Substantial numbers of ground combat Army and Marine Corps servicemembers are exposed to combat experiences often associated with an increased risk of developing PTSD or other mental health conditions. Specifically, according to a 2004 study, more than half of Army or Marine Corps ground combat units in OEF or OIF report being shot at or receiving small-arms fire, seeing dead or seriously wounded Americans, or seeing ill or injured women or children who they were unable to help. More than half of Marine Corps servicemembers and almost half of Army servicemembers reported killing an enemy combatant in OIF. In addition to certain types of experiences, multiple deployments are also associated with mental health problems. For example, a 2006 Army mental health advisory team report found that Army servicemembers who had been deployed more than once were more likely to screen positive for PTSD, depression, or anxiety than those deployed only once. In a 2008 Army mental health advisory team report, 27 percent of Army male non- commissioned officers in their third or fourth deployment screened positive for PTSD, depression, or anxiety (compared to 12 percent of those on their first deployment). Servicemembers are also exposed to events such as blasts that increase their risk of experiencing a TBI. TBI occurs when a sudden trauma causes damage to the brain and can result in loss of consciousness, confusion, dizziness, trouble with concentration or memory, and seizures. Of particular concern are the after-effects of a mild TBI that may not have resulted in readily apparent symptoms at the time of the injury. A recent study found that mild TBI was associated with high combat intensity and multiple exposures to explosions in combat. Identification of mild TBI is important, as treatment has been shown to mitigate the injury's effects, which can include difficulty returning to work or completing routine daily activities. DVBIC has issued a screening tool called the Military Acute Concussion Evaluation (MACE), which is based on a screening tool widely used in sports medicine and is intended to evaluate a servicemember within 48 hours of the suspected injury. In June 2007, the Army required health care providers to document a servicemember's blast exposure in theater using the MACE. DVBIC also issued in December 2006 a CPG for the management of mild TBI in theater. The guidance contains a structured series of questions that include certain "red flags," such as worsening headaches or slurred speech, that should trigger further evaluation for a possible mild TBI. Treatments for mild TBI may include education, medication, and physical and psychiatric therapy. There are multiple opportunities during the deployment cycle for screening and assessing servicemembers' health status. Specifically, DOD requires three health assessments during the deployment cycle: the pre- deployment health assessment, the PDHA, and the PDHRA. In addition, DOD requires an annual periodic health assessment (PHA). These assessments and their associated forms are described in Table 1. DOD's Instruction on Deployment Health, which implements policies and prescribes procedures for deployment health activities, requires deploying servicemembers to complete the pre-deployment health assessment form, the DD 2795, within 60 days prior to the expected deployment date. The DD 2795 is a brief form for servicemembers to self-report general health information in order to identify any health concerns that may limit deployment or need to be addressed prior to deployment, and consists of eight questions that each servicemember must complete (see fig. 1). DOD's Instruction on Deployment Health states that after the servicemember completes the DD 2795, the form is to be reviewed by a health care provider, who can be a nurse, medical technician, medic, or corpsman. If the servicemember indicates a positive, or "yes," response to any one of certain questions (2, 3, 4, 7, or 8) the servicemember is to be referred for an interview by a trained health care provider such as a physician, physician assistant, nurse practitioner, or advanced practice nurse. The provider signs the form indicating whether the individual is medically ready for deployment, and a copy of the DD 2795 is placed in the servicemember's deployment health record. The deployment health record is a summary of the medical record that is to accompany the servicemember into theater. According to DOD's Instruction on Deployment Health, this record should also contain a record of the servicemember's blood type, allergies, corrective lens prescription, immunization record, and a summary sheet listing past and current medical conditions, screening tests, and prescriptions. DOD's Instruction on Deployment Health requires servicemembers returning from deployment to complete the post-deployment health assessment form, the DD 2796, within 30 days of leaving a combat theater or within 30 days of returning to home or a processing station. The DD 2796 is a form for servicemembers to self-report health concerns commonly associated with deployments. In January 2008, DOD released a new version of the DD 2796 that contains screening questions related to mental health, including questions used to screen for depression, suicidal thoughts, and PTSD. The screening questions for depression, suicidal thoughts, and alcohol abuse are more detailed on the new form than on the previous version of the DD 2796 (See appendix I for a copy of the new version of the DD 2796). The DD 2796 must be reviewed, completed, and signed by a health care provider. According to DOD's Instruction on Deployment Health, the health care provider conducting the assessment must be a physician, physician assistant, nurse practitioner, advanced practice