The Prevalence and Course of Pathological Gambling in the Mood Disorders

Disordered gambling among people with psychotic disorders: a systematic review

Disorders of gambling are more common among the mentally ill, including in people with psychotic disorders. The aim of this study was to conduct a systematic review of the literature regarding the prevalence and correlates of gambling disorders in people with psychotic disorders. We systematically reviewed English-language literature through searches of six bibliographic databases, all run on 11 November 2022: Medline ALL, Embase, Emcare, APA PsycINFO, CINAHL and the Cochrane Library. Observational studies that reported the prevalence of gambling in psychotic disorders or psychosis among gamblers were included. Studies were critically appraised using the Joanna Briggs Institute Critical Appraisal Tools. Sixteen studies, including 1,116,103 participants, from across a range of settings, were included. Most studies were done on males and recruited participants with a mean age of 40 years. Most of the studies (n = 12) were cross-sectional, and the remaining were case control in design. Most of the studies rated fair in quality. The prevalence of gambling among psychotic population ranged from 0.32 to 19.3%, with the majority of the studies reporting rates between 6.4 and 17%. The rates were 5-25 times higher than in the general population. While there were no consistent associations found with socio-demographic indices, several studies reported an association between gambling behaviours and substance use disorder among those with psychotic illnesses. Our research suggests that clinicians should assess for comorbid gambling among those with psychotic illness, particularly in those with mood symptoms, impulsivity, and substance use disorders. Gambling can negatively impact on their financial and social situations. Future research should study specific strategies or therapies among those with comorbid gambling and psychotic disorders.

Do Gender Norms Matter? General Strain Theory and a Gendered Analysis of Gambling Disorder among Chinese Married Couples

Despite the emergence of literature on gender differences in gambling problems, few empirical studies have explored how gender norms inform the gender dynamics involved in the development of gambling disorder. This study addresses this research gap by applying general strain theory to gambling disorder across genders. The objectives of this study are twofold. First, we examine the role of gender norms in the social strain-gambling disorder relationship across genders. Second, we explore the extent to which males and females who conform to traditional gender norms are likely to express strain-induced negative emotions that result in gambling disorder. These relationships are examined with data from a cross-sectional survey of 1,620 Chinese married couples in Hong Kong. Our results indicate that gender norms function differently between genders. Specifically, gender norms exacerbate the effect of social strain on gambling disorder in males but mitigate the effect of social strain on gambling disorder in females. In addition, gender norms amplify the effect of strain-induced negative emotions on gambling disorder in males only.

Adult Gambling Problems and Histories of Mental Health and Substance Use: Findings from a Prospective Multi-Wave Australian Cohort Study

Little is known about the cumulative effect of adolescent and young adult mental health difficulties and substance use problems on gambling behaviour in adulthood. We use data from one of Australia's longest running studies of social and emotional development to examine the extent to which: (1) mental health symptoms (depressive and anxiety symptoms) and substance use (weekly binge drinking, tobacco, and cannabis use) from adolescence (13-18 years) into young adulthood (19-28 years) predict gambling problems in adulthood (31-32 years); and (2) risk relationships differ by sex. Analyses were based on responses from 1365 adolescent and young adult participants, spanning seven waves of data collection (1998-2014). Persistent adolescent to young adult binge drinking, tobacco use and cannabis use predicted gambling at age 31-32 years (OR = 2.30-3.42). Binge drinking and tobacco use in young adulthood also predicted gambling at age 31-32 years (OR = 2.04-2.54). Prior mental health symptoms were not associated with gambling and no risk relationships differed by sex. Findings suggest that gambling problems in adulthood may be related to the earlier development of other addictive behaviours, and that interventions targeting substance use from adolescence to young adulthood may confer additional gains in preventing later gambling behaviours.

