Pathways to Gambling Disorder: Why Screening and Assessment of All Behavioral Health Clients is So Important

March is Problem Gambling Awareness Month (PGAM) – “Awareness + Action”. The CASAT OnDemand post, Problem Gambling Awareness Month 2019: Tips for Behavioral Health Professionals, focused on what PGAM means for professionals in Behavioral Health, what reasons the research base provides for holding the month-log observance, and five recommendations for all behavioral health providers who want to take action. This post will dive deeper into the research base that demonstrates why behavioral health providers in Nevada might consider implementing those recommendations, particularly the recommendation to screen clients for gambling disorder – even if clients don’t happen to mention it.

Facts About Gambling in Nevada

To get a handle on a few of the basic facts about gambling in Nevada, the scope of the problem Nevada faces, and how it is being addresses, here are a few facts about gambling and gambling disorder in Nevada.

• Based on a 2016 U.S. Census Bureau estimate of 2,260,905 persons age 18+ and standardized past year problem gambling rate reported for Nevada, an estimated 2.7% of Nevada adults (61,044) are believed to manifest a gambling problem in Nevada (Williams, Volberg, & Stevens, 2012).
• Based on combined revenue reports from: (a) The American Gaming Association (2016); (b) Meister, A. (2017); and (c) North America State and Provincial Lotteries (2016), in 2016, approximately $12.6 billion were spent on legalized gambling in Nevada.
• Based on State Revenues from Gambling. Rockefeller Institute’s Blinken Report, the state collected $909.9 million in taxes and fees from major types of gambling in 2015 (Dadayan, 2016).
• “In 2016, Nevada ranked 13th out of the 50 U.S. states in terms of per capita public funds invested in problem gambling services. The average per capita allocation for problem gambling services in the 40 states with publicly funded services was 37 cents; Nevada’s per capita public investment was 47 cents” (Marotta et al., 2017).

Surprising Results of Recent Research About Prevalence of Gambling

The Survey of Gambling in the US telephone surveys conducted in 1999-2000 (SOGUS 1) and repeated in 2011-2013 (SOGUS 2), using the same assessment questions, same mode of administration, and the same methods. Results showed that the rates of “gambling in the last year” among US residents reduced from 59.9 days in SOGUS 1 to 53.7 days in SOGUS 2. The rates of pathological and problem gambling also remained stable or were reduced in some analyses of variables (Welte et al., 2014). The study authors hypothesized that this could have been caused by the economic crisis that began in 2008, yet further analysis revealed that gaming industry indicators showed that the industry was not seriously affected as revenues did not decline significantly. Another explanation was that the early effects of increased availability of gambling venues leads to increases in initial rates of problem gambling that decline over time as the population adjusts. The results were not definitive and further research is warranted.

Predictors for Gambling Disorder

Even though the rates of gambling and disordered gambling appear at this juncture to have reduced slightly, the problem remains, and researchers are now able to identify some characteristics of people who may be at higher risk for developing disordered gambling. In a study of predictors of problem gambling in the U.S., Welte et al., 2017 found that the following were significant predictors of gambling disorder:

• Males in the 31-40-year-old age range;
• Blacks (with education, income, and neighborhood disadvantage held constant);
• High school graduate or less: the rate of problem gambling is triple that of those with education beyond college;
• Church attendance at least once per week show fewest symptoms;
• Participants from a poor neighborhood had 2 ½ times the rate of those in the least disadvantaged neighborhoods.
• Impulsiveness, anxiety and depression are associated with gambling problems, with impulsiveness and depression serving as significant predictors;
• The most impulsive 25% of respondents have triple the gambling disorder symptoms of the 25% least impulsive;
• Participants who were diagnosed with depression had twice the rate of gambling disorder symptoms;
• Those participants who were the highest 20% reporting gambling is convenient have seven times the rate of the 20% of respondents reporting gambling is the least convenient;
• Respondents whose friends have a high approval of gambling have over three times the gambling disorder symptoms of those whose friends have low approval of gambling;
• Symptoms of gambling disorder are correlated with the number of casinos within 30 miles of the respondent’s home and self-reported convenience of gambling.

Results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

In wave 1 of the NESARC, Petry and colleagues (2005) found the following results:

• Almost three quarters (73.2%) of pathological gamblers had an alcohol use disorder;
• 1% had a substance use disorder;
• 4% had nicotine dependence;
• 6% had a mood disorder;
• 3% had an anxiety disorder;
• And 60.8% had a personality disorder.

The study authors stated, “A large majority of the associations between pathological gambling and substance use, mood, anxiety, and personality disorders were overwhelmingly positive and significant (p < .05), even after controlling for sociodemographic and socioeconomic characteristics” (Petry et al., 2005). In addition, male sex, black race, divorced/separated/widowed marital status, middle age, and living in the West and Midwest were associated with increased risk for pathological gambling. The associations between alcohol dependence, any drug use disorder, drug abuse, nicotine dependence, major depressive episode, and generalized anxiety disorder and pathological gambling were stronger among women than men (p > .05). Two study limitations were cited that provide some insight into how widespread co-occurring disorders may be. One was that not all psychiatric disorders were included in the studies. Another limitation was that researchers did not look at which came first, the gambling disorder or the other co-occurring psychiatric disorders.

