Journal of Psychiatric Practice:
Winner of Resident Paper Award 2013
Gambling and the Onset of Comorbid Mental Disorders: A Longitudinal Study Evaluating Severity and Specific Symptoms
PARHAMI, IMAN MD, MPH; MOJTABAI, RAMIN MD, PhD, MPH; ROSENTHAL, RICHARD J. MD; AFIFI, TRACIE O. PhD; FONG, TIMOTHY W. MD
PARHAMI: Delaware Division of Substance Abuse and Mental Health, New Castle, DE; MOJTABAI: John Hopkins University School of Medicine; ROSENTHAL and FONG: University of California, Los Angeles; AFIFI: University of Manitoba, Winnipeg, Canada.
Funded by a travel award from the National Center for Responsible Gaming, results from this study were presented at the American Academy of Addiction Psychiatry’s Annual Meeting (December 2013: Scottsdale, Arizona). This study was also awarded the 2014 APA/Lilly Resident Research Award.
Dr. Mojtabai has received consulting fees from the pharmaceutical company H. Lundbeck A/S; the other authors declare no conflicts of interests.
Please send correspondence to: Iman Parhami, MD, MPH, Delaware Psychiatry Residency Program; Delaware Division of Substance Abuse and Mental Health; 1901 North Dupont Highway, Springer Building, New Castle, DE 19702. email@example.com
While the association between gambling disorders and comorbid mental disorders has been extensively studied, only a few studies have used longitudinal data or evaluated the association across different levels of gambling behavior and specific gambling-related symptoms. In this study, longitudinal data from waves 1 and 2 of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) were used to determine whether different levels of gambling behavior and gambling-related symptoms were associated with the onset of psychiatric disorders. Although NESARC used DSM-IV diagnoses, for this study, the recently published DSM-5 diagnostic criteria for gambling disorder were used to group the NESARC respondents (N=34,653) into three levels of gambling (gambling disorder, sub-threshold gambling disorder, and recreational gambling) and one non-gambling comparison group. Three years after the initial intake interview, compared to the non-gamblers, those reporting any gambling behavior at baseline were at increased risk to have any mood, anxiety, or substance use disorders (recreational gambling: adjusted odds ratio [AOR]=1.16, 95% confidence interval [CI]=1.10–1.23; sub-threshold gambling disorder: AOR 1.77, 95% CI 1.63–1.92; gambling disorder: AOR 2.51, 95% CI 1.83–3.46). Similar graded relationships were found for a number of specific disorders. In addition, multiple specific gambling-related symptoms were associated with comorbid disorders, possibly suggesting the interaction of different mechanisms linking gambling disorder and the onset of comorbid psychopathology. In conclusion, a graded or dose-response relationship exists between different levels of gambling and the onset of comorbid psychopathology. Among gambling groups, those with a gambling disorder were at the highest risk for the new onset of comorbid conditions and those with recreational gambling were at the lowest risk, while the risk among participants with sub-threshold gambling disorder fell between these two groups. (Journal of Psychiatric Practice 2014;20:207–219)
Gambling in the United States is a socially acceptable and widespread activity. Although most adults gamble without incurring problems, nearly 4% of the adult U.S. population currently suffer gambling- related problems, and 6% will experience harm from gambling during their lifetime.1,2 Those with gambling problems are at increased risk for experiencing financial problems (e.g. bankruptcy, lost job, sizeable debt),3–6 legal problems (e.g. crime, arrests),7,8 relational problems (e.g. divorce, domestic violence, child abuse),9–11 and health problems (e.g. increased stress, sleep disturbances).8,12–17 In addition, these individuals have exponentially higher rates of suicide attempts and completions than the general public.18,19 Taken as a whole, some believe the estimated economic cost from gambling disorder reaches $5 billion per year in the United States.6
Gambling disorders are strongly associated with comorbid psychopathology.20,21 A recent meta-analysis of 11 population surveys found a high mean prevalence of nicotine dependence (60.1%), other substance use disorders (57.5%), mood disorders (37.9%), and anxiety disorders (37.4%) in individuals with disordered gambling.1 However, since most research that has evaluated comorbidity in those with gambling disorders has used cross-sectional data, it is difficult to determine whether those with gambling pathology are at increased risk to develop comorbid psychopathology.
