Gambling problems seldom come alone: prevalence and temporal relationships of mental health problems in casino excluders

ABSTRACT

To estimate the effectiveness of gambling exclusion programmes, previous research focused on changes in gambling behaviour post-exclusion. Although other mental health problems, especially co-morbid mental disorders, may be crucial for relapse and recovery of gambling-related problems, these factors have rarely been studied in excluders. Therefore, this study aimed to assess a comprehensive mental health status of excluders using well-validated diagnostic instruments. Fifty-eight casino excluders participated in face-to-face diagnostic interviews and completed several validated questionnaires (e.g. Stinchfield Questionnaire, Brief Symptom Inventory). Retrospective temporal sequences of diagnosed mental disorders, help-seeking behaviour and exclusion were examined. The majority of excluders reported impairments in mental health aspects. About three-quarters met criteria of lifetime gambling disorder, more than half in the last 12 months whereby screening and diagnostic measures correlated moderately. Other mental disorders were frequent, especially affective and substance-related disorders and typically preceded the onset of gambling disorder. Six years passed between self-awareness of gambling problems and help-seeking. Two more years passed until exclusion. Frequent mental health problems suggest the need for individually tailored support beyond exclusion programmes (e.g. psychotherapy, pharmacotherapy, counselling services). Late help-seeking and exclusion entry claim for improved early detection and intervention concepts that consider underlying mental disorders.     

Reduced inhibitory control predicts persistence in laboratory slot machine gambling

Impairments in inhibitory control characterize a range of addictive behaviours including gambling disorder. This study investigated the relationship between a neuropsychological measure of inhibitory control and behaviour on a simulated slot machine that included a measure of gambling persistence, in a non-clinical sample of regular gamblers. Regular gamblers (n = 75) performed a laboratory slot machine task for 30 trials where they could win real money, followed by a persistence phase under extinction (i.e. without wins). Participants also completed a stop-signal task, along with measures of gambling-related cognitions, social desirability, and symptoms of disordered gambling. In hierarchical regression models, reduced inhibitory control was found to predict greater persistence and a higher subjective desire to play again after both wins and near-misses (i.e. unsuccessful outcomes close to the jackpot). These data illustrate the impact of low inhibitory control on relevant behavioural tendencies in a group of regular gamblers. Our results help elucidate a cognitive process that may contribute to problem gambling, with implications for screening and treatment.     

Me,myself and money: having a financially focused self-concept and its consequences for disordered gambling

The article describes a test of the hypothesis that some people’s self-concept is overly focused on financial success and that this focus contributes to disordered gambling. Study 1 reported on the development and validation of the Financially Focused Scale (FFS) with a sample of community gamblers (N = 197). As predicted, participants whose self-concept was financially focused attached greater importance to the money they possess as a domain of self-worth. They also indicated that the money they possess is a more important domain of self-worth relative to other life domains. Importantly, greater financial focus was a positive predictor of disordered gambling severity and did so over and above other known predictors of disordered gambling severity (i.e. personal income, Big-Five personality domains, global self-esteem, personal relative deprivation and materialism). Study 2 (N = 220) replicated and extended the findings of Study 1 by examining the motivational mechanisms that may link being financially focused with disordered gambling severity. As hypothesized, monetary gambling motives mediated the relationship between participants’ FFS scores and disordered gambling severity. Having a financially focused self-concept may play a critical role in the development and maintenance of disordered gambling. Addressing this self-concept in treatment may help alleviate gambling disorder.     

Demand for gambling: development and assessment of a gambling purchase task

Self-report purchase tasks are a novel approach examining the reinforcing value of addictive behaviour relative to increasing monetary costs required to access the addictive behaviour (i.e. demand). These measures reveal a positive relationship between the indices of demand and addiction problem severity and can elucidate factors associated with motivation for substance use. Gambling is an addictive behaviour that has not been examined using this paradigm. This study seeks to adapt and examine the purchase task for gambling behaviour. A gambling purchase task was devised that asked individuals how often per month they would gamble at various cover charges. Participants were 73 adults from the community with either gambling disorder (n = 28) or alcohol use disorder (n = 24) or were a healthy control (n = 21). Both the alcohol and gambling purchase tasks were administered. Results demonstrate discriminant validity of the gambling purchase task, as individuals with gambling disorder have significantly greater demand for accessing gambling than other groups. The alcohol purchase task also evidenced discriminant validity in that individuals with alcohol use disorder have significantly greater demand for alcohol than other groups. These findings support the use of the gambling purchase task to assess the demand for gambling.     

