Post-Traumatic Stress Disorder
DOD Needs to Identify the Factors Its Providers Use to Make Mental Health Evaluation Referrals for Servicemembers Gao ID: GAO-06-397 May 11, 2006Many 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.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-06-397, Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its Providers Use to Make Mental Health Evaluation Referrals for Servicemembers
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
May 2006:
Post-Traumatic Stress Disorder:
DOD Needs to Identify the Factors Its Providers Use to Make Mental
Health Evaluation Referrals for Servicemembers:
GAO-06-397:
GAO Highlights:
Highlights of GAO-06-397, a report to congressional committees.
Why GAO Did This Study:
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.
What GAO Found:
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.
What GAO Recommends:
GAO recommends that DOD identify factors that its providers use in
issuing referrals for further mental health evaluations. DOD concurred
with GAO‘s recommendation, but disagreed with GAO‘s finding that DOD
has not provided reasonable assurance that servicemembers who need
referrals for further mental health evaluations receive them. DOD
identified factors that may affect referrals, but did not provide data
on how its providers apply these factors. VA concurred with the facts
related to VA in the report.
[Hyperlink, www.gao.gov/cgi-bin/getrpt?GAO-06-397].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Cynthia A. Bascetta at
(202) 512-7101 or bascettac@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
For Veterans, DOD Offers a Benefit for a Specific Period of Time and VA
Offers Various Health Care Services:
Based on DOD Data, About 5 Percent of OEF/OIF Servicemembers May Have
Been at Risk for Developing PTSD and Over 20 Percent Received Referrals:
DOD Cannot Provide Reasonable Assurance That OEF/OIF Servicemembers Who
Need Mental Health Referrals Receive Them:
Conclusions:
Recommendation for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Defense:
Appendix III: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: TRICARE Beneficiary Costs Through TAMP:
Table 2: VA Specialized Outpatient and Inpatient PTSD Treatment
Programs:
Figures:
Figure 1: Portion of the DD 2796 Used by DOD Health Care Providers to
Indicate a Referral for a Further Mental Health or Combat/Operational
Stress Reaction Evaluation Is Needed:
Figure 2: OEF/OIF Servicemembers Who May Have Been at Risk for
Developing PTSD, by Military Service Branch:
Figure 3: Referral Rates for Mental Health or Combat/Operational Stress
Reaction Evaluation for OEF/OIF Servicemembers Who May Have Been at
Risk for Developing PTSD, by Military Service Branch:
Abbreviations:
AMSA: Army Medical Surveillance Activity:
CHCBP: Continued Health Care Benefit Program:
DMDC: Defense Manpower Data Center:
DOD: Department of Defense:
NDAA: National Defense Authorization Act for Fiscal Year 2005:
OEF: Operation Enduring Freedom:
OIF: Operation Iraqi Freedom:
PTSD: post-traumatic stress disorder:
TAMP: Transitional Assistance Management Program:
TRS: TRICARE Reserve Select:
VA: Department of Veterans Affairs:
United States Government Accountability Office:
Washington, DC 20548:
May 11, 2006:
Congressional Committees:
Servicemembers returning from the military conflicts in Afghanistan and
Iraq--Operation Enduring Freedom (OEF) and Operation Iraqi Freedom
(OIF),[Footnote 1] respectively--have engaged in intense and prolonged
combat, which research has shown to be strongly associated with the
risk for developing PTSD.[Footnote 2] PTSD can occur after experiencing
or witnessing a life-threatening event and is the most prevalent mental
health disorder resulting from combat. Mental health experts state that
early identification and treatment of symptoms through education, peer
and family support, therapy, or medications may lessen the severity of
the condition and improve the overall quality of life for those with
PTSD.
