Military Personnel: DOD and the Coast Guard Need to Screen for Gambling Disorder Addiction and Update Guidance
Published: 2017-01-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The American Psychiatric Association's 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders defines gambling disorder as persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress.
Public Law 114-92 included a provision for GAO to review gambling among members of the armed forces. This report (1) describes what is known about the prevalence of gambling disorder among servicemembers in DOD and the CG; (2) assesses DOD's and the CG's approaches to screening, diagnosing, and treating servicemembers for gambling disorder; and (3) evaluates the extent to which DOD and CG guidance address gambling disorder in a manner similar to substance-use disorders. GAO analyzed DOD's most recent data related to gambling disorder prevalence (fiscal years 2011–2015) and DOD and CG policies.
section_title: What GAO Found
paragraphs: Department of Defense (DOD) data show 514 DOD and Coast Guard (CG) active-duty servicemembers and 72 Reserve Component servicemembers—less than 0.03 percent of the average number of servicemembers in each year—were diagnosed with gambling disorder or were seen for problem gambling in fiscal years 2011 through 2015 in the Military Health System (MHS). The MHS provides health services to beneficiaries across a range of care venues, such as military treatment facilities and civilian facilities through TRICARE. DOD bases this prevalence of gambling disorder and problem gambling on MHS data and does not include other sources of information, such as DOD-wide surveys and records of treatment provided outside of the MHS. The Defense Health Agency compiles these data in the MHS Data Repository, which includes data on clinical interactions between servicemembers and health-care professionals. The MHS Data Repository does not include data on DOD and CG servicemembers who received treatment or counseling for gambling disorder or problem gambling outside of the MHS.
DOD and the CG do not systematically screen for gambling disorder and, according to medical officials, both DOD and the CG use the 2013 Diagnostic and Statistical Manual of Mental Disorders criteria to diagnose servicemembers with gambling disorders, and they employ the same evidence-based treatments. Clinicians who GAO interviewed stated that financial counseling is also an important part of gambling disorder treatment. However, DOD's and CG's medical professionals do not incorporate medical screening questions specific to gambling disorder as they do for other similar medically determined addictive disorders, such as substance use. DOD officials stated they do not screen for gambling disorder because they focus on mental-health disorders that are high risk to overall readiness, high volume, and have validated measures for assessment. While gambling disorder is not a frequently diagnosed condition, the preoccupation with gambling, financial hardship, and increased risk of suicide can pose a risk to individual readiness. In addition, the Substance Abuse and Mental Health Services Administration has indicated that screening is important because few seek treatment directly for gambling disorder. Without proactively asking gambling disorder questions as part of screening to help detect gambling disorder, DOD and the CG risk not identifying affected servicemembers and providing treatment or counseling.
DOD and CG nonmedical personnel do not have clear guidance addressing gambling disorder. Neither DOD's nor CG's guidance for substance-use disorders explicitly includes gambling disorder. DOD health officials stated that their substance-use instruction “implicitly” covers gambling disorder; however, it refers only to problematic substance use. The Coast Guard has three documents that provide guidance and policy to both medical and nonmedical personnel on substance abuse, but these documents do not specifically discuss gambling disorder as an addiction. Without explicitly including gambling disorder in DOD and CG guidance on substance use, DOD and the CG may not being able to identify and provide appropriate treatment and counseling to DOD and CG servicemembers afflicted by gambling disorder and mitigate or prevent individual readiness issues.
section_title: What GAO Recommends
paragraphs: GAO makes eight recommendations, including that DOD incorporate gambling disorder questions in a systematic screening process and DOD and the CG update guidance to include gambling disorder. DOD concurred with five recommendations focused on updating guidance, but did not concur with incorporating gambling questions into a screening process due to the disorder's low prevalence. GAO maintains that this recommendation is still valid because, among other things, DOD's prevalence data are limited. The CG concurred with the two recommendations focused on updating guidance.

section_title: Letter
paragraphs: Gambling disorder is a complex addiction that frequently occurs with  other behavioral health conditions and an increased likelihood of  developing other conditions. Gambling disorder is also associated with  poor physical health and financial or legal consequences. Like other  addictions, gambling disorder can include depression, loss of control, and  withdrawal, and without proper diagnosis and treatment can become  more severe. The Department of Defense’s (DOD) military services have  slot machines at overseas military installations, for example in bowling  alleys and clubs on base. Slot machines were removed from all domestic  military installations after Congress passed a law in 1951 prohibiting  gambling devices from being installed or used on any possession of the  United States. However, some domestic military installations are located  in close proximity to privately operated casinos. The Army manages most  of the Navy’s and all of the Marine Corps’ slot machines overseas, and  the Air Force manages the slot machines on its overseas installations.  Coast Guard installations do not have slot machines. In appendix I, we  included a summary of the number and location of DOD slot machines  and the total revenue generated from these slot machines in fiscal years  2011 through 2015.
In 2013, the American Psychiatric Association identified gambling as an  addiction similar to substance-use disorders, such as those associated  with alcohol and drugs. This change in categorization is reflected in the  most recent edition of the Diagnostic and Statistical Manual of Mental  Disorders, Fifth Edition—the primary source used by civilian and military  mental-health-care providers to diagnose mental disorders. This edition  defines “gambling disorder” as a preoccupation with gambling and a loss  of control, associated with a higher risk of suicide attempts, substance- use disorders, and other mental-health conditions, in addition to being  associated with financial and legal problems.
Section 731 of the National Defense Authorization Act for Fiscal Year  2016 included a provision for us to conduct a study on gambling among  members of the armed forces. This report (1) describes what is known  about the prevalence of gambling disorder among servicemembers in  DOD and the Coast Guard; (2) assesses DOD’s and the Coast Guard’s  approaches to screening, diagnosing, and treating servicemembers for  gambling disorder; and (3) evaluates the extent to which DOD and Coast  Guard guidance address gambling disorder in a manner similar to  substance-use disorders.
For the first objective, we analyzed the most-recent complete data from  the Military Health System Data Repository, which the Defense Health  Agency oversees, on the number of servicemembers who were seen by  the Military Health System for problem gambling and gambling disorder in  fiscal years 2011–2015. We found these data to be sufficiently reliable to  show how many servicemembers were seen by the Military Health  System for problem gambling and gambling disorder during this period by  reviewing database documentation and interviewing agency officials  responsible for maintaining the database. In addition, we reviewed DOD’s  most-recent Health Related Behavior Surveys that asked respondents  about gambling behaviors—conducted in 2002 and 2003 for the active- duty component and in 2010 and 2011 for the Reserve and National  Guard—to identify what is known about the prevalence of problematic  gambling behaviors among servicemembers.
We also conducted two separate literature searches regarding the  prevalence of gambling disorder in the general population as well as the  military population. The first prevalence search focused on the active-duty  and reserve U.S. military population, including the Coast Guard, in  English-language professional journals, government reports, and other  published and unpublished papers issued between 2001 and 2016; from  this search, we identified three studies. The second prevalence review  focused on the adult U.S. general population in English-language  professional journals, government reports, and other published and  unpublished papers published with data collected in 2006 or later; from  this search, we identified one study.
For the second objective, we compared DOD and Coast Guard policies  for screening, diagnosing, and treating DOD and Coast Guard  servicemembers with gambling disorders with the authoritative source for  civilian and military mental health professionals for diagnosing patients  with gambling disorder—the American Psychiatric Association’s  Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. We  reviewed screening tools, such as DOD’s Periodic Health Assessment, to  identify whether they contained gambling-disorder screening questions.  We also reviewed the American Society of Addiction Medicine treatment  criteria for addictive conditions, which assess the appropriate treatment  venue for each patient based on a multidimensional assessment; these  criteria were designed to define one national set of criteria for providing  outcome-oriented and results-based care in the treatment of addiction.