Chou and Afifi addressed this issue in 2011 by examining the incidence, or new onset, of comorbid psychopathology in disordered gamblers in a national epidemiological survey.22 In this 3-year follow-up study, they found that, compared to those without disordered gambling behavior at baseline, disordered gamblers (those who met three or more of the DSM- IV criteria for pathological gambling) had increased odds of new onset Axis I disorders (odds ratio [OR]=4.11, 99% confidence interval [CI]=1.01–16.66), including mood disorders (2.77, 1.16–6.60) and substance use disorders (1.76, 1.38–2.22). However, this study did not evaluate whether different levels of gambling behavior were also associated with the incidence of comorbid disorders.
Given that gambling is a heterogeneous behavior with multiple levels of severity, different gambling patterns, dissimilar motivations for gambling, and unique personality related traits,23–25 it is valuable to determine whether the risk of developing comorbid conditions is limited only to more severe gambling behavior or is associated only with specific symptoms of gambling disorder. This study will assess the association between different gambling levels, including less severe gambling behavior, and specific gambling symptoms and the onset of comorbid psychiatric disorders.
Three Levels of Gambling Severity
Gambling behavior can be categorized into three levels of severity: gambling disorder, sub-threshold gambling disorder, and recreational gambling. The most severe level of gambling behavior, which occurs in those with gambling disorder, consists of persistent, recurrent, and sometimes progressive maladaptive gambling behavior despite negative consequences.26,27 These gamblers, usually referred to as disordered gamblers, meet four or more of the nine DSM-5 diagnostic criteria for gambling disorder.28
These criteria deal with preoccupation, tolerance, withdrawal, loss of control, escapism, dishonesty, chasing, bailouts, and risk-taking behaviors related to gambling. Individuals who have gambling-related problems but whose symptoms don’t reach diagnostic threshold (subthreshold gambling disorder—i.e., those who meet only one to three criteria) are referred to as problem gamblers.26,27,29 Finally, recreational (social) gamblers do not encounter any repercussions from gambling and do not meet any of the diagnostic criteria for gambling disorder.
Gambling disorder and subthreshold gambling disorder are both associated with social, psychological, and medical repercussions.30–32 Those with gambling disorder experience the greatest impact, including higher rates of comorbidity and psychological symptoms from comorbid disorders.24,33–35 For the most part, those with subthreshold gambling disorder continue to experience these repercussions but to a lesser degree.29 This includes a diminished quality of life,36 health-related consequences,15 and sociological consequences such as bankruptcy, economic impact, legal problems, and divorce.6 Moreover, compared to those without gambling problems, those with subthreshold gambling disorder have a higher risk of developing a gambling disorder some time in the future.26,37
The impact of recreational gambling is less clear.32 Some studies suggest that those who gamble socially have higher rates of psychiatric disorders than the general population38–40 and experience greater social and health-related repercussions.15,41 Other studies have found that recreational gamblers are more likely to report better health than non-gamblers.42,43 Characteristics of the samples or the methodology used may have contributed to these differences. For example, Lynch and colleagues sampled 1000 young adults and found higher rates of substance related- disorders in those who gambled compared to non- gamblers,40 while Desai and colleagues only looked at the elderly.42,43
Gambling may have advantages as well. Certain research indicates that gambling is associated with an enhancement of memory, problem-solving skills, mathematical proficiency, and concentration for the elderly.44 Some also use gambling as a fun and exciting social experience to reduce stress45–47 and raise self-esteem.48,49 Furthermore, particular cultures embrace gambling as a family activity with historical significance.50,51
The nine DSM-5 criteria for gambling disorder represent the most common symptoms experienced by those with gambling problems. These symptoms characterize three heterogeneous dimensions: damage or disruption, loss of control, and dependence. Seven of the nine criteria resemble the DSM diagnostic criteria for substance use disorders.52 The other two criteria inquire about chasing one’s losses (“after losing money gambling, often returns another day to get even”) and bailouts (“relies on others to provide money to relieve desperate financial situations caused by gambling”).28,53 Particular symptoms usually cluster together.23,54,55 For example, those who meet one or two criteria are more likely to report chasing their losses or gambling as an escape, while those who meet five to seven criteria are more likely to report problems with control, withdrawal, and tolerance.56 Furthermore, the total number of criteria or symptoms the gambler meets can represent an index of severity.56,57
The primary objective of this study was to use longitudinal data from waves 1 and 2 of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) to determine whether different levels of gambling behavior are associated with the onset of psychiatric disorders. To date, a number of gambling-related studies have used data from NESARC wave 1 (e.g., Petry et al. 200521 and Nower et al. 201323) and wave 2 (Chou et al. 201122 and Pilver et al. 201358). This study extends past research by examining the association of any gambling behavior, including recreational gambling, with the onset of psychiatric disorders. In addition, given the heterogeneity of symptoms in gambling disorders, the secondary objective of this study was to evaluate whether certain symptoms are more likely to be associated with the onset of comorbid disorders.