The diagnostic accuracy of brief screening instruments for problem gambling: A systematic review and meta-analysis

Non-gambling specialist services, such as primary care, alcohol and other drug use, and mental health services, are well placed to enhance the identification of people with gambling problems and offer appropriate generalist first level interventions or referral. Given time and resource demands, many of these clinical services may only have the capacity to administer very short screening instruments. This systematic review was conducted to provide a resource for health service providers and researchers in identifying the most accurate brief (1-5 item) screening instruments to identify problem and at-risk gambling for their specific purposes and populations. A systematic search of peer-reviewed and grey literature from 1990 to 2019 identified 25 articles for inclusion. Meta-analysis revealed five of the 20 available instruments met criteria for satisfactory diagnostic accuracy in detecting both problem and at-risk gambling: Brief Problem Gambling Screen (BPGS-2), NODS-CLiP, Problem Gambling Severity Index-Short Form (PGSI-SF), NODS-PERC, and NODS-CLiP2. Of these, the NODS-CLiP and NODS-PERC have the largest volume of diagnostic data. The Lie/Bet Questionnaire and One-Item Screen are also promising shorter options. Because these conclusions are drawn from a relatively limited evidence base, future studies evaluating the diagnostic accuracy of existing brief instruments across settings, age groups, and timeframes are needed.

The Reciprocal Association between Problem Gambling and Mental Health Symptoms/Substance Use: Cross-Lagged Path Modelling of Longitudinal Cohort Data

To date, studies have highlighted cross-sectional and unidirectional prospective relationships between problem gambling and mental health symptoms or substance use. The current study aims to: (1) examine the reciprocal relationships between problem gambling and mental health symptoms (depression, generalized anxiety)/substance use variables (hazardous alcohol use, daily tobacco use, and drug use) using cross-lagged path models in a prospective general population cohort sample; and (2) determine whether these associations are moderated by age and gender. This study involved secondary data analysis from 1109 respondents who provided data during Wave 2 or 3 (12-months apart) of the Tasmanian Longitudinal Gambling Study (Australia). Depression (odds ratio (OR) = 2.164) and generalized anxiety (OR = 2.300) at Wave 2 were found to have cross-lagged associations with the subsequent development of any-risk gambling (low-risk, moderate-risk, or problem gambling) at Wave 3. Hazardous alcohol use, daily tobacco use, and drug use at Wave 2 were not associated with the development of any-risk gambling at Wave 3. Any-risk gambling at Wave 2 was not associated with the subsequent development of any mental health symptoms or substance use variables at Wave 3. Age and gender failed to be significant moderators in the associations between any-risk gambling and mental health symptoms or substance use variables. Future longitudinal and event-level research is required to further substantiate these prospective relationships, with a view to developing targeted preventions and interventions.

Behavioral addictions in bipolar disorders: A systematic review

Clinical and epidemiological research suggests that behavioral addictions (BA) are associated with a wide range of psychiatric disorders. However, the relationship between BA and bipolar disorders (BD) has not been thoroughly explored. The aim of this systematic review was to critically summarize and evaluate the current available evidence regarding a possible association between BA and BD. A systematic review of major electronic databases according to PRISMA guidelines was conducted from inception to 31st December 2017. We sought quantitative studies data concerning prevalence of comorbidity, features and treatment related to BA-BD comorbidity. Data were narratively synthesized. Of the 1250 studies returned from the search, a total of 28 articles were included in this review. BA may be overrepresented in BD samples, and the other way around. Pathological gambling and kleptomania were the most prevalent conditions followed by compulsive buying, compulsive sexual behavior and internet addiction. BA was also associated with other mood disorders, anxiety disorders and substance use disorder. BD-BA comorbidity was related with more severe course of illness. Studies on treatment strategies for BD-BA comorbidity are rather limited; only one randomized controlled trial that fulfilled inclusion criteria was identified. Methodological heterogeneity in terms of design and results among studies was found. BD-BA commonly co-occurs although there is a need for rigorous studies. Routine screening and adequate assessment may be helpful in BD patients to identify individuals at risk for BA and to effectively manage the complex consequences associated with BA-BD comorbidity.