We also reviewed financial counseling services available for  servicemembers and their dependents to address problem gambling.
For the third objective, we compared DOD’s and the Coast Guard’s  respective policies on substance use against GAO’s Standards for  Internal Control in the Federal Government. According to Standards for  Internal Control in the Federal Government, management must  communicate high-quality information internally to enable personnel to  perform key roles in achieving objectives, addressing risks, and  supporting the internal control system. We also reviewed DOD (including  service-level) and Coast Guard guidance pertaining to the screening,  diagnosis, and treatment of gambling disorder. For all the objectives, we  interviewed Defense Health Agency officials as well as DOD and Coast  Guard service medical officials to corroborate our understanding of DOD  and Coast Guard policies on problem gambling and gambling disorder.  We conducted site visits to a nongeneralizable sample of Army, Navy, Air  Force, and Coast Guard military treatment facilities in California that had  reported at least one diagnosed case of gambling disorder, and we  conducted telephone interviews with behavioral health officials at military  treatment facilities in Japan and the Republic of Korea. A more-detailed  discussion of our scope and methodology is provided in appendix II.
We conducted this performance audit from December 2015 to January  2017 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Governance and Structure of the Military Health System
paragraphs: DOD established the Defense Health Agency on October 1, 2013, to  provide administrative support for the services’ respective medical  programs, combine common “shared” services, and coordinate the work  of the services’ military treatment facilities with care purchased from the  private sector. The Defense Health Agency supports the delivery of  services to Military Health System beneficiaries and is responsible for  integrating clinical and business processes across the Military Health  System.
The Military Health System, which serves all of the military services  including the Coast Guard, has two missions: (1) supporting wartime and  other deployments and (2) providing peacetime health care. The Military  Health System is a complex organization that provides health services to  almost 10 million DOD and Coast Guard servicemembers and their  dependents across a range of care venues, including the battlefield,  traditional hospitals and clinics at stationary locations, and authorized  civilian providers. The Military Health System employs more than 150,000  military, civilian, and contract personnel working in military treatment  facilities. In the Military Health System, care is provided through  TRICARE, DOD’s regionally structured health-care system. Under  TRICARE, DOD and Coast Guard active-duty servicemembers typically  receive most of their care in what is known as the direct-care  component—that is, in military hospitals and clinics referred to as military  treatment facilities. The care provided in military treatment facilities is  supplemented by services offered through TRICARE’s purchased-care  networks of civilian providers. The Defense Health Agency oversees the  TRICARE health plan and military treatment facilities and subordinate  clinics, but does not have direct command and control of the military  services’ military treatment facilities outside of the National Capital  Region. Each military service, including the Coast Guard, operates its  own military treatment facilities and their subordinate clinics. In addition,  the military services, including the Coast Guard, administer medical programs and provide medical and mental-health services to  servicemembers. Military medical personnel providing mental-health  services include psychiatrists, psychologists, mental-health nurse  practitioners, licensed social workers, and alcohol and drug counselors.  Although it is part of the Military Health System, the Coast Guard has  adopted some, but not all, of DOD’s health-related guidance.
According to DOD officials, the Navy, the Marine Corps, and the Air Force  provide nonmedical education and counseling services for individuals with  problem gambling who do not meet the criteria for gambling disorder  diagnosis. These educational and supportive services are provided  through the Fleet and Family Service Centers, the Marine Corps  Community Services Behavioral Health Clinics, and the Airman and  Family Readiness Centers, respectively, as well as through the Military  OneSource program—a program that provides confidential, short-term,  nonmedical counseling services and information both face-to-face and  remotely. Coast Guard servicemembers can receive counseling  services through CG SUPRT, a confidential program similar to Military  OneSource. Army officials told us that gambling disorder is not currently  addressed within the Army Substance Abuse Program and that Army  regulation does not require the program to cover gambling disorder. In  addition, service chaplains offer nonmedical counseling services for DOD  and Coast Guard servicemembers. DOD officials stated that individuals  with a diagnosable gambling disorder would be referred to a military  treatment facility.
section_title: Behavioral Health Definitions Regarding Gambling
paragraphs: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,  defines gambling disorder as the “persistent and recurrent problematic  gambling behavior leading to clinically significant impairment or distress.”  The term gambling disorder replaced pathological gambling as the  gambling-related diagnosis in the most recent (2013) edition of the  Diagnostic and Statistical Manual of Mental Disorders. The primary difference between the two diagnostic terms is that pathological gambling  was considered an impulse-control disorder whereas gambling disorder is  in the diagnostic category of substance-related and addictive disorders.  Table 1 presents the diagnostic criteria in the fourth and fifth editions of  the Diagnostic and Statistical Manual of Mental Disorders.
In addition, the American Society of Addiction Medicine published criteria  that evaluate the appropriate venue for an individual to be treated based  on a multidimensional assessment and that are designed to define one  national set of criteria for providing outcome-oriented and results-based  care in the treatment of addiction. According to the American Society of  Addiction Medicine, addiction—which it defines as “pathologically  pursuing reward and/or relief by substance use and other behaviors”— can be associated with various substances and behaviors, such as  alcohol and gambling. In explaining its decision to recategorize gambling  disorder as an addiction in the 2013 revision of the Diagnostic and  Statistical Manual of Mental Disorders, the American Psychiatric  Association observed that gambling disorder and substance-related  disorders display commonalities in symptoms as well as treatment. In  addition, the Diagnostic and Statistical Manual of Mental Disorders states  that individuals with gambling disorder have high rates of other mental  disorders, such as substance-use disorders, depressive disorders,  anxiety disorders, and personality disorders. Table 2 presents the  similarities and differences between substance use and gambling  disorder.
section_title: DOD and the Coast Guard Determined That the Prevalence of Gambling Disorder Is Low, Based on Military Health System Data DOD and the Coast Guard Determined That the Prevalence of Problem Gambling and Gambling Disorder Is Low, Based on Servicemembers’ Use of the Military Health System
paragraphs: Based on DOD data that show 514 DOD and Coast Guard active-duty  servicemembers and 72 Reserve Component servicemembers—less  than 0.03 percent of the average number of servicemembers in each  year—were diagnosed with gambling disorder or seen for problem  gambling in fiscal years 2011 through 2015, DOD officials stated that the  prevalence of gambling disorder in the military is low. DOD bases its  determination of prevalence of gambling disorder and problem gambling  on Military Health System data and does not include other sources of  information, such as DOD-wide surveys and records of treatment  provided outside of the Military Health System. The active-duty  components of the DOD military services and the Coast Guard averaged  about 1.4 million servicemembers each year, and the Reserve  Component averaged about 0.8 million servicemembers each year.  Table 3 shows the number of DOD and Coast Guard servicemembers  who were seen through the Military Health System for pathological  gambling, gambling disorder, and problem gambling during fiscal years  2011 through 2015.
The Defense Health Agency compiles these problem gambling and  gambling disorder data in the Military Health System Data Repository, which includes data on clinical interactions between DOD and Coast  Guard servicemembers and health-care professionals in military  treatment facilities and in civilian facilities through the TRICARE system,  and DOD health officials told us that they use these data to determine the  prevalence of gambling disorder. The prevalence of alcohol-related  disorders is higher by comparison, according to data from the Military  Health System Data Repository. For example, in fiscal years 2011  through 2015, 107,702 DOD and Coast Guard active-duty  servicemembers and 10,896 Reserve Component servicemembers were  seen through the Military Health System for alcohol-related disorders.
