DOD and VHA Have Developed Medication Treatment Recommendations for PTSD and Mild TBI and VHA Monitors the Prescribing of Certain Medications for PTSD

		DOD and VHA Have Collaborated to Develop Clinical Practice Guidelines for Medication Treatment for PTSD and Mild TBI

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. Additionally, the guideline states that the use of antipsychotics (atypical  and conventional) to treat PTSD is not supported because the existing  evidence is insufficient to warrant their use. VHA Monitors the Prescribing of Medications to Treat PTSD, but DOD and the Army Do Not; None Monitor Mild TBI Medications Given Lack of Specific Medication Recommendations in Mild TBI Clinical Guideline

VHA monitors the prescribing of medications that are included in the  PTSD guideline, but DOD and the Army do not monitor such prescribing  among servicemembers. This requirement encompasses measures focused  on reducing prescriptions for benzodiazepines, antipsychotics, and other  classes of psychiatric medications to treat veterans with PTSD. DOD officials told us  that DOD relies on each military service to review the medication  prescribing practices of its providers and helps facilitate medication  reviews by generating reports for all MTFs that include a list of patients  who are prescribed multiple psychiatric and pain medications. Federal  internal control standards require federal agencies to have control  activities in place to establish and review performance measures over  time and then implement ongoing monitoring to assess the quality of  performance and ensure that the findings of reviews are promptly  resolved. Without ongoing monitoring of Army providers’ prescribing of  antipsychotics and benzodiazepines to servicemembers with PTSD, the  Army may be unable to identify and address prescribing practices that are  inconsistent with the guideline and do not have a clinical justification. These  medications are prescribed to treat symptoms that are common among  servicemembers and veterans with PTSD or mild TBI. DOD and VHA  officials we spoke with agreed that the formulary differences did not affect  the continuation of medications for servicemembers transitioning from  DOD to VHA. We also found that the vast  majority of these medications that were actually prescribed by DOD in  fiscal year 2014 were on both formularies. VHA Has Two Key Efforts to Help Ensure Continuation of Medications, but Lack of Clarity of One Effort May Limit Its Effectiveness

		VHA’s Nonformulary Request Process Helps Ensure Continuation of Medications and Most Requests Are Adjudicated within 96 Hours and Approved

VHA’s nonformulary request process is one key effort that helps newly  transitioned veterans, including those with PTSD or mild TBI, avoid  medication discontinuations that could occur as the result of differences in  the DOD and VA formularies, according to providers we interviewed and  VHA documents we reviewed. VHA’s nonformulary request data show that pharmacists approved the  majority of the nonformulary requests that providers submitted from fiscal  years 2012 through 2014. The VHA data also showed  that the vast majority of requests that providers appealed were  adjudicated within the required timeline of 96 hours (91 percent) from  fiscal years 2012 through 2014. VHA Issued a Policy to Help Ensure Continuation of Certain Medications for Transitioning Servicemembers, but It Lacks Clarity

VHA issued a policy in January 2015 that instructs providers not to  discontinue mental health medications initiated by DOD providers due to  differences in the DOD and VA formularies; another key effort to help  ensure medication continuation. This lack  of clarity in VHA’s policy is inconsistent with federal internal control  standards, which state that agencies should establish control activities,  such as developing clear policies, in order to accomplish the agency’s  objectives. Ensuring that medication regimens are continued when clinically  appropriate is critical for servicemembers transitioning their health care  from DOD to VHA, including those with PTSD and mild TBI. However, we found that VHA’s new policy to ensure the  continuation of mental health medications lacks clarity on the types of  medications considered mental health medications, and, as a result, VHA  providers may be inappropriately changing or discontinuing mental health  medications due to formulary differences, potentially increasing the risk of  adverse health effects for transitioning servicemembers. Appendix I: Formulary Comparison