The role of acculturative stress and cultural backgrounds in migrants with pathological gambling

The objective of the present study was to differentiate specific migration-related factors that can account for an increased vulnerability to pathological gambling (PG) among migrants in Germany. One hundred and six gamblers (61 migrants, 45 Germans) with varying degrees of gambling problems participated in the study. We analysed (1) differences between migrants and Germans regarding gambling patterns, severity of gambling problems, motivation and craving; influence of (2) acculturative stress; (3) acceptance and popularity of gambling in the culture of origin on gambling problems; (4) differences between migrants and Germans regarding family gambling and peer gambling; and (5) differences in religiosity and its influence on gambling problems. Results suggest no differences between migrants and Germans regarding gambling patterns and the severity of gambling problems. However, findings indicate that migrants have higher motivation and craving to gamble. Findings further suggest that acculturative stress is associated with more severe gambling problems. In contrast, acceptance and popularity of gambling in the country of origin was not a significant predictor of gambling problems. At the same time, family gambling and peer gambling was significantly more prevalent among migrants, constituting an additional risk factor in the present sample. On the other hand, migrants in the sample benefit more often from a protective influence of religiosity.     

The South Oaks Gambling Screen Revised for Adolescents (SOGS-RA): Further Psychometric Findings from a Community Sample

The broad expansion of gambling across North America during the last two decades has generated concern about the extent of gambling and problem gambling in youth, and the need to more accurately monitor it. The South Oaks Gambling Screen-Revised for Adolescents (SOGS-RA) is a promising instrument for screening problem gambling (Winters, Stinchfield, & Fulkerson, 1993) that requires more evaluation. Accordingly, further psychometric analysis of the instrument was conducted as part of a community survey of gambling in a sample of 1,000 male and female youth, aged 12 to 17 years. The analyses extended previous focus by including females, young adolescents, and an evaluation of youth classified as at-risk. Consistent with preliminary findings obtained during scale development, the distribution of item endorsement revealed trends of over-endorsement for some items (e.g., gambled more than intended, felt bad about the amount bet), and under-endorsement for others (e.g., criticized or told you had a gambling problem). These results suggest consideration of some form of weighting procedure, item deletion or re-wording. A factor analysis of the SOGS-RA items suggested a two-factor solution, with one factor interpreted as Control over Gambling and the other Gambling Consequences. It is proposed that the two factors may represent early versus more severe levels of gambling problems, respectively. The results highlight the need for further psychometric evaluation and refinement of instruments used to identify gambling problems in young people.     

Thoughts and acts of self-harm,and suicidal ideation,in online gamblers

Gambling problems have been linked to suicidal ideation and enhanced risk of suicide attempts. However, we know very little about the factors associated with either thoughts or acts of self-harm amongst people who gamble. A web-based study of 4125 online gamblers (79% males; mean age 35.5 years), analysed using hierarchical multiple regression, revealed that self-reported non-gambling-related self-harm was negatively related to age and marital status, and positively related to problematic alcohol use. Self-reported acts of self-harm both related and unrelated to gambling were associated with drug misuse. Thoughts and acts of gambling-related self-harm were associated with problem gambling, gambling involvement and parental problem gambling. All types of self-harm were associated with mood disorder symptoms, unemployment and certain gambling motivations. When tailoring assessment and interventions for individuals at risk for gambling-related deliberate self-harm, it is important to recognize that contributory factors may include some that differ from those for deliberate self-harm in general, and that there is potential value in evaluating gambling involvement and motivations, and history of parental gambling.     