At-risk gambling in patients with severe mental illness: Prevalence and associated features

Background and aims The primary objective of this study was to investigate the prevalence of at-risk gambling in a large, unselected sample of outpatients attending two community mental health centers, to estimate rates according to the main diagnosis, and to evaluate risk factors for gambling. Methods All patients attending the centers were evaluated with the Canadian Problem Gambling Index and the Mini International Neuropsychiatric Interview. Diagnoses were checked with the treating psychiatrists and after a chart review of the university hospital discharge diagnoses. Results The rate of at-risk gambling in 900 patients was 5.3%. In those who gambled over the last year, 10.1% were at-risk gamblers. The rates in the main diagnostic groups were: 4.7% schizophrenia and related disorders, 4.9% bipolar disorder, 5.6% unipolar depression, and 6.6% cluster B personality disorder. In 52.1% of the cases, at-risk gambling preceded the onset of a major psychiatric disorder. In a linear regression analysis, a family history of gambling disorder, psychiatric comorbidities, drug abuse/dependence, and tobacco smoking were significantly associated with at-risk gambling. Discussion and conclusion The results of this study evidenced a higher rate of at-risk gambling compared to community estimates and call for a careful screening for gambling in the general psychiatric population.

Screening for problem gambling within mental health services: a comparison of the classification accuracy of brief instruments

BACKGROUND AND AIMS

Despite the over-representation of people with gambling problems in mental health populations, there is limited information available to guide the selection of brief screening instruments within mental health services. The primary aim was to compare the classification accuracy of nine brief problem gambling screening instruments (two to five items) with a reference standard among patients accessing mental health services.

DESIGN

The classification accuracy of nine brief screening instruments was compared with multiple cut-off scores on a reference standard.

SETTING

Eight mental health services in Victoria, Australia.

PARTICIPANTS

A total of 837 patients were recruited consecutively between June 2015 and January 2016.

MEASUREMENTS

The brief screening instruments were the Lie/Bet Questionnaire, Brief Problem Gambling Screen (BPGS) (two- to five-item versions), NODS-CLiP, NODS-CLiP2, Brief Biosocial Gambling Screen (BBGS) and NODS-PERC. The Problem Gambling Severity Index (PGSI) was the reference standard.

FINDINGS

The five-item BPGS was the only instrument displaying satisfactory classification accuracy in detecting any level of gambling problem (low-risk, moderate-risk or problem gambling) (sensitivity = 0.803, specificity = 0.982, diagnostic efficiency = 0.943). Several shorter instruments adequately detected both problem and moderate-risk, but not low-risk, gambling: two three-item instruments (NODS-CLiP, three-item BPGS) and two four-item instruments (NODS-PERC, four-item BPGS) (sensitivity = 0.854-0.966, specificity = 0.901-0.954, diagnostic efficiency = 0.908-0.941). The four-item instruments, however, did not provide any considerable advantage over the three-item instruments. Similarly, the very brief (two-item) instruments (Lie/Bet and two-item BPGS) adequately detected problem gambling (sensitivity = 0.811-0.868, specificity = 0.938-0.943, diagnostic efficiency = 0.933-0.934), but not moderate-risk or low-risk gambling.

CONCLUSIONS

The optimal brief screening instrument for mental health services wanting to screen for any level of gambling problem is the five-item Brief Problem Gambling Screen (BPGS). Services wanting to employ a shorter instrument or to screen only for more severe gambling problems (moderate-risk/problem gambling) can employ the NODS-CLiP or the three-item BPGS. Services that are only able to accommodate a very brief instrument can employ the Lie/Bet Questionnaire or the two-item BPGS.

Quelle est l’influence du genre dans la recherche de soins chez les joueurs?

Cette étude vise à décrire l’influence du genre sur les différentes étapes amenant un joueur ayant des problèmes de jeu à prendre la décision de rechercher de l’aide. Le modèle de recherche d’aide de Goldsmith, Jackson et Hough (1988) a été utilisé pour conceptualiser les étapes de prise de décision menant à consulter des services d’aide pour un problème de jeu de hasard et d’argent. Au total, 83 participants, dont 45 femmes et 38 hommes adultes, y ont pris part. Les résultats indiquent que, comparativement aux hommes, les femmes sont plus nombreuses à habiter en couple, ont plus souvent de faibles revenus et subviennent moins fréquemment seules à leurs besoins, rapportent des conduites de jeu plus conséquentes, souffrent davantage de troubles anxieux au cours de leur vie et, enfin, consultent surtout des services non spécialisés. Au cours des 12 derniers mois, les femmes avaient consulté plus souvent les services médicaux de première ligne et avaient eu moins fréquemment recours aux services spécialisés que les hommes.The aim of this study was to describe the influence of gender on the various stages of the decision-making process that bring problem gamblers to seek help. The authors used the help-seeking model developed by Goldsmith, Jackson and Hough (1988) to conceptualize the different stages of the process that leads to consulting support services for a gambling problem. A total of 83 participants (45 females and 38 males) took part in the study. Results show that women are more likely to have a partner and to earn a lower income; they provide for their own needs less frequently than men; report more consistent gaming behaviours; are more prone to anxiety disorder during their lifetime; and consult primarily non-specialized services. In the previous 12 months, they had accessed front-line services more often and specialized services less frequently than men.

