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Are addictive? : two-year cumulative incidence and stability of pathological among Dutch scratchcard buyers de Fuentes Merillas, L.

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Citation for published version (APA): de Fuentes Merillas, L. (2005). Are scratchcards addictive? : two-year cumulative incidence and stability of pathological scratchcard gambling among Dutch scratchcard buyers.

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Lauraa DeFuentes-Merillas Aree Scratchcards addictive? ©© Laura DeFuentes-Merillas, 2004 Aree Scratchcards Addictive? Thesis,, Medical Faculty (AmC), Universityy of Amsterdam

Coverr illustration: Scratchcards are reproduced with the permission of "De Lotto*'.

Printedd in the Netherlands by Drukkerij Qwckprint, Nijmegen

ISBNN 90-807598-2-1

Partt II of this thesis was one of the conditions attached by the Dutch government to the permissionn given to "De Lotto" to sell scratchcards in the Netherlands. The study was conductedd by The Amsterdam Institute for Addiction Research (ALAR) and funded by "De Lotto".. Scientific integrity and independence was guarded by a supervising board comprising representativess of the addiction treatment centres and the Ministries of Health, Welfare and Sportss and Justice. Chapters 2 and 3 are reproduced with the permission of Addiction and Blackwelll Publishing. Aree scratchcards addictive?

ACADEMISCHH PROEFSCHRIFT

terr verkrijging van de graad van doctor aann de Universiteit van Amsterdam opp gezag van de Rector Magnificus prof.. mr. P.F. van der Heijden tenn overstaan van een door het college voor promoties ingestelde commissie,, in bet openbaar te verdedigen in de Aula der Universiteit

opp vrijdag 2 juli 2004, te 11.00 uur

door r

Lauraa De Fuentes Merillas

geborenn te Valladolid, Spanje Promoo tores: Prof.. dr. W. van den Brink Prof.. dr. G. M. Schippers

Co-promotor: : Dr.. M.W.J. Koeter

Faculteitt Geneeskunde AA mis padres, que me dieron la vida, yy a Guido, con quien la comparto.

CONTENTS S

PARTI I INTRODUCTION N

CHAPTERR 1 General introduction

PARTT II THE ADDICTIVE POTENTIAL OF SCRATCHCARDS

CHAPTERR 2 Are scratchcards addictive? The prevalence of pathological scratchcardd gambling among adult scratchcard buyers in the Netherlands s

CHAPTERR 3 Temporal stability of pathological scratchcard gambling among adult scratchcardd buyers: two years later

CHAPTERR 4 A clinical re-evaluation of the DSM-IV criteria for pathological scratchcardd gambling

PARTT m THE ASSESSMENT OF GAMBLING-RELATED PROBLEMS

CHAPTERR 5 Prevalence of pathological gambling: Validity of the Dutch version off the South Oaks Gambling Screen

CHAPTERR 6 The Gambling Problems Severity Scale (GPSS): A new multi- domainn instrument with Rasch properties to asses the severity of gamblingg related problems

PARTT IV GENERAL DISCUSSION AND SUMMARY

CHAPTERR 7 General discussion

Summary y Samenvattingg (Summary in Dutch) Resumenn (Summary in Spanish) Acknowledgements s Aboutt the author Listt of publications

PARTI I

INTRODUCTION N

Chapterr 1

CHAPTERR 1

GENERALL INTRODUCTION

Inn the last two decades scratchcards, scratchies or instant were launched in more than 400 countries. The introduction of scratchcards in the Netherlands in 1994 was preceded and accompaniedd by a long and often heated public debate about their potential negative side effectss in terms of excessive playing. Opponents of the introduction of scratchcards referred too their structural game characteristics, and considered them potentially addictive. The most importantt characteristics in this respect are low threshold, short-payout intervals and "near misses".. Because of the assumed hazards, the Dutch government imposed several conditions too the introduction of this on the Dutch legal gambling market. However, the addictivee potential of scratchcards in the Dutch situation had never been thoroughly assessed. Thee study launched in the first year of the introduction (Hendriks, Meerkerk, Oer, & Garretsen,, 1997) did not allow a proper assessment of the addictive potential of scratchcards sincee it generally takes several years for problems to develop and people to get addicted to a gamee of chance (Meyer, 1992; Poppel, 1994; Jacques, Ladouceur, & Ferland, 2000). Therefore,, a large socio-epidemiological study was needed to scientifically evaluate and monitorr the potential negative side effects of scratchcards at the community level, in order to assesss the addictive potential and the social burden of this form of gambling. Thee purpose of this thesis is twofold: first, to investigate the addictive potential of scratchcardss in the Netherlands (Part II), and second, to investigate some unresolved issues in thee assessment of gambling problems in general. The latter includes the validation of the Southh Oaks Gambling Screening and the development of a new instrument to assess the severityy of gambling problems, the Gambling Problems Severity Scale (Part EQ). Before elaboratingg on the twofold purpose of this thesis, it is necessary to briefly illustrate the role thatt gambling has played throughout history, as well as to review some important concepts in orderr to clarify the nature of gambling problems. Thiss introductory chapter (Part I) aims: (I) to describe the role of gambling from a historicall perspective, (2) to define pathological gambling and to review some factors that are importantt in the addictive potential of different types of gambling, as well as to refer to some methodologicall issues in the identification and assessment of gambling problems, (3) to illustratee the situation of legalised gambling in the Netherlands, specifically with regard to scratchcards,, and finally, (4) to present the aims and structure of this thesis.

THEE ROLE OF GAMBLING THROUGHOUT HISTORY

Gamblingg is part of human nature, and as such has been found in all cultures, societies and sociall classes. Among other aspects, gambling combiness two important elements in a person's developmentt and socialisation: "playing" and "taking risks".

11 1 Generall introduction

Theree is evidence that games of chance have been around as long as civilisation itself. Forr example, circa 2000 BC the Egyptians were using knuckle bones painted as four-sided dice,, and around 2300 BC the Chinese were already playing a sort of (Becofla, 1996; Bellringer,, 1999). The Greeks always played for money. It is documented that Aristoxene criticisedd Socrates because "he speculated, wagered money, won, quickly spent his win, and beganbegan to gamble again". Once Plato "insulted a man who was playing dice. The other respondedresponded that he was losing his temper over a little thing, and Plato said to him: "But the habithabit of playing is not a little thing" (Ladouceur, Sylvain, Boutin, & Doucet, 2002, page 2). Gamblingg was a very popular activity in the Roman Empire. Actually, emperors like Nero or Claudiuss gambled excessively with dice. Evidence seems to indicate that dice were also used whenn the Roman soldiers raffled the clothes of Jesus Christ. Closerr to our time, there are reports of famous excessive gamblers like Columbus (1451-1506),, the English king Henry the VIII (1509-47), the French scientist and philosopher Descartess (1596-1650), the French king Louis XTV (1638-1715), or even pathological gamblerss like Dostoyevsky, who, in order to settle gambling debts, wrote, in less than a month,, his autobiographic novel "The Gambler" -1866- (Becofia, 1996,2003).

Gamblingg from reprobation to a noble status Excessivee gambling has always been perceived as morally inferior and as subversive to the sociall order. For this reason governments or institutions that hold powerful positions in societyy have tried to regulate, or even ban, gambling. Religious authorities in particular have censoredd gambling by considering it a vice, morally wrong and evil (Bellringer, 1999). Ann important shift in the conception of gambling took place when it became associatedd with worthy causes, sometimes even promoted by powerful figures or institutions. Sincee the fifteenth century, countries like Spain, France, England or the Netherlands have usedd lotteries as a way of financing useful and worthy causes. There are plenty of examples of thesee forms of charity through history. For instance, in England, Queen Elizabeth I (1533- 1603)) organised a for the public good and the profits were used to renovate her realm's bridgess and aqueducts (Ladouceur et al., 2002). In Italy, the proceeds derived from organised lotteriess helped finance the construction of the cathedral of Milan. Since then, lotteries have beenn linked with charities and novel causes. Today, not only governments but also influential institutionss and associations like universities or non-governmental organisations (NGOs) organisee various games of chance in order to fund scientific research, to build hospitals and schoolss in developing countries or to help the victims of naturall catastrophes and other similar causes.. Throughout history, whether encouraged or prohibited, the need for humans to gamble hass been exploited by both public and private organisations.

TOWARDSS A DEFINITION OF PATHOLOGICAL GAMBLING

Too gamble literally means betting or staking something of value on the outcome of a game or eventevent (Encyclopaedia Britannica Online, 2003). But when does gambling become excessive or

12 2 Chapterr 1 problematicc or even pathological? How can we define pathological gambling and identify pathologicall gamblers? Do all pathological gamblers follow the same career in the developmentt of their gambling problems and do all forms of gambling have the same addictivee potential? These questions will be addressed in this section. Nowadays,, gambling is a common leisure activity and over two-thirds of adults engagee in it on a regular basis. For instance, in 1998, 86% of the general adult American populationn had gambled at some point in their lives (National Opinion Research Center (NORC),, 1999). Similarly, European studies have shown that 95% of the Swedish population participatedd in one or more gambling activities at some time during their lives (Volberg, Abbott,, Ronnberg, & Munck, 2001), over 60% of English adults gamble every week (Griffithss & Macdonald, 1999) and a Dutch study found that more than half (55%) of the generall population between 12 and 35 years of age had gambled in the preceding year (Koeter,, Brink, & Niewijk, 1996). Gambling, like other potential addictive behaviours (i.e. drinkingg or smoking), is a socially accepted behaviour in which a minority of individuals reachess levels that disrupts social adaptation or becomes dependent. For most people, however,, gambling is and remains a relaxing activity that does not carry any negative consequences.. Less than 10% of the adult gamblers develop gambling-related problems (Potenza,, Kosten, & Rounsaville, 2001a). They lose control over their gaming and become "addicted".. For those individuals compulsive wagering is a source of both excitement and relaxationn in the short term, which, in the long term, starts to dominate their lives with all its' negativee consequences (Ladouceur et al., 2002). Such consequences significantly affect their financial,financial, occupational, interpersonal and social areas of functioning. Differentt terms have been used to describe problem gambling, including excessive (Cornish,, 1978; Ladouceur et al., 2002), pathological (Moran, 1970; Lesieur & Custer, 1984), compulsivee (Bergler, 1957; Gamblers Anonymous), dependent (Bellringer, 1999), addictive (Dickerson,, 1977) or disordered gambling. Due to this diversity in terminology there is no uniformlyy accepted term to denominate gambling problems. Inn 1977, the term pathological gambling (PG) was included in the International Classificationn of Diseases (ICD-9, World Health Organization, 1977), and in 1980, in the thirdd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IH) as one off the impulse-control disorders not elsewhere classified (American Psychiatric Association, 1980).. The DSM criteria have become the scientific standard to diagnose pathological gambling.. Since the DSM-IH, the criteria for this disorder have been modified on two occasionss (American Psychiatric Association, 1987; American Psychiatric Association, 1994).. The first modification was in response to Lesieur's criticism (1988) that the DSM-III (1)) suffered from a bias that led to an overestimation of pathological gambling in the middle- classes,, (2) failed to recognise that many compulsive gamblers are self-employed, (3) excludedd individuals with Antisocial Personality Disorders leading to an underestimating of thee prevalence of this disorder, and (4) that its criteria did not allow for individuals who spend aa disproportionate amount of time gambling but still without serious consequences. Additionally,, there was a growing acceptance that gambling shares many characteristics with addictivee behaviours (Lesieur, 1988; Griffiths, 1995). The American Psychiatric Association,

13 3 Generall introduction addictivee behaviours (Lesieur, 1988; Griffiths, 1995). The American Psychiatric Association, takingg these points of criticism into account, developed the DSM-IÏÏ-R criteria modelled on thee DSM criteria for substance abuse disorders (APA, 1987). However, Rosenthal's study (1989)) reported some dissatisfaction with the DSM-III-R criteria among treatment professionals.. These clinicians advocated a new modification of the criteria for pathological gamblingg that would include: (1) a combination of the DSM-in and the DSM-HI-R criteria, (2)) the addition of "escapism" as a criterion and (3) the exclusion of individuals with a current Manicc Episode. The resulting DSM-IV criteria for PG are presented in Table 1.1 (APA, 1994).. As in many other disorders, the DSM-IV symptom criteria for pathological gambling aree a product of clinical experience, research findings, expert group consensus, and possible culturall and political biases (Stinchfield, 2002).

Tablee 1.1 DSM-IV criteria for pathological gambling (APA, 1994, p. 271).

