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.