nurse, independent duty medical technician or IDC, or Special Forces medical sergeant. According to DOD's Instruction on Deployment Health, the health care provider review is to take place in a face-to-face interview with the servicemember. The health care provider is to review the completed DD 2796 to identify any responses that may indicate a need for further medical evaluation. In addition, the new DD 2796 contains guidance intended to assist a provider in determining whether to make a referral for some mental health concerns. For example, the form prompts the provider to conduct a risk assessment for suicide depending on the servicemember's response to the suicide risk questions. Health care providers use a section of the DD 2796 to indicate when a servicemember needs a referral. The referral field specifies both the concern for which the servicemember is being referred, such as depression or PTSD symptoms, and the type of care or provider to whom the servicemember is being referred, such as primary care, mental health, specialty care, family support services, chaplains, or Military OneSource. DOD requires that the DD 2796 be placed in the servicemember's medical record. DOD requires an annual health assessment, the PHA, for all servicemembers. The PHA is designed to ensure servicemember medical readiness through monitoring servicemember health status and helps DOD provide preventive care, information, counseling, or treatment if necessary. In February 2006, DOD required the military services to begin administering the PHA, which includes servicemember self-reporting of health status, conditions, treatments, and medications; provider review of the medical record and identification of and referral for any health issues. The PHA also includes efforts to identify and manage preventive needs, occupational risk and exposure as well as identifying and recommending a plan to manage risks. DOD requires its providers to record the results of the PHA in servicemembers' medical records. DOD has created an online tool to capture self-reported information from the PHA. A draft of this form contains several mental health questions, including PTSD and depression screening questions that are similar to the current PTSD and depression questions on the DD 2796. While several DOD information systems contain servicemember medical information, the Composite Health Care System (CHCS) I and the Armed Forces Health Longitudinal Technology Application (AHLTA), formerly known as CHCS II, are the two electronic medical records systems generally used by DOD health care providers to make PDHA referrals. Although the military services currently employ both systems, there are several differences between the two. For example, CHCS I is a localized system, meaning information contained within CHCS I is only available to medical facilities on a particular military installation; information is not available to military treatment facilities (MTFs) on other installations. In contrast, information in AHLTA is available to medical facilities at different installations and to providers in theater. Another distinction is that CHCS I sends health care providers an email alert when a servicemember they refer makes, completes, or cancels an appointment. If servicemembers do not make appointments within 30 days, their referral is terminated from CHCS I and the health care provider is notified by email. AHLTA does not have this capability. DOD has been expanding AHLTA's capabilities and plans on replacing certain CHCS I functions, such as laboratory tests, with AHLTA. DOD has taken steps to meet the 2007 NDAA requirements for pre- deployment mental health standards and screening. As required by the 2007 NDAA, which was enacted in October 2006, DOD issued minimum mental health standards that servicemembers must meet in order to be deployed. In a policy issued in November 2006, DOD identified mental health disorders that would preclude a servicemember's deployment, including conditions such as bipolar disorder. DOD's policy also identified psychotropic medications that would limit or preclude deployment if used by servicemembers--including antipsychotic or anticonvulsant medications used to control bipolar symptoms and certain types of tranquilizers and stimulant medications. In addition to identifying the mental health conditions and medications that would preclude deployment, DOD's policy specified the circumstances under which servicemembers with other mental health conditions can be deployed. Specifically, according to DOD's policy, when a servicemember has been diagnosed with a mental health condition that does not preclude deployment, the servicemember should be free of "significant" symptoms associated with this condition for at least three months before he or she can be deployed. The policy also states that in making a deployability assessment, health care providers should consider the environmental and physical stresses of the deployment and whether continued treatment will be available in theater. Finally, the policy identified the pre-deployment health assessment as a mechanism for screening servicemembers for mental health conditions and for ensuring that the standards are utilized in making deployment determinations. The 2007 NDAA also required DOD to use the pre-deployment health assessment to identify those who are under treatment or have taken psychotropic medications for a mental health condition. The pre- deployment health assessment form, the DD 2795, includes a question asking servicemembers whether they have sought mental health counseling or mental health care in the past year. In a July 2007 report to Congress, DOD cited the pre-deployment health assessment in describing its implementation of the 2007 NDAA requirements for