A.. Persistent and recurrent maladaptive gambling behaviour as indicated by five (or more) off the following: (1)) Is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences,, or planning the next venture, or thinking of ways to gett money with which to gamble) (2)) Needs to gamble with increasing amounts of money in order to achieve the desiredd excitement (3)) Has repeated unsuccessful efforts to control, cut back, or stop gambling (4)) Is restless or irritable when attempting to cut down or stop gambling (5)) Gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g.,, feelings of helplessness, guilt, anxiety, depression) (6)) After losing money gambling, often returns another day to get even ("chasing one'ss losses") (7)) Lies to family members, therapist, or others to conceal the extent of involvementt with gambling (8)) Has committed illegal acts such as forgery, fraud, theft, or embezzlement to financee gambling (9)) Has jeopardized or lost a significant relationship, job, or educational or career opportunityy because of gambling (10)) Relies on others to provide money to relieve a desperate financial situation causedd by gambling B.. The gambling behaviour is not better accounted for by a Manic Episode.

Notwithstandingg the ongoing debate about the most adequate definition and symptomatologyy of this disorder, which shares similarities with both impulse control disorderss and substance dependence, the DSM-IV criteria for pathological gambling have

14 4 Chapterr 1

(Nationall Opinion Research Center (NORC), 1999; Stinchfield, 2003). Therefore these criteriaa will be the definition of pathological gambling used in this thesis.

Stagess of the pathological gambler's career Althoughh at the individual level there are many characteristics that differ from gambler to gambler,, some groups seem to be more at risk of pathological gambling than others. For example,, relatively high prevalence rates have been found among young adults (age group 18- 29,, Abbott & Volberg, 1996; Gotestam & Johansson, 2003), adolescents (Griffiths & Sutherland,, 1998; Kaminer & Perry, 1999; Griffiths, 2000b; Gupta & Derevensky, 1998) and adultss in mental health and substance abuse treatment (Crockford & elGuebaly, 1998; Shaffer, Hall,, & Vander-Bilt, 1999; Potenza et al., 2001a). Most epidemiological surveys also reported thatt men are more at risk of pathological gambling than women (Tavares, Zilberman, Beites, && Gentil, 2001; Potenza et al., 2001b; Gotestam et al., 2003). Clinicall evidence suggests that there are three common stages in the development of pathologicall gambling: the winning phase, the losing phase and the desperation phase (Custer, 1984;; Lesieur, 1984; Griffiths, 1995; Griffiths et al., 1999 & Bellringer, 1999). TheThe winning phase often occurs the first few times the individual gambles. Small wins orr an early significant win lead the gambler to believe that he/she is lucky by nature and that he/shee is "skilful" at this gambling activity. Several authors report that most recreational gamblerss stop their gambling in this phase (Custer, 1984; Griffiths, 1995). Others, however, willl continue gambling, convinced that "lady luck" is on their side. During the career of the problemm gambler this winning stage may return at any time, following non-fixed reinforcementt schedules, which strongly rewards and justifies their continuing gambling behaviour. . Duringg the next stage, the losing phase, gamblers mainly incur losses as a result of theirr wagering. Yet, these losses are not experienced as such by the problematic gamblers becausee they have the unrealistic belief that these losses precede ultimate and total success (Bellringer,, 1999). Inevitably, the losing phase is more persistent than the gambler expects andd takes away all his/her resources, and the gambler needs to get money elsewhere. This phasee is characterised by the so-called "chasing pattern", i.e. gambling for the "big win" that willl repay all the losses and solve the problems. However, instead of "cutting their losses" gamblerss get deeper and deeper into financial problems, and as a consequence other areas of functioningg are also affected (Griffiths, 1995). As a result of this repetitive gambling despite lossess the gambler reaches the desperation phase in which debts accumulate and relationship problemss become acute. Bellringer (1999) reported that the trigger into desperation very often occurss when gamblers cannot cover a debt that is being requested by a third party (family member,, loan shark, employer, etc.). This crisis could precipitate the gambler crossing the linee into illegal behaviours in order to finance his/her gambling as the last effort to repay his/herr debts. Even when a gambler has reached this desperation stage gambling may continue forr several years until there are no more options left. At this point the gambler could suffer severee depression and suicidal thoughts or may be imprisoned. Usually it is during this

15 5 Generall introduction desperationn phase that the gambler seeks professional help, often under constraint, having beenn urged to by family members or compelled by the legal system. Inn addition to these three phases of the pathological gambler's career, there is a fourth andd final phase, the so-called rock bottom phase, as suggested by Gamblers Anonymous. Duringg this phase excessive players continue gambling until illness, death or a successful suicidee attempt ends their addictive behaviour (Bellringer, 1999). Fortunately, not all gamblerss reach this rock bottom phase. Findings from experimental studies have also describedd an alternative fourth phase called the hopeless or giving up phase (Rosenthal, 1989; Griffithss et al., 1999). In this phase gamblers realise that "they cannot possibly recover their losseslosses and they do not care, leading to play for play's sake" (Griffiths, 1995, p. 9). Similar to "laboratory"laboratory animals with electrodes planted in their pleasure center, they gamble to the point ofof exhaustion " (Lesieur & Rosenthal, 1991, pp. 14-15). Thesee are the phases that seem to explain the development of the pathological gambler'ss career at an individual level -from social to pathological gambling. However, there aree other factors that may play a role in this development. For example, scientific evidence, thatt will be presented next, suggests that not all forms of gambling have the same addictive potential.. In other words, some games of chance are more hazardous than others. The followingg section explores some of the characteristics that increase a game's addictive potential. .

Gamee characteristics and addictive potential Severall authors have pointed to the association between the increased availability of gambling opportunitiess and the rise in the prevalence of gambling-related problems and pathological gamblingg (Lester, 1994; Hendriks et al., 1997; Shepherd, Ghodse, & London, 1998a; Wood & Griffiths,, 1998; Volberg et al, 2001; Welte, Barnes, Wieczorek, Tidwell, & Parker, 2002; Gotestamm et al., 2003). But the term gambling denotes a heterogeneous groups of games of chancee such us wagering in , playing in the lotteries, horse or dog race betting, playing slott machines, card games, scratchcards, , participating in internet gambling, and charity raffles.. Since the 1950s, various authors have related the addictive potential of a game of chancee to a number of structural characteristics of the game (Royal Commission on Gambling,, 1951; Kingma, 1993; Griffiths, 1995; Pugh & Webley, 2000; DeFuentes-Merillas, Koeter,, Schippers, & Brink, 2003; Dickerson, 2003). The games that allow for continuous playy and have relatively short-payout intervals between stake and outcome (e.g. games, slott machines, scratchcards, and horse/dog racing) are particularly likely to lead to excessive gambling.. These structural characteristics are believed to either induce the player to gamble or inducee continued playing. Thee six basic elements that are considered to increase a game's addictive potential (Griffiths,, 1995) will be discussed in more detail next. (1) The pay-off schedule and event frequencyfrequency of the game, i.e. the time between the initial wager and reward (payment). A distinctionn is made between short and long-payout interval games. Based on this characteristic

16 6 Chapterr 1

Dickersonn (1996) uses the terms continuous versus non-continuous or discontinuous (Dickerson,, Baron, Hong, & Cottrell, 1996). The former identifies hazardous games of chance thatt permit a repeated cycle of stake, play and outcome (e.g. slot or fruit machines, casino games,, scratchcards) and the latter characterises gambling forms such as lotteries, where there mayy be a period of hours, days or even months between stake and outcome. (2) The frequency ofof "near misses " or failures that are close to being successful are believed to encourage future playy and to induce continued gambling. Games with a high proportion of these "near misses" givee a player the feeling that he/she is not constantly losing but constantly nearly winning (e.g.. slot machines, roulette, scratchcards). (3) The multiplier potential refers to whether one cann gamble on only one or on a series of events; more specifically, whether the game allows forr gambling at a variety of odds and/or stake levels. For example, fruit machine gamblers can choosee the rate at which their wins and/or losses multiply. (4) The win probability and payout ratio,ratio, referring to the probability that the player wins an individual bet and to the ratio of potentiall winnings to the gamblers' stake, respectively. For scratchcards in the Netherlands thee payout ratio in 2002 was approximately 50% and the mean win probability over the last 122 series was 20% or 26% depending whether a free scratchcard was counted as a win. (5) GameGame presentation, naming, sound, light and colour effects also play a crucial role in attractingg gamblers and finally, (6) the suspension of judgement, by which the structural characteristicss that temporarily dislocate the player's financial value system (or money's true value),, such as in playing with chips instead of money at casinos, are meant. Inn addition to these structural characteristics four situational features that influence the addictivee potential of a game are frequently mentioned: (1) The location of the game and environmentalenvironmental characteristics may attract the potential player to gamble and/or to maintain gambling.. (2) Also the availability of the game in a specific area, possible membership requirementsrequirements and enforcement of the gaming laws, stipulating the availability of a specific gamee for a potential player, may either encourage or discourage gambling. For example, roulettee in the Netherlands can only be played in casinos and access to casinos is limited to adults2.. (3) The influence of advertising presented on television, radio, in newspapers, on billboards,, shops, etc., including "prime time" television shows (with popular media figures) andd related news broadcasts (publicity surrounding the winning numbers and the winners). Alll these activities are meant to attract players and to induce them to gamble. (4) The accessibility/availabilityaccessibility/availability of other continuous forms of gambling, e.g. slot machines, casinos, bets,, bingo. Thus, scratchcards might be more addictive in a context where, compared with thee Netherlands, access to continuous gambling forms is more restricted (DeFuentes-Merillas ett al., 2003). Based on nine of these characteristics, Kingma classified the six most popular gamess of chance in terms of participation rates in the Netherlands (i.e. lotteries, bingo, casino games,, slot machines, horse race betting and scratchcards; Kingma, 1993). Table 1.2 shows thee total "Kingma-score" per game of chance. The higher the total score the higher the

11 In this thesis we will refer to these forms of gambling as short-payout interval games. 22 In this study the term adult refers to a person who is 18 years old or older.

17 7 Generall introduction addictivee potential. It remains yet to be proven that this so called "Kingma score" is a valid indicatorr of addictive potential Nevertheless, Kingma's classification is frequently used in the Netherlandss by various key figures (policy makers, journalists, the gaming industry, etc.).

Tablee 1.2 Kingma's risk profile* of the 6 most popular Dutch games of chance (1993) Scratchcards s Gamee characteristics Lotteries s Bingo o Casino o Slott machines Horse e games s racing g Pay-offf schedules -- -- -H-- -H-- + + ++ + Stake e +-- +-- + + -- + + -- Payoutt ratio + + +-- -- +-- -- + + Environment t -- + + + + +-- + + -- Rapidd event frequency -- -H-- + + + + +-- +-- Prizee attractiveness ++ + -- + + +-- + + + + Skill/player'ss involvement -- -- + + +-- ++ + -- Supervisionn and control -- -- + + + + -- -- Availability y + + + + +-- ++ + +-- -- Total l -1 1 0 0 +7 7 +5 5 +4 4 +2 2 ** Risk profile = - (low riskX +- (moderate risk), + (risk), ++ (high risk). "Pay-offf schedules (time between stake and game outcome); Stake (minimal amount, variation per purchase); Payoutt ratio (the ratio of potential winning to the gambkr's stake); Environment (and its influence in the game); Rapidd event frequency (time spent pa- purchase and playing sequence); Prize attractiveness (amount, win probabilityy and variation); Skill and player's involvement (how the player can influence the outcome); Supervisionn and control; Availability (and accessibility).

Identificationn and assessment of gambling problems Ass mentioned in the discussion of the development phases of pathological gambling, the majorityy of problem gamblers who seek treatment do so when their problem has reached a criticall stage. This is the reason why the early detection and assessment of gambling-related problemss is such an important issue. Reliable and valid instruments for the general population aree needed to assess, monitor and evaluate the effect of existing gaining policy and new developmentss on the extent and character of gambling availability. Many epidemiological studiess on pathological gambling have used diagnostic interviews and/or self-report screening questionnairess to estimate prevalence rates. In our opinion, the most appropriate instrument, inn terms of validity, is a structured psychiatric interview like the DIS-T (Pathological Gamblingg Section of the Diagnostic Interview Schedule, APA 1994). However, in the case of relativelyy rare diseases like pathological gambling, large samples are needed to get prevalence estimates3.. In this situation structured psychiatric interviews are too time consuming and too expensive.. Therefore, a more cost-effective solution to estimate the prevalence of gambling problemss is the use of self-report screening instruments like the South Oaks Gambling Screeningg (SOGS, Lesieur & Bhime, 1987). A drawback is that such screening instruments

33 The Se(p) is defined as V(p(l - p)/n) and is maximised for p=.50 and becomes smaller when p becomes smaller orr larger than .50. In the case of rare diseases, however, you need at least some cases to be able to make an estimatee and describe the characteristics of these cases. This makes large samples necessary.

