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

Letter

Background

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.

Separations for Misconduct: Types and Processes

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.)

Service Characterization for Separating Servicemembers: Potential Impact on VA Benefits and Services

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.

Legislative and DOD Policy Requirements

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.

Many Servicemembers Separated for Misconduct Had PTSD, TBI, or Certain Other Conditions; About a Quarter Were Potentially Ineligible for VA Benefits and Services

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.

Some Military Services’ Screening and Training Policies Related to PTSD and TBI Are Inconsistent with DOD Policy

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.

Army and Marine Corps May Not Have Adhered to Their Own Policies Related to PTSD and TBI Screening, Training, and Counseling

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.

DOD, Army, and Marine Corps Do Not Routinely Monitor Adherence to Policies to Address the Impact of PTSD and TBI on Servicemembers

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.

Conclusions

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.

Recommendations for Executive Action

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.

Agency Comments and Our Evaluation

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.

Appendix I: Additional Information on GAO’s Data Analyses

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.

Appendix II: Prior Diagnoses for Servicemembers Separated for Misconduct from Fiscal Years 2011 through 2015

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.

Appendix III: Additional Information on Separations for Active Duty Servicemembers, Fiscal Years 2011 through 2015

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.

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

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.

Appendix V: Military Services’ Policies that Address the Impact of PTSD and TBI on the Separation of Servicemembers for Misconduct

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.

Appendix VI: Comments from the Department of Defense

Appendix VII: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

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.