Wave 2 of the NESARC: Wave 2 of the NESARC included modules assessing posttraumatic stress disorder, attention deficit/hyperactivity disorder, and narcissistic, borderline, and schizotypal personality disorders, which were examined in association with pathological gambling (Hasin & Grant, 2015). The results largely confirmed results of the earlier wave 1 study with more information on the nuances of differences in the predictors for different age groups and genders, with one example being that younger participants were found to be at higher risk for co-occurring conditions such as substance and personality disorders, and at lower risk of depression or anxiety disorder. Additional results from the study also showed that mistreatment during childhood (similar to Adverse Childhood Experiences identified in other studies) predicted psychopathology, alcohol use disorder was usually not treated, and that attitudinal barriers to treatment such as little perceived need, perceived stigma, and lack of belief in treatment success prevented entering treatment more than financial barriers (Hasin & Grant, 2015).

Another study of the same data by Barnes and colleagues (2015) found that disordered gambling and the three substance abuse measures were highly related. The study also confirmed results of other studies showing that current problem gambling was predicted by being male, being black, having low socio-economic status and by alcohol abuse/dependence, tobacco dependence and marijuana abuse/dependence. Thus, problem gambling is linked to other problem behaviors, especially substance abuse.

Takeaways for Behavioral Health Providers in Nevada

What the research tells us is that pathological gambling is highly comorbid with substance use, mood, anxiety, and personality disorders, suggesting that treatment for one condition should involve assessment and possible concomitant treatment for comorbid conditions. The most important takeaway from the results of recent research is likely that people who fall into the categories of many of the predictors or factors associated with increased risk for disordered gambling are often being treated for another disorder by behavioral health providers. Providers may not treat gambling disorder or even know that the client before them has a problem because the client is unlikely to bring it to the level of conversation. The reasons for this are more often related to lack of perceived need, stigma, and lack of belief in the effectiveness of treatment. Consequently, effective treatment approaches should screen and intervene for both gambling disorder as well as co-occurring substance abuse.

For training opportunities in Nevada related to gambling and other behavioral health disorders please visit CASAT Training. For additional resources, websites, and tools on gambling and other behavioral health disorders please visit the Resources and Downloads section of CASAT OnDemand.

References

Barnes, G. M., Welte, J. W., Tidwell, M. O., & Hoffman, J. H. (2015). Gambling and substance use: Co-occurrence among adults in a recent general population study in the united states. International Gambling Studies, 15(1), 55-71. doi:10.1080/14459795.2014.990396

Buth, S., Wurst, F. M., Thon, N., Lahusen, H., & Kalke, J. (2017). Comparative Analysis of Potential Risk Factors for at-Risk Gambling, Problem Gambling and Gambling Disorder among Current Gamblers-Results of the Austrian Representative Survey 2015. Frontiers in psychology, 8, 2188. doi:10.3389/fpsyg.2017.02188

Hasin, D. S., & Grant, B. F. (2015). The national epidemiologic survey on alcohol and related conditions (NESARC) waves 1 and 2: Review and summary of findings. Social Psychiatry and Psychiatric Epidemiology, 50(11), 1609-1640. doi:10.1007/s00127-015-1088-0

Howe, P., Vargas-Sáenz, A., Hulbert, C. A., & Boldero, J. M. (2019). Predictors of gambling and problem gambling in Victoria, Australia. PloS one, 14(1), e0209277. doi:10.1371/journal.pone.0209277

Marotta, J., Hynes, J., Rugle, L., Whyte, K., Scanlan, K., Sheldrup, J., & Dukart, J. (2017). 2016 Survey of Problem Gambling Services in the United States. Boston MA: Association of Problem Gambling Service Administrators.

Petry, N. M., Stinson, F. S., & Grant, B. F. (2005). Comorbidity of DSM-IV pathological gambling and other psychiatric disorders: Results from the national epidemiologic survey on alcohol and related conditions. The Journal of Clinical Psychiatry, 66(5), 564-574. doi:10.4088/JCP.v66n0504

Romanczuk-Seiferth N., Potenza M.N., Heinz A. (2019) Gambling Disorder: Future Perspectives in Research and Treatment. In: Heinz A., Romanczuk-Seiferth N., Potenza M. (eds) Gambling Disorder. Springer, Cham

Welte, J. W., Barnes, G. M., Tidwell, M. O., Hoffman, J. H., & Wieczorek, W. F. (2015). Gambling and problem gambling in the united states: Changes between 1999 and 2013. Journal of Gambling Studies, 31(3), 695-715. doi:10.1007/s10899-014-9471-4

Welte, J. W., Barnes, G. M., Tidwell, M. O., & Wieczorek, W. F. (2017). Predictors of problem gambling in the U.S. Journal of Gambling Studies, 33(2), 327-342. doi:10.1007/s10899-016-9639-1

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