We found that the Department of Veterans Affairs (VA) formulary included  57 percent of the psychiatric, pain, and sleep medications on the  Department of Defense (DOD) formulary, as of August 2015, and these  medications represented the most frequently prescribed psychiatric, pain,  and sleep medications on the DOD formulary in fiscal year 2014.
Why GAO Did This Study

Medication continuation, when clinically appropriate, is critical for transitioning servicemembers with PTSD or TBI who have been prescribed psychiatric, pain, or sleep medications. Adverse health effects may occur if these medications are inappropriately discontinued.
The National Defense Authorization Act for Fiscal Year 2015 included a provision for GAO to assess transitions of care, particularly medication continuation for servicemembers with PTSD or TBI transitioning to VHA. GAO examined (1) the extent to which DOD and VHA developed and monitored recommended medication practices for PTSD and TBI; (2) the extent to which psychiatric, pain, and sleep medications on DOD's formulary are on VA's formulary, and how differences might affect medication continuation; and (3) key efforts VHA has to help ensure medication continuation, and the extent it is monitoring these efforts. GAO reviewed documents and analyzed DOD and VHA data from fiscal years 2012 through 2015; and interviewed DOD and VHA officials from headquarters and five Army and DOD facilities, selected for variation in size and location. GAO focused on the Army as the largest number of its servicemembers served in recent conflicts.

What GAO Found

The Department of Defense (DOD) and the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) have collaborated to develop clinical practice guidelines for post-traumatic stress disorder (PTSD) and mild traumatic brain injury (TBI). The mild TBI guideline does not include recommendations based on scientific evidence regarding the use of medications to treat symptoms because of a lack of available research; however, the PTSD guideline discourages the use of benzodiazepines (a sedative) and states that the use of antipsychotics to treat PTSD lacks support, based on available research. VHA monitors the prescribing of benzodiazepines and antipsychotics to treat PTSD nationally and by VA medical centers (VAMC) and requires VAMCs to implement improvement plans if their prescribing is significantly higher than the average of all VAMCs. GAO found that DOD relies on each military service to review the medication prescribing practices of its providers and that the Army does not monitor the prescribing of medications to treat PTSD on an ongoing basis. Without such monitoring, the Army may be unable to identify and address practices that are inconsistent with the guideline. Federal internal control standards require agencies to have control activities to establish performance measures, implement ongoing monitoring to assess performance, and ensure that the findings of reviews are promptly resolved.
As of August 2015, VA's formulary included 57 percent of the psychiatric, pain, and sleep medications on DOD's formulary. These medications are prescribed to treat symptoms common among servicemembers and veterans with PTSD or mild TBI, and most of the DOD prescriptions in fiscal year 2014 for these medications (88 percent) were on both formularies. In addition, DOD and VHA officials GAO interviewed agreed that the differences did not affect the continuation of medications for servicemembers transitioning from DOD to VHA.
VHA has two key efforts to help ensure continuation of medications for transitioning servicemembers, including those with PTSD or mild TBI, but a lack of clarity of one effort may limit its effectiveness. VHA's nonformulary request process is one key effort that helps ensure newly transitioned veterans avoid medication discontinuations due to differences between the DOD and VA formularies. VHA monitors nonformulary requests. VHA data show that 81 percent of requests submitted from fiscal years 2012 through 2014 were approved, and 98 percent of requests were adjudicated within VHA's required time frame of 96 hours. The other key effort is VHA's 2015 policy instructing its providers not to discontinue mental health medications initiated by DOD providers due to formulary differences. However, VHA providers GAO interviewed had varying interpretations of which medications are covered by this policy, and VHA officials acknowledged that the definition of a mental health medication could be subjective. Federal internal control standards state that agencies should establish control activities, such as developing clear policies. Because VHA's policy lacks clarity, VHA providers may be inappropriately discontinuing mental health medications due to formulary differences, which could increase the risk of adverse health effects for transitioning servicemembers.

What GAO Recommends

GAO recommends that the Army monitor prescribing practices of medications discouraged under the PTSD guideline and that VHA clarify its medication continuation policy. DOD and VHA concurred with the recommendations.