18 8 Chapterr 1 alwayss generate misclassifications (false positives and false negatives). In the case of a low prevalencee disorder like PG, even a screener with excellent specificity like the SOGS will producee a substantial number of false positives, and as a consequence will overestimate the prevalence. . AA methodological solution to this dilemma is the use of a cost-effective two-stage samplingg design (Cullenton, 1989; Volberg & Abbott, 1994; Abbott et al., 1996; Ladouceur, 2002;; DeFuentes-Merillas et al., 2003). In the first stage, a self-report screener is used to identifyy people at risk of pathological gambling in a large and representative sample of the targett population. In the second stage, all screener positives and a random sample of the screenerr negatives are given a structured diagnostic interview to assess whether or not they meett the diagnostic criteria for pathological gambling. This two-stage sampling design was appliedd several times in the studies reported in this thesis.

COMMERCIALL GAMBLING IN THE NETHERLANDS

Gamblingg has been around in Dutch society through the ages, and similar to many other countries,, gambling laws were developed to canalise gambling behaviour. In the Netherlands, variouss government institutions are involved in the licensing and controlling of gaming. The Dutchh has three main aims: (a) the prevention of pathological gambling, (b) the protectionprotection of players by assuring fair games of chance, and (c) the prevention of criminal practicess by excluding illegal providers of gambling. At the national level, the departments of Justice;; Economic Affairs; Finance; Public Health, Welfare and Sports, and Agriculture are involvedd in licensing the gaming monopolies. In addition, an independent advisory body appointedd by the Crown, "Het College van toezicht op the kansspelen" (the Netherlands Gamingg Control Board), advises the departments on the issue, alteration and withdrawal of thee licenses of the legal gaming monopolies, as well as on the approval of their constitution andd regulations. Currently, there are six legal monopolies in the Netherlands (the state lottery, scratchcards,, sports pools, horse race betting, lotto and casino games) plus three charitable lotteriess with exclusive rights (bankgiro lottery, postal code lottery and sponsor lottery; The Netherlandss Gaming Control Board, 2004). In addition, there are approximately 35,000 slotmachiness outside the casinos which are not monitored by the Netherlands Gaming Control Board. . Sincee the introduction of the "Wet op de Kansspelen" ("Gaming Law") in 1964, the Dutchh legal gambling market has expanded rapidly: between 1989 and 1994, for example, it greww almost nearly 75% (Meerkerk, et al., 1995). Simultaneous with the proliferation of gamingg opportunities there has been an increase in the number of gamblers participating in gamess of chance (Hendriks et al., 1997). For the vast majority of the Dutch population gamblingg is a harmless recreational activity, but for some it may become problematic. Therefore,, it is vital to understand any new game's potential negative consequences to society.. Such knowledge can best be obtained by an independent evaluation of the available evidencee on the addictive potential of the game involved prior to its introduction. Based on

19 9 Generall introduction thesee results and in order to protect any at-risk groups, the authorities may, if necessary, adapt thee existing gaming law pertaining to that particular form of gambling by imposing specific restrictionss (e.g. an age limit or maximum amount per transaction). Ideally, such an empirical evaluationn study should also be conducted after its introduction. Unfortunately, methodologicallyy sound evaluation studies are rarely performed in the gambling field due to thee high costs. To illustrate this feet, the process of the introduction of scratchcards in the Netherlands,, as well as the conditions surrounding the introduction, will be discussed in the nextt section.

THEE POSITION OF SCRTATCHCARDS IN THE DUTCH LEGAL GAMBLING MARKET T

Publicc debate around scratchcards Thee introduction of scratchcards in the Netherlands in 1994 was preceded and accompanied byy a long and often heated public debate about their addictive potential. Opponents of the introductionn of this new game referred to its structural game characteristics and to Kingma's riskk profile, and consequently considered it potentially addictive. Based on the structural and situationall characteristics outlined in the previous section, the addictive potential of scratchcardss can be considered to be moderate, i.e. higher than the risk of standard lotteries butt lower than the risk associated with slot or fruit machines and casino games. The characteristicss of scratchcards that might facilitate excessive gambling are their "short-payout intervals"" and "low threshold" (both in terms of accessibility i.e. high availability, and costs), whichh may additionally motivate the player due to the psychological effect of the "near miss". Thiss "near miss" effect can be considered one of the main marketing strategies used by the scratchcardd providers. Because of these and other similarities with fruit machines, scratchcardss have been referred to as "paper fruit machines" (Griffiths, 2000a), a term with strongg negative connotations, considering that fruit machines are believed to be the most addictivee hazard game. In feet, in the Netherlands, the majority of the pathological gamblers undergoingg treatment have problems relating to fruit machines. Becausee of the potential negative side effects the Dutch government imposed several conditionss on the introduction of scratchcards on the Dutch legal gambling market A number off these regulations aimed to protect the consumers, such as the limitations on the volume of scratchcardd sales per year, the number of scratchcards per customer and per transaction and thee restriction of the sales to adults only. In the Netherlands, the scratchcard age ban (> 18 years)) is quite restrictive in comparison with the sale regulations of other addictive substances likee tobacco or alcohol. For example, the age ban for tobacco is 16 years. An evaluation study focusingfocusing on potential problems related to scratchcard gambling, to be conducted following the game'ss introduction, was also imposed. This study was carried out among a sample of 4,497 adultt scratchcard buyers. In this sample 4.1% were classified as "at-risk gamblers", defined as playerss that bought at least 25 scratchcards in the month preceding the assessment and met at leastt one "risk" or "problem" indicator (Hendriks et al, 1997). However, due to the feet that

20 0 Chapterr 1 thiss study was conducted within one year of the introduction of the scratchcards, no conclusionss could be drawn with regard to the addiction potential since it takes on average severall years for players to become addicted (Meyer, 1992; PoppeL 1994). For the same reasonn the prevalence estimate of "at-risk gamblers" in this study probably underestimates the "true"" prevalence of scratchcard-related problems.

EvidenceEvidence from the literature Att an international level several studies have addressed the issue of scratchcard-related problemss in the last decade. Based on their main research goals the studies can be divided into threee subgroups: (1) studies assessing the effect of public availability of scratchcards by estimatingg the prevalence of scratchcard playing and/or identifying vulnerable groups, (2) studiess exploring under-age scratchcard gambling, and (3) studies that investigated whether theoreticall assumptions about gambling or pathological gambling apply to scratchcards. Thee first group comprises five studies (IPM Research en Advies, 1993; Lester, 1994; Aasvedd & Schaefer, 1995; Hendriks et aL, 1997; Shepherd, Ghodse, & London, 1998b). Despitee heterogeneity in designs, samples and methodological limitations, most studies reportedd the following results: first, most scratchcard gamblers did not experience scratchcard-relatedd problems. One of the British studies reported that affirmative responses to DSM-IVV criteria for pathological gambling (but not the number of pathological gambling diagnoses)) increased significantly six months after the introduction of the National Lottery andd scratchcards (Shepherd et aL, 1998b). Second, when scratchcard problems were reported, theirr prevalence was low and mostly restricted to specific subgroups (IPM Research en Advies,, 1993 & Hendriks et al., 1997). And finally, two characteristics were mentioned as potentiall risk factors: heavy involvement in other forms of gambling (IPM Research en Advies,, 1993; Aasvedd et aL, 19954; Hendriks et al., 1997), and lower income and education levellevel (Aasved et aL, 1995; Hendriks et aL, 1997; Shepherd et aL, 1998b). However, these findingss on the effects that scratchcards may have on gamblers need to be viewed with cautionn due to the limited number of studies, the disparity between study goals, samples, designss and methodological limitations. Thee second group of studies includes three British studies (Wood et aL, 1998; Griffiths, 2000a;; Pugh et aL, 2000a) all conducted among under-aged players. The first study reported a prevalencee of 6% for pathological gambling according to DSM-IV-J criteria among their total samplee of scratchcard players. The second found that 5% of the total sample met the DSM-IV criteriaa for pathological scratchcard gambling, and that this was 12% for the scratchcard gamblerss (who had bought scratchcards themselves). The last study (Pugh et aL, 2000) not onlyy showed that 54% of their sample purchased scratchcards but also laid bare the lack of adequatee enforcement of the laws prohibiting sales to minors: only six of the 137 under-age scratchcardd gamblers had ever been refused scratchcards at an outlet. All three studies reportedd a strong influence of the parents' scratchcard playing on their child's participation in thee game. It needs to be noted, however, that these studies probably addressed specific

44 Aasvod's study was included in this review because reports on pull-tabs, which are very similar to scratchcards.

21 1 Generall introduction subgroupss with specific psychological characteristics and life styles (minors buying scratchcardss in a situation where this is illegal), which makes the generalisation of these findingss to the general population rather problematic. Thee third group of studies comprises three studies investigating the generalisability of theoreticall assumptions about gambling or pathological gambling to scratchcards (Frost, Meagher,, & Riskind, 2001; Lange, 2001; Wood, Griffiths, Derevensky, & Gupta, 2002). The firstfirst study examined hypotheses about the diagnosis of PG and its symptoms in a population off lottery and scratchcard gamblers. The authors state that PG falls under a family of disorders withh obsessive-compulsive disorders at its core. The other two publications addressed two importantt and closely related issues: the self-perception of gamblers and the reliability of self- reportedd gambling. These studies revealed a great ambiguity in the self-perception of gamblers,, especially in connection with their gambling behaviour regarding scratchcards and lotteryy tickets. These two forms of gambling were generally not perceived as gambling by the majorityy of the players, unless the items were purchased frequently. This ambiguity about the definitionn of "gambling" has been reported in other studies too (see e.g. Shepherd et al., 1998b,, and Lange, 2001). Inherently, due to this ambiguity the reliability of self-reported gamblingg for lottery and scratchcards is somewhat questionable.

TheThe need for a prospective study Owingg to their diverse target populations, national legislation and market situations and becausee of their methodological limitations (non-representative samples, self-report data, low responsee rates, etc.), generalisation of the results of the above-mentioned studies about the addictivee potential of scratchcards to the Dutch situation is complicated. The only Dutch studyy available beforee the initiation of the prospective study presented in this thesis found that amongg a sample of adult scratchcards buyers 4.1% were "at-risk players" (having bought at leastt 25 scratchcards in the previous month and meeting at least one at-risk problem indicator, Hendrikss et al., 1997). However, this study was conducted within the first year after the introductionn of scratchcards, which prevented conclusions to be drawn with respect to pathologicall scratchcard gambling because it takes, on average, about 3.5 years before excessivee gambling is recognised as a problem by the gambler himself or his social environmentt (Meyer, 1992). Consequently, the addictive potential of scratchcards for the adultt general population, and specifically for the population of the Netherlands, remained unclear.. Therefore, a new study was needed to assess the addictive potential of scratchcards in thee Netherlands. Ideally, this study should include a random sample of the general population andd should be prospective to facilitate a sound exploration of the prevalence and incidence of scratchcard-relatedd problems, as well as the stability of the pathological scratchcard gambling diagnosiss over time (Wood et al., 1998; Crockford et al., 1998; Griffiths, 2000a; Ladouceur, 2002;; Toce-Gerstein, Gerstein, & Volberg, 2003). The present thesis is the first to present suchh investigations in the Netherlands, initiated 5 years after the game's launch. The second partt of the thesis describes the design and results of a large socio-epidemiological study on the addictivee potential of scratchcards. The third part focuses on the identification of problem gamblerss and pathological gamblers.

22 2 Chapterr 1

AIMSS AND STRUCTURE OF THE THESIS

Thee main focus of this thesis is to investigate the addictive potential of scratchcards in the Netherlandss (Part II). However, it is impossible to know whether a specific form of gambling iss addictive or not without the aid of proper, validated instruments. Therefore, the secondary focuss of this thesis is to investigate several of the unresolved issues in the assessment of gamblingg problems in general, i.e. a validation of the South Oaks Gambling Screen in a communityy study and the development of a new instrument to asses the severity of gambling problemss (Part HI). With these purposes in mind, the research described in this thesis includes threee separate empirical studies. First, a large prospective three-phase study among adult scratchcardd buyers in the Netherlands (Part II, Chapters 2, 3 and 4). Next, an epidemiological studyy among the Dutch general population (Part HI, Chapter 5) is presented and, finally, a multi-samplee study to develop and validate the Gambling Problems Severity Scale (GPSS; Partt m, Chapter 6) is reported. Each of these chapters describes in more detail the existing knowledgee at the time the particular paper was written, the research methodology used and thee specific research questions underlying the study5.