The Military Health System Data Repository does not include data on  DOD and Coast Guard servicemembers who received treatment or  counseling for gambling disorder or problem gambling outside of the  Military Health System. For example, Marine Corps officials stated that  Marines may receive short-term, nonmedical counseling at Marine Corps  Community Services Behavioral Health Substance Abuse Counseling  Centers, and these interactions will be reflected in the Military Health  System Data Repository only when the patient also visits a military  treatment facility for this issue. Additionally, the Military Health System  Data Repository does not capture data regarding treatment received by  servicemembers of the Reserve Component unless they are on active  orders for more than 30 days, need treatment for a line-of-duty injury or  condition, or enrolled in TRICARE Reserve Select. According to DOD  officials, Reserve Component medical personnel also are unlikely to learn  about an individual’s gambling problem because of the short periods that  nonactivated members of the Reserve Component spend in uniform,  which limits the ability of the medical personnel to refer them for treatment  and counseling. DOD officials also told us that servicemembers who call  Military OneSource—a telephonic resource for servicemembers—for  referrals for gambling problems may be referred to a military treatment  facility or a TRICARE provider, but they also may be referred to local,  civilian treatment programs or support groups. For example,  servicemembers may seek treatment through state programs or from a  nearby Gamblers Anonymous chapter. DOD officials told us that they do  not collect data on the number of servicemembers who call Military  OneSource for problem gambling or gambling disorder, nor do they  collect data on gambling-related referrals.
section_title: Problem Gambling and Gambling Disorder Prevalence Data from Other Sources Provide Contextual Information, but Are Not Directly Comparable to Military Health System Data
paragraphs: DOD surveys of servicemembers, data on medical care provided by the  Department of Veterans Affairs, and reviews of literature provide  contextual information on the prevalence of problem gambling and  gambling disorder in the military, but these data are not directly  comparable to DOD clinical data. DOD’s 2002 Health Related Behaviors  Survey of the DOD active-duty population and the 2010–2011 survey of  the DOD Reserve Component populations asked respondents about their  problematic gambling behaviors, but the results of these surveys are not  directly comparable to the DOD data, as shown in table 3. An estimated  1.2 percent (with a standard error of 0.2 percent) of active-duty military  personnel met the Diagnostic and Statistical Manual of Mental Disorders,  Fourth Edition, criteria for lifetime prevalence of probable pathological  gambling based on the self-administered survey of health-related  behaviors. Similarly, an estimated 1.3 percent (with a standard error of  0.1 percent) of Reserve Component respondents to the 2010–2011 DOD  Health Related Behaviors Reserve Component Survey met the  Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,  criteria for lifetime prevalence of probable pathological gambling. These  survey data are not comparable to DOD data presented in table 3 for  three reasons. First, the surveys were based on the Diagnostic and  Statistical Manual of Mental Disorders criteria that were applicable at the  time of the surveys, which, as discussed above, differed from the current  version in the disorder’s categorization and the number of diagnostic  criteria. Second, the surveys were based on anonymous self- administered questionnaires, while gambling disorder and problem  gambling clinical data were based on clinicians’ interactions with  servicemembers. Third, the estimate of lifetime prevalence does not  indicate current prevalence. Further, according to the most-recent edition  of the Diagnostic and Statistical Manual of Mental Disorders, a majority of  individuals with gambling disorder do not seek out treatment, which  implies that servicemembers may report problematic gambling behaviors  on an anonymous survey but not seek treatment. DOD stated that since  2002 more-recent versions of the active-duty Health Related Behavior  Survey, which occurs approximately every 3 years, have not asked about  gambling behaviors because previous iterations of the survey in 1992 and  1998 showed similar low rates of gambling behaviors for the active-duty  force, and DOD officials stated that they had sought to shorten the length  of the survey. However, the Health Related Behavior Surveys have  regularly included at least one question regarding financial difficulties,  which may indicate a gambling problem.
The Department of Veterans Affairs also collects data on the number of  former servicemembers who visit the Veterans Health Administration for  treatment for problem gambling or gambling disorder. However, Veterans  Health Administration officials stated that they do not have data on how  many individuals developed gambling problems during their military service. Data from the Veterans Health Administration showed that  10,012 veterans were seen for problem gambling or gambling disorder  through the Veterans Health Administration in fiscal years 2011 through  2015. On average, 8.9 million veterans were enrolled in the Veterans  Affairs health-care system each year. However, Department of Veterans  Affairs officials stated that they do not systematically collect information  on which facilities provide services for treating gambling disorder, and  that there is not a required screening program for veterans with problem  gambling or gambling disorder.
In addition, we conducted two reviews of literature on the prevalence of  problem gambling and gambling disorder: one on the U.S. general adult  population and one on the U.S. military population. For the U.S. general  population review, we identified only one report within our scope; that  study estimated the prevalence of past-year problem gambling to be 4.6  or 5.0 percent of the population and the prevalence of past-year  pathological gambling to be 2.4 or 1.0 percent of the population (using the  South Oaks Gambling Screen–Revised and the Diagnostic Interview  Schedule-IV instruments, respectively). This study is not directly  comparable to Military Health System data because it analyzed the  results of phone-based surveys of the U.S. general population; on the  other hand, Military Health System data are based on clinical interactions  of the U.S. military population. In a separate literature search on the  prevalence of problem gambling and gambling disorder in the U.S.  military, three of the four results were the previously discussed DOD  Health Related Behavior Surveys. The fourth result was a small,  nonrepresentative, 6-month self-report questionnaire study of incoming  patients at a Navy outpatient psychiatric clinic that indicated 1.9 percent  of 360 military personnel were diagnosed with a lifetime prevalence of  pathological gambling using the South Oaks Gambling Screen.  However, this is the prevalence among those patients voluntarily  presenting to a psychiatric clinic who agreed to complete the questionnaire and is not a valid indicator of prevalence among all clinic  patients, the base population, the military service, or the military as a  whole.
section_title: DOD and the Coast Guard Do Not Systematically Screen for Gambling Disorder, but DOD and Coast Guard Medical Personnel State That They Address Gambling Disorder in Line with Current Medical Practices
subsections: section_title: DOD and the Coast Guard Do Not Systematically Screen for Gambling Disorder
paragraphs: DOD and the Coast Guard do not systematically screen for gambling  disorder through DOD’s annual health assessment or any other type of  periodic health screening of servicemembers. DOD Instruction 6025.19,  Individual Medical Readiness, which is applicable to the military services,  including the Coast Guard, requires military departments to screen  servicemembers for physical and mental health conditions using an  annual screening tool called the Periodic Health Assessment. DOD and  the Coast Guard use the annual Periodic Health Assessment to assess  each servicemember’s overall health and medical readiness and to  initiate preventive services, as warranted. The Periodic Health  Assessment assesses health conditions that may limit or prevent a  servicemember from deploying, and the behavioral-health section asks  specific questions on prescription drugs, alcohol consumption, and post- traumatic stress. However, there are no questions on the assessment that explicitly mention gambling that would allow for medical personnel to  screen for gambling disorder—an addictive disorder medically similar to  substance abuse, as previously discussed. Furthermore, DOD Instruction  6490.07, Deployment-Limiting Medical Conditions for Service Members  and DoD Civilian Employees, which a 2013 DOD memorandum  supplements, describes mental-health conditions that would limit or  prevent personnel from deploying. These conditions may include, but are  not limited to, individuals with substance-use disorders undergoing active  treatment as well as those at risk for suicide.