pre-deployment screening. The report also identified a medical record review as a component of the pre-deployment health assessment process to help meet these mental health screening requirements. According to a senior DOD official, because servicemembers may be reluctant to disclose symptoms or treatment that may prevent them from deploying, the provider review of the medical record should be done to verify the self-reported information on the DD 2795. While medical records are an important part in making deployment determinations, DOD's deployment policies are not consistent with respect to their review. DOD's November 2006 policy on minimum mental health standards for deployment states that the pre-deployment health assessment includes a medical record review as part of ensuring the standards are utilized, and DOD officials confirmed that the policy requires such a review. However, DOD's August 2006 Instruction on Deployment Health, which implements policies and prescribes procedures for deployment health activities, is silent on whether a review of medical records is required as part of the pre-deployment health assessment. This Instruction states only that the pre-deployment health assessment form, DD 2795, must be completed by each deploying servicemember and the responses reviewed by a health care provider. A health care provider following DOD's Instruction may not conduct the medical record review during the pre-deployment health assessment required by DOD's policy on minimum mental health standards for deployment. Because of DOD's inconsistent policies, providers determining if OEF and OIF servicemembers meet DOD's minimum mental health deployment standards may not have complete medical information. During our site visits, we found that practices varied with respect to pre- deployment mental health screening, and medical records were not routinely reviewed at the time of the pre-deployment health assessment by the provider reviewing the DD 2795. While a review of medical records can serve to validate information reported by servicemembers, the health care providers we spoke with during our site visits were unaware that it was required as part of the pre-deployment health assessment. At all three installations we visited, servicemembers completed the DD 2795 form. At two of the three installations all servicemembers were interviewed by a health care provider to review their responses on the DD 2795 and discuss any additional health concerns. At the third installation, providers interviewed servicemembers if they indicated any concerns on the DD 2795. While the deployment health record was available to providers at all three installations, the medical record was routinely reviewed by the provider at only one of the three installations during the pre-deployment health assessment. At the other two installations, providers told us the record was reviewed only if servicemembers identified concerns on the DD 2795 or during the interview. Health care providers at Fort Campbell and Camp Lejeune manually track whether servicemembers who receive mental heath referrals from the PDHA make or keep appointments for evaluations with mental health providers. DOD does not require that individual referrals from the PDHA be tracked; however, DOD has a quality assurance program that monitors the PDHA, including follow-up encounters. In addition, because Guard and Reserve servicemembers generally receive civilian care, which they do not have to disclose, and because servicemembers may be reluctant to disclose mental health encounters due to stigma concerns, Guard and Reserve referrals are difficult to track. While DOD health care providers generally make PDHA referrals using one of two DOD information technology systems, AHLTA or CHCS I, health care providers at military installations we visited have developed different manual systems to track whether referred servicemembers made or kept appointments with mental health providers. DOD does not require these referrals to be tracked. However, a Fort Campbell health care provider we spoke with said that the health care providers who make referrals from the PDHA may not have an ongoing relationship with the referred servicemembers and, therefore, manual systems have been created to track whether referred servicemembers completed their evaluations. According to installation health care providers, manually tracking referrals is labor-intensive and time-consuming, and necessary to ensure that referred servicemembers receive their evaluations. We found that health care providers at Fort Campbell and Camp Lejeune have developed manual tracking systems to ensure that servicemembers receive evaluations. At Fort Campbell, the installation's readiness processing manager, who is the health care provider who tracks PDHA referrals, created an Access database for this purpose. The manager checks CHCS I, the information technology system Fort Campbell healthcare providers use to make PDHA referrals, daily to obtain their status. Then, this individual manually enters the status of each referral into the Access database, which allows all PDHA referrals and their status to be viewed in one list. Servicemembers who fail to make or keep their appointments are contacted, and if a servicemember does not respond after two follow-up attempts, the unit commander is informed. At Camp Lejeune, health care providers track division servicemembers' PDHA mental health referrals to the division psychiatrist using hard-copy logbooks. Because the division psychiatrist's clinic does not have access to AHLTA or CHCS I, health care providers make referrals by phoning the division psychiatrist and follow-up with the psychiatrist every two weeks to track whether servicemembers kept their appointments. Camp Lejeune