The design and sample characteristics of the NESARC are described elsewhere.59,60 Briefly, the NESARC was a survey of the general population of the United States, including residents of Hawaii and Alaska. Sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), this survey included face-to-face interviews regarding mental and substance disorders (including gambling pathology) using DSM-IV diagnostic criteria as operationalized in the Alcohol Use Disorder and Associated Disabilities Interview Schedule–DSM-IV version (AUDADIS-IV).61–64 The test-retest reliability and clinical validity of the AUDADIS-IV diagnoses have previously been reported.59
The NESARC wave 1 (baseline) was fielded between 2001 and 2002 and included 43,093 participants 18 years of age and older. Of these, 39,959 were eligible for wave 2 (follow-up) interviews. Ineligible respondents included those who were deceased, deported, mentally or physically impaired, or on active military duty at the time of the follow-up interview. A total of 34,653 eligible wave 1 participants were successfully followed up in the wave 2 survey between 2004 and 2005. The survey response rates for wave 1 and eligible wave 2 participants were 81% and 87%, respectively.59
At wave 1, all participants were assessed with a screening question inquiring whether they had gambled at least five times in any year. Respondents who answered positively to this question were then asked 15 additional questions about the past year based on the ten DSM-IV criteria for pathological gambling. Although NESARC used DSM-IV diagnoses, for the study reported here, the recently published DSM-5 diagnostic criteria for gambling disorder were used to group the respondents into three levels of gambling severity (gambling disorder, sub-threshold gambling disorder, and recreational gambling) and one non-gambler comparison group. The comparison group included individuals who responded negatively to the question inquiring about gambling at least five times in any year. The recreational gambling group included respondents who answered positively to the screening question, but did not meet any of the criteria for gambling disorder. The sub-threshold gambling disorder group included those who met one to three criteria and the gambling disorder group included those who met four to nine criteria for gambling disorder. The internal consistency of all symptom items and the validity of the gambling scale were established previously.21,22
Mood, anxiety, and substance-related disorders were ascertained using the AUDADIS-IV. This structured interview assessed disorders identically in wave 1 and wave 2 except for the time frames. In wave 1, lifetime and the year preceding the interview were assessed, and in wave 2, the time frame included the previous year and the time between wave 1 and wave 2.
For this study, the DSM-IV Axis I disorders ascertained in NESARC using the AUDADIS-IV were grouped into three main categories: mood disorders (major depressive, manic, and hypomanic episodes and dysthymia), anxiety disorders (panic disorder with and without agoraphobia, agoraphobia without panic disorder, social phobia, specific phobia, generalized anxiety disorder), and substance use disorders (alcohol abuse, alcohol dependence, nicotine dependence, and non-alcohol non-nicotine substance use disorder which included cannabis, sedatives, tranquilizers, opioids, amphetamines, hallucinogens, cocaine, inhalants, heroin, or other drugs). Posttraumatic stress disorder was only assessed at wave 2.
