DOD and VHA provide health care, including medications for psychiatric, pain, and sleep conditions, to servicemembers and veterans through their respective health care systems. DOD provides health care to active duty servicemembers; Reserve and National Guard members on active duty; and other beneficiaries, such as family members and retired servicemembers, through TRICARE, its health care program. TRICARE beneficiaries can obtain comprehensive health care services—including outpatient and inpatient care, mental health care, and prescriptions for medications—through a direct-care system of MTFs operated by the Departments of the Army, Navy, and Air Force, or through a purchased- care system of civilian health care providers. Prescription medications can be obtained through MTF pharmacies, retail pharmacies, and the TRICARE mail-order pharmacy. DOD is required by law to make all clinically appropriate medications available to servicemembers, and, with the exception of certain classes of medications, such as weight-loss medications, DOD makes all Food and Drug Administration-approved prescription medications available. DOD’s formulary process is administered by DOD’s Pharmacy and Therapeutics Committee, and the formulary includes a list of medications that all MTFs must provide and medications that an MTF may elect to provide on the basis of the types of specialized services that the MTF offers (such as cancer medications). DOD classifies certain medications as “nonformulary” on the basis of its evaluation of their cost and clinical effectiveness, and DOD’s nonformulary classification applies to all MTFs and DOD’s purchased- care system. Nonformulary medications are available to beneficiaries at a higher cost, unless the provider can establish medical necessity. Veterans who served in active military duty, and were discharged or released under conditions other than dishonorable are generally eligible for VHA health care. In general, veterans must enroll in VHA health care to receive VHA’s medical benefits—a set of services that includes a full range of hospital and outpatient services, mental health care, and prescription medications. VHA provides health care services at various types of facilities, including VAMCs and community-based outpatient clinics. Veterans may obtain prescription and over-the-counter medications through VAMC or community-based outpatient clinic pharmacies, VHA’s mail-order pharmacy, or through certain non-VHA pharmacies. VA’s formulary provides access to medications for eligible beneficiaries. VHA manages VA’s formulary and makes decisions about whether to add medications to the formulary on the basis of clinical and cost effectiveness and, like DOD, provides access to nonformulary medications when providers establish medical necessity. Because VHA only fills prescriptions written by VHA providers or providers VHA has authorized its patients to see, VHA generally has direct control over the medications that are prescribed to its patient populations. PTSD is a trauma and stressor-related disorder that can occur after a person is exposed to a traumatic or stressful event such as a death or serious injury; its onset may be delayed. As defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, to be diagnosed with PTSD, patients must have experienced four types of symptoms that continue for more than 1 month after the event: persistently re-experiencing the event such as through flashbacks persistently avoiding trauma-related stimuli such as places or situations that are reminders of the event; negative changes in cognitions and mood that began or worsened after the event, such as persistent negative beliefs about oneself or the world; and changes in arousal and reactivity that may include aggressive or self-destructive behavior and insomnia. The symptoms cause significant distress or impairment—for example, in the patient’s social relationships and work life—and the duration of symptoms varies, according to the Diagnostic and Statistical Manual of Mental Disorders. That is, some patients with PTSD have symptoms for less than 3 months while others may experience symptoms for longer than a year and sometimes for many years. In addition to providing medication therapy, DOD and VHA provide psychotherapy, which has been shown to be effective in the treatment of PTSD in clinical research studies, as well as other types of therapies. Mild TBI (also known as a concussion) is caused by a blow or jolt to the head that temporarily disrupts the normal function of the brain. The diagnosis is based on several factors including that the patient has an alternation of consciousness that may last from a moment up to 24 hours or has a loss of memory for the events immediately before or after the injury that lasts for a day or less. There are many causes of this condition—such as blasts and car accidents—and, while not all patients with mild TBI have symptoms, those that do typically experience symptoms immediately following the event. Headache is the most common symptom, and other common symptoms include dizziness, fatigue, irritability, and insomnia. A very small proportion of patients with mild TBI have symptoms that persist beyond 6 months, although symptoms may last longer after repeated mild TBIs. In addition to