Military Personnel: DOD and the Coast Guard Need to Screen for Gambling Disorder Addiction and Update Guidance

GAO-17-114 Published: Jan 30, 2017. Publicly Released: Jan 30, 2017.
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Highlights

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.

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.

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Recommendations

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.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Defense The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to 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.
Closed – Implemented
DOD non-concurred with this recommendation. However, the FY 2019 National Defense Authorization Act (NDAA) mandated that DOD implement this recommendation. According to Senate staff, they included this provision in the FY 2019 NDAA as a result of our review and since DOD non-concurred with the recommendation. As of August 2019, DOD had modified the Health Related Behaviors Survey (HRBS) to include questions on gambling and DOD and the Services were in the process of updating the electronic Periodic Health Assessment (PHA) assessment forms to capture the gambling screening data required by the legislation. In September 2022, we obtained a copy of a DOD report to Congress in response to the provisions of the FY 2019 NDAA that addressed this recommendation. Specifically, in July 2022, DOD issued a report to the Congressional Armed Services Committees that addressed the inclusion of screening questions for gambling disorder in the annual PHA for members of the Armed Forces and the HRBS of active duty and Reserve Component personnel. It states that the Department of Defense incorporated screening questions for gambling disorder into the PHA and HRBS, and data were collected for a 1-year period in accordance with section 733 of the NDAA for FY 2019. It further states that DOD will continue to screen for gambling disorder in the PHA and HRBS in order to monitor potential long-term changes in rates of gambling disorder in the military population. Explicitly including screening questions on gambling disorder in the PHA and HRBS meets the intent of our recommendation. By implementing our recommendation, DOD may now be better able to identify affected servicemembers and provide assistance for the disorder.
Department of Defense The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to 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.
Open
DOD concurred with this recommendation. As of July 2022, DOD stated that DOD Instruction 1010.04 will be updated to prevent and eliminate problematic alcohol use, substance use, and addictive behavioral problems to include gambling. Gambling addictions will be treated similarly to other behavioral addictions. DOD further stated that the updated to this instruction is currently in internal coordination and estimated to be completed by December 2022. We will continue to follow up on the status of this recommendation.
Department of Defense The Secretary of Defense should direct the Secretary of the Army to update Army Regulation 600-85, The Army Substance Abuse Program, to explicitly include gambling disorder.
Closed – Implemented
DOD concurred with this recommendation. As of August 2021, the Army provided an update to this recommendation. Specifically, in July 2020, Army Regulation 600-85 was updated to explicitly include gambling disorder. We believe this update meets the intent of our recommendation.
Department of Defense The Secretary of Defense should direct the Secretary of the Navy to update Naval Operations Instruction 5350.4D, Navy Alcohol and Drug Abuse Prevention and Control, to explicitly include gambling disorder.
Closed – Implemented
DOD concurred with this recommendation. In March 2022, the Navy published an updated version of OPNAV Instruction 5350.4E on Alcohol and Drug Abuse Prevention and Control that explicitly included gambling disorder. Specifically, chapter 6 titled Gambling Disorder includes gambling disorder along with alcohol and drug use. Explicitly including gambling disorder in the Navy's instruction on Alcohol and Drug Abuse Prevention and Control meets the intent of our recommendation. By implementing our recommendation, the Navy will be able to identify and provide appropriate treatment and counseling to servicemembers affected by gambling disorder and mitigate or prevent individual readiness issues.
Department of Defense The Secretary of Defense should direct the Secretary of the Air Force to update Air Force Instruction 44-121, Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program, to explicitly include gambling disorder.
Closed – Implemented
DOD concurred with this recommendation. In July 2018, the Air Force updated AFI 44-121 to include gambling disorder with other addictive behaviors.
Department of Defense The Secretary of Defense should direct the Commandant of the Marine Corps to update Marine Corps Order 5300.17, Marine Corps Substance Abuse Program, to explicitly include gambling disorder.
Closed – Implemented
DOD concurred with this recommendation. In June 2018, the Marine Corps updated MCO 5300.17 to include gambling disorder.
United States Coast Guard The Commandant of the Coast Guard should update Commandant Instruction M6000.1F, Coast Guard Medical Manual, to classify gambling disorder as an addiction and not as an impulse control issue.
Open
The U.S. Coast Guard/DHS concurred with this recommendation. As of July 2022, according to a Coast Guard official, Revision G of Commandant Instruction M6000.1F, which includes the classification of gambling disorder diagnosis as an addiction, is under review and expected to enter concurrent clearance this fall. Estimated promulgation of the manual is before the end of calendar year 2022.
United States Coast Guard The Commandant of the Coast Guard should update Commandant Instruction M1000.10, Coast Guard Drug and Alcohol Abuse Program, to explicitly include gambling disorder.
Closed – Implemented
The U.S. Coast Guard/DHS concurred with this recommendation. In June 2018, Commandant Instruction M1000.10 was updated to include gambling disorder.

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