The Department of Defense (DOD) uses a questionnaire to screen OEF/OIF
servicemembers after their deployment outside of the United States has
ended.[Footnote 3] The questionnaire assesses servicemembers' physical
and mental health and includes four questions that are used to identify
those who may be at risk for developing PTSD. In conjunction with
completion of the questionnaire, each OEF/OIF servicemember is
interviewed by a DOD health care provider who reviews the completed
questionnaire and discusses with the servicemember any deployment-
related health concerns, including mental health concerns. From among
those who may be at risk for PTSD or other mental health conditions,
these DOD health care providers then determine which servicemembers
need referrals for a further mental health evaluation. Providers use a
section of the post-deployment screening questionnaire to indicate when
a servicemember needs a referral.[Footnote 4]
OEF/OIF servicemembers can obtain mental health evaluations, as well as
any necessary treatment for PTSD, while they are servicemembers--that
is, on active duty--or when they transition to veteran status after
being discharged or released from active duty.[Footnote 5] DOD provides
mental health evaluations and treatment for PTSD to servicemembers,
including OEF/OIF servicemembers, and the department also provides
these mental health benefits for OEF/OIF veterans through an extended
health care benefit created for this population. The Department of
Veterans Affairs (VA) also provides mental health benefits to OEF/OIF
veterans as part of health care services that it offers to these and
other veterans. In this report, we use the term OEF/OIF servicemembers
when we refer to those returning from the OEF/OIF conflicts who are
screened for PTSD and may receive referrals during active duty. We use
the term OEF/OIF veterans when we refer to those returning from the
OEF/OIF conflicts who, after being discharged or released from active
duty, are eligible for DOD and VA mental health benefits and could
access the departments' services.
The Ronald W. Reagan National Defense Authorization Act for Fiscal Year
2005 (NDAA)[Footnote 6] directed that we describe the mental health
benefits available for OEF/OIF veterans. NDAA further directed that we
examine the process DOD uses to refer OEF/OIF servicemembers who need
further mental health evaluations. In this report, we (1) describe
DOD's extended health care benefit for OEF/OIF veterans and VA's health
care services for OEF/OIF veterans; (2) analyze DOD data 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; and (3) examine whether DOD can
provide reasonable assurance that OEF/OIF servicemembers who need
further mental health evaluations receive referrals for these
evaluations.
To describe DOD's extended health care benefit and VA's health care
services for OEF/OIF veterans, we reviewed DOD policies and the
educational materials DOD provides to individuals on its health
insurance benefits, including information on the length of coverage of
these benefits. We also interviewed DOD officials and the military
service branches about these benefits. In addition, we reviewed VA's
policies, directives, and educational information on its health care
services, including the mental health services that VA has available
for OEF/OIF veterans. We reviewed the types of mental health services
available through VA's health care system for OEF/OIF veterans. We also
interviewed VA headquarters officials about these services.
To determine the number of OEF/OIF servicemembers who may be at risk
for developing PTSD and the number of these servicemembers referred for
further mental health evaluations, we analyzed DOD computerized data.
We obtained from DOD a list of OEF/OIF servicemembers who (1) were
deployed in support of OEF/OIF from October 1, 2001, through September
30, 2004; (2) had since been discharged or released from active
duty;[Footnote 7] (3) completed DOD's post-deployment screening
questionnaire; and (4) had the record of their completed questionnaire
available in a DOD computerized database. From this list, we identified
178,664 OEF/OIF servicemembers who answered the four PTSD screening
questions on DOD's post-deployment screening questionnaire, the DD
2796.[Footnote 8] To determine the number of OEF/OIF servicemembers who
may have been at risk for developing PTSD, we reviewed a clinical
practice guideline for PTSD developed jointly by VA and DOD, which
indicates that servicemembers who provide three or four positive
responses to the four PTSD screening questions may be at risk for
developing PTSD.[Footnote 9] We also 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.[Footnote 10] To determine the number of OEF/OIF
servicemembers who received referrals from a DOD health care provider,
we used information from the post-deployment questionnaires of the
178,664 OEF/OIF servicemembers in our review. The questionnaires
indicate whether a DOD health care provider issued a referral for a
mental health or combat/operational stress reaction evaluation. We
determined that DOD's data were sufficiently reliable for the purposes
of the report.
To examine whether DOD can provide reasonable assurance that OEF/OIF
servicemembers who need further mental health evaluations receive
referrals, we reviewed DOD's policies and guidance, including guidance
for DOD health care providers who use the DD 2796. We reviewed DOD's
quality assurance program and spoke to a researcher about a DOD study
on PTSD referrals to examine the extent to which DOD studies its
providers' decisions to issue referrals. We interviewed DOD officials,
including mental health clinicians involved with the DD 2796 and asked
them about DOD's criteria for issuing referrals to those who may be at
risk for developing PTSD.
NDAA also directed us to determine the number of OEF/OIF veterans who,
because of their DOD provider-issued 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.
For a complete discussion of our scope and methodology, see appendix I.
We conducted our work from December 2004 through April 2006 in
accordance with generally accepted government auditing standards.