As part of the Department of Health and Human Services, the Substance  Abuse and Mental Health Services Administration aims to reduce the  effect of substance abuse and mental illness and to focus the nation’s  public-health agenda on these issues as well as addiction. They provide  some examples for screening-question sets that are used to identify  potential gambling disorders in the general population by health-care  personnel that could be used on the DOD Periodic Health Assessment.  One example is the South Oaks Gambling Screen that consists of  questions in categories such as frequency of gambling, type of gambling,  and patient perceptions. Another screening example is the “Lie/Bet”  screening which requires just two questions:  1.  Have you ever had to lie to people important to you about how much  you gambled?  2.  Have you ever felt the need to bet more and more money?
DOD and Coast Guard officials stated that they do not screen for  gambling disorder because they focus military health surveillance on  mental-health disorders that are high risk to overall readiness, high  volume, and have validated measures for assessment. However, while  gambling disorder is a comparatively low-volume disorder, the  preoccupation with gambling, financial hardship, and increased risk of  suicide can pose a risk to individual readiness and has been identified in  the recent Diagnostic and Statistical Manual of Mental Disorders as  sharing similar symptoms and treatment methods with substance-use  disorders. According to DOD Instruction 6490.07, individuals with clinical  psychiatric disorders with residual symptoms that impair duty  performance are precluded from contingency deployment unless a waiver  is granted. In addition, a 2013 Assistant Secretary of Defense for Health  Affairs memorandum that supplements this instruction also states that  individuals with mental disorders should demonstrate a pattern of stability  without significant symptoms or impairment for at least 3 months prior to  deployment, unless a waiver is granted. It also states that  servicemembers diagnosed with substance-use disorders should not  deploy if doing so would interrupt active treatment. Therefore, for  servicemembers with gambling disorder, it may be difficult to maintain  individual deployment readiness and perform duties effectively. For  example, according to the 2013 Diagnostic and Statistical Manual of  Mental Disorders, gambling disorder is a risk factor for suicide attempts,  with roughly 17 percent of those in treatment attempting suicide at some  point. In addition, data from the DOD Suicide Event Report show there  were 8 suicides and 13 suicide attempts related to gambling behavior by  servicemembers in fiscal years 2011–2015.
Additionally, gambling disorder is difficult to detect because there are no  objective laboratory tests, such as urinalysis for substance use, to identify  individuals with potential gambling disorder, according to the American  Society of Addiction Medicine. For this reason, screening is even more  important to identifying servicemembers that may need assistance. In  addition, military servicemembers may also be reluctant to seek mental- health treatment because of perceived stigma. According to the 2013  Diagnostic and Statistical Manual of Mental Disorders, less than 10  percent of individuals with gambling disorder seek treatment. Similarly,  the Substance Abuse and Mental Health Services Administration has  indicated that screening is important because few seek treatment directly  for gambling disorder, and they instead seek treatment for other problems  such as depression. Gambling disorder can also be easier to hide than  other addictions, according to the American Society of Addiction  Medicine. Without proactively asking gambling disorder questions as part  of screening to help detect gambling disorder, DOD and the Coast Guard  risk not identifying affected servicemembers and providing assistance for  the disorder. When coupled with higher suicide rates, high rate of co- occurrence of other mental disorders, and the potential for critical  financial situations, the effect that gambling disorder can have on  individual readiness and the military family could be significant.
section_title: DOD and Coast Guard Medical Personnel State That They Use Current Diagnostic Standards to Diagnose Gambling Disorder and They Treat It Using Established Substance-Use Addiction Treatment Programs
paragraphs: According to Defense Health Agency and service medical officials, both  DOD and Coast Guard medical personnel use the Diagnostic and  Statistical Manual of Mental Disorders criteria to diagnose  servicemembers with gambling disorders, and they employ the same  evidence-based practices, such as cognitive behavioral therapy, to treat  the disorder. DOD and Coast Guard medical providers diagnose and  treat servicemembers on a case-by-case basis in behavioral- and mental- health departments of military treatment facilities. DOD also has  dedicated outpatient programs for a variety of addiction and mental-health  disorders. For example, the Navy has developed the “Centering Heroes  on Integrating Changes and Enhancing Strength” program, in which  medical professionals treat individuals with gambling disorder as well as  other addictions. This program also includes treatment for post-traumatic  stress and other mental-health disorders. In addition, each service  provides counseling services on most bases where servicemembers can  seek help and receive limited nonmedical treatment in the form of  counseling sessions or other forms of support that do not require a  medical diagnosis. Servicemembers may also be referred to civilian  treatment facilities through TRICARE if inpatient treatment is required, as  there are few residential DOD addiction treatment programs and none  operated by the Coast Guard. Much like DOD, the competencies and  resources of civilian facilities vary by location, but all locations that have  state-certified mental-health providers are able to treat those with  gambling disorder.
In addition to mental-health treatment, clinicians with whom we spoke  stated that financial counseling is also an important part of gambling  disorder treatment. Servicemembers with gambling disorder would be  provided with financial counseling services in addition to mental-health  treatment. DOD and Coast Guard officials stated that financial counseling  programs are available to all servicemembers and their families. For  example, the Navy operates the Fleet and Family Support Program that  provides financial counseling services on all naval installations and is free  to all servicemembers and their families.
According to DOD officials, military and civilian clinicians may have  certifications or training specific to the treatment of gambling disorder, but  it is not required to have these certifications or training to provide  treatment. As long as the clinician maintains state-required licenses to  treat individuals with mental-health disorders, the clinician is able to  assess, diagnose, and treat conditions within the scope of practice  determined by the state license and can treat gambling disorder with the  training the clinician has. DOD mental-health providers include  psychologists, psychiatrists, mental-health nurse practitioners, licensed  social workers, and alcohol and drug counselors. Additional or  supplemental training specific to gambling is made available to clinicians.  For example, the Naval Medical Center San Diego offers continuing  medical education, which includes a session on the clinical management  of gambling disorder.
section_title: DOD and Coast Guard Guidance Does Not Address Gambling Disorder in a Similar Manner to Other Addictive Disorders
paragraphs: DOD and the Coast Guard do not have guidance that address gambling  disorder in a similar manner as other addictive disorders, such as  substance abuse. DOD Instruction 1010.04, Problematic Substance Use  by DOD Personnel, outlines education and awareness policies for all  DOD personnel, including commanders and nonmedical personnel, for  substance use disorders, but not for gambling disorder, and officials were  not aware of any other guidance that explicitly addressed gambling  disorder. DOD health officials stated that this instruction “implicitly”  covers gambling disorder; however, it refers only to problematic  substance use and does not reference gambling disorder. DOD defines  problematic substance use as the use of any substance in a manner that  puts users at risk of failing in their responsibilities to mission or family, or  that is considered unlawful by regulation, policy, or law. This definition  includes substance use that results in negative consequences to the  health or well-being of the user or others; or meets the criteria for a  substance use disorder. However, DOD servicemembers without detailed  knowledge of the 2013 Diagnostic and Statistical Manual of Mental  Disorders that recategorized gambling disorder as an addiction rather  than a behavior issue may not be able to translate its application to  gambling disorder. In addition, the instruction establishes guidelines for  problematic substance use, such as its incompatibility with readiness and  military discipline, the goal of substance treatment programs to maintain  force health and readiness, and implications for eligibility for access to  classified information. As previously discussed, gambling disorder is the  only non-substance-related condition categorized as an addiction in the  Diagnostic and Statistical Manual of Mental Disorders. The non- substance-use terminology is significant because of its absence  throughout the DOD instruction, while problematic substance use is a  repetitive theme. Although medical personnel with whom we spoke are  aware of the change in the treatment of gambling disorder between the  manual’s editions, this change is not reflected in the guidance for DOD’s  nonmedical personnel that would help ensure that servicemembers are  referred to medical providers for gambling problems.
