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

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