Results in Brief:
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. 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, 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's health
benefits include health care services, as well as specialized PTSD
services. These specialized PTSD services are delivered by clinicians
who have concentrated their clinical work in the area of PTSD
treatment. These clinicians work as a team to coordinate veterans'
treatments and offer expertise in a variety of disciplines, such as
psychiatry, psychology, social work, readjustment counseling, and
nursing. VA offers its health care services to OEF/OIF veterans at no
cost for 2 years following discharge or release from active duty. After
their 2-year benefit expires, OEF/OIF veterans may continue to receive
VA care under VA's eligibility rules but may be subject to copayments.
Using data provided by DOD from the DD 2796 forms, 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 of these servicemembers
received a referral--that is, had a DD 2796 indicating that they needed
a further mental health or combat/operational stress reaction
evaluation. 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. Using these criteria, we found that of the 178,664 OEF/OIF
servicemembers in our study, DOD data indicate that 5 percent--9,145--
may have been at risk for developing PTSD. Of these, we found that
2,029 or 22 percent were referred by DOD health care providers for
further mental health or combat/operational stress reaction
evaluations. Moreover, across the military service branches, DOD health
care providers varied in the frequency with which they issued referrals
to OEF/OIF servicemembers with three or more positive responses to the
PTSD screening questions; the Army referred 23 percent, the Marines
referred about 15 percent, Navy referred 18 percent, and the Air Force
referred about 23 percent.
DOD cannot provide reasonable assurance that OEF/OIF servicemembers who
need referrals for further mental health or combat/operational stress
reaction evaluations receive them. Determining who needs a referral
occurs when DOD health care providers interview servicemembers after
they complete the DD 2796. DOD's guidance for health care providers
using the DD 2796 advises the health care providers to give particular
attention during the interview to those who completed the DD 2796 and
answered positively to three or four of the four PTSD screening
questions. According to DOD officials, not all of the OEF/OIF
servicemembers with three or four positive responses will need
referrals for further mental health evaluations. As directed by DOD's
guidance for using the DD 2796, health care providers are to rely on
their clinical judgment to decide which of these servicemembers need
further mental health evaluations. However, DOD has not identified the
factors its health care providers used to determine which OEF/OIF
servicemembers needed referrals. While DOD has taken steps to monitor
the post-deployment process, these steps are not designed to identify
the factors upon which DOD health care providers base their clinical
judgments in issuing referrals for further mental health or combat/
operational stress reaction evaluations. Knowing these factors could
help explain the variation in the referral rates and allow DOD to
provide reasonable assurance that such judgments are being exercised
appropriately.
We recommend that DOD identify the factors that DOD health care
providers use in issuing referrals for further evaluations for mental
health or combat/operational stress reaction to explain provider
variation in issuing referrals. In commenting on a draft of this
report, DOD concurred with our conclusions and recommendation. DOD
noted that it plans a systematic evaluation of referral patterns for
the post-deployment health assessment through the National Quality
Management Program. Despite its planned implementation of our
recommendation, 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. Until DOD has better
information on the factors its health care providers use 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. VA concurred with the
facts in the draft report that related to VA services.
Background:
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.[Footnote 11] 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 Post-Deployment Process and Screening for PTSD:
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.[Footnote 12] 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.
Figure 1: Portion of the DD 2796 Used by DOD Health Care Providers to
Indicate a Referral for a Further Mental Health or Combat/Operational
Stress Reaction Evaluation Is Needed:
[See PDF for image]
Source: DOD.
[End of figure]
DOD and VA Health Care Systems:
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.[Footnote 13] Vet Centers are also community
points of access for many returning veterans, providing them with
information and referrals to VA medical facilities.
DOD's Quality Assurance Program:
In January 2004, DOD implemented the Deployment Health Quality
Assurance Program.[Footnote 14] 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.[Footnote 15] 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.[Footnote 16]
For Veterans, DOD Offers a Benefit for a Specific Period of Time and VA
Offers Various Health Care Services:
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.
DOD Offers Mental Health Benefits to OEF/OIF Veterans for 180 Days or
More:
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.[Footnote 17] 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.
Table 1: TRICARE Beneficiary Costs Through TAMP:
Annual deductible; TRICARE Prime (managed care): None;
TRICARE Extra (preferred provider): $50-$150 (individual) and $100-$300
maximum (family), depending on military rank;
TRICARE Standard (fee-for- service): $50-$150 (individual) and $100-
$300 maximum (family), depending on military rank.