We also found that the DOD military services—Army, Marine Corps, Air  Force, and Navy—do not include gambling disorder in their substance  abuse policy and guidance documents:
Army: Army Regulation 600-85, The Army Substance Abuse Program,  provides alcohol- and drug-abuse prevention and control policies, as  well as individual responsibilities. Officials from the Army Substance  Abuse Program told us that the program does not provide services to  servicemembers with gambling disorder. However, Army Regulation  600-85 derives its program authority from DOD Instruction 1010.04,  which, according to Defense Health Agency officials, implicitly applies  to gambling disorder and, therefore, requires the Army substance- abuse program to include gambling disorder as well. This example  indicates that there is not a clear understanding whether DOD  Instruction 1010.04 covers gambling disorder within the Army.
Navy: The Navy provides its policy for alcohol- and drug-abuse  prevention in Chief of Naval Operations Instruction 5350.4D, Navy  Alcohol and Drug Abuse Prevention and Control. In addition, the Navy  also uses the Bureau of Medicine and Surgery Instruction 5353.4B,  Standards for Provision of Substance Related Disorder Treatment  Services, to update a uniform set of standards for the provision of  substance-related disorder treatment services within the Department  of the Navy. Both of these Navy documents list the current version of  the Diagnostic and Statistical Manual of Mental Disorders as a  reference, but neither discusses any specific information on gambling  disorder.
Air Force: Air Force Instruction 44-121, Alcohol and Drug Abuse  Prevention and Treatment (ADAPT) Program, outlines the Air Force’s  policies for its alcohol- and drug-abuse prevention and treatment  program. The Air Force guidance does list the 2013 Diagnostic and  Statistical Manual of Mental Disorders as a reference, but does not  specifically mention gambling disorder.
Marine Corps: Marine Corps Order 5300.17, Marine Corps Substance  Abuse Program, provides policy and procedural guidance to  commanders, substance-abuse personnel, and Marines to effectively  use and carry out the Marine Corps substance-abuse program, and  so that commanders may improve their capability to treat and prevent  alcohol- and drug-abuse problems. This guidance does reference the  2013 Diagnostic and Statistical Manual of Mental Disorders, but does  not include any policy or guidance information on gambling disorder.
The Coast Guard, which DOD Instruction 1010.04 does not cover, has  three documents that provide guidance and policy to both medical and  nonmedical personnel on substance abuse, but Coast Guard officials  stated that they do not have any policy that specifically discusses  gambling disorder. However, they did indicate that, from a medical  perspective, gambling disorder has multiple similarities with substance  abuse and is treated in accordance with Commandant Instruction  M6200.1C, Coast Guard Health Promotion Manual. While this document  does not list the Diagnostic and Statistical Manual of Mental Disorders as  a reference, it does mention it in several sections primarily in regard to  diagnostic codes. Commandant Instruction M1000.10, Coast Guard Drug  and Alcohol Abuse Program, details the Coast Guard’s general  administrative policies on the substance-use program, that although does  not mention gambling disorder, is currently under revision to remove all  reference to medical issues. Although Commandant Instruction M6000.1F  Coast Guard Medical Manual, does refer to pathological gambling (the  former name of gambling disorder), the manual classifies the condition as  an impulse-control disorder, not as an addiction as prescribed by the  most recent edition of the Diagnostic and Statistical Manual of Mental  Disorders. According to Commandant Instruction M6000.1F, a diagnosis  of an impulse-control disorder may warrant separation from the Coast  Guard, whereas certain types of substance use disorders are addressed  in the Coast Guard Drug and Alcohol Abuse Program. Thus, gambling  disorder is not being treated in the same manner as other addictive  disorders, such as alcohol-use disorder.
According to GAO Standards for Internal Control in the Federal  Government, management must communicate high-quality information  internally to enable personnel to perform key roles in achieving  objectives, addressing risks, and supporting the internal control system.  In addition, these standards require that DOD communicates high-quality  information throughout the entity using established reporting lines. High- quality information is to be communicated down, across, up, and around  reporting lines to all levels of the entity. DOD and the Coast Guard do not  explicitly communicate their policies to unit commanders and other  nonmedical personnel that gambling disorder should be addressed in the  same manner as other addictive disorders, such as substance-use  disorders, that is, through each service’s substance-use programs or  civilian providers through TRICARE.
DOD has taken the initial step in communicating high-quality information  regarding the diagnostic classification of gambling disorder as an  addiction to its medical personnel through a memorandum in December  2013 directing the adoption of the recent edition of the Diagnostic and  Statistical Manual of Mental Disorders. Given this action, DOD health  officials stated that DOD Instruction 1010.04 “implicitly” covers gambling  disorder, but this implied knowledge would only likely be derived from a  detailed awareness of the Diagnostic and Statistical Manual of Mental  Disorders publication and its diagnostic classifications. Coast Guard  officials told us they do not have a formal instruction on gambling  disorder. Additionally, because the Coast Guard’s medical manual,  Commandant Instruction M6000.1F, is based on the previous edition of  the Diagnostic and Statistical Manual of Mental Disorders, pathological  gambling is not classified as an addiction. When the issue of gambling  disorder was raised with DOD and Coast Guard health-care officials, the  officials agreed that, while their guidance on substance use technically  covers problem gambling, the guidance would help clarify if it was revised  to explicitly include problem gambling. However, the officials at this point  do not have any plans to update the guidance accordingly.
By not explicitly including mention of gambling disorders in its guidance  for problematic substance use, the Office of the Secretary of Defense  (OSD) and the military services, including the Coast Guard, are not  communicating necessary policy, education, and awareness information  to nonmedical personnel. As currently written, OSD and military service,  including Coast Guard, personnel, such as unit commanders, do not have  guidance that instructs them to refer personnel with gambling problems  for medical evaluation of a potentially addictive disorder, thus possibly  preventing personnel from receiving necessary and appropriate medical  assistance. This could lead to administrative or disciplinary actions that  address only the misconduct associated with the behavior. Also, gambling  disorder is one of the factors that can also lead to the revocation or failing  of a background security investigation for security clearances, thus  affecting individual readiness and the capacity of the organization to meet  its mission. While gambling disorder is a comparatively low-volume  disorder, DOD instructions acknowledge that mental health issues may  affect individual readiness. Gambling disorder may also be a risk to  national security. A 2006 memorandum from the Under Secretary of  Defense for Intelligence stated that compulsive gambling is a concern as  it may lead to financial crimes including espionage. Absent explicit  guidance, OSD, the DOD military services, and the Coast Guard risk not  being able to identify and provide appropriate treatment and counseling to  DOD and Coast Guard servicemembers afflicted by gambling disorder  and mitigate or prevent individual readiness issues.
section_title: Conclusions
paragraphs: Gambling disorder has been identified within the medical community as  an addiction similar to drug or alcohol use. Gambling disorder can also  develop in conjunction with other addictions. Gambling disorder is a risk  factor for suicide—and according to the Diagnostic and Statistical Manual  of Mental Disorders about 17 percent of individuals in treatment for  gambling disorder attempt suicide at some point in their life. A person with  gambling disorder may also have financial or legal issues that, combined  with other addictions, could spiral out of control. According to the  American Psychiatric Association, only 10 percent of individuals with  gambling disorder seek treatment. However, DOD and the Coast Guard  do not include gambling disorder questions as part of a systematic  screening process for identifying servicemembers who may have a  gambling disorder. Implementing systematic screening for gambling  disorder may help to identify servicemembers with problem gambling or  gambling disorder. Without incorporating medical screening questions  specific to gambling disorder, gambling problems may not be identified  until they reach a critical point affecting the individual’s readiness in  addition to harming the financial situation of the servicemember and,  potentially, national security.