Partt II. The Addictive potential of scratchcards Partt II of this thesis addresses the addictive potential of scratchcards and the nature of the problems.. To this end a large epidemiological study was conducted among adult scratchcard buyerss in the Netherlands. This prospective study used a non-proportional stratified sample of 12,2222 adult scratchcard buyers and had three independent assessment phases: a prevalence phase,, an incidence phase and a qualitative phase. Chapterr 2 describes the results of the first-phase of this study: a cross-sectional prevalencee survey among a non-proportional stratified sample of 12,222 adult scratchcard buyers.. Its main aim was to obtain a valid estimate of the addictive potential of scratchcard gamblingg by establishing the one-year prevalence of recreational, problematic and pathologicall scratchcard gambling among a representative sample of adult scratchcard buyers fivefive years after the introduction of scratchcards in the Netherlands. Chapterr 3 comprises the second -phase of this prospective study, i.e. the incidence phase,, conducted to provide the final evidence of the addictive potential of scratchcards. A cost-effectivee design was used in this follow-up conducted two years after the prevalence phase,, in that only those scratchcard buyers (n=201) that had already experienced some scratchcard-relatedd problems at the initial assessment were included. The threefold aim of mis incidencee study was (1) to estimate the two-year cumulative incidence of pathological scratchcardd gambling (PSG) among a representative sample of high-risk scratchcard buyers, (2)) to assess the two-year temporal stability of PSG and scratchcard-related problems, and finally,finally, (3) to estimate the adjusted one-year prevalence for PSG taking into account the temporall dynamics of this diagnosis.

Thiss book integrates some of our published papers and reports. In the original publications different styles were used.. However, for the reader's convenience, a uniform style has been used in this thesis. This does not have any consequencess for the information contained in these chapters.

23 3 Generall introduction

Chapterr 4 presents the final qualitative phase of this prospective study, an in-depth face-to-facee interview. Participants were those respondents that fulfilled the DSM-IV criteria forr pathological scratchcard gambling at the prevalence phase who consented to take part and havee the interview recorded (n = 10). The chapter explores the following two questions: what iss the extent and nature of scratchcard-related problems in this cohort, and does the DSM-IV clinicall significance criterion minimise the number of false positive diagnoses?

Partt III. The Assessment of gambling-related problems Partt in deals with relevant issues in the assessment of gambling problems in general. The focuss of the two chapters presented in this section is on the identification of individuals with gamblingg problems and the measure of the severity of those problems. Chapter 5 used a two- stagee sample design among a representative sample of 5,830 Dutch young adults (12-35 years old).. The aim of this study was twofold: to estimate the prevalence of pathological gambling inn a community sample and to test the validity of the South Oaks Gambling Screen (SOGS) as aa screener (self-report questionnaire) for pathological gambling against the DSM criteria for pathologicall gambling. Chapterr 6 states that although pathological gambling is an increasing problem, there is stilll no instrument that accurately and quickly assesses the severity of this disorder in different life-dimensions.. Such an instrument would be most useful for clinicians by allowing them to sett their treatment priorities, and for researchers and treatment centres by facilitating the assessmentt of the effect of different gambling treatments. This chapter describes the developmentt of such an instrument, i.e. the "Gambling Problems Severity Scale" (GPSS), in whichh both the findings reported in the scientific literature and experiences from the clinical practicee are integrated. A sample of 636 adults covering the entire continuum of gambling severityy was used to develop the instrument.

Partt IV. General discussion Thee fourth and final part of this thesis includes the general discussion section. Chapter 7 integratess the main findings of this thesis in terms of the addictive potential of scratchcards, andd in the use of the various assessment instruments to measure prevalence and severity of gamblingg problems in general. Additionally, methodological issues that are important for the interpretationn of our results and their extrapolation to other populations and/or contexts will bee provided. Finally, the implications of this thesis are outlined as to the extent to which the resultss of the empirical studies presented can lead to further tools and suggestions for future research. .

REFERENCES S

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24 4 Chapterr 1

Abbott,Abbott, M. W. & Volberg, R. A. (1996) The New Zealand national survey of problem and pathologicall gambling. Journal of Gambling Studies. 12,143-160. Americann Psychiatric Association (1980) Diagnostic and statistical manual of mental disorders, Washington:: American Psychiatric Association. Americann Psychiatric Association (1987) Diagnostic and statistical manual of mental disorders. Washington:: American Psychiatric Association. Americann Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders. (4th ed.)) Washington: American Psychiatric Association. Becofla,, E. (1996) La Ludopatia. Madrid: Aguilar. Bellringer,, P. (1999) Understanding problem gamblers: A practitioner's guide to effective intervention.intervention. London: Free Association Books. Bergler,, E. (1957) The psychology of gambling. New York: Hill and Wang. Cornish,, D. B. (1978) Gambling: A review of the literature and its implications for policy and research.research. London: Her Majesty's Stationery Office. Crockford,, D. N. & elGuebaly, N. (1998) Psychiatric comorbidity in pathological gambling: A critical review.. Canadian Journal of Psychiatry, 43,43-50. Cullenton,Cullenton, R.P. (1989) The prevalence rates of pathological gambling: A look to the methods. Journal ofof Gambling Behavior, 5, 339-349. Custer,, R. L. (1984) Profile of the pathological gambler. Journal of Clinical Psychiatry, 45, 35-38. DeFuentes-Merillas,, L., Koeter, M. W. J., Schippers, G. M., & Brink, W. v. d. (2003) Are scratchcards addictive?? The prevalence of pathological scratchcard gambling among adult scratchcard buyers in thee Netherlands. Addiction, 98, 725-731. Dickerson,, M. G. (1977) "Compulsive" gambling as an addiction: dilemmas. Scottish Medical Journal,Journal, 22,251-252. Dickerson,, M. G. (2003) The evolving contribution of gambling research to addiction theory. Addiciton,Addiciton, 98,709. Dickerson,, M. G., Baron, E., Hong, S.-M., & Cottrell, D. (1996) Estimating the extent and degree of gamblingg related problems in the Australian Population: A National Survey. Journal of Gambling Studies,Studies, 4,135-151. Encyclopaediaa Britannica Online (2003) http://www.eb.com/ [On-line]. Frost,, R. O., Meagher, B. M., & Riskind, J. H. (2001) Obsessive-Compulsive features in pathological lotteryy and scratch-ticket gamblers. Journal of Gambling Studies, 17, 5-19. Gotestam,, K. G. & Johansson, A. (2003) Characteristics of gambling and problematic gambling in the Norwegiann context - A DSM-IV-based telephone interview study. Addictive Behaviors, 28, 189- 197. . Griffiths,, M. D. (1995) Adolescent Gambling. London: Routledge. Griffiths,, M. D. & Macdonald, H. F. (1999) Counselling in the treatment of pathological gambling: an overview.. British Journal of 'Guidance & Counselling, 27, 179-190. Griffiths,, M. D. (2000a) Scratchcard gambling among adolescent males. Journal of Gambling Studies, 16,79-91. . Griffiths,, M. D. (2000b) Awareness of gambling-related problems, policies and educational programs amongamong high school and college administrators. US: Kluwer Academic. Griffiths,, M. & Sutherland, I. (1998) Adolescent gambling behavior: A prevalence study and examinationexamination of the correlates associated with problem gambling. US: Kluwer Academic.

25 5 Generall introduction

Gupta,, R. & Derevensky, J. L. (1998) Adolescent gambling behavior: a prevalence study and examinationn of the correlates associated with problem gambling. Journal of Gambling Studies, 14, 319-345. . Hendriks,, V. M., Meerkerk, G. J., Oer, H. A. M. v., & & Garretsen, H. F. L. (1997) The Dutch instant lottery:: prevalence and correlates of at-risk playing. Addiction, 92, 346. IPMM Research en Advies (1993) Oriënterend onderzoek naar de wijze waarop instantloterijen in enkeleenkele landen zijn ingevoerd en naar de eventuele problemen die zich hierbij hebben voorgedaan. Rotterdam:: IPM. Jacques,, C, Ladouceur, R., & Ferland, F. (2000). Impact of availability on gambling: A longitudinal study.. Canadian Journal of Psychiatry, 45, 810-815. Kaminer,, V. & Petry, N. M. (1999) Gambling behaviour in youths: Why we should be concerned. PsychiatricPsychiatric Services, 50, 167-168. Kingma,, S. (1993,). Risicoanalyse kansspelen: Onderzoek naar de aard en omvang van gokverslaving inin Nederland. Tilburg: Katholieke Universiteit Brabant. Koeter,, M. W. J., Brink, W. v. d., & Niewijk, A. (1996) Een gokje wagen of gewaagd gokken. (Vol. 1) Amsterdam. . Ladouceur,, R. (2002) What kind of research do we need, a critical approach. 5 th European Conference onn Gambling Studies and Policy Issues. 2-5 October 2002 Barcelona: European Association for the Studyy of Gambling Ladouceur,, R., Sylvain, C, Boutin, C, & Doucet, C. (2002) Understanding and treating the pathologicalpathological gambler. Sussex: John Wiley & Sons. Lange,, M. A. (2001) "If you do not gamble, check this box": Perceptions of gambling behaviours. JournalJournal of Gambling Studies, 17,247-254. Lesieur,, H. (1988) Altering the DSM-m Criteria for pathological gambling. Journal of Gambling Behavior,Behavior, 4, 38-47. Lesieur,, H. R. (1984) The Chase: Career of the Compulsive Gambler. Cambridge: Schenkman Books Lesieur,, H. R. & Blume, S. B. (1987) The South Oaks Gambling Screen (SOGS): a new instrument for thee identification of pathological gamblers. American Journal of Psychiatry, 144,1184-1188. Lesieur,, H. R. & Custer, R. L. (1984) Pathological gambling: roots, phases and treatment. Annals of TheThe American Academy of Political and Social Science, 474,146-156. Lesieur,, H. R. & Rosenthal, R. J. (1991) Pathological gambling: a review of the literature. Journal of GamblingGambling Studies, 7, 5-39. Lester,, D. (1994) Access to gambling opportunities and compulsive gambling. International Journal ofof Addictions, 29,1611-1616. Meerkerk,, G. J., Oer, H. A. M. v., Hendriks, V. M., & Garretsen, H. F. L. (1995) De Krasloterij Geëvalueerd:Geëvalueerd: Een onderzoek naar deelname en risico's van deelname onder spelers in Nederland. (Vol.. 11) Rotterdam: Instituut voor Verslavingsonderzoek (IVO). Meyer,, G. (1992) The gambling market in the Federal Republic of Germany and the helpseeking of pathologicall gamblers. Journal of Gambling Studies, 8, 11-20. Moran,, E. (1970) Clinical and social aspects of risk-taking. Proceedings of the Royal Society of Medicine,Medicine, 63,1275. Nationall Opinion Research Center (NORC) (1999) Gambling Impact and Behavior Study: Report to thethe National Gambling Impact Study Commission. Chicago: NORC. Poppel,, P. V. (1994) Gokverslaafden bij het CAD Amsterdam. Maandblad Geestelijke Volksgezondheid.. Maandblad Geestelijke Volksgezondheid, 49,1238-1244.

26 6 Chapterr 1

Potenza,, M. N., Kosten, T. R., & Rounsaville, B. J. (2001a) Pathological gambling. JAMA, 286, 141- 144. . Potenza,, M. N., Steinberg, M. A., McLaughlin, S. D., Wu, R., Rounsaville, B. J., & CMalley, S.-S. (2001b)) Gender-related differences in the characteristics of problem gamblers using a gambling helpline.. American Journal ofPsychiatry, 158,1500-1505. Pugh,, P. & Webley, P. (2000) Adolescent participation in the U.K. National Lottery Games. Journal ofof Adolescence, 23, 1-11. Rosenthal,, R. J. (1989) Compulsive gambling. In San Diego, November: Paper presented at the Californiaa Society for the Treatment of Alcoholism and Other Drug Dependencies. Royall Commission on Gambling (1951) Report of the Royal Commission on betting lotteries and gamingg 1941 -1951. London: HMSO. Shaffer,, H. J., Hall, M. N., & Vander-Bilt, J. (1999) Estimating the prevalence of disordered gambling behaviorr in the United States and Canada: a research synthesis. American Journal of Public Health, 89,1369-1376. . Shepherd,, R. M, Ghodse, H., & London, M. (1998a) A pilot study examining gambling behaviour beforee and after the launch of the National Lottery and scratch cards in the UK. Addiction Research,Research, 6, 5-12. Shepherd,Shepherd, R. M, Ghodse, H., & London, M. (1998b) The Lie/Bet questionnaire for screening pathologicall gamblers: A follow-up study. Psychological Reports. Stinchfield,, R. (2003) Reliability, validity and classification accuracy of a measure of DSM-IV diagnosticc criteria for pathological gambling. American Journal of Psychiatry, 160,180-192. Stinchfield,, R. (2002) An assessment of the validity and reliability of the SOGS-RA. Addictive Behavior,Behavior, 16,275-88. Tavares,, H., Zilberman, M. L., Beites, F. J., & Gentil, V. (2001) Gender differences in gambling progression.. Journal of Gambling Studies, 17,151-159. Thee Netherlands Gaming Control Board (2004) The Netherlands Gaming Control itoard.www.toezichtkansspelen.nll [On-line]. Toce-Gerstein,, M., Gerstein, D. R., & Volberg, R. A. (2003) A hierarchy of gambling disorders in the community.. Addiction, 98,1661-1672. Volberg,, R. A. & Abbott, M. W. (1994) Lifetime prevalence estimates of pathological gambling in Neww Zealand. International Journal of Epidemiology, 23,976-983. Volberg,, R. A., Abbott, M. W., Ronnberg, S., & Munck, I. M. E. (2001) Prevalence and risks of pathologicall gambling in Sweden. Acta Psychiatrica Scandinavica, 104,250-256. Welte,, J. W., Barnes, G. M, Wieczorek, W. F., Tidwell, M. C, & Parker, J. (2002) Gambling participationn in the U.S. -Results from a National Survey. Journal of Gambling Studies, 18, 313- 337. . Wood,, R. T. A. & Griffiths, M. D. (1998) The acquisition, development and maintenance of lottery andd scratchcard gambling in adolescence. Journal of Adolescence, 21, 265-273. Wood,, R. T. A., Griffiths, M. D., Derevensky, J. L., & Gupta, R. (2002) Adolescent accounts of the UKK national lottery and scratchcards: An analysis using Q-sorts. Journal of Gambling Studies, 18, 161-183. . Worldd Health Organization (1977) The ICD-9 Classification of mental and behavioural disorders. Geneva:: World Health Organization.