Cost share after deductibles for mental health visits; TRICARE Prime
(managed care): Outpatient: None;
TRICARE Extra (preferred provider): Outpatient: 15% of the fee
negotiated by TRICARE contractor after the deductible is met;
TRICARE Standard (fee-for-service): Outpatient: 20% of allowable
charges for covered services after the deductible is met.
TRICARE Prime (managed care): Inpatient: None;
TRICARE Extra (preferred provider): Inpatient: greater of $20/day or
$25 minimum charge per admission;
TRICARE Standard (fee-for-service): Inpatient: greater of $20/day or
$25 minimum charge per admission.
Source: DOD.
[End of table]
In addition, OEF/OIF veterans may purchase DOD health care benefits
through CHCBP for 18 months.[Footnote 18] 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.[Footnote 19] 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.[Footnote 20] 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 Offers Health Services, Including Specialized PTSD Services, to OEF/
OIF Veterans:
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.[Footnote 21],[Footnote 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.
Table 2: VA Specialized Outpatient and Inpatient PTSD Treatment
Programs:
Outpatient treatment program: PTSD Clinical Team;
Description of service:
* Group and one-on-one evaluation, education, counseling and
psychotherapy;
Number of facilities with specialized PTSD treatment program: 152.
Outpatient treatment program: Substance Use and PTSD Team;
Description of service:
* Education, evaluation, and counseling with a focus on veterans with
both substance abuse and PTSD;
Number of facilities with specialized PTSD treatment program: 10.
Outpatient treatment program: Women's Stress Disorder Treatment Team/
Military Sexual Trauma Team;
Description of service:
* Individual evaluation, counseling, and psychotherapy for women;
* Group counseling and psychotherapy for women;
* Mostly women, may include small number of men separate from women;
Number of facilities with specialized PTSD treatment program: 17.
Outpatient treatment program: PTSD Day Hospital;
Description of service:
* Social, recreational, and vocational activities and counseling;
Number of facilities with specialized PTSD treatment program: 11.
Inpatient treatment program: Evaluation and Brief Treatment Unit;
Description of service:
* Evaluation, education, and psychotherapy for PTSD;
* Duration of service: 14 to 28 days;
Number of facilities with specialized PTSD treatment program: 4.
Inpatient treatment program: Specialized Inpatient PTSD Unit;
Description of service:
* Evaluation, education, and counseling for substance use and PTSD
psychotherapy;
* Duration of service: 28 to 90 days;
Number of facilities with specialized PTSD treatment program: 5.
Inpatient treatment program: PTSD Residential Rehabilitation Program;
Description of service:
* Residential service providing evaluation, education, and counseling
to help veterans resume a productive involvement in community life;
* Duration of service: 28 to 90 days;
Number of facilities with specialized PTSD treatment program: 14.
Outpatient treatment program: Women's Trauma Recovery Program;
Description of service:
* Residential service with an emphasis on interpersonal skills for
veterans with PTSD;
* Duration of service: up to 60 days;
Number of facilities with specialized PTSD treatment program: 2.
Outpatient treatment program: PTSD Domiciliary;
Description of service:
* Residential program providing integrated rehabilitative and
restorative care with the goal of helping veterans with PTSD achieve
and maintain the highest level of functioning and independence
possible;
* Duration of service: about 85 days;
Number of facilities with specialized PTSD treatment program: 8.
Source: VA, March 2006.
[End of table]
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.
Based on DOD Data, About 5 Percent of OEF/OIF Servicemembers May Have
Been at Risk for Developing PTSD and Over 20 Percent Received Referrals:
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.
About 5 Percent of OEF/OIF Servicemembers May Have Been at Risk for
Developing PTSD:
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.[Footnote 23]
Figure 2: OEF/OIF Servicemembers Who May Have Been at Risk for
Developing PTSD, by Military Service Branch:
[See PDF for image]
Source: GAO analysis of DOD data.
Note: This figure is based on the number of OEF/OIF servicemembers in
our review who were deployed from October 1, 2001 through September 30,
2004 and answered positively to three or four of the four PTSD
screening questions on the DD 2796.
[End of figure]
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.[Footnote 24]
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.[Footnote 25]
Twenty-two Percent Who May Have Been at Risk for Developing PTSD
Received Referrals:
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.
