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

Letter

Background

Governance and Structure of the Military Health System

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.

Behavioral Health Definitions Regarding Gambling

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.

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

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.

Problem Gambling and Gambling Disorder Prevalence Data from Other Sources Provide Contextual Information, but Are Not Directly Comparable to Military Health System Data

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.

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

DOD and the Coast Guard Do Not Systematically Screen for Gambling Disorder

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.

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

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.

DOD and Coast Guard Guidance Does Not Address Gambling Disorder in a Similar Manner to Other Addictive Disorders

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.

Conclusions

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.

Recommendations for Executive Action

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.

Agency Comments and Our Evaluation

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.

Department of Homeland Security

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.

Appendix I: Number and Location of Slot Machines by Military Service on Department of Defense Military Installations Overseas

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.

Appendix II: Scope and Methodology

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.

Appendix III: Comments from the Department of Defense

Appendix IV: Comments from the Department of Homeland Security

Appendix V: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

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.