In addition, guidance for nonmedical personnel does not discuss  gambling disorder as an addiction; therefore, DOD and service guidance  do not direct nonmedical personnel that gambling should be treated in a  medical manner. Explicitly including gambling disorder in guidance would  identify it as a medical issue for nonmedical personnel. Communicating  this change throughout DOD would make clear the proper steps to be  taken to address this addiction before it becomes an administrative or  disciplinary issue. Given the importance of and concern with maintaining  individual readiness among servicemembers, without updated guidance  to nonmedical personnel, DOD and the Coast Guard may not be able to  increase awareness that gambling disorder is a medical condition and  that individuals with a potential gambling problem should be referred to  appropriate medical officials.
section_title: Recommendations for Executive Action
paragraphs: We recommend that the Secretary of Defense direct the Under Secretary  of Defense for Personnel and Readiness to take the following two actions:  Incorporate medical screening questions specific to gambling disorder  as part of a systematic screening process across DOD, such as  DOD’s annual Periodic Health Assessment, for behavioral and  mental-health issues.
Update DOD Instruction 1010.04, Problematic Substance Use by  DOD Personnel, to explicitly include gambling disorder as defined in  the 2013 Diagnostic and Statistical Manual of Mental Disorders.
We recommend that the Secretary of Defense direct the Secretary of the  Army to take the following action:
Update Army Regulation 600-85, The Army Substance Abuse  Program, to explicitly include gambling disorder.
We recommend that the Secretary of Defense direct the Secretary of the  Navy to take the following action:
Update Naval Operations Instruction 5350.4D, Navy Alcohol and Drug  Abuse Prevention and Control, to explicitly include gambling disorder.
We recommend that the Secretary of Defense direct the Secretary of the  Air Force to take the following action:
Update Air Force Instruction 44-121, Alcohol and Drug Abuse  Prevention and Treatment (ADAPT) Program, to explicitly include  gambling disorder.
We recommend that the Secretary of Defense direct the Commandant of  the Marine Corps to take the following action:  Program, to explicitly include gambling disorder.
We recommend that the Commandant of the Coast Guard take the  following two actions:
Update Commandant Instruction M6000.1F, Coast Guard Medical  Manual, to classify gambling disorder as an addiction and not as an  impulse control issue.
Update Commandant Instruction M1000.10, Coast Guard Drug and  Alcohol Abuse Program, to explicitly include gambling disorder.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to DOD and the Department of  Homeland Security for review and comment. In written comments,  reproduced in appendix III, DOD concurred with five recommendations,  did not concur with one recommendation, and provided two substantive  technical comments for our consideration. In written comments,  reproduced in appendix IV, the Department of Homeland Security  concurred with both of the recommendations directed to the Coast Guard  and, separately, provided technical comments, which we incorporated as  appropriate.
DOD concurred with the five recommendations to update DOD and  military service policies to explicitly include gambling disorder as defined  in the 2013 Diagnostic and Statistical Manual of Mental Disorders.  However, DOD did not concur with our recommendation to incorporate  medical screening questions specific to gambling disorder as part of a  systematic screening process across DOD, such as in DOD’s annual  Periodic Health Assessment for behavioral and mental-health issues. In  its written comments, DOD stated that there is no evidence to suggest  that gambling disorder is a high-prevalence disorder in DOD and that it is  impractical to screen for every low-prevalence disorder. DOD noted that  there are numerous mental health disorders with similar or higher  prevalence (e.g., bipolar disorder, psychotic disorders, and obsessive- compulsive disorder) for which DOD does not routinely screen. DOD  stated that screening for additional conditions in the Periodic Health  Assessment adds time and resources and would require an additional  burden on the servicemember and provider. DOD noted that priority to  screen for a disorder is given to high-risk, high-volume, and problem- prone disorders with validated measures for assessment.
We disagree that DOD can definitively conclude that gambling disorder  and problem gambling among DOD and Coast Guard servicemembers  are “low prevalence,” and therefore related screening questions should  not be a part of a systematic screening. First, as we noted in our report,  DOD prevalence data are limited to those compiled in the Military Health  System Data Repository, which reflects only DOD and Coast Guard  servicemembers who seek care for gambling-related issues through the  TRICARE system, and excludes information from sources outside of the  Military Health System. These sources include, for example, nonmedical  counseling that a Marine might receive from the Marine Corps Community  Counseling Program, Behavioral Health Program, or Consolidated  Substance Abuse Counseling Center; from treatment or counseling  provided at civilian facilities outside the TRICARE system; or from  counseling received at local support groups, such as Gamblers  Anonymous. Second, the data do not reflect care received by Reserve  Component members unless they are on active orders for more than 30  days. Third, the data does not account for those who do not seek care  inside or outside the TRICARE system. Screening specifically for  gambling disorder takes on particular importance because, as noted in  the 2013 Diagnostic and Statistical Manual of Mental Disorders (i.e., the  primary source used by civilian and military mental-health-care providers  to diagnose mental disorders), less than 10 percent of individuals with  gambling disorder seek help and because, according to the American  Society of Addiction Medicine, gambling disorder can be easier to hide  than other addictions. According to the 2013 Diagnostic and Statistical  Manual of Mental Disorders, persons diagnosed with gambling disorder  exhibit a preoccupation with gambling, are at risk of a higher rate of a co- occurrence of other mental disorders, are at increased risk of suicide, and  are at risk of critical financial situations. We note that these issues can  pose a significant risk to individual readiness and, potentially, to national  security.
Furthermore, DOD stated that the two examples for screening-question  sets that we cite in our report, the “Lie/Bet” screening and the South Oaks  Gambling Screen are not appropriate diagnostic tools because the  “Lie/Bet” screening has scored poorly as a diagnostic screening tool and  the South Oaks Gambling Screen has a high rate of false positives and  would result in an additional burden to servicemembers and the provider.  To clarify, in our recommendation we do not limit DOD to using these two  examples for screening-question sets as the specific questions that we  are recommending that DOD incorporate as part of a systematic  screening process across DOD. DOD further stated that it is actively  engaged in screening servicemembers for financial difficulties and other  symptoms often associated with gambling through the Health Related  Behavior Survey and the Periodic Health Assessment. As we note in our  report, limiting screening to questions about financial difficulties will likely  not result in the identification of individuals with gambling disorder before  it affects individual readiness. Due to each of these reasons, we continue  to believe that our recommendation to incorporate medical screening  questions specific to gambling disorder as part of a systematic screening  process across DOD is valid.