Demographic variables included age, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other), sex, education (less than high school degree, high school degree, some college or higher), annual household income ($0–$19,999, $20,000–$34,999, $35,000–$69,999, $70,000 and greater), and marital status (married/cohabiting, separated/divorced, never married).
The onset of mental and substance use disorders in the period between wave 1 and wave 2 was compared among the three gambling groups and the non-gamblers using contingency table analysis and multivariable logistic regression models. The multivariable models were adjusted for age, sex, race, marital status, annual income, and education. Separate models were tested for each target comorbid disorder. Each analysis was limited to participants without a 12-month history of the target disorder at baseline. Thus, for example, when comparing the onset of a depressive episode among the groups, participants with a 12-month history of a depressive episode at baseline were excluded. This method of analysis was also used to assess the relationship between each gambling symptom at baseline and the onset of psychiatric disorders. Since PTSD was not assessed at wave 1, all participants with any anxiety disorder were excluded when calculating PTSD onset. Taylor Series Linearization technique as incorporated in the SPSS 21 complex samples analysis module was used to account for the NESARC survey weights, clustering, and stratification. All percentages were weighted by survey weights. A two-sided p<0.05 was used to assess statistical significance of tests.
Sample Characteristics at Baseline
The non-weighted baseline prevalence rates for the different levels of gambling in wave 1 included recreational gambling: 23% (n=9,876); sub-threshold gambling disorder: 2.6% (n=1,136); and gambling disorder: 0.33% (n=141). Weighted demographic characteristics of this sample based on gambling severity are summarized in Table 1. As expected, significant statistical differences were found among the groups with regard to age, sex, education, income, and marital status (p<0.001). Approximately 73.2% (n=25,353) of the respondents who completed wave 2 of the NSERC did not report gambling behavior (non-gamblers).
Different Levels of Gambling Behavior and Onset of Comorbid Psychopathology
Of the respondents with no Axis I disorder at baseline (other than gambling in some cases), 32% (standard error=4%) of those with gambling disorder, 27% (0.8%) of those with sub-threshold gambling disorder, 19% (0.3%) of those with recreational gambling, and 18% (0.2%) of the non-gamblers experienced an episode of a mood, anxiety, or substance-related disorder during the period between the wave 1 and 2 interviews. Specific onset rates for the different disorders are listed in Table 2.
Association Between Gambling Levels and Onset of Comorbid Psychopathology
Overall, compared to the non-gamblers, those in any gambling group had increased odds (p≤0.001) for the onset of a comorbid mood, anxiety, or substance- related disorder (recreational gambling: adjusted odds ration [AOR]=1.16, 95% CI=1.10–1.23; sub- threshold gambling disorder: 1.77, 1.63–1.92; gambling disorder: 2.51, 1.83–3.46) (Table 3). A statistically significant graded relationship was also found for any type of mood disorder (recreational gambling: 1.07, 1.01–1.14; sub-threshold gambling disorder: 1.37, 1.21–1.54; gambling disorder: 4.38, 3.28–5.85), any anxiety disorder (recreational gambling: 1.10, 1.05–1.16; sub-threshold gambling disorder: 1.70, 1.57–1.84; gambling disorder: 3.11, 2.15–4.49), any substance use disorder (recreational gambling: 1.29, 1.22–1.37; sub-threshold gambling disorder: 1.89, 1.69–2.11; gambling disorder: 2.07, 1.55–2.76), as well as for several specific disorders including specific phobia, posttraumatic stress disorder, alcohol-related disorder, and any non-alcohol, non-nicotine substance-related disorder.