27 7

PARTT II THEE ADDICTIVE POTENTIAL L OFF SCRATCHCARDS

Chapterr 2

CHAPTERR 2

AREE SCRATCHCARDS ADDICTIVE? THE PREVALENCE OF PATHOLOGICALL SCRATCHCARD GAMBLING AMONG ADULT SCRATCHCARDD BUYERS IN THE NETHERLANDS1

ABSTRACT T AimsAims To determine the prevalence of regular, potential problematic, and pathological scratchcardscratchcard gambling (PSG) five years after the introduction of scratchcards in the Netherlands. Netherlands. DesignDesign and Participants A non-proportional stratified random sample of 12,222 scratchcard buyersbuyers was approached. Regular scratchcard buyers (N = 3,342) were asked to fill out the SouthSouth Oaks Gambling Screen (SOGS). Those with a SOGS score of 3 or more (N = 340) were interviewedinterviewed with the gambling section of the DSM-IV Diagnostic Interview Schedule (DIS-T). WeightedWeighted data were used to get unbiased prevalence estimates. FindingsFindings The estimated prevalence of regular and potential problematic scratchcard gamblinggambling were 28.4% and 2.68% respectively. Only 0.24% met DSM-IV criteria for PSG. Of those,those, only 0.09% was uniquely addicted to scratchcards. The remaining 0.15% was also addictedaddicted to other games of chance. Demographic and gambling characteristics of these "combined""combined" PSG (young men, mainly slot machines players) resembled characteristics of pathologicalpathological gamblers in general. In contrast to these 'combined' PSG, 'unique' PSG were mainlymainly women between 25 and 34 years who spent relatively small amounts of money on scratchcardsscratchcards (equivalent to one scratchcard a day). ConclusionConclusion Scratchcards have a very low addiction potential among adults in the Netherlands.Netherlands. Given the specific characteristics of the unique PSG and the relatively small amountamount of money they spent, the appropriateness of DSM criteria for this particular form of gamblinggambling can be questioned.

INTRODUCTION N

Thiss report describes one of the largest studies in the world regarding the prevalence of problematicc and pathological scratchcard gambling (PSG) among adult scratchcard buyers. So far,, this relatively new game of chance has been introduced in more than 40 countries, among whichh are the USA, Canada, Great Britain, Germany, Australia and China. After a long and oftenn heated public debate about their potential negative side-effects in terms of excessive playing,, scratchcards were introduced in the Netherlands in 1994. Since the 1950s several authorss have noted that the structural characteristics of different games are related to their addictivee potential (Royal Commission on Gambling, 1951; Griffiths, 1995). Based on these structurall characteristics, the addictive potential of scratchcards is generally considered to be

11 This chapter has been published as DcFuentes-Merillas, L., Koeter, M. W. J., Schippers, G. M., & Brink, W. vann den (2003) Are scratchcards addictive? The prevalence of pathological scratchcard gambling among adult scratchcardd buyers in the Netherlands. Addiction, 98, 725-731.

31 1 Aree scratchcards addictive? moderate,, i.e. higher than the risk of standard lotteries but lower than the risk of slot or fruit machiness and casino games. The most important characteristics that may actually facilitate excessivee gambling with scratchcards are: (1) "short-payout intervals" referring to the short periodd of time between the stake and the outcome; (2) "low threshold" in terms of accessibilityy and costs; and (3) the psychological effect of the "near miss", i.e. the occurrence off failures that are close to being successful, encouraging future play. As consequence of thesee and other similarities with fruit machines, scratchcards have been referred to as "paper fruitfruit machines" (Griffiths, 2000). Empiricall evidence of the "addiction potential" of instant lotteries, however, is scarce. Hendrikss et al. (1997) found among a sample of Dutch scratchcards buyers, that 4.1% were classifiedd as "at-risk players" who bought at least 25 scratchcards in the previous month and mett at least one at-risk or problem indicator. This study was conducted within a year of the introductionn of the scratchcards in the Netherlands, and therefore, no conclusions could be drawnn with regard to the risk of actual development of PSG, because it takes on average about 3.55 years before excessive gambling is recognised as a problem by the gambler himself or his sociall environment (Meyer, 1992). Severall British studies suggest a potential addiction risk of scratchcards. In a adult populationn sample, Shepherd, Ghodse & London (1998) found that the number of DSM-IV criteriaa met (but not the number of pathological gambling diagnoses) had increased 6 months afterr the introduction of the National Lottery Instants. In a study among 11-15-year-old adolescents,, 6% of the scratchcards players were diagnosed as pathological gamblers accordingg to DSM-IV-J criteria (Wood & Griffiths, 1998). In another study among 11-16- year-oldd boys, 5% of the total sample and 12% of the gamblers (who had bought scratchcards themselves)) met DSM-IV criteria for PSG (Griffiths, 2000). However, in Britain the sale of scratchcardss to persons under the age of 16 is forbidden, and therefore the latter two studies aree likely to address specific subgroups with specific psychological characteristics and life- styles,, which make the generalisation of these findings to a general adult population rather problematic. . Inn summary, the addictive potential of scratchcard gambling is still unknown. In order too obtain a valid estimate of the addictive potential of scratchcard gambling a large epidemiologicall study is needed. The current study attempts to establish the prevalence of regular,, potential problematic and PSG among a representative sample of adult scratchcard buyerss 5 years after their introduction in the Netherlands using standardised assessments procedures. .

METHODS S

Casee definition and assessment instruments Regularr scratchcard gamblers were defined as people who bought their first scratchcard more thann 6 months ago and who purchased of 10 or more scratchcards in the month prior to the assessment.. Two simple questions were used to obtain this information. Regular scratchcard

32 2 Chapterr 2 gamblerss were defined as potential problematic scratchcard gamblers if they had a score of threee or more on an adapted Dutch version of the South Oaks Gambling Screen (SOGS, Lesieurr & Blume, 1987). The original SOGS was adapted for this study through the replacementt of the word "gambling" by "scratchcard gambling" and through the refining of thee questions regarding the loss of control by exclusion of an impulsive purchase as an indicatorr of problematic gambling. The cut-off score of three was chosen to maximise sensitivityy and to ininimise the number of false negatives. Potential problematic scratchcard gamblerss were defined as pathological scratchcard gamblers if they met the adapted criteria of aa DSM-IY diagnosis pathological gambling, i.e. presence of at least five of the defining criteriaa during the year prior to the assessment. An adapted version of the Pathological Gamblingg Section of the DSM-IV Diagnostic Interview Schedule (DIS-T, Diagnostic and Statisticall Manual of Mental Disorders, 1994) was used with separate questions on each item regardingg scratchcard gambling and other games of chance excluding scratchcards and with onsett and recency questions for each individual item. An example of this adaptation is: "has yourr scratchcard gambling ever caused you trouble with your partner or a family member?", andd "has your gambling on other games of chance excluding scratchcards ever caused you troublee with your partner, or a family member?", instead of the original question "has your gamblinggambling ever caused you trouble with your partner or a family member?" In order to exclude thee presence of a manic episode, a mania screener was developed based on Section F of the DSM-IVV Diagnostic Interview Schedule (DIS-F, APA, 1994).

Sample e AA non-proportional stratified sample was approached according to the following three steps. Inn the first step, a random sample of 246 out of the 2,285 sales outlets was drawn, stratified by regionn (north, south, west and east), urbanisation (urban and rural), and monthly scratchcards saless (< 3,630 €; 3,630 - 7,260 €; and > 7,260 €). For each outlet, opening days and hours weree divided into 3-5-hour periods. In the second step, a random sample of these opening periodss was drawn. In the third and final step, a random sample of all scratchcard buyers at thee selected time period was asked to participate in the study in all selected outlets. For a moree efficient data collection, outlets and time periods with relatively high sales were oversampled.. In total, 12,222 scratchcard buyers were approached at 246 outlets during a total off 4,379 hours of data collection, divided into 1,072 daily periods. Off these 12,222 scratchcard buyers, 1.2% (n=148) were not eligible due to the presence off one or more of the following exclusion criteria: younger than 18 years, foreign resident, insufficientt command of the Dutch language. Another 23.2% (n = 2839) refused to participate.. Of these, 25% (n = 711) were willing to participate in a non-response analysis. Thee remaining 9,235 scratchcard buyers (75.6%) entered, a three-stage diagnostic procedure. Inn the first stage, 3,342 respondents fulfilled the criteria for regular scratchcard gambling. In thee second stage, 3,111 regular scratchcard gamblers (93.1%) were screened with the SOGS forr the presence of potential problematic scratchcard gambling. Of the 340 regular gamblers whoo fulfilled the criteria for potential problematic scratchcard gambling, 201 (59%) were interviewedd with the DIS-IV and the Mania screen of the DIS-F in order to establish the

33 3 Aree scratchcards addictive?

DSM-IVV diagnosis pathological gambling. Non-response analyses were performed for all stages.. No statistically significant differences were found between the participants and refuserss on demographics or gambling participation.

Statisticall analysis Itt follows from the description of the sampling procedure that the crude sample is not representativee of the Dutch scratchcard buyers for at least two reasons: (1) because scratchcardd buyers from outlets with high monthly sales are over-represented in the non- proportionall sample, and (2) because sampling at sales points gives regular scratchcard buyers aa higher inclusion probability than occasional buyers. In order to get unbiased prevalence estimatess weighting procedures were applied. In these procedures, the weight for a specific respondentt approached for the study, at a specific time, at a specific outlet, is a function of his orr her inclusion probability, which is a combination of (a) the probability of the outlet being inn the sample, (b) the probability of the specific time period being in the sample given the outlet,, (c) the probability of the specific respondent being in the sample given the outlet and timee period, and (d) the frequency of scratchcards purchasing in the last 2 weeks before the assessment.. The probability functions and the weighting procedures are further explained in Appendixx 2.1 (see end of this chapter).

RESULTS S

Regularr scratchcard gambling Thee estimated prevalence of regular scratchcard gambling among adult scratchcard buyers in thee Netherlands is 28.4%. This means, that the vast majority of Dutch scratchcard buyers (71.6%)) plays incidentally or has not been playing scratchcards for more than half a year (see Tablee 2.1). Thee prevalence of regular scratchcard gambling is higher among men than women and seemss to increase slightly with age. Regular scratchcard gambling is more prevalent in urban areass than in rural areas. A large majority of regular scratchcard players had bought 10-30 scratchcardss during the previous month (men 81.6%; women 88.8%) and played scratchcards forr more than 49 years.

Potentiall problematic scratchcard gambling Thee prevalence of potential problematic scratchcard gambling among Dutch scratchcard buyerss is estimated to be 2.68% (see Table 2.1). Men have a much higher prevalence of scratchcardd problems according to the adapted SOGS than women. The prevalence of potentiall problematic scratchcard gambling seems to be related to age, with the lowest prevalencee in the age group between 35 and 50. Again, urban areas have a higher prevalence thann rural areas.

34 4 Chapterr 2

35 5 Aree scratchcards addictive?

Pathologicall scratchcard gambling Onlyy 0.24% of the sample met DSM-IVV criteria for PSG. Moreover, half of these pathological scratchcardd gamblers also met pathological gambling criteria for other games of chance, with ann earlier onset of pathological gambling to these other games (slot machines, bingo, casino, etc.).. The prevalence of "unique" pathological scratchcard gambling is estimated to be only 0.09%.. Prevalence estimates of PSG combined with other forms of pathological gambling and uniquee PSG are shown in Table 2.1.

Comparisonn of potential problematic and pathological scratchcard gamblers Forr comparison reasons, potential problematic scratchcard gamblers are divided into three groups:: (1) problematic non-pathological scratchcard gamblers (SOGS score > 3, but no pathologicall scratchcard gambling diagnoses; N=3,083), (2) combined pathological scratchcardd gamblers (meeting DSM-IV criteria of both PSG and pathological gambling on otherr games of chance; N=14), and (3) unique pathological scratchcard gamblers (meeting DSM-IVV criteria for pathological scratchcard gambling but not for other forms of gambling; N=14).. Table 2.2 displays the demographic and gambling characteristics of these three groups. .