DOD also included two substantive technical comments as part of its  written response. First, DOD stated that it is unclear what is within our  scope for inclusion of epidemiological studies on the prevalence of  gambling disorder. DOD felt the prevalence percentages in the Kessler  study (2008) should have been included as part of our results. We did  identify this study in our literature search and, although it was published  after 2006, the data were collected between 2001 and 2003, which is  outside the time frame of our review, as stated in appendix II. To address  DOD’s comment, we included more specific language related to the  scope of the literature search in the abbreviated scope and methodology  section earlier in the report. Second, DOD noted that our statement  regarding 8 suicides and 13 suicide attempts related to gambling behavior  should be put into context. Specifically, DOD stated that, according to  DOD Suicide Event Reporting data, only 0.6 percent of all suicides and  0.3 percent of all attempts had a history of problem gambling. We did not  address this comment in the report because the contextualization does  not apply to the entire scope of the population included in this review.  DOD Suicide Event Reporting data do not include the entire reserve  component population—as we stated in the report—only those in an  active-duty status. As a result, including these percentages would not be  appropriate in this case.
subsections: section_title: Department of Homeland Security
paragraphs: The Department of Homeland Security concurred with the  recommendations to update Commandant Instruction M6000.1F and  Commandant Instruction M1000.10 to explicitly include gambling  disorder. With respect to Commandant Instruction M1000.10, they stated  that it is currently under revision and being updated to remove all  references to medical issues and associated terminology, including those  related to gambling disorder. Once revised, the manual will strictly focus  on administrative separation policy based on misconduct associated with  alcohol and drug abuse and will meet the intent of our recommendation.
We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, the Under Secretary of Defense  for Personnel and Readiness, the Chairman of the Joint Chiefs of Staff,  the Secretaries of the military departments, the Secretary of Homeland  Security, and the Commandant of the Coast Guard. The report is also  available at no charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-3604 or farrellb@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 who made key contributions to this report  are listed in appendix V.
section_title: Appendix I: Number and Location of Slot Machines by Military Service on Department of Defense Military Installations Overseas
paragraphs: On certain overseas U.S. military installations, the Department of Defense  (DOD) has slot machines both to generate revenue to fund other  recreational activities and to serve as a recreational opportunity for DOD  servicemembers, their adult family members, and local civilians with  access to the installations. The slot machines are generally located in  recreational centers, such as bowling alleys and clubs for officers and  enlisted personnel. As of July 31, 2016, DOD has 3,141 slot machines  located primarily on installations in Japan, the Republic of Korea, and  Germany, as shown in table 4.
The Army Recreation Machine Program, under the Army Installation  Management Command, operates slot machines on Army, Navy, and  Marine Corps installations. The Army operates most of the slot machines  on Navy installations and all of the slot machines on Marine Corps  installations in accordance with two memorandums of agreement. The  Army’s revenue generated from slot machines comprises the revenue  from slot machines on Army installations and a share of the revenues  generated from slot machines on Navy and Marine Corps installations.  The Navy and Marine Corps receive a share of the revenues generated  from slot machines on their respective installations by mutual agreement  with the Army on a site-by-site basis. The Navy’s proceeds also include  revenue generated from Navy-operated machines on installations on  Diego Garcia. The Air Force Gaming Program, part of the Air Force  Personnel Center, operates all of the Air Force’s slot machines, and the  Air Force retains all of the revenue from these slot machines. The Army  and the Air Force pay for nonappropriated personnel, operation,  maintenance, and other overhead expenses related to the slot machines  out of their respective proceeds. The Navy pays only for personnel,  operation, maintenance, and other overhead expenses for the Navy- operated machines on Diego Garcia. Coast Guard installations overseas  do not have any slot machines.
According to data provided by DOD, in fiscal years 2011 through 2015,  DOD-run slot machines generated a total of $538.9 million in revenue.  DOD calculates this revenue, listed by service in table 5, by subtracting  payouts to gamblers from the amounts they paid to play.
section_title: Appendix II: Scope and Methodology
paragraphs: The scope of our review included all Department of Defense (DOD) and  Coast Guard offices responsible for oversight or administration of  gambling activities and medical commands or offices responsible for  diagnosing and treating gambling disorder. We included both the active  and reserve components, including the federal components of the  National Guard. Table 6 contains a list of the agencies and offices we  contacted during the course of our review.
To describe what is known about the prevalence of gambling disorder  among servicemembers in DOD and the Coast Guard (objective 1), we  analyzed the most-recent data from the Military Health System Data  Repository for fiscal years 2011–2015 for active duty servicemembers  from the military services, including the Coast Guard, and Reserve  Component servicemembers diagnosed with gambling disorder or seen  for problem gambling. To assess the reliability of these data, we sent a  questionnaire to officials from the Defense Health Agency, which  oversees the Military Health System Data Repository system, and  interviewed knowledgeable Defense Health Agency and service officials  about how the data are entered, collected, stored, and processed. We  also met with service mental-health providers to learn, among other  things, how they diagnose patients and enter their information into the  electronic health records. We also reviewed Military Health System Data  Repository documentation including the user’s guide and data dictionary.  We analyzed the summary data for accuracy and obvious errors, and we  found none. We found these data to be sufficiently reliable to show the  number of servicemembers seen for gambling disorder, pathological  gambling, or problem gambling in the Military Health System in fiscal  years 2011 through 2015.
In addition, we reviewed DOD’s most-recent health-related behaviors  surveys that included specific questions on gambling—conducted in 2002  for the active component and in 2010 and 2011 for the Reserve and  National Guard—to identify what is known about the prevalence of  problematic gambling behaviors among servicemembers. We analyzed  Department of Veterans Affairs data on the prevalence of problem  gambling and gambling disorder, interviewed cognizant officials, and  reviewed Department of Veterans Affairs medical record documentation.  We reviewed summary data for accuracy and obvious errors and  determined that the data were sufficiently reliable to report on the total  number of individuals diagnosed with gambling disorder or seen for  problem gambling in the Department of Veterans Affairs system. We also  conducted literature searches regarding the prevalence of problem  gambling and gambling disorder in the general population as well as the  military population. Specifically, for the military prevalence review, we  searched for studies reporting the prevalence of problem gambling within  the active and reserve (but not veteran) U.S. military population, including  the Coast Guard, in English-language professional journals, government  reports, and other published and unpublished papers published between  2001 and 2016. We searched Proquest, Proquest professional, SCOPUS,  Homeland Security Digital Library, ECO, ArticleFirst, WorldCat, PolicyFile,  and CQ hearings databases using search terms including variations and  Boolean combinations of the following terms: DOD, defense, armed  forces, military, army, navy, marines, air force, coast guard, service  members, gambling, betting, wagering, gaming, casino, prevalence, risks,  problem, diagnosed, treated, treatment, and financial counseling. This  search resulted in identifying 94 potentially relevant sources. We  screened these sources by reviewing the titles and abstracts and other  necessary bibliographic information and excluded sources that were out  of scope. We also reviewed bibliographies to identify additional sources,  but no new sources meeting the review criteria were identified. This  process resulted in identifying four sources for a complete review, of  which two were found not to contain relevant data. DOD also brought two  other DOD survey studies to our attention, making one of the search- based studies obsolete. Therefore, a total of three studies on military  prevalence were fully reviewed by two specialists and are described in  this report.
For the U.S. general-population prevalence review, we searched for  studies reporting the prevalence of problem gambling in the adult U.S.  general population in English-language professional journals, government  reports, and other published and unpublished papers published with data  collected in 2006 or later. We searched Proquest, Proquest professional,  SCOPUS, Homeland Security Digital Library, ECO, ArticleFirst, WorldCat,  PolicyFile, and CQ hearings databases using search terms including  variations and Boolean combinations of the following terms: Gambling,  gambler, problem, disorder, pathological, personality traits, prevalence,  risk, population, statistics, epidemiology, risk factors, frequency,  occurrence, rate, amount, occasion, incident, US, USA, and United  States. This search resulted in identifying 278 potentially relevant  sources. We then modified the criteria to include only studies with data  collected in or after 2006 because this would more closely match data  provided by DOD. We screened the sources by reviewing the titles and  abstracts and other necessary bibliographic information and excluded  sources that were out of scope. We also reviewed bibliographies to  identify additional sources, but no new sources meeting the review criteria  were identified. Thirty of the 278 sources were excluded because they  were redundant with other sources, and another 224 were excluded  because they were out of scope. Three sources from the 278 sources  were reviewed to identify new sources from their bibliographies but they  did not identify any new in-scope sources. This process resulted in  selecting 21 sources for a full review. However, upon reviewing them, 2  were found to be redundant with the previously discussed sources, and  18 were found to be out of scope or were review papers that did not  contain any new in-scope sources. Therefore, only one study was found  to meet the review criteria. That study was fully reviewed by two  specialists and is described in this report.