Gambling problems in treatment for affective disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

Gambling problems co-occur frequently with other psychiatric difficulties and may complicate treatment for affective disorders. This study evaluated the prevalence and correlates of gambling problems in a U. S. representative sample reporting treatment for mood problems or anxiety.

METHODS

n=3007 respondents indicating past-year treatment for affective disorders were derived from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Weighted prevalence estimates were produced and regression analyses examined correlates of gambling problems.

RESULTS

Rates of lifetime and past-year problem gambling (3+DSM-IV symptoms) were 3.1% (95% CI=2.4-4.0%) and 1.4% (95% CI=0.9-2.1%), respectively, in treatment for any disorder. Rates of lifetime problem gambling ranged from 3.1% (95% CI=2.3-4.3%) for depression to 5.4% (95% CI=3.2-9.0%) for social phobia. Past-year conditions ranged from 0.9% (95% CI=0.4-2.1%) in dysthymia to 2.4% (95% CI=1.1-5.3%) in social phobia. Higher levels were observed when considering a spectrum of severity (including 'at-risk' gambling), with 8.9% (95% CI=7.7-10.2%) of respondents indicating a history of any gambling problems (1+ DSM-IV symptoms). Lifetime gambling problems predicted interpersonal problems and financial difficulties, and marijuana use, but not alcohol use, mental or physical health, and healthcare utilisation.

LIMITATIONS

Data were collected in 2001-02 and were cross-sectional.

CONCLUSIONS

Gambling problems occur at non-trivial rates in treatment for affective disorders and have mainly psychosocial implications. The findings indicate scope for initiatives to identify and respond to gambling problems across a continuum of severity in treatment for affective disorders.

Online interventions for problem gamblers with and without co-occurring mental health symptoms: Protocol for a randomized controlled trial

BACKGROUND

Comorbidity between problem gambling and depression or anxiety is common. Further, the treatment needs of people with co-occurring gambling and mental health symptoms may be different from those of problem gamblers who do not have a co-occurring mental health concern. The current randomized controlled trial (RCT) will evaluate whether there is a benefit to providing access to mental health Internet interventions (G + MH intervention) in addition to an Internet intervention for problem gambling (G-only intervention) in participants with gambling problems who do or do not have co-occurring mental health symptoms.

METHODS

Potential participants will be screened using an online survey to identify participants meeting criteria for problem gambling. As part of the baseline screening process, measures of current depression and anxiety will be assessed. Eligible participants agreeing (N = 280) to take part in the study will be randomized to one of two versions of an online intervention for gamblers - an intervention that just targets gambling issues (G-only) versus a website that contains interventions for depression and anxiety in addition to an intervention for gamblers (G + MH). It is predicted that problem gamblers who do not have co-occurring mental health symptoms will display no significant difference between intervention conditions at a six-month follow-up. However, for those with co-occurring mental health symptoms, it is predicted that participants receiving access to the G + MH website will display significantly reduced gambling outcomes at six-month follow-up as compared to those provided with G-only website.

DISCUSSION

The trial will produce information on the best means of providing online help to gamblers with and without co-occurring mental health symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02800096 ; Registration date: June 14, 2016.

Gambling problems in bipolar disorder in the UK: prevalence and distribution

BACKGROUND

North American studies show bipolar disorder is associated with elevated rates of problem gambling; however, little is known about rates in the different presentations of bipolar illness.

AIMS

To determine the prevalence and distribution of problem gambling in people with bipolar disorder in the UK.

METHOD

The Problem Gambling Severity Index was used to measure gambling problems in 635 participants with bipolar disorder.