Mindfulness in Patients With Gambling Disorders

This study explored facets of mindfulness between patients diagnosed with a gambling disorder (n = 26) and a community sample of non-gambling-disordered individuals (n = 33). Multivariate statistics comparing group differences showed the gambling-disordered patients exhibited significantly lower levels of mindfulness, emotional regulation, stress coping, and impulse control compared to the non-gambling-disordered group. Overall, gambling severity was negatively associated with higher levels of mindfulness and positively linked to indices of emotional dysregulation, stress proneness, and impulsivity. Correlations between mindfulness and emotional dysregulation and impulsivity were much stronger than those between mindfulness and the severity of disordered gambling behaviors as measured by the National Opinion Research Center DSM Screen for Gambling Problems (NODS). These findings are discussed in the context of possible implications for future directions in exploring mindfulness-based interventions as a plausible intervention among those with gambling disorders.     

Prevention of problem gambling: modifying misconceptions and increasing knowledge

Research on gambling clearly demonstrates that today's youth are very much involved in gambling activities. As they take part in these activities, young people develop and entertain irrational thoughts about gambling and become at risk for developing severe gambling problems. In this study, a video specifically designed to correct misconceptions and increase knowledge about gambling was tested on 424 grade 7 and 8 students. The effectiveness of the video was evaluated using four different experimental conditions. Findings indicated that the video significantly improved subjects' knowledge about gambling and corrected their misconceptions. The implications of these results for the prevention of gambling problems are discussed.     

Gambling disorder and suicidality within the UK: an analysis investigating mental health and gambling severity as risk factors to suicidality

Greater severities of gambling behaviour and poorer mental health have been identified in the literature as risk factors for suicidality within gambling disorder (GD) populations. This is the first known study within the UK to use empirical data, taken from a UK treatment clinic for GD (National Problem Gambling Clinic, UK) to explore the associations between current suicidality (thoughts and plans) and measures assessing gambling severity and mental health. Self-report data from 122 participants were collected during the intake process at the clinic through a variety of methods including the use of questionnaires and a standardized 90-minute interview with a psychologist. Reported suicidality was high (current suicidal thoughts [28.7%] and plans [6.6%]), yet only one measure of gambling severity (estimated total losses) was found to be inversely associated with suicidality. Indices of poorer mental health were found to have a greater association with suicidality than measures of gambling severity, and a logistic regression analysis identified depressive symptomology and a history of psychiatric disorder in the participants’ family as significant factors associated with suicidality. Overall, within GD populations, factors associated with poorer mental health rather than gambling severity are seemingly a greater risk factor in patients with suicidality.     

Epidemiological Associations between Gambling Behavior, Substance Use & Mood and Anxiety Disorders

Objective To compare gambling behaviors in a random sample of community residents with and without mental disorders identified by the Composite International Diagnostic Interview (CIDI).Method A large national community survey conducted by Statistics Canada included questions about problems arising from gambling activities as per the Canadian Problem Gambling Index (CPGI). We compared respondents within three gambling severity categories (non-problem, low severity and moderate/high severity gambling) across three diagnostic groupings (mood/anxiety disorders, substance dependence/harmful alcohol use, no selected psychiatric disorder).Results Of the 14,934 respondents age 18–64 years who engaged in at least one type of gambling activity in the previous 12 months, 5.8% fell in the low severity gambling category while 2.9% fell in the moderate/high severity category. Females accounted for 51.7% of the sample. The risk of moderate/high severity gambling was 1.7 times higher in persons with mood or anxiety disorder compared to persons with no selected disorder. For persons with substance dependence or harmful alcohol use, the risk of moderate/high severity gambling was 2.9 times higher. Persons with both mood/anxiety and substance/alcohol disorders were five times more likely to be moderate/high severity gamblers. The odds ratio for females was 0.6 and for those with less than post-secondary education it was 1.52. Differences in age and personal income were not significant.Conclusions Individuals in the community suffering from mood/anxiety disorders and substance dependence/harmful alcohol, and especially those with both, experience a higher risk for gambling problems. The treatment of these comorbidities should be integrated into any problem gambling treatment program.Disclaimer: The data upon which of the analyses contained in this paper derive from surveys conducted by Statistics Canada. The opinions expressed in this paper do not represent the opinions of Statistics Canada.     