Figure 3: Referral Rates for Mental Health or Combat/Operational Stress
Reaction Evaluation for OEF/OIF Servicemembers Who May Have Been at
Risk for Developing PTSD, by Military Service Branch:
[See PDF for image]
GAO: GAO analysis of DOD data.
Note: This figure is based on the number of OEF/OIF servicemembers in
our review who were deployed from October 1, 2001 through September 30,
2004 and answered positively to three or four of the four PTSD
screening questions on the DD 2796.
[End of figure]
DOD Cannot Provide Reasonable Assurance That OEF/OIF Servicemembers Who
Need Mental Health Referrals Receive Them:
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.[Footnote 26]
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.[Footnote 27] 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.
Conclusions:
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.
Recommendation for Executive Action:
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.
Agency Comments and Our Evaluation:
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 [Hyperlink, 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.
Signed By:
Cynthia A. Bascetta:
Director:
Health Care:
List of Committees:
The Honorable John Warner:
Chairman:
The Honorable Carl Levin:
Ranking Minority Member:
Committee on Armed Services:
United States Senate:
The Honorable Larry E. Craig:
Chairman:
The Honorable Daniel K. Akaka:
Ranking Minority Member:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Kay Bailey Hutchison:
Chairman:
The Honorable Dianne Feinstein:
Ranking Minority Member:
Subcommittee on Military Construction, Veterans' Affairs, and Related
Agencies:
Committee on Appropriations:
United States Senate:
The Honorable Ted Stevens:
Chairman:
The Honorable Daniel K. Inouye:
Ranking Minority Member:
Subcommittee on Defense:
Committee on Appropriations:
United States Senate:
The Honorable Duncan L. Hunter:
Chairman:
The Honorable Ike Skelton:
Ranking Minority Member:
Committee on Armed Services:
House of Representatives:
The Honorable Steve Buyer:
Chairman:
The Honorable Lane Evans:
Ranking Minority Member:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable James T. Walsh:
Chairman:
The Honorable Chet Edwards:
Ranking Minority Member:
Subcommittee on Military Quality of Life and Veterans Affairs and
Related Agencies:
Committee on Appropriations:
House of Representatives:
The Honorable C. W. Bill Young:
Chairman:
The Honorable John P. Murtha:
Ranking Minority Member:
Subcommittee on Defense:
Committee on Appropriations:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
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.[Footnote 28]
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.[Footnote 29] 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.[Footnote 30]
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.
[End of section]
Appendix II: Comments from the Department of Defense:
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
The Assistant Secretary Of Defense:
1200 Defense Pentagon:
Washington, DC 20301-1200:
Health Affairs:
Ms. Cynthia Bascetta:
Director:
Health Care - Veterans' Health and Benefits Issues:
U.S. Government Accountability Office:
Washington, DC 20548:
Dear Ms. Bascetta:
This is the Department of Defense (DoD) response to the Government
Accountability Office (GAO) Draft Report, "Post-Traumatic Stress
Disorder: DoD Needs to identify the Factors Its Providers Use to Make
Mental Health Evaluation Referrals for Servicemembers," dated March 20,
2006, GAO Code 290437/GAO-06-397.
Thank you for the opportunity to review your draft report. We commend
the GAO team for their diligence in addressing a complex issue and the
associated implications in two complex healthcare systems. We also wish
to thank the Congressional Committees for their ongoing interest in the
mental health of our military personnel.
Overall, I concur with the draft report's conclusions and
recommendations. However, I nonconcur with GAO's premise that
reasonable assurance is not available to support that Operation Iraqi
Freedom/Operation Enduring Freedom servicemembers receive referrals
when needed.
Specific comments are provided addressing various aspects of the
report. A response to the recommendations is provided with technical
comments for your consideration to help strengthen the report and make
it more valuable to the Department.
Please direct any questions to my points of contact on this matter, Dr.
Michael Kilpatrick (functional) at (703) 578-8510 and Mr. Gunther J.
Zimmerman (Audit Liaison) at (703) 681-3492, extension 4065.
Signed By:
William Winkenwerder, Jr., MD:
Enclosures: As stated:
Gao Draft Report - Dated March 20, 2006 (GAO CODE - 290437/GAO-06-397):
"Post-Traumatic Stress Disorder: DoD Needs to Identify the Factors Its
Providers Use to Make Mental Health Evaluation Referrals for
Servicemembers"
Department Of Defense Comments:
Overall Comments:
While DoD concurs with the recommendation to clearly identify the
factors actually used by clinicians in making a referral decision, DoD
non-concurs with the premise that reasonable assurance is not available
to support the position that OIF/OEF servicemembers receive referrals
when needed. DoD recommends that this statement be eliminated from the
report, based on information in the specific comments above and in
addition to the general comments that follow. Occupationally related
health decisions are made by clinicians who are familiar with the
occupational demands. Military deployments represent occupationally
unique situations. Decisions are made based on knowledge of clinical
concerns as well as occupational environment. All relevant factors need
to be considered in the assessment and referral process.