In addition, both sub-threshold gambling disorder and gambling disorder at baseline were associated with the onset of multiple disorders (Table 3). Gambling disorder at baseline was associated with the onset of major depressive episodes (AOR 3.07, 95% CI 2.06–4.56), dysthymia (3.23, 1.27–8.23), hypomanic episodes (6.16, 4.00–9.48), generalized anxiety disorder (3.60, 2.34–5.54), and social phobia (0.56, 0.33–0.95). Sub-threshold gambling disorder at baseline was associated with the onset of major depressive episodes (1.30, 1.12–1.50), manic episodes (1.84, 1.51–2.23), hypomanic episodes (1.59, 1.16–2.18), social phobia (1.41, 1.27–1.56), generalized anxiety disorder (1.58, 1.37–1.84), nicotine dependence (1.54, 1.36–1.74). dysthymia (0.41, 0.19–0.89), and panic disorder (0.70, 0.56–0.87).
Of note, respondents with recreational gambling at baseline were not statistically significantly less likely to experience any type of or specific psychopathology than the non-gamblers except for dysthymia (0.83, 0.75–0.93), and they were at increased risk for onset of a manic episode (1.20, 1.08-1.33) and nicotine dependence (1.20, 1.11-1.30) compared with non-gamblers.
Associations Between Specific Gambling Symptoms and Onset of Comorbid Psychopathology
Most of the gambling-related symptoms were significantly correlated with the onset of psychopathology during follow-up (Table 4). The top three criteria associated with the onset of any mood, anxiety, or substance-related disorder were the withdrawal (OR=3.16, 95% CI=2.07–4.83), relationship (2.75, 2.64–2.87), and control-related criteria (2.24, 1.74–2.88). In addition, the withdrawal and control criteria were among the top two criteria associated with any mood disorder (withdrawal-related criteria: 4.34, 3.24–5.95; control-related criteria 3.86, 3.00–4.97) and any anxiety disorder (withdrawal: 2.74, 1.54–4.86; control: 3.36, 2.33–4.85). Finally, all criteria were consistently related to the onset of any mood or substance-related disorder.
Primary Findings: Graded Relationship Between Levels of Gambling and Onset of Comorbidity
This longitudinal study examined a large, nationally representative sample and found a graded or dose- response relationship between different levels of gambling and the onset of comorbid psychopathology. Those with gambling disorder were at the highest risk of new onset of comorbid conditions and those with recreational gambling were at the lowest risk among gambling groups, while the risk among participants with sub-threshold gambling disorder fell between these two groups. Furthermore, individuals who did not report any gambling behavior generally had a lower risk than the gambling groups. This dose-like association was observed for a number of disorders, including any mood disorder, any anxiety disorder, any substance use disorder, and specifically, specific phobia, posttraumatic stress disorder, any alcohol-related disorder, and any non-alcohol, non- nicotine-related substance use disorder. In addition to corroborating previous research that has demonstrated a strong correlation between gambling disorders and comorbid psychopathology, these findings suggest that even recreational gamblers have an attenuated but still significantly increased risk for onset of these comorbid disorders.
To determine the mechanisms linking gamblers with the onset of comorbid psychopathology, it is first necessary to understand the processes responsible for transitioning between different levels of gambling severity. Although poorly understood, it has been proposed that multiple biopsychosocial factors and interactions influence these transitions, such as trauma, stress, early exposure to and initiation of gambling, impulsive tendencies, and other genetic and environmental factors.37 Given that any gambling may develop into a gambling disorder, the risk factors for those with gambling disorder to experience comorbid psychopathology may also be risk factors for gamblers without a gambling disorder but to a lesser extent. For example, those with gambling disorders are more likely to experience higher levels of stress14 and sleep problems,16,17 both of which are associated with the onset of psychiatric disorders.65–68 Overall, with any loss, gamblers may experience shame, guilt, depression, helplessness, anxiety, and anger, which may affect the gambler’s mental well-being. Gambling can also cause financial hardship, conflicts with family, and problems with work, which can all increase the risk of developing comorbid disorders. Biologically, gambling pathology and other psychiatric disorders may be associated with similar predisposed tendencies, such as greater traits for impulsivity and poor emotional regulation.69–72
Secondary Findings: Specific Gambling Symptoms and Onset of Comorbidity