officials told us that, unlike the division, the air wing's and logistics group's PDHA mental health referral tracking is facilitated by having greater access to AHLTA, which allows providers to check the status of appointments scheduled at the MTF. We found that mental health PDHA referrals for Marine Reserve members who complete the PDHA at Camp Lejeune are tracked manually. Officials from the Marine Reserves' Deployment Support Group (DSG) at Camp Lejeune inform the home units of Reserve member referrals and track their status. According to a Fort Campbell health care provider, Army Reserve members are not processed through Fort Campbell following deployment and, therefore, do not complete the PDHA at this installation. According to Guard and Reserve officials, home units rely largely on servicemembers to disclose whether they receive care from a mental health provider. Tracking PDHA mental health referrals is challenging for the Guard and Reserves because their members generally receive civilian care. Military health care providers would be unaware of civilian care unless disclosed by the Guard and Reserve member. In addition, Military OneSource, which is operated by a vendor contracted by DOD, guarantees that it will not release the identity of servicemembers who receive counseling unless servicemembers are at risk of harming themselves or others. As a result, PDHA mental health referral tracking is challenging for Guard and Reserve units due to their reliance on servicemembers to disclose mental health encounters with civilian providers, which Guard and Reserve officials told us they may be reluctant to do because of stigma concerns. While DOD policy allows several types of health care providers to conduct the PDHA, health care providers at Fort Campbell and Camp Lejeune told us that health care providers actually conducting the assessments are generally physicians, physician assistants, or, in the case of the Marine Corps, IDCs. According to installation health care providers, most of the physicians conducting the assessments have specialties in primary care, which includes the specialties of family practice and internal medicine. The health care providers conducting these health assessments receive varying levels of training in mental health issues based on provider type during their basic medical education. For example, physician assistants complete a rotation in psychiatry and may elect an additional psychiatry rotation, while IDCs receive training in psychiatric disorders as part of a unit on medical diagnosis and treatment that covers several types of medical conditions. Physicians receive mental health training in medical school. DOD provides several types of guidance for health care providers to help them conduct mental health assessments and decide whether to make referrals for further evaluation. DOD maintains a Web site that contains CPGs and other guidance and training that can be accessed by health care providers conducting the assessments. For example, DOD provides a set of reference materials on the Web site that contains information on and steps to assess servicemembers for PTSD and major depressive disorder. According to DOD, hard copy versions of these reference materials were distributed to MTFs beginning in July 2004, and MTFs may order additional copies. We found that health care providers conducting the PDHA had varying familiarity with the CPGs and levels of comfort in conducting assessments. For example, at Camp Lejeune, some of the physicians and IDCs we interviewed about DOD's guidance were not familiar with the CPGs for depression and PTSD. Some physicians and IDCs cited resource constraints, in the form of limited access to computers and internet connectivity, as barriers to accessing these CPGs posted on the Web site. At Fort Campbell, a brigade surgeon we spoke to who supervises providers conducting the PDHA said that these providers have varying knowledge of the CPGs. He stated that the guidance is distributed to email accounts that some health care providers may not check regularly. In addition, health care providers varied in their level of comfort in making mental health assessments. At Camp Lejeune, eight of the 15 physicians and IDCs we interviewed were comfortable making mental health assessments, while the remaining seven were less comfortable making these assessments and expressed interest in receiving more training on making mental health assessments. At Fort Campbell, the division mental health providers we spoke with stated that while physician assistants, for example, could identify a servicemember with mental health concerns, these providers were generally not comfortable in assessing servicemembers for mental health issues. DOD and the military services have implemented and are in the process of implementing several new mental health training initiatives. DOD created the Center of Excellence for Psychological Health and Traumatic Brain Injury in November 2007 that will focus on research, education, and training related to mental health. According to DOD, the Center will develop and distribute a core mental health curriculum for health care providers, as well as implement policies to direct training in the curriculum across the services. DOD plans to begin training primary care providers in July 2008. The Army has created a program, RESPECT-MIL, that trains primary care providers in identifying and treating servicemembers with depression and PTSD. By the end of 2008, the Army plans to train providers at 15 installations. The Army also directed all servicemembers, including health care providers, to participate in a training program that includes information on PTSD by October 18, 2007. The training focused on the causes and physical and psychological effects