Impulsivity and pathological gambling across depressive versus bipolar disorders

Impulsivity has been implicated in the development of pathological gambling (PG); sensation seeking and urgency in particular have predicted gambling pathology in undergraduate and psychiatric samples. In light of the relevance of both depressed and elevated mood to impulsivity and gambling, the components of impulsivity associated with PG across mood disorders warrants investigation. The aim of the current investigation was to examine the association between impulsivity and gambling pathology severity across depressive versus bipolar disorders. A total of 275 participants with lifetime depressive or bipolar disorder completed measures of impulsivity and gambling. Urgency was consistently associated with gambling pathology indicators; lack of perseverance was specifically associated with gambling pathology within participants with depressive disorders. Reckless action during negative mood is associated with gambling pathology across mood disorders, whereas difficulty remaining focused is associated with PG solely within depressive disorders. Impulsivity and affective comorbidity may inform current understanding of PG.     

Adverse Childhood Experiences and Gambling: Results From a National Survey

Pathological gambling disorder and problem gambling are addictive disorders with severe consequences for individuals, families, and society. Knowledge about associations between childhood adverse experiences (i.e., physical, sexual, and emotional abuse) and gambling pathology in adulthood is limited. Using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), associations between adverse childhood experiences and lifetime gambling status were tested. Strong bivariate associations between adverse childhood experiences and gambling status were found, which were attenuated with the inclusion of clinical covariates. Adverse childhood experiences might be related to pathological gambling in adulthood, but this relationship might not be gambling-specific.     

Brief Communications: Gender Differences in Gambling Progression

The authors compared 39 women and 38 men entering an outpatient treatment program for pathological gambling. They were diagnosed according to DSM-IV and selected by SOGS, followed by a semi-structured interview for demography and progression of the gambling behavior prior to treatment. Women were more often single (59% vs. 26%; p = .005) and started gambling significantly later than men (34.2 vs. 20.4 years; p < .001). The progression of the disorder was more than 2 times faster in women than in men. There was no difference in the age of seeking treatment (44.7 vs. 42.3 years). Findings from this study resemble gender differences in other addictions—in particular the faster progression among women—challenge pharmacodynamic hypotheses for this phenomenon, and suggest gender into account when devising treatment strategies for pathological gambling.     

A scoping review of co-morbidity in individuals with disordered gambling

Individuals with disordered gambling often report at least one other lifetime psychiatric diagnosis. Although prevalence rates vary, there is substantial evidence for co-morbidity being the rule rather than the exception. Despite this known association, there has not been a recent comprehensive review of co-morbidity in disordered gambling other than prevalence surveys. The goal of this study was to broadly summarize and review the current literature on the extent, range and nature of disordered gambling co-morbidity. Following an initial search and screening of 6 databases, 251 articles were included in the final synthesis and evaluation. The main findings showed that few studies examine the mechanisms of co-morbidity in gambling beyond prevalence rates; few studies report on temporal sequencing of gambling and co-morbid disorders; there is a lack of treatment evaluation studies designed specifically for dual-diagnosis individuals; there is a need for system-level initiatives to address co-morbidity at the policy level; and the substance use literature may act as a useful model for guiding future gambling research on co-morbidity. The results suggest that despite a reasonable amount of published research on co-morbidity in disordered gambling, most study conclusions relegate to acknowledgements of high co-occurrence between disorders without follow-up.     

Co-morbidity of gambling and Internet use among Internet and land-based gamblers: classic and network approaches

This study investigated co-morbidity of problem gambling and problematic Internet use (PIU) among adolescent Internet and land-based gamblers, with the classic approach using sum-scores of symptoms and a promising new method, namely the network perspective. This perspective allows testing for how multiple disorders are associated, showing symptoms overlap and centralities. We used cross-sectional data from two population-based samples of adolescents aged 17 years in France (n = 2,240) and Switzerland (n = 944). Measures included Internet gambling, problem gambling and PIU. The classic approach showed that Internet gambling was associated with increased levels of disordered gambling and PIU, but that correlations between disorders were weak (R² min = 3.2%, R² max = 17.6%). The network perspective showed that the co-morbid network of Internet gamblers was more connected in comparison with land-based gamblers. Problem gambling and PIU appeared as separate disorders, but their relationship was increased among Internet gamblers in comparison with land-based gamblers. The network perspective appeared as a promising avenue for a better understanding of addictive disorders, but it should not replace the classic approach, which showed increased levels of addictive behaviours among Internet gamblers.     