Combat and Operational Stress Reactions (COSR), philosophy of
intervention. Decades of experience have resulted in the currently
accepted practice of rest and restoration as a method of intervention
for COSR. In past conflicts, providers and line personnel discovered
that it is very common to have a negative reaction to the stress and
trauma of combat; it is just a part of human nature. If these normal
reactions to an abnormal situation are immediately medicalized, the
individual takes on a patient role and the symptoms that may normally
dissipate with rest and restoration tend to persist. Therefore, the
recommended action is to expect the symptoms to remit naturally and to
offer social support through unit cohesion along with a few nights of
restful sleep and restorative nutrition in a safe environment. This
philosophy of treatment has served the military well in the more recent
conflicts. Symptoms associated with COSR, adjustment difficulties or
bereavement may spontaneously remit once the individual assimilates or
processes the event, reduces fatigue and replenishes natural defensive
processes. Over-pathologizing symptoms in the interim may do more harm
than good. Clearly, if the symptoms impair an individual's ability to
function in this demanding environment or if they do not remit after a
period of rest, clinical intervention is certainly warranted. There is
no reason to expose an individual to pain and suffering when medical
care could remediate the problem. However, it is also not prudent to
assume that a medical treatment is immediately warranted.
Timing of assessment. The PDHA is conducted immediately at the end of
the deployment; most often before the servicemember leaves the theater
of operation. At this point in time, servicemembers still feel as if
they are in the combat environment, even if the threat is reduced.
Symptoms associated with PTSD, such as hyperarousal, emotional numbing,
trouble sleeping, compartmentalizing or trying to avoid thinking about
the combat experience, nightmares and similar thoughts and feelings are
not uncommon and may even be adaptive in the high-threat combat
environment. To label those symptoms as denoting a disorder may not be
appropriate at this time.
Symptoms that present clinically significant distress or functional
impairment in the first few days after a traumatic event are generally
diagnosed as Acute Stress Disorder. Only when symptoms persist for more
than 30 days would PTSD be considered. While it is conceivable that a
highly traumatic event could occur early in the deployment that
generated symptoms, it is less likely that the nature of the symptoms
could be discerned until after the individual left the environment. The
timing of the assessment prior to arrival home does not lend itself to
clinical diagnosis of PTSD.
Potential risks associated with false positives. No medical
intervention is without risks. The general premise of medical practice
is that the benefits should outweigh the risks. In terms of PTSD, the
risks are associated with potentially issuing a diagnosis of PTSD for
an individual who has no diagnosable mental health disorder.
Individuals who experience a diagnosable mental health disorder are
generally relieved to have a name to put to their symptoms. However,
those without a disorder often respond with some anxiety and a sense of
foreboding about what this diagnosis will mean to their lives and their
military careers. While, for the most part, it is a false perception
that mental health treatment will in itself ruin a military career, it
is still a widely held perception that generates distress in itself, in
addition to the distress associated with any symptoms the individual
may have. In making a clinical determination associated with a mental
health referral, the risks of false positive must always be weighed
against the accuracy of clinical judgment. Watchful waiting may be more
appropriate in situations in which the clinician is not sure about a
diagnosis or the severity of the symptoms.
Watchful waiting. The concept of watchful waiting is common in medical
practice. Symptoms may present for any number of reasons that do not
reach clinical significance or cannot be readily diagnosed. Frequently,
individuals are provided the advice that they should pay attention to
the symptoms and return if they do not dissipate or if they get worse.
Watchful waiting is a clinically relevant position to take in the case
of PTSD-related symptoms at the point in time at which the PDHA
assessment is conducted.
PDHA is not the only avenue to care. The position espoused by GAO in
their report hinges on the concern that individuals who need mental
health care may not get a referral, and therefore, may not get access
to care they need to treat their condition. However, the PDHA is not
the only avenue to care available to the veteran or servicemember. As
the report indicates, numerous avenues to care are offered to active
duty, Reserve, and separated servicemembers both from DoD and from the
VA. The absence of a referral does not preclude access to care.