Table2.22 Demographics and participation in games of chance for potential problematic scratchcardd gamblers (PPSG) and pathological scratchcard gamblers (PSG) PPSP P PSG G

Combined d Unique e Men n 70.1% % 87.2% % 28.8% % Women n 29.9% % 12.8% % 71.2% % Meann age 43.44 4 26.95 5 42.09 9 Autochthon n 79.6% % 66.9% % 82.5% % Participationn in Scratchcards in the previous month Frequencyy (median) Amountt of money spent/median 4 4 3 3 5 5 €€ 22.69 €90.76 6 €€ 18.15 Participationn in other games of chance in the previous month h Mediann games of chance played 1 1 1 1 0 0 Amountt of money spent/median €€ 36.30 €€ 340.34 €0 0

Slott machines 33.8% % 83.1% % 13.5% % frequencyy (median) 2 2 10 0 2 2 Lotto/toto/otherr sort of lotteries 67.2% % 40.5% % 28.1% % frequencyy (median) 2 2 4 4 2 2 Bingo o 6.1% % 28.2% % 1.2% % frequencyy (median) 6 6 4 4 4 4 Cardss for money outside of the house, frequency 2.1% % 23.1% % 13.0% % (median) ) 5 5 1 1 4 4 Casinoss (ExcL Slot machines) 27.2% % 23.6% % frequencyy (median) 3 3 3 3 'Nonee of subjects have participated on internet gambling, bet on horses or other games of chance not included in Tablee 2.2.

36 6 Chapterr 2

Uniquee pathological scratchcard gamblers constitute a rather distinctive group. More thann two-thirds (67.2%) were women aged 25-35 years with no more than primary education andd only about a quarter (23.4%) were men aged 50 or older. The median frequency of scratchcardss purchasing is higher among the unique pathological gamblers than among either problematicc non-pathological and combined PSG. However, the amount of money spent on scratchcardss was higher among combined PSG. The median amount of money spent on scratchcardss in the previous month by the unique pathological gamblers was the equivalent of onlyy one scratchcards per day and very similar to the amount of money spent by problematic non-pathologicall scratchcard gamblers. Unique pathological gamblers did not seem to be very involvedd in other forms of gambling. The median amount of money spent on other forms of gamblingg was zero (min 0 - max. € 192.84) and percentages of participation in other games off chance during the previous month were low, in contrast with the frequency of participation inn playing slot machines from the combined PSG (83.1%).

DISCUSSION N

Thee findings of the current study show that pathological scratchcard gambling is a rare phenomenonn among adult scratchcard buyers in the Netherlands. More than 12,000 buyers of scratchcardss were approached to find 28 pathological scratchcard gamblers. In half of these 288 cases PSG seems to be part of a more general pathological gambling problem, which had developedd prior to the start of the problems with scratchcard gambling. This finding suggests thatt scratchcard gambling is not a stepping-stone towards other forms of pathological gambling.. However, a longitudinal study is needed to test this hypothesis adequately. Uniquee PSG was even more rare and exceptional. Pathological gambling is generally moree prevalent among men, while the group of unique PSG consisted mainly of women players.. This finding corroborates Grupta & Deverensky's (1998) suggestion that women are indeedd more attracted to particular games of chance such as scratchcards. With these unique PSGG our study might have identified an unknown risk group for pathological gambling. These uniquee PSG are not found in treatment settings; the only pathological scratchcard gamblers foundd at treatments settings are the combined group, which make the unique group even more exceptional.. This fact was also confirmed in a German study (IPM, 1993). However,, one could also question the appropriateness of the term "pathological" in the casee of these gamblers. According to the DSM, the essential feature of pathological gambling iss persistent and recurrent maladaptive gambling behaviour that disrupts personal, family or vocationall pursuits. A large degree of disruption of these scratchcard gamblers' lives is improbable.. The amount of money that this group spent on scratchcards is relatively small andd comparable to the amount of money that non-pathological scratchcard gamblers spent. It iss hard to image that these small amounts of money could be the cause of severe financial problems.. There are several explanations for this finding. On one hand, there is a growing literaturee questioning the validity of self-report data on money spent on gambling; the consensuss on this issue is that the reported amount underestimates substantially the actual

37 7 Aree scratchcards addictive? amountt of money spent. On the other hand, fulfilling DSM-IV criteria for pathological gamblingg might not indicate the same level of gambling related problems for a person with scratchcardd related gambling problems than for a person with -related gambling problems.. If this is the case, the threshold of these criteria for pathological gambling is lower forr scratchcard gamblers than for slot machine gamblers. Further qualitative research is neededd to investigate the singularity of this exceptional group of unique pathological scratchcardd gamblers and to assess whether their problems justify a DSM-IV diagnosis of PSG. . Althoughh the present study is one of the largest studies in the world regarding the prevalenceprevalence of regular, potential problematic and PSG among adult scratchcard buyers, the authorss would like to acknowledge the following limitations. First excluding under-age buyerss and new Dutch residents who are not fully competent in the Dutch language may bias ourr prevalence rate. However, we do not expect excluding respondents with insufficient commandd of the Dutch language to have a big impact on the prevalence estimates, as we excludedd only those unable to understand the questions. In the Netherlands these are two groupss of people: (1) tourists and (2) immigrants not well integrated into the Dutch culture. Thee first group should be excluded in a Dutch prevalence estimate, the latter is a relatively smalll fraction of the ethnic minorities in Holland but might be more at risk for PSG. Adding under-agee gamblers to our study would increase the denominator of the prevalence estimate butt also the numerator. The net effect will be an increase in the prevalence estimate only underr the assumption that under-age players are more at risk to develop PSG. Exclusion of personss under 18 year of age also implies that our findings pertain only to adults and cannot bee generalised to under-age gamblers. Second,, national differences in gambling opportunities must be taken into account. Thee addiction potential of a specific game of chance is also a function of the accessibility/availabilityy of other continuous forms of gambling (i.e. slot machines, casinos, bets,, bingo, etc.). Thus, scratchcard might be more addictive in a context where, compared withh the Netherlands, access to continuous gambling forms is very limited. Finally,, all prevalence estimates pertain to adult scratchcard buyers. However, as the penetrationn rate of scratchcard in the Dutch general adult population in 1999 was 19%, the prevalencee of pathological scratchcard gambling for the general adult population can be estimatedd to be 0.046% (0.029% combined and 0.017% unique pathological scratchcard players). .

REFERENCES S

Americann Psychiatric Association (APA) (\994).Diagnostic and statistical manual of mental disorders,disorders, 4th ed., Washington, DC: APA. Dik,, J.J. (1977) Approximation of Confidence Bounds, Report 77-09. Amsterdam: Department of Mathematics.. University of Amsterdam. Griffiths,, M. (1995) Adolescent Gambling. London:, Routledge.

38 8 Chapterr 2

Griffiths,, M. (2000) Scratchcard gambling among adolescent males. Journal of Gambling Studies,Studies, 16,79-91. Gupta,, R. & Deverensky, J.L. (1998) Adolescent gambling behavior: a prevalence study and examinationn of the correlates associated with problem gambling. Journal of Gambling Studies, 14, 319-345. . Hendriks,, V.M., Meerkerk,G.-J., Oers, H.A.M., van & Garretsen, H.F.L. (1997) The Dutch instantt lottery: prevalence and correlates of at-risk playing. Addiction, 92,335-346.

Lesieur,, H.R. & Blume S.B.(1987) The South Oaks Gambling Screen (SOGS): a new instrument forr the identification of pathological gamblers. American Journal of Psychiatry, 144, 1184-1188. Meyer,, G.(1992) The gambling market in the Federal Republic of Germany and the helpseelring off pathological gamblers. Journal of Gambling Studies, 8,11-20. Royall Commission on Gambling (1951) Report of the Royal commission on betting lotteries and gaminggaming 1949-1951. London: HMSO. Shepherd,Shepherd, R.M., Ghodse, H. & London, M. (1998) A pilot study examining gambling behaviour beforee and after the launch of the National Lottery and scratch cards in the UK. Addiction Research, 6, 355-377. . Wood,, R.T.A & Griffiths, M. (1998) The acquisition, development and maintenance of lottery andd scratchcard gambling in adolescence. Journal of Adolescence, 21,265-273. IPMM Research en Advies (1993) Oriënterend onderzoek naar de wijze waarop instantloterijen in enkeleenkele landen zijn ingevoerd en naar de eventuele problemen die zich hierbij hebben voorgedaan. Rotterdam:: IPM. Zwart,, W.M. de, Monshouwer, K., & Smit, F. (2000) Jeugd en riskant gedrag. Kerngegevens 1999.. Roken, drinken, drugsgebruik en gokken onder scholieren vanaf tien jaar. Utrecht: Trimbos- Instituut. .

39 9 Aree scratchcards addictive?

APPENDIXX 2.1 - A three-stage sampling procedure was used:

A:: inclusion probabilities indexess i = strata, j = outlets, k = time periods, 1 = transactions.

Samplingg was conducted in three steps. Step 1, sample outlet from stratum with n4 = number off outlets selected in stratum i; Nj = number of outlets in stratum i, step 2, sample time periodss from all time periods in the selected outlet with, Uij = number of time periods selected outlett j stratum i; Uy = total number of time periods outlet j stratum i and step 3, sample transactionss from all transactions in the selected outlet at the selected time period with m^k =numberr selected transactions period k, outlet j stratum I; Hjk = total number of transactions periodd k, outlet j stratum i. At all three steps a random sampling procedure was used. At step 11 and 2 we used a computer program (SPSS 8, procedure 'sample'), at step 3 interviewers weree instructed to interview the first person buying a scratchcard, when more people were buyingg a scratchcard simultaneously (for instance a couple) the person who paid for the scratchcardd was selected when the interview was finished the procedure was repeated.

Firstt step: n y= inclusion probability of outlet j from stratum i

7L:: =—-

Secondd and third step: Pyki = Inclusion probability for a specific person buying a scractchcardd at time period 1 in outlet j of stratum i

6f6f x x Pm=Pm=iikll jW U mTTmTTM Thee factor 6%] converts the transaction probability into the probability of the selected respondentt by taking into account the frequency with which the person buys scratchcards. fjjki iss the average number of times a week the selected respondent bought scractchcards, this is multipliedd by '6' because we sampled 6 weeks at each outlet.

B:: Corrected prevalence estimates Estimatedd total number of pathological scratchcard gamblers in the Netherlands t-Zt, , i=l l withh t,-2;j..; t^ZZf^ j=ll "ij k=l 1=1 Pijkl Yijkii indicates whether a selected respondent is a pathological scratchcard gambler (1 = yes; 0 == no)

40 0 Chapterr 2

Estimatedd prevalence of pathological scratchcard gamblers in the Netherlands prevv = 100 — where a = estimated total number of scratch buyers in the Netherlands a a withh » = £»,; «,-Z-i-.; i^ZE— i=II j=l nü k=I 1=1 Pijkl

C:: 95% Confidence interval for estimates. Duee to the complexity of sampling procedure, we used a method that does not give the exact butt approximated confidence intervals.

Numberr of pathological scratchcard gamblers in a specific outlet is assumed to follow a Poissonn distribution. Total number of pathological scratchcard gamblers is a weighted sum of thee number per outlet. The sum of a Poisson distributed variable also follows a Poisson distribution. . Whenn the total number of scratchcard buyers z is a stochastic variable that follows a Poisson distributionn the lower bound and upper bound for the 95% confidence interval of z are approximatedd by (Vz -0.98)2 and (Vz+T+0.98)2; (J.J. Dik, 1977).

AA confidence interval for the prevalence can be obtained by dividing the lower and upper boundd estimates of the total number of pathological scratchcard gamblers by the estimated totall number of scratchcard buyers and multiply this figure by 100.

