PTSD can develop following exposure to life-threatening events, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. PTSD is the most prevalent mental disorder arising from combat. 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. If the symptoms of acute stress reaction or combat stress continue for more than 1 month, PTSD is diagnosed. PTSD services are provided in VA medical facilities and VA community settings. VA medical facilities offer PTSD services as well as other services, which range from complex specialty care, such as cardiac or spinal cord injury, to primary care. VA’s community settings include more than 800 community-based outpatient clinics and 206 Vet Centers. Community- based outpatient clinics are an extension of VA’s medical facilities and mainly provide primary care services. Vet Centers offer PTSD and family counseling, employment services, and a range of social services to assist veterans in readjusting from wartime military service to civilian life. Vet Centers also function as community points of access for many returning veterans, providing them with information and referrals to VA medical facilities. Vet Centers were established as entities separate from VA medical facilities to serve Vietnam veterans, who were reluctant to access health care provided in a federal building. As a result, Vet Centers are not located on the campuses of VA medical facilities. VA has specialized PTSD programs that are staffed by clinicians who have concentrated their clinical work in the area of PTSD treatment. VA specialized PTSD programs are located in 97 VA medical facilities and provide services on an inpatient and outpatient basis. VA PTSD services include individual counseling, support groups, and drug therapy and can be provided in non-specialized clinics, such as general mental health clinics. Veterans who served in any conflict after November 11, 1998 are eligible for VA health care services for any illness, including PTSD services, for 2 years from the date of separation from military service, even if the condition is not determined to be attributable to military service. This 2-year eligibility includes those Reserve and National Guard members who have left active duty and returned to their units. After 2 years, these veterans will be subject to the same eligibility rules as other veterans, who generally have to prove that a medical problem is connected to their military service or have relatively low incomes. In July 2004, VA reported that so far 32,684 or 15 percent of veterans who have returned from service in Iraq or Afghanistan, including Reserve and National Guard members, have accessed VA for various health care needs. DOD and VA have formed a Seamless Transition Task Force with the goal of meeting the needs of servicemembers returning from Iraq and Afghanistan who will eventually become veterans and may seek health care from VA. To achieve this goal, DOD and VA plan to improve the sharing of information, including individual health information, between the two departments in order to enhance VA’s outreach efforts to identify and serve returning servicemembers, including Reserve and National Guard members, in need of VA health care services. Since April 2003, VA requires that every returning servicemember from the Iraq and Afghanistan conflicts who needs health care services receive priority consideration for VA health care appointments. DOD uses two approaches to identify servicemembers who may be at risk of developing PTSD: the combat stress control program and the post- deployment health assessment questionnaire. DOD’s combat stress control program identifies servicemembers at risk for PTSD by training all servicemembers to identify the early onset of combat stress, which if left untreated, could lead to PTSD. DOD uses the post-deployment health assessment questionnaire to screen servicemembers for physical ailments and mental health issues commonly associated with deployments, including PTSD. The questionnaire contains four screening questions that were developed jointly by DOD and VA mental health experts to identify servicemembers at risk for PTSD. DOD’s combat stress control program identifies servicemembers at risk for PTSD by training all servicemembers to identify the early onset of combat stress symptoms, which if left untreated, could lead to PTSD. The program is based on the principle of promptly identifying servicemembers with symptoms of combat stress in a combat theater, with the goal of treating and returning them to duty. This principle is consistent with the views of PTSD experts, who believe that early identification and treatment of combat stress symptoms may reduce the risk of PTSD. To assist servicemembers in the combat theater, teams of DOD mental health professionals travel to units to reinforce the servicemembers’ knowledge of combat stress symptoms and to help identify those who may be at risk for combat stress or PTSD. The teams may include psychiatrists, psychologists, social workers, nurses, mental health technicians, and chaplains. DOD requires that the effectiveness of the combat stress control program be monitored on an annual basis. DOD generally uses the post-deployment health assessment questionnaire, DD 2796, to identify servicemembers at risk for PTSD following deployment outside of the United States. (See app. II for a copy of the DD 2796.) DOD requires certain servicemembers deployed to locations outside of the United States to complete a DD 2796 within 30 days before leaving a deployment location or within 5 days after returning to the United States.This applies to all servicemembers returning from a combat theater, including Reserve and National Guard members. The DD 2796 is a questionnaire used to determine the presence of any physical ailments and mental health issues commonly associated with deployments, any special medications taken during deployment, and possible environmental or occupational exposures. The DD 2796 includes the following four screening questions that VA and DOD mental health experts developed to identify servicemembers at risk for PTSD: 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? Once completed, the DD 2796 must be initially reviewed by a DOD health care provider, which could range from a physician to a medic or corpsman. Figure 1 illustrates DOD’s process for completion and review of the DD 2796. The form is then reviewed, completed, and signed by a health care provider, who can be a physician, physician assistant, nurse practitioner, or an independent duty medical technician or corpsman. This health care provider reviews the completed DD 2796 to identify any “yes” responses to the screening questions—including questions related to PTSD—that may indicate a need for further medical evaluation. The review is to take place in a face-to-face interview with the servicemember and be conducted either on an individual basis, as we observed at the Army’s Fort Lewis in Washington, or in a group setting, as we found at the Marine Corps’ Camp Lejeune in North Carolina. If a servicemember answers “yes” to a PTSD question, the health care provider is instructed to gather additional information from the servicemember and use clinical judgment to determine if the servicemember should be referred for further medical evaluation to a physician, physician’s assistant, nurse, or an independent duty medical technician.To document completion of the DD 2796, DOD requires that the questionnaire be placed in the servicemember’s permanent medical record and a copy sent to the Army Medical Surveillance Activity, which maintains a database of all servicemembers’ completed health assessment questionnaires. The National Defense Authorization Act for Fiscal Year 1998 required DOD to establish a quality assurance program to ensure, among other things, that post-deployment mental health assessments are completed for servicemembers who are deployed outside of the United States. Completion of the DD 2796 is tracked as part of this quality assurance program. DOD delegated responsibility for developing procedures for the required quality assurance program to each of its uniform services. The uniform services have given unit commanders the responsibility to ensure completion of the DD 2796 by all servicemembers under their command. To ensure the DD 2796 is completed, one DOD official we interviewed told us that servicemembers would not be granted leave to go home until the DD 2796 was completed. Another official told us that Reserve and National Guard members would not be given their active duty discharge paperwork until the DD 2796 was completed. VA does not have all the information it needs to determine whether it can meet an increase in demand for VA PTSD services. VA does not have a count of the total number of veterans currently receiving PTSD services at its medical facilities and Vet Centers. Without this information, VA cannot estimate the number of veterans its medical facilities and Vet Centers could treat for PTSD. VA could use demographic information it receives from DOD to broadly estimate the number of servicemembers who may access VA health care, including PTSD services. By assuming that 15 percent or more of returning servicemembers will develop PTSD, VA could use the demographic information to broadly estimate demand for PTSD services. However, predicting which veterans will seek VA care and at which facilities is inherently uncertain, particularly given that the symptoms of PTSD may not appear for years. VA does not have a count of the total number of veterans currently receiving PTSD services at its medical facilities and Vet Centers. Without this information, VA cannot estimate the number of additional veterans its facilities could treat for PTSD.