Most gambling-related symptoms were linked with the onset of comorbid psychopathology and this correlation warrants further investigation. Endorsement of the loss of control criterion was consistently one of the highest risk factors for the onset of comorbid disorders. Some believe that the loss of control over urges and behaviors is the central component of behavioral addictions,73,74 including gambling disorders.75 The decreasing ability to control gambling may be a component of a progressive worsening process in the life span of some gamblers.52,76,77 This behavior involves an obsessive passion or an internal pressure that pushes disordered gamblers to gamble.78 Similar to other DSM-IV Axis I disorders, this process may involve ego-dystonic components.79
The withdrawal-related criterion was consistently linked with the onset of comorbid disorders. The presence of withdrawal in gambling-related disorders helped shift the characterization of gambling disorder toward an addictive behavior.80,81 Previous cross-sectional studies have found that gamblers with withdrawal had more severe gambling problems and were more likely to suffer from comorbid psychiatric symptoms.21,82–84
As expected, respondents who endorsed the escape criterion (“gambles as a way of escaping from problems or of relieving a dysphoric mood [e.g. feelings of helplessness, guilt, anxiety, depression]”) were more likely to have an onset of any of the three types of disorders. These individuals use gambling as a way to regulate emotion.25,85 Since respondents in this survey were without a comorbid disorder at baseline, these findings suggest that, for some, gambling is a poor coping method, which worsens subthreshold or residual symptoms into a diagnosis. This finding reaffirms previous research indicating that individuals who gamble as an escape have more severe problems86–88 and that those problems are likely to facilitate the continuation of problem gambling.86
The findings of this study should be viewed in the context of several limitations. First, NESARC did not assess gambling behavior or the diagnosis of pathological gambling at wave 2. However, the goal of this study was to longitudinally examine the relationship between gambling at baseline and the onset of psychiatric comorbidity regardless of whether the participants continued to demonstrate gambling behavior at follow-up. Future epidemiological studies should examine the stability of gambling disorders over time and the factors that influence the progression of gambling disorders. Second, the diagnoses included in our assessment were based on structured interviews that may or may not correspond to clinician diagnoses. Nevertheless the AUDADIS interviews have been shown to have excellent validity and reliability when compared to diagnoses by clinicians.
Third, as with all survey studies, respondents in this survey may have had response bias regarding the screening question about gambling. Compared to the recent British Gambling Prevalence Survey, in which 43% of respondents reported gambling at least once in the last week and 73% reporting gambling at least once in the last year,89 only 27% of the NESARC respondents reported gambling five or more times in any year at baseline. Although the U.K. survey included different questions, this large discrepancy may suggest that gambling is more accepted in the United Kingdom (possibly due to increased accessibility and decreased regulations). Nevertheless, if the NESARC respondents minimized their gambling, the odds of developing comorbid disorders would be applicable to a greater number of people.
Public Health and Clinical Implications
Although it is difficult to establish whether it is gambling behavior or the unique characteristics of gamblers that contribute to the onset of comorbid conditions, these findings nevertheless have clinical and public health implications. With the increasing availability and accessibility of gambling,90,91 and the potential legalization of online gambling,92 gambling venues (online and in-person) may become efficient settings to detect psychiatric disorders. Furthermore, inquiring about gambling behavior and intervening in early stages of problematic gambling in the clinic may provide an opportunity to prevent progression to more severe forms and prevent future comorbid psychopathology. Notably, research indicates that treatment for gambling disorder not only reduces gambling behavior but can help to reduce comorbid psychiatric symptoms, such as anxiety and depression,93–95 improve quality of life, decrease psychological stress,96 and decrease the likelihood of comorbid psychopathology.97 A number of treatment strategies have shown promise in controlling aberrant gambling behavior, including self- help manuals, brief one-session interventions (motivational therapy), short-term therapy, psychodynamic therapy, cognitive-behavioral treatments, and referrals to 12-step support groups (e.g. Gamblers Anonymous).30,31 Greater availability of these efficacious interventions may curb the deleterious impact of gambling behavior on the public health of the population.
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gambling; comorbidity; epidemiology; longitudinal study; National Epidemiological Survey on Alcohol and Related Conditions (NESARC)
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