41 1

Chapterr 3

CHAPTERR 3

TEMPORALL STABILITY OF PATHOLOGICAL SCRATCHCARD GAMBLINGG AMONG ADULT SCRATCHCARD BUYERS TWO YEARS LATER1 1

ABSTRACT T AimsAims To estimate the two-year cumulative incidence of pathological scratchcard gambling (PSG)(PSG) among a representative sample of high-risk scratchcard buyers, to assess the two-year temporaltemporal stability of PSG and scratchcard-related problems, and to estimate the adjusted one-yearone-year prevalence for PSG taking into account the temporal dynamics of this diagnosis. DesignDesign A prospective study with two assessments was applied to a non-proportional stratified randomrandom sample of 12,222 adult scratchcard buyers in the Netherlands. A cost-effective design waswas used and only those scratchcard buyers (n=201) who had already experienced some scratchcard-relatedscratchcard-related problems at initial assessment were followed-up two-years later. ParticipantsParticipants Two independent cohorts of buyers with scratchcard-related problems were followed-up:followed-up: a cohort of 173 potential problematic scratchcard gamblers (PPSG) at increasedincreased risk for PSG and a cohort of 28 pathological scratchcard gamblers. Incidence and prevalenceprevalence estimates were calculated for the total sample of adult scratchcard buyers and for thethe Dutch adult population. FindingsFindings Of the PPSG group 6.72% (95% C.I. 2.30%-8.90%) became addicted to scratchcardsscratchcards during the two-year period. The two-year cumulative incidence of PSG among DutchDutch adult scratchcard players was 0.24% (95% C.I. 0.16%-0.34%). The stability of the DSM-IVDSM-IV diagnosis of PSG ranged from 11.1% to 42.9%, depending whether or not those lost toto follow-up were considered to be cases of PSG. Taking into account the dynamics of this disorder,disorder, using the most conservative assumption, the adjusted one-year prevalence of PSG forfor the total sample of adult scratchcard buyers was 0.33% (95% CI. 0.23%-0.45%). ConclusionsConclusions PSG proves to be a rare phenomenon among adult scratchcard buyers in the Netherlands.Netherlands. Both incidence and prevalence of the DSM-IV diagnosis PSG were low. StabilityStability of the DSM-IV diagnosis PSG, DSM-IV criteria and South Oaks Gambling ScreeningsScreenings (SOGS-S) problems were low. Prevalence was stable over the time because incidenceincidence and the recovery rates were very similar.

INTRODUCTION N

Inn the last two decades scratchcards, scratchies or instant lotteries have been launched in more thann 40 countries across five continents. This introduction was often accompanied by a rapid expansionn in sales and heated public debate about their potential negative side-effects in terms off excessive playing and pathological gambling.

11 This chapter has been published as DeFuentes-Merillas, L., Koeter, M W. J., Schippers, G. M, & Brink, W. vann den (2004) Temporal stability of pathological scratchcaid gambling among adult scratchcard buyers two yearss later. Addiction, 99,117-127.

43 3 Temporall Stability of PSG

Severall authors related the increased availability of gambling opportunities to a rise in thee prevalence of problems related to gambling (Volberg, 1994; Shaffer, et al., 1999 Grun & McKeigue,, 2000). However, not all hazardous games have the same addictive potential. Scratchcardss are a type of gambling product that appears to have the characteristics of the moree addictive forms (slot machines) and also the less addictive forms (i.e. traditional lottery) (Dickerson,, 2003; DeFuentes-Merillas, et al 2003). The structural characteristics considered too increase the addictive potential of a game of chance are: (1) the pay-off schedules and eventt frequency of the game, (2) psychology of near miss, (3) multiplier potential, (4) win probabilityy and payout ratio, (5) gambling advertising (name, sound, light and colour effects), (6)) suspension of judgement (Griffiths, 1995; Pugh & Webley, 2000). In addition to these structurall characteristics four situational features are frequently mentioned to influence the addictivee potential of a game of chance: (1) location of the game and environmental characteristics,, (2) availability of the game in a specific area or possible membership requirementt and enforcement of the gaming laws, (3) influence of advertising in television radioo etc, 4) accessibility/availability of other continuous games of gambling. Since scratchcardss fulfil several of these characteristics they are considered by some to be moderatelyy addictive and sometimes even referred to as 'paper fruit machines' (Griffiths, 2000).. However, only limited empirical evidence supports the presumed risk of scratchcards. Inn the last decade, several studies have been published on the prevalence of scratchcard-relatedd problems among adults (IPM, 1993; Hendriks et al., 1997; Shepherd et al, 1998;; Grun & McKeigue, 2000; DeFuentes-Merillas et al., 2003) and adolescents (Wood & Griffiths,, 1998; Griffiths, 2000; and Pugh & Webley, 2000). Despite heterogeneity in designs, sampless and the methodological limitations of these studies, the following three conclusions cann be drawn: (1) most scratchcard gamblers do not experience scratchcard-related problems. (Hendrikss et al., 1997 & Shepherd et al.,1998). (2) When scratchcard-related problems were reported,, the prevalence was low and mainly restricted to vulnerable subgroups, especially adolescentss who bought them illegally (Wood & Griffiths, 1998; Griffiths, 2000; and Pugh & Webley,, 2000). (3) Two characteristics are mentioned as potential risk factors among adults: heavyy involvement in other forms of gambling (IPM, 1993; Hendriks et al., 1997); and lower incomee and education level (Shepherd et al., 1998; Hendriks et al., 1997). However,, generalisation of these results is complicated due to methodological limitationss (non representative samples, self-report data, low response rates). Consequently, thee potential negative consequences of scratchcards for the adult general population are still unclear.. Therefore, a new study was needed to assess the addictive potential of scratchcards. Ideally,, this study should include a random sample of the general population and should be longitudinall (Wood & Griffiths, 1998; Griffiths, 2000). Such a study could explore the incidencee and the prevalence of scratchcard-related problems, as well as to assess the stability off the pathological scratchcard gambling (PSG) diagnosis over the time. Thiss paper describes such a study. A prospective study was conducted 5 and 7 years afterr the introduction of scratchcards in the Netherlands. It comprised two parts: a cross- sectionall prevalence study, with a large representative sample of adult scratchcard buyers, and ann incidence study, with a selected sample of those scratchcard buyers who had reported some

44 4 Chapterr 3 scratchcard-relatedd problems in the prevalence phase. For these studies, pathological scratchcardd gambling was defined as fulfilling the DSM-IV criteria for pathological gambling (thiss was assessed with the Diagnosticc Interview Schedule -DIS-T, APA 1994). The DSM-IV criteriaa for pathological gambling is generally considered the current standard (Stinchfield, 2003)) and it has been adopted internationally as the new standard by researchers and treatmentt professionals (National Opinion Research Center, NORC, 1999). Thee primary objective of the prevalence study was to obtain a valid estimate of the one-yearr prevalence of regular, problematic, and pathological scratchcard gambling among a representativee sample of Dutch adult scratchcard buyers. This prevalence study was conductedd between June 1999 and the beginning of 2000. The main findings were: a) 71.61% off the 12,222 scratchcard buyers were occasional gamblers (i.e. bought < 10 scratchcards a month),, b) 25.71% were recreational scratchcard gamblers (i.e. bought > 10 scratchcards in thee month prior to the initial assessment and played scratchcards for more than six months), c) 2.44%% were considered potential problematic scratchcard gamblers (PPSG; i.e. a total score £ 33 on the South Oaks Gambling Screen (SOGS-S), and d) only 0.24%2 met the DSM-IV criteriaa for PSG. Of these PSGs, one-third was uniquely addicted to scratchcards whilst the remainingg two-thirds were also addicted to other hazardous games. A more detailed descriptionn of the results of this prevalence phase was published elsewhere (DeFuentes- Merillass et al, 2003). However,, this prevalence study left several questions unanswered. First, it described thee situation only 5 years after the introduction of scratchcards in the Netherlands. Given that itt takes, on average, 3.5 years to become addicted (Meyer, 1992), it is likely that a number of personss would have yet to develop the full range and intensity of behaviour indicative of PSG. Consequently,, the prevalence estimate could be biased toward the null (i.e. an underestimate). Secondly,, this study did not provide any information about the temporal dynamics of the pathologicall scratchcard gambling diagnosis or about the stability of scratchcard-related problemss as assessed by the SOGS. Too overcome these shortcomings, an incidence study with a two year follow-up was implemented.. This incidence study had three main goals: (1) to estimate the two-year cumulativee incidence of pathological scratchcard gambling (PSG) among a group at- increased-riskk for PSG (potential problematic scratchcard gamblers) and to estimate the incidencee of PSG among all adult scratchcard buyers, (2) to assess the temporal stability of PSGG and scratchcard-related problems among a group of pathological scratchcard gamblers andd a group of potential problematic stractchcard players, and (3) to present an adjusted one- yearr prevalence estimate for PSG taking into account the temporal dynamics of this diagnosis.

22 In contrast with the prevalence study these percentages of occasional, recreational, potential problematic and pathologicall scratchcard gambling were considered mutually exclusive and their sum is 100%. When consideringg these groups as mutually inclusive (i.e. pathological scratchcard gamblers were included in potential problematicc which were included in regular gamblers) the percentages will be as follows: 71.61% occasional, 28.4%% regular, 2.68% potential problematic and 0.24% pathological scratchcard gamblers, as a consequence theirr sum exceeds 100%

45 5 Temporall Stability of PSG

METHODS S

Design n Givenn the low prevalence of PSG (0.24%) and scratchcard-related problems (2.44%) among Dutchh adult scratchcard buyers found in our prevalence study, following-up the total sample off 12,222 scratchcard buyers would be an extremely inefficient study design. For this reason onlyy those buyers already experiencing a number of scratchcard-related problems at the initial assessmentt were followed-up. These 201 respondents comprised a cohort of 173 potential problematicc scratchcard gamblers (i.e. respondents with a SOGS total score £ 3 and not fulfillingg the DSM-ÏV criteria for PSG) and a cohort of 28 respondents fulfilling the DSM-IV criteriaa for pathological scratchcard gambling. Follow-up assessment fa) took place two years afterr the initial assessment, i.e. between June 2001 and January 2002.

Sample e Inn the cohort of 173 potential problematic scratchcard gamblers 39 participants were lost to follow-up.. The remaining 134 (77.5%) potential problematic scratchcard gamblers were mainlymainly men (61.2%), mean age was 42.7 years, 61.9% had a low education level, 35.8% were marriedd and the majority was Dutch (68.7%). Approximately half (51.5%) also participated in otherr short payout interval forms of gambling (mainly slot machines). Thee cohort of 28 participants fulfilling DSM-IV criteria for pathological scratchcard gamblingg at ti was followed-up to assess the stability of the diagnosis PSG. Eighteen (64.3%) off these PSG could be contacted at t2. Of these 18 participants 55.6% were women, the mean agee was 41.8 years, 27.8% was married, Dutch (61.1%) and they were mainly lower educated (66.7%).. 72.2% participated in other short payout interval games, 38.9% were in addition to theirr addiction to scratchcards also addicted to other forms of gambling (mainly slot machines). . Non-responsee analyses showed that loss to follow-up in the potential problematic scratchcardd gamblers cohort was neither related to demographic factors nor to gambling characteristicss or number of gambling-related problems at tj. In the PSG cohort however, loss too follow-up was related to number of gambling problems at ti. In order to minimise selection biass favouring low stability or low prevalence, all respondents lost to follow-up in the PSG cohortt are considered a case at follow-up.

Assessmentt instruments and case definition Initiall and follow-up assessments comprised a combination of structured interviews and a self-reportt questionnaire. The South Oaks Gambling Screen (SOGS, Lesieur & Blume, 1987) iss a 20-item self-report screener for pathological gambling based on the DSM-UI criteria for pathologicall gambling. This instrument correlates well with the DSM-M-R criteria (Lesieur && Blume, 1993) and recently, the SOGS reliability, validity and classification accuracy was examinedd against the DSM-IV criteria (Stinchfield, 2002). In the latter study, the SOGS was foundd to have a satisfactory reliability and validity. The SOGS total score ranges from 0 to 20. Forr this study an adapted version of the SOGS was used. In this version the word "gambling"

46 6 Chapterr 3 wass replaced by "scratchcard gambling" (SOGS-S) and through the refining of the questions regardingg the loss of control by exclusion of an impulsive purchase as an indicator of problematicc gambling. A SOGS score of 0-2 indicates no problem with gambling, 3-4 indicatess possible problematic gambling and a score of 5 or more indicates probable pathologicall gambling. In this study a cut-off score of 3 on the SOGS-S at ti was used as the firstfirst condition to identify participants at-increased risk to develop PSG (potential problematic scratchcardd gamblers). In accordance with several other studies (Emerson & Laundergan, 1996;; Dickerson et al., 1996; Lesieur & Blume, 1993) we changed the time-frame from 'lifetime'' to 'last year'. This makes the SOGS both a better screener for current gambling problemss and facilitates comparisons with other studies. A person is considered a potential problematicc scratchcard gambler if (s)he has a SOGS-S total score > 3 and is not already a pathologicall scratchcard gambler (i.e. not fulfilling the DSM-IV criteria). Ann adapted version of the Pathological Gambling Section of the DSM-IV Diagnostic Intervieww Schedule (DIS-T, APA, 1994) was used, with separate questions on each item regardingg scratchcard gambling and other games of chance excluding scratchcards. Onset and recencyy of scratchcard and other gambling problem were assessed for each individual item. Ann example of the scratchcard adaptation is: "has your scratchcard gambling ever caused you troublee with your partner or a family member?" Instead of the original question: "has your gamblinggambling ever caused you trouble with your partner or a family member?" A mania screener basedd on Section F of the DSM-IV Diagnostic Interview Schedule (DIS-F, APA, 1994) was usedd to exclude the presence of a manic episode.