RESULTS

Moderate to severe gambling problems were four times higher in people with bipolar disorder than in the general population, and were associated with type 2 disorder (OR = 1.74, P = 0.036), history of suicidal ideation or attempt (OR = 3.44, P = 0.02) and rapid cycling (OR = 2.63, P = 0.008).

CONCLUSIONS

Approximately 1 in 10 patients with bipolar disorder may be at moderate to severe risk of problem gambling, possibly associated with suicidal behaviour and a rapid cycling course. Elevated rates of gambling problems in type 2 disorder highlight the probable significance of modest but unstable mood disturbance in the development and maintenance of such problems.

Bipolar disorder and gambling disorder comorbidity: current evidence and implications for pharmacological treatment

BACKGROUND

The co-occurrence of bipolar disorder (BD) and gambling disorder (GD), though of clinical and public health importance, is still scarcely investigated. Comorbid BD-GD subjects experience a more severe course of illness and poorer treatment outcome, due to a range of clinical and psychosocial factors that collectively impede remission and recovery. The aim of our paper is to review the role of pharmacotherapy in the treatment of comorbid BD-GD, in order to support clinical decisions according to the best available evidence.

METHODS

A qualitative systematic review of studies on pharmacological treatment in comorbid BD-GD was performed. A comprehensive literature search of online databases, bibliographies of published articles and gray literature was conducted. Data on efficacy, safety and tolerability were extracted and levels of evidence were assessed. We also provide a brief overview of current epidemiological, neurobiological and clinical findings, with the intention of proposing a dimensional approach to the choice of available drugs.

RESULTS

The only drug with a high level of evidence is lithium. Considering the inclusion of GD in DSM-5 'Substance-related and Addictive Disorders' category, we discuss the use of other drugs with a high level of evidence currently used in BD subjects with co-occurring substance use disorders.

LIMITATIONS

Only few clinical trials are available and the population is limited; therefore no conclusive evidence can be inferred.

CONCLUSIONS

Further randomized controlled trials are required to evaluate the efficacy of pharmacological treatment strategies in large samples of patients with comorbid BD-GD. Also, attempts should be made to identify other shared clinical and psychopathological domains that are amenable to treatment.

Sex addiction and gambling disorder: similarities and differences

OBJECTIVE

Recently, the DSM-5 has developed a new diagnostic category named "Substance-related and Addictive Disorders". This category includes gambling disorder (GD) as the sole behavioral addiction, but does not include sex addiction (SA). The aim of this study is to investigate whether SA should be classified more closely to other behavioral addictions, via a comparison of the personality characteristics and comorbid psychopathology of individuals with SA with those of individuals with GD, which comes under the category of addiction and related disorders.

METHOD

The sample included 59 patients diagnosed with SA, who were compared to 2190 individuals diagnosed with GD and to 93 healthy controls. Assessment measures included the Diagnostic Questionnaire for Pathological Gambling, the South Oaks Gambling Screen, the Symptom CheckList-90 Items-Revised and the Temperament and Character Inventory-Revised.

RESULTS

No statistically significant differences were found between the two clinical groups, except for socio-economic status. Although statistically significant differences were found between both clinical groups and controls for all scales on the SCL-90, no differences were found between the two clinical groups. The results were different for personality characteristics: logistic regression models showed that sex addictive behavior was predicted by a higher education level and by lower scores for TCI-R novelty-seeking, harm avoidance, persistence and self-transcendence. Being employed and lower scores in cooperativeness also tended to predict the presence of sex addiction.

CONCLUSIONS

While SA and GD share some psychopathological and personality traits that are not present in healthy controls, there are also some diagnostic-specific characteristics that differentiate between the two clinical groups. These findings may help to increase our knowledge of phenotypes existing in behavioral addictions.

Hierarchical personality traits and the distinction between unipolar and bipolar disorders

BACKGROUND

The association between personality and psychopathology can provide an insight into the structure of mental disorders and the shared etiology and pathophysiology underlying diagnoses with overlapping symptomatology. The majority of personality-psychopathology research pertinent to the mood disorders has focused upon traits at the higher-order levels of the personality hierarchy, rather than those at intermediate or lower levels. The purpose of the current investigation was to investigate whether unipolar and bipolar mood disorders, and the severity of depressive and manic symptoms, show differential associations with traits at multiple levels of the personality hierarchy.

