Nancy A. Melville

December 11, 2013

SCOTTSDALE, Arizona — Gamblers ― even those who only gamble recreationally ― are at increased risk of developing comorbid mental health disorders, new research shows.

A study examining the relationship between different levels of gambling and the development of psychiatric disorders showed there was an increased risk for comorbidities even at the lowest levels.

"In looking at adjusted odds ratios, we saw a stepwise relationship between the level of gambling disorder and the association with comorbidity," first author Iman Parhami, MD, MPH, with the Delaware Division of Substance Abuse and Mental Health, in New Castle, told Medscape Medical News.

The study was presented here at the American Academy of Addiction Psychiatry (AAAP) 24th Annual Meeting & Symposium.

Progressive Disease

Gambling disorder is well known to be associated with comorbidity, most commonly nicotine dependence, other substance use–related disorders, and mood or anxiety disorders.

In an effort to better understand the relationship between different levels of gambling behavior and the onset of psychiatric disorders and whether specific symptoms are associated with specific comorbidities, the investigators analyzed data on 34,653 respondents older than 18 years from wave 1 (2001 and 2002) and wave 2 (follow-up in 2004 and 2005) of the National Epidemiological Survey on Alcoholic and Related Conditions (NESARC).

Respondents were grouped into categories that included full gambling disorder (n = 141), subthreshold gambling disorder (n = 1,136), and recreational gambling (n = 9876), as determined on the basis of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria. The study also included a control group of nongamblers (n = 31,940).

At the 3-year follow-up, the risk for any mood, anxiety, or substance abuse disorders was higher in all 3 levels of gambling groups after adjusting for factors that included age, sex, race, marital status, annual income, and education.

Compared with the nongamblers, the adjusted odds ratio (OR) for the development of a mood, anxiety, or substance abuse disorder in the recreational gambling group was 1.16; in the subthreshold gambling disorder, the OR was 1.77; and in the gambling disorder group, the OR was 2.51 (P ≤ .001 for all).

Higher ORs were seen with certain comorbid disorders, particularly any alcohol-related disorder, for which recreational gamblers showed a 1.31 OR of developing compared with nongamblers; the OR for developing an alcohol-related disorder was 1.97 for subthreshold gambling disorder; and the OR was 3.90 or gambling disorder (P ≤ .001 for all).

Wake-up Call

The fact that the higher OR was seen even with recreational gamblers, compared with nongamblers, should be an important wake-up call for clinicians, Dr. Parhami said.

"Currently, research is not very conclusive regarding recreational gamblers. This research helps add evidence that recreational gamblers and those with subthreshold gambling disorder may also experience gambling-related harms," he said.

Dr. Parhami added that the findings underscore the importance of clinicians keeping such comorbidities in mind when treating patients with gambling disorders.

"Clinically, this research may encourage clinicians to become more mindful of their patients' gambling behavior. Since some suggest that gambling disorder is a progressive disease and treatment can prevent this progression, clinicians can initiate gambling treatment at an earlier stage and possibly prevent many of the associated repercussions," said Dr. Parhami.

Commenting on the findings for Medscape Medical News, addiction specialist Jon E. Grant, JD, MD, MPH, noted that getting help for people with gambling problems at any stage can be a challenge.

"Most people with gambling problems never seek treatment," said Dr. Grant, who is from the Department of Psychiatry and Behavioral Neuroscience, University of Chicago, in Illinois. "This could be due to the lack of awareness of available treatments, a feeling that they should be able to control it on their own, possible shame and embarrassment, or simply liking it too much to stop," he said.

The study sheds important light on the need to address problems well before they reach a crisis level, he added.

"I think [the study is] important because we tend to focus on disorders, and this ignores those who struggle and will continue to struggle with problematic behaviors that may not rise to the level of a disorder."

"The study reminds us that we do not have to wait until people are very ill before we can intervene and help."

Clinicians should therefore stay aware of the potential for gambling problems ― even if the patient does not bring it up, he added.

"Clinicians should screen for gambling problems in anyone seeking care for other health or mental health problems," he said.

"Many people want to discuss their gambling but won't do so unless specifically asked. Some early signs of problem gambling may include changes in finances, secrecy, depression, and insomnia."

Although there is no US Food and Drug Administration (FDA)–approved treatment for gambling disorder, he noted that naltrexone has shown some promising indications of helping those with strong urges to gamble.

Key Screening Questions

Dr. Parhami noted that some key questions clinicians can ask to help detect the development of a gambling problem, according to the National Center for Responsible Gaming, include the following:

  • During the past 12 months, have you become restless, irritable, or anxious when trying to stop or cut down on gambling?

  • During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?

  • During the past 12 months, did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends, or welfare?

The investigators and Dr. Grant report no relevant financial relationships.

American Academy of Addiction Psychiatry (AAAP) 24th Annual Meeting & Symposium: Presented December 7, 2013.


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