We also interviewed DOD and Coast Guard officials regarding the  prevalence and risk associated with gambling disorder. We also  conducted a literature search to identify any studies testing the  hypothesis that increased availability of gambling opportunities leads to  higher prevalence of problem gambling within the military population. We  initially searched for any studies reporting the correlation between  gambling availability and problem gambling in any adult general  population around the world, published in English-language professional  journals, government reports, and other published and unpublished  papers between 1996 and 2016. We conducted the initial search through  Proquest, SCOPUS, Web of Science, ECO, ArticleFirst, WorldCat, and  PolicyFile databases using search terms including variations and Boolean  combinations of the following terms: Gambling, gambler, problem,  disorder, pathological, availability, proximity, accessibility, near,  correlated, correlation, associated, association, causation, causal, and  related. This search identified 62 potentially relevant sources. Two were  excluded because they were redundant with another source or were  updated by another source already in our list, and another 39 were  excluded because they were found to be outside the original scope.  Based on the original search criteria, 21 were identified as potentially  relevant to be reviewed in full or for a bibliography review. We then  narrowed the criteria to any studies that reported estimates of the causal  effect of gambling availability on problem gambling in the U.S. military  population. We scanned the titles and abstracts and other necessary  bibliographic information, or fully reviewed sources, and determined that  no studies estimated the causal effect of gambling availability on problem  gambling in the U.S. military population.
To assess DOD’s and the Coast Guard’s approaches to screening,  diagnosing, and treating servicemembers for gambling disorder (objective  2), we reviewed the primary source of criteria for civilian and military  mental health professions for diagnosing patients with gambling  disorder—the American Psychiatric Association’s Diagnostic and  Statistical Manual of Mental Disorders, Fifth Edition. We reviewed  screening tools, such as the DOD’s Periodic Health Assessment to  identify whether they contained gambling disorder screening questions.  We also reviewed the American Society of Addiction Medicine treatment  criteria for addictive conditions, which assess the appropriate treatment  venue for each patient based on a multidimensional assessment; these  criteria were designed to define one national set of criteria for providing  outcome-oriented and results-based care in the treatment of addiction.  We interviewed mental-health officials, counselors, chaplains, and  personnel-security officials regarding the screening, diagnosis,  counseling, and treatment of individuals with gambling disorder. We also  conducted interviews with officials from both domestic and overseas  bases to determine practices and methods for diagnosing and treating  gambling disorder. We selected a nongeneralizable sample of four  military installations that represented all four DOD military services as  well as the Coast Guard and had reported at least one diagnosed case of  gambling disorder. We also selected these installations because they  were in close proximity to each other and close to GAO facilities in the  Southern California area, for cost reasons. In addition, the California  National Guard provided written responses to questions on the diagnosis  and treatment of gambling disorder. We selected and met with Army,  Navy, and Marine Corps representatives from four overseas bases in the  Republic of Korea and Japan that had reported more than one case of  gambling disorder or problem gambling in fiscal years 2011–2015 or had  DOD-run slot machines. Only two combatant commands have bases  with slot machines—U.S. Pacific Command and U.S. European  Command. We chose bases in U.S. Pacific Command, which had an  outpatient program for servicemembers with gambling disorder in  Okinawa, Japan. We were unable to arrange any meetings with Air Force  bases in the Republic of Korea and Japan. The overseas interviews  included chaplains stationed in this theater. We also reviewed DOD data  on suicide and suicide attempts that were related to gambling. At our  request, DOD conducted a search of its Suicide Event Report using the  following search terms: gamble, debt, bookie, casino, roulette, cards,  poker. The resulting numbers are underestimates of the number of  suicides and attempted suicides due to the way the data are collected;  the magnitude of the underestimation is unknown, according to DOD  officials. The officials reviewed the search results to ensure that the  content was indicative of monetary gambling (i.e., to ensure that “debt”  referenced gambling debts and not other sources of debt, such as credit  card debt or child support). Death-risk gambling (e.g., Russian Roulette)  was excluded in this analysis. The search identified 8 deaths due to suicide and 13 suicide attempts between fiscal years 2011 and 2015  where the behavioral-health professional completing the DOD Suicide  Event Report indicated any gambling behavior as a relevant antecedent  factor. DOD stated the occurrence of gambling behavior should not be  interpreted as being causally related to the occurrence of the suicide  behavior.
To evaluate the extent to which DOD and Coast Guard guidance address  gambling disorder in a manner similar to substance-use disorder, we  compared DOD’s and the Coast Guard’s respective policies on substance  use against GAO’s Standards for Internal Control in the Federal  Government. According to Standards for Internal Control in the Federal  Government, management must communicate high-quality information  internally to enable personnel to perform key roles in achieving  objectives, addressing risks, and supporting the internal control system.  We also reviewed DOD (including service-level) and Coast Guard  guidance pertaining to the screening, diagnosis, and treatment of  gambling disorder. We compared mental-health criteria documents such  as the 2013 Diagnostic and Statistical Manual of Mental Disorders to  DOD and service-level guidance to assess congruence. Our review  included the following documents:
DOD Instruction 1010.04, Problematic Substance Use by DOD  Personnel (Feb. 20, 2014);
DOD Instruction 6025.19, Individual Medical Readiness (June 9,
Army Regulation 600-85, The Army Substance Abuse Program (Dec.  28, 2012);
Chief of Naval Operations Instruction 5350.4D, Navy Alcohol and  Drug Abuse Prevention and Control (June 4, 2009);
Bureau of Medicine and Surgery Instruction 5353.4B, Standards for  Provision of Substance Related Disorder Treatment Services (July 6,  2015);
Air Force Instruction 44-121, Alcohol and Drug Abuse Prevention and  Treatment (ADAPT) Program (July 8, 2014);
Marine Corps Order 5300.17, Marine Corps Substance Abuse  Program (April 11, 2011);
Commandant Instruction M6200.1C, Coast Guard Health Promotion  Manual (July 9, 2015);
Commandant Instruction M1000.10, Coast Guard Drug and Alcohol  Abuse Program (Sept. 29, 2011);
Commandant Instruction M6000.1F, Coast Guard Medical Manual  (Aug. 22, 2014);
American Psychiatric Association, Diagnostic and Statistical Manual  of Mental Disorders, Fifth Edition; and
American Society of Addiction Medicine, The ASAM Criteria:  Treatment Criteria for Addictive, Substance-Related, and Co- Occurring Conditions, Third Edition.
We conducted this performance audit from December 2015 to January  2017 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
section_title: Appendix III: Comments from the Department of Defense
section_title: Appendix IV: Comments from the Department of Homeland Security
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Kimberly C. Seay (Assistant  Director), Mae Jones, Shari Nikoo, Matthew Sakrekoff, Paul Seely,  Michael Silver, and Eric Warren made major contributions to this report.