of PTSD and provided information on how to seek subsequent treatment for this condition. As of January 31, 2008, 93 percent of Army servicemembers had received the training. The Army also requires commanders to include PTSD awareness and response training in pre- and post-deployment briefings. The Marine Corps has a training program for non-mental health providers, including those that conduct the PDHA, that includes training on PTSD. This training began in January 2008 and is scheduled to train 669 health care providers at 12 sites by August 2008. The Marine Corps also requires pre- and post-deployment briefings on identifying and managing combat stress for all Marine Corps servicemembers and unit leaders. In response to the 2007 NDAA, DOD added TBI screening questions to the PDHA in January 2008 and plans in July 2008 to begin screening all servicemembers prior to deployment. Prior to these TBI screening efforts required by DOD, several installations had already implemented efforts to screen servicemembers before or after their deployments. To help health care providers screen servicemembers for mild TBI and issue referrals, DOD has issued guidance and provided various forms of training. In response to the 2007 NDAA requirement for pre-and post-deployment screening for TBI, DOD has added TBI screening questions to the PDHA, and plans to require screening of all servicemembers beginning in July 2008 for mild TBI prior to deployment. These screening questions are similar to the screening questions on the PDHA. The questions are included in a cognitive assessment tool that will provide a baseline of cognitive function in areas such as memory and reaction time. In January 2008, DOD released a new version of the post-deployment health assessment form, the DD 2796, that contains screening questions for TBI (See appendix I for a copy of the new version of the DD 2796). The TBI screening questions added to the PDHA are designed to be completed by the servicemember in four series. The sequence of questions specifically assesses (a) events that may have increased the risk of a TBI, (b) immediate symptoms following the event, (c) new or worsening symptoms following the event, and (d) current symptoms. (See appendix I.) If there is a positive response to any question in the first series, the servicemember completes the second and third series; if there is a positive response to any question in the third series, the servicemember completes the fourth series about current symptoms. The DD 2796 directs the health care provider to refer the servicemember based on the servicemember's current symptoms. See figure 2 for a description of these screening questions. DOD is planning to require screening of all servicemembers for mild TBI prior to deployment using questions similar to those on the PDHA. This screening is planned to begin in July 2008 and these screening questions are included in a cognitive assessment, the Automated Neuropsychological Assessment Metrics (ANAM). The ANAM will provide a baseline assessment of cognitive function in areas such as memory and reaction time, which may be affected by a mild TBI. If a servicemember experiences an event in theater, the ANAM can be administered again and the differences in function assessed. Because the ANAM does not distinguish between impairments in cognitive function caused by events such as blasts and those caused by other factors such as fatigue, the ANAM needs to be used with screening questions to identify the event that may have caused a TBI. However, the ANAM can be used to identify changes in baseline cognitive function that may warrant further evaluation. According to an Army official, since August 2007 about 50,000 Army servicemembers have been assessed using the ANAM. Prior to DOD's plans to screen all servicemembers on the PDHA and prior to deployment, several installations had implemented, as early as 2000, initiatives for mild TBI screening to be used before or after units from those locations deployed. Generally, servicemembers participating in these initiatives are screened using a three-question screen developed by the DVBIC called the Brief Traumatic Brain Injury Screen (BTBIS). The BTBIS is designed to identify servicemembers who may have had a mild TBI, and includes questions about events and symptoms that are similar to those used on DOD's PDHA. The first of these initiatives began at Fort Bragg, North Carolina in 2000. Since then, Fort Carson, Colorado; Fort Irwin, California; Fort McCoy, Wisconsin and Camp Pendleton, California have initiated screening for mild TBI either pre-deployment, post- deployment, or both. A DVBIC official told us that these initiatives would probably be replaced by the DOD-wide screening. DOD issued guidance for health care providers on the identification of mild TBI, trained some health care providers on identifying mild TBI, and plans additional health care provider training initiatives. In October 2007 DOD released guidance on identifying mild TBI for providers screening, assessing, and treating servicemembers outside the combat theater. The guidance contains information to help health care providers conducting the PDHA, including follow-up questions that the provider can ask a servicemember based on the servicemember's responses to the TBI screening questions on the PDHA. The guidance contains structured series of questions that include certain "red flags," such as double vision or confusion, that suggest a need for referral for further evaluation for a possible mild TBI. The guidance recommends assessments and treatments for servicemembers with symptoms such as irritability and includes screening tools to help health care providers assess the severity of these symptoms. According to a DOD official, DOD also plans