Gambling Among the Military and Veterans. Rani A. Hoff, PhD, MPH Department of Psychiatry Yale University School of Medicine

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1 Gambling Among the Military and Veterans Rani A. Hoff, PhD, MPH Department of Psychiatry Yale University School of Medicine

2 Today I aim to give you information regarding gambling and mental health among servicemembers and Veterans First we will define some terms (e.g. veteran) Some descriptive background on military history and veterans as a sub-population VA as a mental health provider Gambling and mental health among transitioning veterans

3 What is a veteran? Any individual who served on active duty in any branch of the US military at any time for at least 24 months (unless killed in action before 24 months); AND who received an honorable, general, or medical discharge from the military

4 There are no WWI Veterans left. The oldest living Veterans are WWII veterans ( ) Environmental conditions of WWII were severe More than 16 million served and more than 400,000 died Over 350,000 women served The VA has served more than 5 million of these veterans About 850 die each day

5 Korea: the forgotten war ( ) No formal declaration of war 54,000 Americans died 480,000 men and 1,000 women served More than 7,000 POWs were taken; only 4,400 returned US has maintained military presence since

6 Vietnam was the longest war prior to the current conflicts ( ) Of the 536,000 troops who served, about 7,500 were women Two thirds who served were volunteers 58,000 were killed and more than 300,000 were wounded 1,800 service members are still unaccounted for

7 Operation Desert Shield and Desert Storm; the Gulf War (8/1990-6/1991) 697,000 troops served, including 41,000 women About 25% of these veterans suffer from Gulf War Syndrome 250,000 receive disability benefits from the VA 150,000 have received VA treatment for militaryrelated illnesses

8 Operation Enduring Freedom ( ) The first response to 9/11, operations in Afghanistan 104,000 troops served, 15% of them women (15,600) 47% of all Reserve and National Guard troops have been deployed since 2001

9 Operations Enduring Freedom ( 01-14), Iraqi Freedom ( 03-10), New Dawn ( 10-11), Freedom s Sentinel ( 14-), Inherent Resolve ( 14-) 250,000 American troops have served, 15% of them women Early operations had higher levels of combat Urban combat and insurgent contact, guerrilla warfare Later operations focused on training local forces and advisory capacity

10 Women in the Military

11 There are unique challenges for women operating in combat conditions Workarounds for military policy resulted in temporary attachments of women to combat units They did not receive the same combat training as male members of combat units (this is changing) They may be from different branches with differing combat protocols Documentation of combat exposure before 2014 is harder for women, making it difficult to get benefits, receive honors, and attain leadership roles that would allow them to affect military policy In January of 2013 military leaders lifted the ban on women serving in combat positions, opening up more than 230,000 military jobs to women

12 Other operations you may not remember or be aware of Lebanon ( 82-83) Grenada ( 83) Panama ( 89-90) Operation Restore Hope (Somalia, ) Disaster Relief Hurricane Katrina, Haiti Earthquake CIA Operations worldwide in conjunction with Special Forces

13 Those are just the wars. Hundreds of thousands served in between formal conflicts. There are all told 21 million living Veterans in the US Younger veterans fare less well than their civilian counterparts: Less educated Lower income More likely to have mental illness and addiction problems More likely to be homeless Some receive health care services and/or other benefits from the Department of Veterans Affairs (VA)

14 Veterans who served before 1972 will be quite representative of males in the general population of the same age Explained by the draft and widespread volunteering Women have served in every US conflict since the Revolutionary War but will not be representative of the general female population After 1972 the All Volunteer Army results in large shifts in demographics

15 There are about 21 million living Veterans, and their numbers are dropping. More than half served prior to the Gulf War Era. Richard Overton, oldest living Veteran

16 Only 9 million are enrolled in VA health care. Most have private insurance through employers or partners, or have State and Federal coverage

17 The total number of Veterans who utilized VHA services increased by 26.4% between 2005 and ,500,000 6,000,000 5,500,000 5,000,000 4,500,000 4,000,000 3,500,000 3,000,

18 More than a third of VA patients have a mental health diagnosis Total Service Users Service Users With: Possible Mental Illness Confirmed Mental Illness 2,086,400 1,593,970 5,954,537 Percent Service Users With: Possible Mental Illness Confirmed Mental Illness 35.04% 26.77%

19 Most VA patients with a mental health diagnosis receive specialty mental health care Number of Service Users with Possible Mental Illness Proportion of Veterans with Possible Mental Illness Treated in: 2,086,400 Any Mental Health Inpatient Mental Health Residential Mental Health In-Person Outpatient Mental Health 73.0% 2.7% 1.6% 73.0% Number of Service Users with Confirmed Mental Illness Proportion of Veterans with Confirmed Mental Illness Treated in: 1,593,970 Any Mental Health Inpatient Mental Health Residential Mental Health In-Person Outpatient Mental Health 86.8% 3.6% 2.1% 86.8%

