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 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 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. 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 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. 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. 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. 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. In addition to mental-health treatment, clinicians with whom we spoke  stated that financial counseling is also an important part of gambling  disorder treatment. 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. 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. 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. 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. 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.
Why GAO Did This Study

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.

What GAO Found

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.

What GAO Recommends

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.