to provide the military services with guidance on using the new TBI screening questions on the PDHA. In addition to issuing guidance, DOD and the military services also trained health care providers on identifying possible mild TBI. In September 2007 DOD held a tri-service conference in which more than 800 health care providers were trained. According to DVBIC officials, DVBIC staff provide training through workshops for health care providers at its 14 sites and travel to other installations to train health care providers. In addition, DOD's planned Defense Center of Excellence for Psychological Health and Traumatic Brain Injury, which began initial operations on November 30, 2007, and is expected to be fully functional by October 2009, will develop a national collaborative network to advance and disseminate TBI knowledge, enhance clinical and management approaches, and facilitate services for those dealing with TBI, according to DOD. According to Army officials, the Army is also initiating several health care provider training efforts for the summer of 2008 designed to train primary care providers on mild TBI. According to these officials, primary care providers are generally uncomfortable with treating mild TBI, preferring instead to refer these cases to specialty care. The Marine Corps' training program for non-mental health care providers, including those conducting the PDHA, also includes material on diagnosing mild TBI. With respect to the ANAM, DVBIC officials told us that wherever this assessment tool is used, DVBIC officials and officials responsible for the implementation of the ANAM train health care providers in its use. DOD has taken positive steps to implement provisions of the 2007 NDAA related to screening servicemembers for TBI and mental health. For example, DOD has added mild TBI screening to its PDHA and will require screening prior to deployment. With respect to mental health, we found that health care providers' familiarity with DOD's CPGs and comfort in making mental health assessments varied. However, DOD and the military services have implemented or are implementing training initiatives, some of which are specifically aimed at the primary care providers who generally conduct the PDHA. Furthermore, the installations we visited had developed manual systems for tracking those servicemembers who were referred from the PDHA to ensure that they made or completed their appointments. Referral tracking is difficult for the Guard and Reserves because their servicemembers generally receive civilian care. DOD has taken steps to meet 2007 NDAA requirements related to mental health standards and screening, including issuing a policy on minimum mental health standards for deployment. A key component of DOD's efforts to meet these requirements is a review of medical records, and we agree that this should be done to verify information in a screening process that depends on self-reported information. Unfortunately, DOD's policies for reviewing medical records during the pre-deployment health assessment are inconsistent. During our site visits we found that health care providers were unaware a medical record review was required and that medical records were not always reviewed by providers conducting the pre-deployment health assessment. A health care provider following DOD's Instruction on Deployment Health, which is silent on whether medical record review is required during the pre-deployment health assessment, may not conduct the medical record review required by DOD's policy on minimum mental health standards for deployment. Until DOD resolves the inconsistency between its policies, its health care providers may not have complete mental health information when screening servicemembers prior to deployment. In order to address the inconsistency in DOD's policies related to the review of medical record information and to assure that health care providers have reviewed the medical record when screening servicemembers prior to deployment, we recommend that the Secretary of Defense direct the Under Secretary of Defense for Personnel and Readiness to revise DOD's Instruction on Deployment Health to require a review of medical records as part of the pre-deployment health assessment. In commenting on a draft of this report, DOD stated that our concerns regarding provider review of medical records are well-taken and that an assessment is only complete when it includes a medical record review. While DOD concurred with our recommendation and said that it will update its Instruction on Deployment Health to require a medical record review at the time of the pre-deployment health assessment, DOD is limiting this medical record review requirement to servicemembers who have a significant change in health status since their most recent periodic health assessment. According to a senior DOD health official, it is anticipated that the updated Instruction will be published in one year. However, DOD does not explain how providers will be able to identify the subset of servicemembers who have had a significant change in health status. As a result, its response does not fully eliminate the inconsistency between its policy and current Instruction. To fully eliminate the inconsistency, as we recommended, DOD should require a medical record review for all servicemembers as part of the pre-deployment health assessment in its updated Instruction. We also encourage DOD to update its Instruction as quickly as possible so that providers have the complete information that we and DOD agree they need to make pre-deployment decisions. DOD also provided technical comments, which we incorporated as appropriate. We are sending copies of this report to 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 and addressees. 