Military to Civilian Transition: Actions Needed to Ensure Effective Mental Health Screening at Separation

Fast Facts

Separation from the military is a particularly vulnerable time for service members. Veterans Affairs and the Department of Defense jointly developed a separation health assessment that screens for certain mental health conditions. VA began administering the assessment in 2023.

But the screening questions for some of the mental health conditions on the assessment weren't fully validated—meaning that they hadn't been tested or determined to be effective and reliable. Without validation, DOD and VA can't be sure they're effectively identifying service members who need mental health support at separation.

Our recommendations address this issue.

Health Screening

Highlights

What GAO Found

Federal law and Department of Defense (DOD) policy require health exams for service members separating from active duty. DOD administers most exams for these service members. The Department of Veterans Affairs (VA) administers these exams for service members filing for disability benefits at separation, such as those with an illness or injury caused by military service. To help coordinate efforts, VA and DOD developed a joint separation health assessment with mental health screens not included in DOD's existing separation exam. VA implemented the joint assessment in April 2023. As of May 2025, DOD had not implemented the joint assessment but had completed a pilot of it at three sites.

The joint assessment includes five mental health screens for 1) depression, 2) suicide risk, 3) alcohol use, 4) post-traumatic stress disorder (PTSD), and 5) violence risk. GAO found that two of these mental health screens are validated tools. This means that they have been tested and determined to be both effective at identifying individuals at risk for a specific condition and reliable at yielding consistent results if administered to the same individual more than once. Two of the other mental health screens are based on validated tools, but VA and DOD modified the screens without validating the changes.

The remaining joint assessment screen for violence risk is not based on a validated tool. It was included for consistency with other DOD health assessment forms, according to officials. Research shows that violence screening may be useful for service members, but multiple subject matter experts GAO interviewed expressed concerns about the violence risk screen's effectiveness.

Research shows that without validation testing, VA and DOD cannot be sure about the effectiveness or reliability of the screening they are conducting for alcohol use, PTSD, and violence risk. Using validated mental health screens would provide VA and DOD with greater assurance that their efforts to identify service members needing mental health support at separation are effective.

VA data show its contractors administered about 50,500 joint separation health assessments between May 2023 and April 2024 to service members being evaluated for disability benefits. Of those exams, about 67 percent of service members had at least one positive mental health screen. A positive screen indicates elevated risk for the specific mental health condition being assessed and can indicate a need for further evaluation or intervention.

GAO found that VA's most common positive mental health screens on the joint assessment were for PTSD and depression. VA and DOD officials noted that overall, the joint assessment screening rates are higher than would be expected in a clinical setting or based on population prevalence for these disorders. In the case of screening for alcohol use and PTSD, VA and DOD modifications to these tools may have contributed to higher positive screening rates. Additionally, DOD officials said that many factors could increase the possibility of positive mental health screens among separating service members, including that this subgroup of service members intends to file disability claims.

Clinicians administering the joint assessments are required to ensure that service members who screen positive are aware of available mental health care options and offer them a referral to DOD's inTransition program, which is to offer support with mental health services during transitions. GAO's analysis of VA's joint assessment data found that 48 percent of service members who were offered an inTransition referral accepted, and 52 percent declined. VA does not track service members' reasons for declining these referrals. However, VA officials noted that some service members might decline the referral if they are already involved in mental health treatment.

Additionally, when service members screen positive for suicide risk on the joint assessment, clinicians are to assess their level of risk and take specific actions based on that determination. For example, clinicians are required to contact the Veterans Crisis Line for high-risk individuals, among other actions.

Why GAO Did This Study

Thousands of service members separate from the military each year, and research has shown that they are especially vulnerable during this transition to civilian life. A 2018 executive order directed VA and DOD to develop a joint action plan to ensure access to mental health care and suicide prevention services for separating service members. The resulting plan called for mental health screenings of all service members prior to separation, among other initiatives.

The House report accompanying the National Defense Authorization Act for Fiscal Year 2024 includes a provision for GAO to review VA and DOD's implementation of mental health exams for service members transitioning out of the military. Among other topics, this report examines the extent to which VA and DOD based the joint separation health assessment's mental health screening questions on validated screening tools and the outcomes of VA's mental health screening using the joint assessment.

To address these objectives, GAO reviewed selected scientific studies to determine the effectiveness and reliability of the joint assessment's specific mental health screens. GAO also reviewed validated screening tool recommendations in relevant clinical practice guidelines issued by organizations including VA and DOD. GAO interviewed VA and DOD officials, as well as mental health subject matter experts identified by professional associations such as the American Psychiatric Association.

GAO reviewed available mental health screening data from joint separation health assessments completed by VA contractors between May 2023—the month following its implementation— and April 2024. GAO also reviewed VA guidance for administering the joint assessments, including the process to be followed when a service member screens positive for mental health concerns, including their risk for suicide. Finally, GAO interviewed VA officials and representatives of the three contractors that administer the joint assessments about what steps they take if someone screens positive on the mental health screening questions.

Recommendations

GAO is making a total of three recommendations to the VA-DOD Joint Executive Committee that developed the joint separation health assessment to (1) ensure that the joint assessment's alcohol use screen is validated, (2) ensure that the joint assessment's PTSD screen is validated, and (3) assess whether to include violence risk screening in the joint assessment and take appropriate follow-up action. Possible actions could include taking steps to validate the joint assessment's existing violence risk questions, replacing them with a different validated tool, or removing the questions, as appropriate.

VA concurred with GAO's recommendations while DOD partially concurred with them. DOD stated that the VA-DOD Joint Executive Committee should explore using validated screens but did not commit to ensuring that the alcohol use, PTSD, and violence risk screens are validated. GAO maintains its recommendations are warranted and that any screening tool used in the joint assessment be validated.

GAO Contacts

Media Inquiries

Public Inquiries

Topics

Recommendations

GAO is making a total of three recommendations to the VA-DOD Joint Executive Committee that developed the joint separation health assessment to (1) ensure that the joint assessment's alcohol use screen is validated, (2) ensure that the joint assessment's PTSD screen is validated, and (3) assess whether to include violence risk screening in the joint assessment and take appropriate follow-up action. Possible actions could include taking steps to validate the joint assessment's existing violence risk questions, replacing them with a different validated tool, or removing the questions, as appropriate.

VA concurred with GAO's recommendations while DOD partially concurred with them. DOD stated that the VA-DOD Joint Executive Committee should explore using validated screens but did not commit to ensuring that the alcohol use, PTSD, and violence risk screens are validated. GAO maintains its recommendations are warranted and that any screening tool used in the joint assessment be validated.