Recently, I co-authored a response letter to the editor of Military Medicine, on a published article titled “A Meta-Review to Guide Military Screening and Treatment of Gambling Problems.” The article, written by researchers from New York University’s Family Translational Research Group, reviewed the basis for screening for gambling disorder in the military and addressed the difficulties that the Department of Defense (DoD) experiences with this issue. The authors concluded that ‘well-meaning politicians, lobbying groups, and accountability report writers’ left the DoD with ‘no choice’ but to resume screening and set out to feel they should provide evidence-based practices for doing so. They argued that the tools currently used for screening are ineffective because they show a low prevalence (i.e., not many people report gambling issues) and moderate sensitivity (they don’t always pick up on the issue), and instead suggested gambling disorder should only be screened for if there’s a strong suspicion.
I disagree with this conclusion for three issues:
- A growing body of work suggests that prevalence rates of services members are much higher than the reported 0.04% to 1.7% found in DoD and RAND reports.
- Military policy manuals validate the stories of those with lived experience – ultimately, given the potential outcomes, it would be unwise to honestly and openly report problem gambling as a service member.
- The landscape of gambling has changed considerably since 2002, when the DoD last conducted its screening.
Stigma and Honest Reporting
In 2017, the Government Accountability Office (GAO) published a report that recommended that the DoD resume gambling disorder screening and update its substance abuse policy to include gambling disorder as defined in the DSM-V. This led to the 2019 National Defense Authorization Act, which mandated gambling disorder screening through tools like the Brief Biosocial Gambling Screening in the Periodic Health Assessment (an annual health physical) and the Lie Bet screening tool in the Health Related Behavior Survey (HRBS). However, it was unclear if the DoD updated its policy manuals to reflect the GAO’s recommendations. To investigate, Tim Boos, one of KRI’s Military Research Associate and current member of the Militaries Enlisted to Medical Degree Program, evaluated whether the updates met four criteria: explicit inclusion of gambling disorder, a case definition, information about problem gambling, and guidance for non-medical personnel. Tim found that the Coast Guard met all four criteria, while the Army met three but listed gambling disorder under “Crimes Against Society.” The Navy, Air Force, and Marines met only one or no criteria. The Air Force acknowledged gambling disorder as a mental health concern but didn’t fully align with the recommendations.
Overall, the DoD has not updated its policy manual to meet the GAO objectives. This ambiguity in the Air Force’s response may prevent service members from honestly reporting gambling issues. This raises questions about the accuracy of reported gambling disorder prevalence among service members.
A Changing Landscape
The recent addition of gambling in military mental health screeners isn’t new, as it appeared in the HRBS in 1992, 1998, and 2002, with low reported rates of gambling addiction/problem gambling. However, this observation ignores significant events that have taken place in the military and gambling space. The 2018 repeal of the Professional and Amateur Sports Protection Act of 1992 allowed for the creation of legal sports betting programs in 38 states, increasing access through innovations like in-play betting via smartphones. Additionally, since the Global War on Terror, conditions linked to gambling disorder—such as TBI, PTSD, depression, anxiety, suicidality, and substance abuse disorder—have skyrocketed in the military and may increase the risk for the population and create an opportunity for gambling addiction. These factors suggest that gambling may now be a significant issue in the military and given the changing landscape of both gambling accessibility and the mental health challenges faced by service members, broad screening for gambling disorder in the military is not only justified but necessary. Maintaining these screening processes demonstrates the DoD’s commitment to mental health and force readiness, especially in this critical age when recruitment is at an all-time low and younger generations are prioritizing mental health and wellness.
Data Discrepancies
The NYU authors report low gambling disorder rates among service members, but recent studies tell a different story. A 2022 study found gambling disorder rates among active-duty service members to be 3.5 times higher than the general population, and a similar study found that problem gambling scores of past and present service members were double those of civilians. These discrepancies seem to arise when we asses this problem through the lens of veterans alone. In 2020, UNLV researchers found that rates among veterans consistently show higher rates of problem gambling compared to civilian populations. This raises important questions about underreporting, military culture, and potentially flawed DoD assessment methods.
The significant rise in problem gambling among veterans further suggests issues may go undetected during service. This highlights the urgent need for independent, comprehensive research to understand the true scope of the issue and implement effective interventions. Broad and consistent screening processes not only help identify service members in need of support, but also show the DoD’s commitment to addressing mental health challenges proactively, and fostering a culture of readiness and resilience.
Our work at KRI underscored the importance of a multifaceted approach to this issue. Research programs like 50×4 Vets have provided novel insights into the characteristics of the veteran population and highlighted the significant barriers to care that still exist within the military. In the state of Colorado, we can offset these barriers by providing access to managing gambling-related harms among military populations while the Department of Defense continues to improve and update its systems of care.