METHODS

Participants (N=275; 63% women; mean age 42.95 years) with depressive disorders (n=139) and bipolar disorders (n=136), as assessed by the Structured Clinical Interview for DSM-IV, Axis I Disorders, Patient Version (SCID-I/P; First et al., 1995), completed the Hamilton Depression Rating Scale, Young Mania Scale, Revised NEO Personality Inventory and Big Five Aspect Scales.

RESULTS

Results support the hypothesis that lower levels of the personality hierarchy provide additional differentiation of affective pathology. As compared to the widespread association of depressive symptoms with traits across the personality hierarchy, manic symptoms demonstrated more specific associations with traits at lower levels of the personality hierarchy.

LIMITATIONS

Patients with severe mania were excluded, thus the full range of mania is not represented in the current sample.

CONCLUSIONS

These results support the use of lower-order personality traits to discriminate between unipolar versus bipolar mood disorder, and are consistent with changes proposed to the psychiatric nosology to increase diagnostic precision.

Cognitive Behaviour Therapy for Problem Gamblers: A Clinical Outcomes Evaluation

Cognitive-Behaviour Therapy (CBT) is considered the number one non-pharmacological treatment for a number of mental and psychological disorders (Tolin, 2010; Stuhlmiller & Tolchard, 2009). While CBT with problem gamblers has shown promise, the quality of the research in this area is lacking. One area of concern is that across the many trials and reports using CBT with gamblers no single unified approach has been used and so comparison across studies is limited. Similarly, translation of the CBT research into clinical practice is almost entirely absent (Walker, 2005). This article will explore the concepts of CBT with problem gamblers and identify common elements across all reported approaches. A unified model of CBT with problem gamblers will be suggested and the direct clinical application of this model described from a state-wide gambling service in Australia (Flinders Approach) with 205 problem gamblers. The results indicate that the Flinders Approach is successful in treating gamblers considered to be at the severest end of the experience, with a 69% completion rate. Implications for future research in which this model may be tested against other therapies and pharmacological treatments will be discussed.

Personality dimensions and disorders in pathological gambling

PURPOSE OF REVIEW

This review presents the most current research in personality dimensions and disorders with respect to pathological gambling.

RECENT FINDINGS

Personality dimensions, such as impulsivity and impulsivity-related variables, are important aspects that may shape our understanding of the pathogenesis and treatment of pathological gambling. Furthermore, a large percentage of pathological gamblers have a co-occurring personality disorder which may impact the clinical presentation of pathological gambling.

SUMMARY

Evidence suggests that pathological gamblers exhibit impulsivity or impulsivity-related traits, as well as a range of personality disorders. Subtyping pathological gamblers based on personality domains has been proposed; however, more research is needed to provide support for these models. Overall, recent research represents an advancement in our understanding of how personality impacts pathological gambling, but further research is warranted to better understand how personality impacts the clinical presentation and treatment outcomes of pathological gambling.

Behavioral activation and inhibition, negative affect, and gambling severity in a sample of young adult college students

The prevalence of pathological gambling among college students is increasing. Few studies have directly examined the relation between reward processing and gambling severity while concurrently examining the effects of co-occurring negative affect in this at risk population. This study used Structural Equation Modeling (SEM) techniques to analyze results from an online survey of 352 female and 96 male students age 18-25. Participants completed measures of past year gambling behavior and severity of gambling problems using the Canadian Problem Gambling Index and the Problem Gambling Severity Index. Negative affect and reward processing were measured by the 21-item version of the Depression, Anxiety, and Stress Scales and the Behavioral Inhibition System and Behavioral Activation System (BIS/BAS) scales, respectively. Thirty-five percent of participants reported gambling in the previous 12 months, and 11% had gambling severity scores indicative of "moderate-risk" or "problem gambling." Gambling severity was associated with negative affect. Negative affect, in turn, was correlated with the unitary BIS scale and inversely associated with the BAS reward responsiveness scale. Reward responsiveness was also inversely associated with gambling severity. In the SEM models, the association between reward responsiveness and gambling severity was mediated by negative affect among males but not among females. Potential explanations for these findings and their implications for addressing problem gambling are discussed.