Education and Clinical Health Risk Communication. PDHRA is a process
that includes a mandatory medical threat debrief and benefits briefing
and handouts. The medical threat debriefing includes signs and symptoms
that may be associated with PTSD or other common deployment-related
mental health conditions. It is not the case that PTSD is the primary
or the only deployment-related mental health concern. Depression is
equally common, equally distressing and clinically treatable. The
educational process includes information on how to recognize mental
health problems and where to go for help if these concerns arise at any
time post-deployment. Since signs and symptoms may not immediately
present, and given the fact that servicemembers may be reluctant to
recognize or report these symptoms during the PDHA period, education is
essential to alert them to things to watch for and what to do when they
get back home. Based on recent research (Hoge, et al, JAMA, 2006), a
high percentage of land combat troops, both soldiers and Marines, self-
refer to mental health care during the first two months after they
return home. This information provides a sense of assurance that our
servicemembers are listening to the education our clinicians provide
and are seeking care through the many avenues available to them rather
than relying solely on a referral during the PDHA process.
Recommendation: The GAO recommended 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
evaluations in order to explain provider variation in issuing
referrals. (Page 24/GAO Draft Report):
Dod Response: Concur. The Department generally concurs with this
recommendation, but notes that a systematic evaluation of referral
patterns is planned for the Post Deployment Health Assessment (PDHA)
through the National Quality Management Program (NQMP). In addition, a
thorough program evaluation, including a validation of the PDHA and
PDHRA (Post-Deployment Health Reassessment) procedures, is already in
progress, which will include all the mental health scales and provider
referrals arising from use of the information in those scales in their
clinical decision-making. The validation study is projected for
completion in October 2006.
GAO Contact:
Cynthia A. Bascetta at (202) 512-7101 or bascettac@gao.gov:
Acknowledgments:
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.
FOOTNOTES
[1] OEF/OIF servicemembers include National Guard and Reserve members.
[2] Hoge, Charles W., MD et al., "Combat Duty in Iraq and Afghanistan,
Mental Health Problems, and Barriers to Care," The New England Journal
of Medicine, 351 (2004): 13-22.
[3] Servicemembers who are deployed for 30 or more continuous days to
locations without permanent DOD treatment facilities are required to
complete a post-deployment screening questionnaire.
[4] DOD's referrals are used to document DOD's assessment that
servicemembers are in need of further mental health evaluations,
including those for PTSD. In this report, we refer to such referrals as
issued to or received by servicemembers.
[5] In this report, we use the term discharged to describe
servicemembers who have completed their active duty service commitment
and have not made a future service commitment. We use the term released
to describe Reserve and National Guard servicemembers who have
completed their active duty service commitment, made a future
commitment to active duty, and therefore can be recalled to active
duty.
[6] Pub. L. No. 108-375, § 598(b)(8), (9), 118 Stat. 1811, 1939-41
(2004).
[7] We did not include military retirees in our analysis because the
mandate specifies that we include servicemembers who have been
discharged or released from active duty, not retired servicemembers.
According to a DOD official, DOD does not include retirees in its
definition of discharged servicemembers or servicemembers who have been
released from active duty status.
[8] Department of Defense, Department of Defense Post-Deployment Health
Assessment DD-2796 (Washington, D.C.: April 2003).
[9] Department of Veterans Affairs and Department of Defense, Veterans
Health Administration/DOD Clinical Practice Guideline for Management of
Post-Traumatic Stress (Washington, D.C.: January 2004).
[10] Prins, Annabel et al. "The Primary Care PTSD Screen (PC-PTSD):
Development and Operating Characteristics," Primary Care Psychiatry, 9
(2004): 9-14. This study was conducted using VA primary care patients.
[11] Because the symptoms of PTSD may be delayed, in October 2005, DOD
began offering a post-deployment health reassessment for individuals 90
to 180 days after returning from deployment as part of OEF/OIF. These
individuals could be servicemembers or veterans. The reassessment
includes the same four PTSD screening questions that are found on the
DD 2796.
[12] The questionnaire is used to satisfy the requirement for post-
deployment mental health assessments established by the National
Defense Authorization Act for Fiscal Year 1998. Pub. L. No. 105-85, §
765(a)(1), 111 Stat. 1629, 1826, codified at 10 U.S.C. § 1074f(b)
(2000).