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 have any questions about this report, please contact me at (202) 512-7114 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 who made major contributions to this report are listed in appendix III. In addition to the contact named above, Marcia Mann, Assistant Director; Eric Anderson; Krister Friday; Lori Fritz; Adrienne Griffin; Amanda Pusey; and Jessica Cobert Smith made key contributions to this report. VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain. GAO-08-276. Washington, D.C.: February 8, 2008. VA and DOD Health Care: Administration of DOD's Post-Deployment Health Reassessment to National Guard and Reserve Servicemembers and VA's Interaction with DOD. GAO-08-181R. Washington, D.C.: January 25, 2008. Defense Health Care: Comprehensive Oversight Framework Needed to Help Ensure Effective Implementation of a Deployment Health Quality Assurance Program. GAO-07-831. Washington, D.C.: June 22, 2007. Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its Providers Use to Make Mental Health Evaluation Referrals for Servicemembers. GAO-06-397. Washington, D.C.: May 11, 2006. Military Personnel: Top Management Attention Is Needed to Address Long-standing Problems with Determining Medical and Physical Fitness of the Reserve Force. GAO-06-105. Washington, D.C.: October 27, 2005. Defense Health Care: Occupational and Environmental Health Surveillance Conducted during Deployments Needs Improvement. GAO-05-903T. Washington, D.C.: July 19, 2005. Defense Health Care: Improvements Needed in Occupational and Environmental Health Surveillance during Deployments to Address Immediate and Long-term Health Issues. GAO-05-632. Washington, D.C.: July 14, 2005. VA Health Care: VA Should Expedite the Implementation of Recommendations Needed to Improve Post-Traumatic Stress Disorder Services. GAO-05-287. Washington, D.C.: February 14, 2005. Defense Health Care: Force Health Protection and Surveillance Policy Compliance Was Mixed, but Appears Better for Recent Deployments. GAO-05-120. Washington, D.C.: November 12, 2004. VA and Defense Health Care: More Information Needed to Determine If VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder Services. GAO-04-1069. Washington, D.C.: September 20, 2004.

Summary:
The John Warner National Defense Authorization Act for Fiscal Year 2007 included provisions regarding mental health concerns and traumatic brain injury (TBI). GAO addressed these issues as required by the Act. In this report GAO discusses (1) DOD efforts to implement pre-deployment mental health screening; (2) how post-deployment mental health referrals are tracked; and (3) screening requirements for mild TBI. GAO selected the Army, Marine Corps, and Army National Guard for the review. GAO reviewed documents and interviewed DOD officials and conducted site visits to three military installations where the pre-deployment health assessment was being conducted. DOD has taken positive steps to implement mental health standards for deployment and pre-deployment mental health screening. However, DOD's policies for providers to review medical records are inconsistent. DOD issued minimum mental health standards that servicemembers must meet in order to be deployed to a combat theater and identified the pre-deployment health assessment as a mechanism for ensuring their use in making deployment decisions. DOD's November 2006 policy implementing these deployment standards requires a review of servicemember medical records during the pre-deployment health assessment. However, DOD's August 2006 Instruction on Deployment Health, which implements policy and prescribes procedures for conducting pre-deployment health assessments, is silent on whether such a review is required. Because of this inconsistency, providers determining if Operation Enduring Freedom and Operation Iraqi Freedom servicemembers meet DOD's mental health deployment standards may not have complete medical information. Health care providers at the installations GAO visited where the post-deployment health assessment (PDHA) is conducted manually track whether servicemembers who receive mental health referrals from the PDHA make or complete appointments with mental heath providers. Because health care providers conducting the PDHA and making referrals from the PDHA may not have an ongoing relationship with referred servicemembers, health care providers responsible for tracking referrals at these installations have developed manual systems to track servicemembers to ensure that they made or kept their appointments for evaluations. Tracking is more challenging for Guard and Reserve units because their servicemembers generally receive civilian care. Guard and Reserve units do not know if servicemembers used civilian care to complete their PDHA referrals unless disclosed by the servicemembers, which they may be reluctant to do because of stigma concerns. DOD is addressing the TBI requirement through implementing screening for mild TBI in its PDHA and prior to deployment. DOD has also provided guidance and training for health care providers. DOD in January 2008 added TBI screening to the PDHA, and plans to require screening of all servicemembers for mild TBI prior to deployment beginning in July 2008. The TBI screening questions on the PDHA assess the servicemember's exposure to events that may have increased the risk of a TBI and the servicemember's symptoms. The TBI screening questions to be used prior to deployment are similar to those on the PDHA. Prior to DOD's screening efforts, several installations had been screening servicemembers for mild TBI before or after deployment. An official from the Defense and Veterans Brain Injury Center told GAO that these initiatives would probably be replaced by the DOD-wide screening.