20 The percent of total VHA service users that received mental health services increased by 52.6% between 2005 and % 28% 26% 24% 22% 20% 18% 16% 14% 12% 10%

21 VHA Mental health workload, key measures 2018 Total Service Users Number of Service Users that Received Mental Health Services Percent of Service Users that Received Mental Health Services 5,954,537 1,703,862 29% Percent of Service Users that Received Mental Health Services Treated In Inpatient Mental Health Residential Mental Health Outpatient Mental Health 3.34% 2.00% % Average O/P Stops by Stop Type (Among Veterans with 1 Stop) Psychiatry Substance Use Disorder All Mental Health Average Daily Census MH Inpatient MH Residential All MH Bed Types 2,226 5,709 7,936

22 Veterans are at higher risk for gambling problems than civilians Service members have ready access to gambling opportunities such as slot machines on every military base outside US soil (>3,000 machines worldwide) Ample down time promotes informal gambling games, primarily cards and bingo, and other gambling Self selection of service members may result in higher baseline risk for impulse control disorders Prolonged exposure to trauma may increase likelihood of escapist behaviors Those who gamble to escape are at higher risk for developing PPG Those with substance use disorders are at very elevated risk for PPG PPG is very frequently comorbid with another mental health disorders

23 The military treats gambling disorders differently than other addictions The military takes in $2 billion a year in overseas slot machines In the US they take in $120 million in on-base slot machines and $7 million in bingo games However, reporting a gambling problem can and does result in discharge, frequently dishonorable Gambling problems are considered a risk for blackmail or treason as well as criminal behavior Treatment is not available even when service members want it

24 Its difficult to know what proportion of servicemembers and Veterans have a gambling problem Estimates for problem and pathological gambling in active duty personnel about 8% Estimates among Veterans seeking VA health care about 10% In civilians similar estimates are around 6% for PPG and 1.6% PG Estimates are likely to be underestimates: Lack of screening Lack of treatment options Reluctance to seek care Punishment for seeking care

25 Veterans are at higher risk for gambling problems and comorbidity is the rule rather than the exception The rate of PPG was almost 18% among Veterans who gamble at all All Veterans with PPG symptoms also had PTSD symptoms Rates of childhood and predeployment physical and sexual abuse were high Rates of binge drinking were above 50% 22% of those with PPG met likely criteria for a substance use disorder (mostly alcohol) Depression symptoms were also high Only 20% of respondents with any mental health symptoms had received any mental health treatment

26 Comorbidity among SERV respondents with PPG Women Men Alcohol dependence 13.86* 22.9 Mod/hi Nicotine dependence Drug dependence Panic disorder GAD PTSD 79.5* 90.3 Depression Intermittent explosive disorder Compulsive sexual behavior 1.5* 2.6 ## 53.1 Binging and/or purging 5.1* 2.5

27 Non-combat trauma Trauma % in Men % in Women P value Physical assault child 78.4% 64.6% Sexual assault child 12.7% 31.7% Physical assault predeployment 14.0% 12.7% After deployment 4.4% 2.5% Sexual harassment/assault pre-deployment 11.0% 41.8% < During deployment 0.5% 12.7% < After deployment 1.5% 11.5%

28 Once discharged, veterans with a gambling disorder may be able to seek help from the VA Veterans cannot get disability payments for any addiction or PPG However, they can get treatment There are very few specialized clinics for PPG in the VA However, an increasing number of clinicians are trained in evidence based interventions that would be effective for PPG As the largest mental health provider in the country, the VA has a unique opportunity to address PPG among Veterans where community services are scarce More research and education of VA clinicians is needed

29 But they don t. Why don t people seek care? They don t think they have a problem They have a problem but aren t ready to seek care stigma, shame and fear They don t know how to seek care There are no services available at a reasonable distance They can t afford care The services available are not the ones they want Concerns about privacy Why don t people get care from the VA? They don t think they are eligible They don t know that VA has mental health services They don t know who will see their records They believe that treatment seeking will affect their benefits or their career They believe that the VA will take away their firearms They believe that the DoD and the VA are the same people and don t trust either one General hostility towards the government

30 Tips for Veteran clients Getting urgent care Transitioning Veterans are eligible for crisis care from the VA even if their discharge is other than honorable Every VA hospital has a full range of mental health services, for any age group and any severity Every VA hospital is required to get an LIP in touch with any Veteran in crisis and asking for help within a day Veterans Crisis Line 24/7 hotline for Veterans that can help link individuals to local VA services , press 1 for Veterans You can call the VCL as a provider if you have grave concerns about a client s safety Mental health care in VA Contact any hospital switchboard and ask for mental health Contact eligibility by phone or enroll in VA services online at vets.gov Ask for evidence based treatments Veterans who get VA mental health services are overwhelmingly positive about their experiences Don t want to go to VA? Try a Vet Center if a combat Veteran Look for assistance programs such as Wounded Warriors, VSOs Look at Make the Connection web site for information about mental health treatment (maketheconnection.net) Veteran cheat sheet

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