[13] Readjustment counseling is intended to help veterans resolve war-
related psychological difficulties and achieve a successful postwar
readjustment to civilian life.
[14] We recommended in 2003 that DOD establish a quality assurance
program. See GAO, Defense Health Care: Quality Assurance Process Needed
to Improve Force Health Protection and Surveillance, GAO-03-
1041(Washington, D.C.: Sept. 19, 2003).
[15] The Army has lead responsibility for DOD's medical surveillance
and operates a centralized data repository.
[16] Office of the Assistant Secretary of Defense, DOD Deployment
Health Quality Assurance Program 2004 Annual Report, (Washington, D.C.:
2005).
[17] The Ronald W. Reagan National Defense Authorization Act for Fiscal
Year 2005, Pub. L. No. 108-375, § 706(a)(1), 118 Stat. 1811, 1983
(2004), signed into law on October 28, 2004, extended the health care
benefits offered under TAMP from 120 days to 180 days to help
servicemembers with the transition from military service to civilian
status. Dependents may also be included in these benefits. OEF/OIF
veterans who are eligible for TAMP benefits are those who have
involuntarily separated from active duty; separated from active duty
after being involuntarily retained in support of a contingency
operation; separated from active duty following a voluntary agreement
to stay on active duty for less than 1 year in support of a contingency
operation; and National Guard and Reserve members who have separated
from active duty after being called up or ordered in support of a
contingency operation and served for more than 30 days.
[18] OEF/OIF veterans who have ended TAMP coverage or who are not
eligible for TAMP benefits may be eligible to enroll in CHCBP if they
are no longer eligible for TRICARE benefits or other benefits under the
military health care system. To be eligible, OEF/OIF veterans must have
been discharged or released from active duty, either voluntarily or
involuntarily, under other than adverse conditions and have been
entitled to coverage under a military health care plan immediately
prior to discharge or release. OEF/OIF veterans must enroll in CHCBP
within 60 days after separation from active duty or loss of eligibility
for military health care benefits.
[19] The National Defense Authorization Act for Fiscal Year 2005, Pub.
L. No. 108-375, § 701, 118 Stat. 1980. Under TRS, these veterans must
have been called or ordered to active duty for more than 30 consecutive
days and have served continuously in active duty for 90 or more days
under those orders. OEF/OIF Reserve and National Guard veterans can
purchase TRICARE coverage for themselves and their dependents for a
period of either 1 year for each consecutive period of 90 days of
active duty they served, or the number of full years for which the
individual agrees to continue service, whichever is less.
[20] Active duty servicemembers and their dependents are also eligible,
as well as members of the National Guard and Reserves who have been
released from active duty. These groups can access Military OneSource
beyond 180 days.
[21] See 38 U.S.C. § 1710(e)(1)(D), 1712A(a)(2)(B) (2000), and VHA
Directive 2004-017, Establishing Combat Veteran Eligibility.
[22] 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).
[23] Hoge, Charles W., MD et al. "Mental Health Problems, Use of Mental
Health Services, and Attrition From Military Service After Returning
From Deployment to Iraq or Afghanistan," Journal of the American
Medical Association, 295 (2006): 1023-1032. While this study reviewed
screening for PTSD and referrals in addition to other mental health
conditions, the results cannot be compared to ours because this study
covered active duty servicemembers.
[24] Friedman, Mathew J., "Veterans' Mental Health in the Wake of War,"
The New England Journal of Medicine, 352 (2005): 1287-1290.
[25] DOD officials have stated that some OEF/OIF servicemembers may be
reluctant to accurately report symptoms of PTSD because they could be
delayed in returning home after deployment.
[26] The DD 2796 is to be placed in the servicemember's medical record
and a copy sent to AMSA. AMSA is DOD's centralized repository for DD
2796 information from all of the military service branches. It provides
ongoing and special analyses and reports for policy makers, medical
planners, and researchers.
[27] In addition to the four PTSD screening questions, the DD 2796
contains other questions related to mental health, such as asking "Over
the last 2 weeks how often have you been bothered by any of the
following problems--feeling depressed or having thoughts of harming
yourself?"
[28] VA and DOD, Veterans Health Administration/DOD Clinical Practice
Guideline for Management of Post-Traumatic Stress Disorders.
[29] Prins, Annabel et al. "The Primary Care PTSD Screen (PC-PTSD):
Development and Operating Characteristics."
[30] GAO-03-1041.
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