially be caused or  exacerbated by military service, or that could be misdiagnosed as PTSD  or TBI. For example, one of the reasons we included depressive  disorders was the discussion of major depressive disorder and  depressive symptoms in a 2008 RAND study. This study noted that  depression could be linked to specific war experiences such as loss, and  affects mood, thoughts, and behavior, but often goes unrecognized and  unacknowledged. Furthermore, because we understand that there can be  conflicting evidence on these issues, in key parts of the report we  separate discussions of PTSD and TBI data from the data on other health  conditions. In response to DOD’s concern, we also included additional  data on PTSD and TBI separately from the data related to other health  conditions.
Finally, DOD expressed concern that our use of the word “officials” to  describe servicemembers’ defense counsel implied that they represented  the interests of the military services rather than the servicemembers. In  response, we removed the word “officials” in describing defense counsel.
We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, the Secretary of Veterans Affairs,  the Secretaries of the Air Force, Army, and Navy, the Commandant of the  Marine Corps, the Assistant Secretary of Defense for Health Affairs, and  other interested parties. In addition, the report is available at no charge on  the GAO website at http://www.gao.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or williamsonr@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 key contributions to this  report are listed in appendix VI.
section_title: Appendix I: Additional Information on GAO’s Data Analyses
paragraphs: To determine the number of servicemembers—officers and enlisted— separated for misconduct in fiscal years 2011–2015 and diagnosed with  post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), or  certain other conditions, we obtained data from the Department of  Defense’s (DOD) Defense Manpower Data Center (DMDC) and the  Defense Health Agency (DHA). DMDC provided us with data on total  separations of active duty servicemembers from the Army, Air Force,  Marine Corps, and Navy, as well as a list of active duty servicemembers  who were administratively separated for misconduct or in lieu of trial by  court-martial from the military services during this timeframe. For each  servicemember who was administratively separated for misconduct or in  lieu of trial by court-martial, DMDC provided the characterization of  service upon separation as well as other relevant data. For the data on  total separations and separations for misconduct, we included only  servicemembers who were separated to civilian life—that is, we excluded  separations due to factors such as death, joining officer commissioning  programs, joining military academies, or separating to the National Guard  or Reserve. If servicemembers had multiple relevant separation dates, we  used only the most recent date. We excluded Reservists and National  Guard members because, according to DMDC officials, reliable data were  not available for the Army Reserve and National Guard. For each  servicemember who was identified by DMDC as having been  administratively separated for misconduct or in lieu of trial by court- martial, DHA provided us with data on whether the servicemember was  diagnosed with PTSD, TBI, or certain other conditions within the 2 years  prior to the servicemember’s separation date. To determine which  conditions, in addition to PTSD and TBI, to include in our analysis, we  reviewed relevant literature and consulted with clinical experts regarding  the prevalence in the military population of conditions that cause  behaviors that could contribute to misconduct. The conditions we selected  are adjustment disorders, alcohol-related disorders, anxiety disorders,  bipolar disorders, depressive disorders, personality disorders, and  substance-related disorders.
To determine how many of the servicemembers who were separated for  misconduct and previously diagnosed with PTSD, TBI, or certain other  conditions were potentially ineligible for Department of Veterans Affairs  (VA) benefits and services, we analyzed the data provided by DMDC on  servicemembers’ characterizations of service upon separation. In  addition, we obtained data from VA’s Veterans Benefits Administration on  the extent to which servicemembers who were administratively separated  for misconduct or in lieu of trial by court-martial and previously diagnosed  with PTSD, TBI, or certain other conditions were deemed ineligible by VA  for benefits and services. Specifically, we provided VA with a list of  servicemembers who DMDC and DHA data show were administratively  separated for misconduct or in lieu of trial by court-martial in fiscal years  2011-2015 and diagnosed within the prior 2 years with PTSD, TBI, or  another condition included in our study. For each of these  servicemembers, the Veterans Benefits Administration provided data on  (1) whether the servicemember ever submitted a claim to VA for benefits  or services, as well as the date of the most recent claim; (2) whether VA’s  characterization of service determination process was ever completed for  the servicemember, as well as the completion dates; and (3) the outcome  of this process each time it was performed—that is, whether the  servicemember was deemed eligible or ineligible for VA benefits and  services.
We assessed the reliability of the data provided by DMDC, DHA, and  VA’s Veterans Benefits Administration in several ways, including  discussing the reliability of the data with DOD and VA officials, performing  electronic tests of the data to identify any outliers or anomalies, reviewing  relevant documentation, and comparing the data with data from published  sources. We determined that the data were sufficiently reliable for the  purposes of our reporting objectives.
section_title: Appendix II: Prior Diagnoses for Servicemembers Separated for Misconduct from Fiscal Years 2011 through 2015
paragraphs: Table 3 provides additional information on the extent to which  servicemembers who were separated for misconduct from fiscal years  2011 through 2015 were previously diagnosed with post-traumatic stress  disorder (PTSD) or traumatic brain injury (TBI), previously diagnosed with  certain other conditions, or not previously diagnosed with any of the  conditions. Tables 4 and 5 provide additional information on the extent to  which servicemembers who were administratively separated for  misconduct or administratively separated in lieu of trial by court-martial  from fiscal years 2011 through 2015 were previously diagnosed with the  individual conditions included in our study.
section_title: Appendix III: Additional Information on Separations for Active Duty Servicemembers, Fiscal Years 2011 through 2015
paragraphs: Table 6 provides information on total separations of active duty  servicemembers from military service from fiscal years 2011 through  2015. Tables 7 and 8 provide information on administrative separations  for misconduct and administrative separations in lieu of trial by court- martial for active duty servicemembers during this timeframe.
section_title: Appendix IV: Characterization of Service for Servicemembers Separated for Misconduct from Fiscal Years 2011 through 2015 and Previously Diagnosed with PTSD, TBI, or Certain Other Conditions
paragraphs: Tables 9 and 10 provide information on characterization of service for  servicemembers who were administratively separated for misconduct or  administratively separated in lieu of trial by court-martial from fiscal years  2011 through 2015 and diagnosed within the 2 years prior to separation  with post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), or  certain other conditions.
section_title: Appendix V: Military Services’ Policies that Address the Impact of PTSD and TBI on the Separation of Servicemembers for Misconduct
paragraphs: All four military services have policies related to screening  servicemembers for post-traumatic stress disorder (PTSD) and traumatic  brain injury (TBI) prior to separation; training servicemembers, including  officers, on how to identify mild TBI symptoms in the deployed setting;  and counseling servicemembers on eligibility for Department of Veterans  Affairs (VA) benefits and services. Table 11 provides a brief description of  the screening requirements outlined in the Department of Defense (DOD)  and the military service policies. Table 12 illustrates selected DOD and  military service policies that include requirements for training on mild TBI  in the deployed setting. Finally, Table 13 outlines the policies that require  counseling for servicemembers.
section_title: Appendix VI: Comments from the Department of Defense
section_title: Appendix VII: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact name above, Karin Wallestad, Assistant  Director, Deitra H. Lee, Analyst-In-Charge, Priyanka Sethi Bansal,  Carolyn Fitzgerald, Krister Friday, Q. Akbar Husain, and Jennifer Rudisill  made key contributions to this report. Also contributing were Christine  Davis, Cynthia Grant, Dae Park, Vikki Porter, Steven Putansu, and James  Whitcomb.