providing medication therapy for certain symptoms, DOD and VHA provide other services for the treatment of mild TBI symptoms which may include physical and occupational therapy and neuropsychological care. Servicemembers that are diagnosed with mild TBI as a result of combat also have a higher risk of experiencing PTSD. Additionally, servicemembers with either PTSD or mild TBI often experience other co- occurring conditions, such as chronic pain, which may be related to their combat-related injuries. As we previously have reported, the length of time that servicemembers take to transition their health care from DOD to VHA or another health care system varies. Some servicemembers may not transition their care to VHA at all and instead seek care from other health care systems and providers. Of those transitioning to VHA, some servicemembers separate from the military and have their first appointment at VHA the following week. Others may take more time to transition to VHA, waiting months or years before scheduling their first appointment. Effective transitions of care, including for servicemembers transitioning from DOD to VHA, should include education and counseling about medication adherence, medication lists at discharge, and a plan for how to get medications during transitions, according to the National Transitions of Care Coalition—a nonprofit organization that produces tools and resources to assist with such transitions. As we previously have reported, DOD and VHA have established several programs to assist servicemembers, such as those with PTSD or mild TBI, with care transitions, including help with medication management. For example, Army nurse case managers have procedures both to assess if servicemembers receiving care at MTFs have sufficient supplies of medications until their initial VAMC appointment and to share servicemembers’ medication lists with VA liaisons. VA liaisons, who are nurses or social workers stationed at MTFs, in turn, have procedures to ensure that VHA providers receive servicemembers’ medication lists and that transitioning servicemembers have adequate supplies of medications until their initial appointments. Another example is DOD’s inTransition Program. The inTransition Program is a confidential personal coaching program that helps servicemembers with mental health conditions as they move between health care systems or providers. The inTransition Program coaches are social workers who encourage transitioning servicemembers with mental health needs to continue their medications. The continuation of medication therapy, that is, prescribing the same medications when a servicemember separates from DOD and transitions to other health care systems including VHA, is another important element of effective care transitions. Continuing clinically appropriate medications during this transition is especially important for servicemembers and veterans with mental health or pain conditions, such as PTSD, whose symptoms may have been stabilized as a result of medications that DOD providers have prescribed. The treatment of symptoms with medications can enable patients with mental health conditions to return to near-normal functioning and can enhance the effectiveness of psychotherapy. DOD and VHA have jointly developed clinical practice guidelines related to PTSD and mild TBI, which include recommendations for the treatment of symptoms among servicemembers and veterans with these conditions. Each guideline includes a discussion of, and recommendations on, management of care for servicemembers and veterans with these conditions, such as screening and diagnosis, types of treatment interventions, and assessing treatment responses. The PTSD clinical practice guideline includes evidence-based recommendations to assist DOD and VHA clinicians in their decision making about which medications to prescribe to treat the symptoms of PTSD. The mild TBI clinical practice guideline also includes recommendations related to medications for treating the symptoms of the condition; these recommendations are based on expert opinions, rather than evidence- based research, because of the lack of published studies on mild TBI medication treatments. The guidelines state that the recommendations should not prevent providers from using their own clinical expertise in the care of an individual patient and should never replace sound clinical judgment. In addition to providing guidance for clinical decision making, the guidelines are intended to help improve the quality and continuum of care and the health outcomes for servicemembers and veterans with PTSD and mild TBI. The PTSD guideline recommends that patients with PTSD be offered certain types of antidepressants and discourages the use of benzodiazepines, a type of sedative. According to the guideline, the use of selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors (types of antidepressants) are strongly recommended because there is good evidence that they are effective in reducing the core symptoms of PTSD and are generally well tolerated by servicemembers and veterans with PTSD. In contrast, the guideline states that the use of benzodiazepines should be discouraged because of their lack of effectiveness in treating PTSD and because the risks may outweigh potential benefits.