Problem Gambling and Comorbid Psychiatric and Substance Use Disorders Among Drug Users Recruited from Drug Treatment and Community Settings

Little is known about gambling rates of drug users recruited from drug treatment compared with those recruited from the community. We use the Diagnostic Interview Schedule (DIS) to provide lifetime prevalence estimates of problem gambling (i.e., at least one gambling problem) and DSM-III-R pathological gambling (i.e., at least four gambling problems) and describe the association between gambling and psychiatric disorders for drug users recruited from drug treatment settings (n = 512) and from the community (n = 478). We also report the relative risk of being a recreational and problem gambler in this sample. The sample was first interviewed in 1989–90 as a partof two NIDA-funded St. Louis-based studies. The prevalence of problem gambling in the overall sample was 22% and the prevalence of pathological gambling was 11%. There were no statistically significant differences in problem and pathological gambling rates for subjects recruited from drug treatment and those recruited from the community. The conditional prevalence rates, that is, the rate of problem and pathological gambling only among gamblers were 27% and 13.5%, respectively. Major findings indicate that problem gambling was associated with Antisocial Personality Disorder (ASPD), even after controlling for recruitment source and socio-demographic characteristics. In fact, when examining the temporal order of these disorders, we found that pathological gambling was always secondary to ASPD, occurring on average 11.4 years after the onset of ASPD. Problem gamblers, compared with everyone else, were more likely to be male, African-American, recruited from drug treatment, have ASPD and be dependent on illicit drugs. Multinomial logistic regression analysis predicted the relative risk of being a recreational and problem gambler (compared with a nongambler) in this sample according to socio-demographics, ASPD, and dependence on illicit drugs. Results imply that screening for gambling problems will need to be broad-based among drug users.     

Gambling Involvement and Drug Use Among Adolescents

The literature on youth gambling often notes the relationship of gambling involvement to drug use. The extent of this association and its importance toward advancing knowledge about the origins and course of adolescent gambling are discussed. The authors contend that (a) adolescent gambling, like drug use, may be a normal part of adolescence from a statistical perspective, (b) claims that the prevalence rate of problem/pathological gambling is comparable or higher than the rate of substance use disorders are not supportable at this time given the weaker methodological studies in the gambling area, (c) while research suggests that similar risk factors may be important determinants for both behavior domains, prospective studies of adolescent development are needed to further clarify which factors are unique and common to adolescent gambling, and (d) greater documentation of the harm associated with adolescent gambling is a major barrier to garnering more prevention and treatment resources for this issue.     

Urge to Gamble in a Simulated Gambling Environment

Cue reactivity, while increasingly recognized as a central feature of drug and alcohol addiction, is not well studied in gambling. We evaluated the urge to gamble in a simulated casino environment among frequent gamblers who alternated between cycles in which they observed others playing ten hands of Blackjack (first, third and fifth cycle) and cycles in which they played ten hands of Blackjack themselves (second and fourth cycle). The played cycles served as a manipulation for the observed cycles in terms of “priming” (having previously gambled in the environment vs. not) and “anticipation” (expecting more opportunities to gamble in the environment vs. not) and, thus, allowed these conditions: observed cycle 1 = anticipation (+) and prime (−); observed cycle 2 = anticipation (+) and prime (+); and observed cycle 3 = anticipation (−) and prime (+). Subjects’ urge to gamble was greater in the gambling environment than in a neutral setting and both positive anticipation and positive priming increased cue reactivity within the gambling environment. The frequency of gambling outside of the study did not affect cue reactivity. However, a preference for Blackjack (vs. other types of gambling) and observing winning (vs. losing) hands were both associated with stronger cue reactivity in the study. These findings contribute to our understanding of pathological gambling.