Statisticall analysis Becausee potential problematic scratchcard gamblers are both a small fraction and, in terms of addictionn risk, a highly selective subgroup of all scratchcard buyers, all estimates from this cohortt overestimate the addictive potential of scratchcards for adult scratchcard buyers in general.. By combining results of the prevalence study with results of the incidence study and makingg some assumptions about the incidence of PSG in occasional and recreational scratchcardd gamblers an incidence estimate for all adult scratchcard gamblers was calculated. Thee two assumptions were: 1) incidence of PSG for occasional scratchcard gamblers is a quarterr of the prevalence of PSG at ti (Ii = 0.25* 0.0024 = 0.0006) and 2) the incidence of PSGG for recreational scratchcard gamblers is half of the prevalence of PSG at tj (I2 = 0.50*0.00244 = 0.0012). Given that the two-year cumulative incidence of PSG for potential problematicc scratchcard gamblers is 6.72% (I3), the cumulative incidence rate for the total samplee can be estimated as the weighted sum of these three incidence estimates using the relativee frequency of these subgroups at tj as weight factors. The specific assumptions with theirr legitimisation and the procedure followed to achieve an incidence estimate for all scratchcardd buyers can be found in Appendix 3 1. Appendix 3 2 describes the calculation of thee adjusted prevalence estimates for PSG taking into account the temporal dynamics of PSG. Penetrationn rates among the general population were used to calculate the one-year adjusted prevalencee of PSG for the general Dutch adult population. The latter prevalence rates can be

47 7 Temporall Stability of PSG usedd to compare the public health impact of scratchcards with the public health impact of alcohol,, tobacco or other drugs.

RESULTS S

Two-yearr cumulative incidence of pathological scratchcard gambling (PSG) Thee estimated two-year cumulative incidence of PSG for potential problematic scratchcard gamblerss was 6.72% (95% confidence interval 2.30%-8.90%). Potential problematic scratchcardd gambling clearly is a risk for the development of PSG. However, even in this groupp the overall majority (93.28%) did not become addicted to scratchcards during the two- yearr follow-up. Using a procedure described in the statistical analysis section and in Appendixx 3 1, the two-year incidence for the total sample is estimated to be 0.24% (95% confidencee interval 0.16%-0.34%).

Stabilityy of PSG Stabilityy (or chronicity) of the DSM-IV diagnosis 'pathological scratchcard gambling' was low.. Only two (11%) of the 18 people addicted to scratchcard at tj still fulfilled the DSM-IV criteriaa two years later (see Table 3.1). However dropout analyses in this group showed that losss to follow-up was related to the number of scratchcard-related problems and the amount of moneyy spent on scratchcards and other hazard games at ti. To adjust for potential selection biass as a 'worst case scenario' all persons lost to follow-up were assumed to be still addicted att t2. This approach gives the highest stability estimate: 42.9%. This relatively low stability didd not mean that those people no longer fulfilling DSM-IV criteria for PSG at t2 did not experiencee scratchcard-related problems at t2. Between 50% and 67.9% of them still had a SOGS-SS total score £ 3. These problems were however less frequent, less intense or there weree just too few of them to warrant a DSM-IV diagnosis pathological scratchcard gambling.

Tablee 3.1 Stability of SOGS-S > 3 and PSG. SOGS-SS total score £ 3 DSM-IVV for PSG ti i h h ti i t2 2 PSGG (18) 100% % 500 %-67.9 %* 100% % ll.l%-42.9%* * PPSGG (134) 100% % 18.66 % 0.00 % 4.55 % *Thiss interval represents the best- and worst-case scenarios.

Thee same low stability is observed with scratchcard-related problems as assessed by thee SOGS-S. Of the potential problematic scratchcard players at tj only 18.6% still had a SOGSS total score > 3 at the follow-up assessment two years later. Tablee 3.2 shows the temporal stability of scratchcard-related problems in the cohort of potentiall problematic scratchcard gamblers as assessed by the SOGS-S. Table 3.3 shows the symptomm and non-symptom stability for each of the 10 DSM-IV criteria in the cohort pathologicall scratchcard gamblers. Stability of a symptom is defined as the proportion of peoplee who did have the symptom at ti and still have the symptom at t2. On the other hand,

48 8 Chapterr 3

non-symptomm stability is defined as the proportion of people who did not have the symptom att t) and still do not have it at t2-

Tablee 3.2 Symptom and non-symptom stability of scratchcard-related problems among potentiall problematic scratchcard gamblers1. Symptomm Stability Non-Symptom mStabilit y y

ti+ + Stable e Recovered d ti-- Stable e Incident t

ti42+ + M2-- t..t2. . ti-ta+ +

1.. When tost money with scratchcard cards did go back 59 9 15.3% % 84.7% % 75 5 92.0% % 8.0% % anotherr day to win back the money lost 2.. Claimed to be winning money playing scratchcards 41 1 7.3% % 92.7% % 93 3 96.8% % 3.2% % butt was not really? In fact lost money? 3.. Felt that you have had a problem with scratchcards? 35 5 11.4% % 88.6% % 99 9 94.9% % 5.1% % 4.. Spent more money on scratchcards than one intended 107 7 30.8% % 69.2% % 27 7 81.5% % 18.5% % to? ? 5.. People criticised scratchcard cards playing, or told 69 9 14.5% % 85.5% % 65 5 93.8% % 6.2% % youu that you have a problem with scratchcard cards? (regardless(regardless whether this is is true) 6.. Felt guilty about the way you play scratchcard or what 51 1 29.4% % 70.6% % 83 3 95.2% % 4.8% % happenss when you play scratchcard? 7.. Felt you would like to stop playing scratchcards but 58 8 20.7% % 79.3% % 76 6 92.1% % 7.9% % didn'tt think you could? 8.. Hid scratchcard tickets, money for scratchcards, or 47 7 10.6% % 89.4% % 87 7 89.7% % 10.3% % otherr signs of scratchcard playing from your spouse, children,, or other important people in your life?1 10.. Had money arguments centred on your scratchcard 22 2 13.6% % 86.4% % 112 2 92.0% % 8.0% % playing? ? 11.Borrowedd money from someone and did not paid 11 1 0% % 100% % 123 3 99.2% % 0.8% % themm back as a result of your scratchcard playing? 12.. Lost time from work (or school) due to scratchcard 5 5 0% % 100% % 129 9 98.4% % 1.6% % playing? ? 13.. If borrowed money to play scratchcards who or were didd you borrow from? a)) From household money 30 0 26.7% % 73.3% % 104 4 75.4% % 2.9% % b)) From your spouse 16 6 0% % 100% % 118 8 97.5% % 2.5% % c)) From other relatives or in-laws 9 9 11.1% % 88.9% % 125 5 98.4% % 1.6% % d)) From banks, loan companies, or credit unions 16 6 12.5% % 87.5% % 118 8 97.5% % 2.5% % e)) From credit cards 6 6 16.7% % 83.3% % 128 8 99.2% % 0.8% % g)) From loan sharks (Shylocks) 0 0 0% % 0% % 134 4 100% % 0% % h)) You cashed in stocks, bond, or other securities 2 2 0% % 0% % 132 2 0.8% % 99.2% % i)) You sold personal of family property 7 7 14.3% % 85.7% % 127 7 0% % 100% % j)) You borrowed from your checking account 22 2 31.8% % 68.2% % 112 2 2.7% % 97.3% % Percentagess were rounded to 1 decimal place. 22 Item 9 is excluded from this table because it refers toargument ss with people about money in general.

Thee three most stable problems on the SOGS-S were: spent more money than intended too (item 4), felt guilty about the way you play scratchcards or what happens when you play

49 9 Temporall Stability of PSG scratchcardss (item 6) and borrowed money to play scratchcards from household money (item 13.a).. However, for each of the SOGS-S item the percentages of recovery were higher than the percentagess of symptom stability. Additionally, the larger part of non-symptom stability can be attributedd to the fact that respondents reported not to have encountered the problem at both ti andt2. .

Tablee 3.3 Symptom and non-symptom stability of DSM-IV criteria among the PSG followed-up1 Symptomm Stability Non-Symptomm Stability

DSM-IVV criteria ti+ + Stable e Recovered d ti-- Stable e Incident t tl+t2+ + tl-42-- ti.t2. . ti-fe* * Preoccupation n 17 7 35.3% % 64.7% % 1 1 100% % 0% % Tolerance e 13 3 23.1% % 76.9% % 5 5 80.0% % 20% % Losss of control 15 5 20.0% % 80.0% % 3 3 33.3% % 66.7% % Withdrawal l 10 0 40.0% % 60.0% % 8 8 100% % 0% % Escapism m 10 0 50.0% % 50.0% % 8 8 87.5% % 12.5% % Chasing g 15 5 33.3% % 66.7% % 3 3 66.7% % 33.3% % Liess / deception 15 5 33.3% % 66.7% % 3 3 100% % 0% % Illegall acts 0 0 0% % 0% % 18 8 100% % 0% % Familyy / job disruption 8 8 12.5% % 87.5% % 10 0 100% % 0% % Financiall bailout 5 5 40.0% % 60.0% % 13 3 92.3% % 7.7% % 'Percentagess were rounded to 1 decimal place.

Comparedd to SOGS-S data, DSM-IV criteria have a higher threshold and as a consequencee reflect more severe problems. Escapism was the criterion most stable between ti andd t2 (50%) followed by withdrawal, financial bailout (40%) and preoccupation (35.3%). Family/jobb disruption was the least reported symptom at U. None of the 18 pathological scratchcardd gamblers reported to have committed illegal acts such as forgery, fraud, theft, or embezzlementt to finance their scratchcard gambling. During the two-year follow-up interval, thee prevalence of all the DSM-IV criteria substantially decreased with a recovery rate ranging fromfrom 50% to 87.5%.

Adjustedd one-year prevalence estimate for PSG Ann adjusted prevalence estimate was made taking into account the temporal dynamics of the diagnosiss using the procedure described in Appendix 3TJ. The adjusted one-year prevalence estimatee was 0.24% (95% C.I.0.16%- 0.34%) using the lenient assumption and 0.33% (95% C.I.. 0.24%- 0.45%) using the conservative assumption. Both prevalence estimates were low. Thee value of the 'true* prevalence one-year prevalence will probably lie between these two estimates.. This finding corroborates our cross-sectional last-year prevalence estimate at ti (0.24%)) for adult scratchcard gamblers in the Netherlands (DeFuentes-Merillas et al., 2003), andd shows that the prevalence of PSG is quite stable over time. This stable prevalence estimatee is a result of the fact that the number of new cases was approximately the same as the numberr of recovered cases.

50 0 Chapterr 3

DISCUSSION N

Inn contrast to the supposedly moderate addictive potential of scratchcards, pathological scratchcardd gambling (PSG) proves to be a rare phenomenon among adult scratchcard buyers inn the Netherlands. Both incidence and stability of the DSM-IV diagnosis of PSG are low. Thee low prevalence estimate is in line with previous studies reporting that most of the scratchcardd players do not experience scratchcard-related problems (TPM, 1993; Lester, 1994; Aasved,, 1995; Hendriks et al., 1997). Even in the cohort of potential problematic scratchcard gamblerss (i.e. those persons already experienced scratchcard-related problems at ti, and who weree considered to be potential problematic scratchcard gamblers) only 6.7% developed PSG withinn the two-year follow-up period. Thee stability of the diagnosis "pathological scratchcard gambling" (PSG) appeared to bee low. A substantial number of respondents (16 out of 18) that were PSG at ti did not fulfil thee DSM-IV criteria for PSG any more two years later. Even when using a "worst-case scenario"" approach, more than half of the PSG no longer met the DSM-IV criteria two years later.. This does not mean, however, that these people no longer experience scratchcard-related problemss (between 50% and 67.9% of them still had a SOGS-S total score >3 at t2) but the prevalencee of scratchcard-related problems is much lower and probably less intense. The stabilityy of cases according to the SOGS is also low. More than three quarters of the SOGS-S casess at ti (81%) no longer had a SOGS-S-totaJ score £ 3 at t2. These findings suggest that scratchcard-relatedd problems are transient. This low stability at diagnostic and symptom level seemss somewhat contradictory to the stable prevalence between ti and t2 This study, however,, clearly shows that a stable prevalence estimate does not imply a stable diagnosis.

Thee fact that the prevalence at ti was the same as the prevalence at t2 was due to the fact that thee number of new cases in the follow-up period was almost the same as the number of recoveredd cases. Additionally, the incidence cases resemble the findings from the prevalence casess in terms of comorbidity of pathological scratchcard gambling with other games of change.. Although both groups, "unique" and "combined" PSG3, met the DSM-IV criteria for pathologicall scratchcard gambling, the "combined" group scored positive in more number of SOGS-SS items and DSM-IV criteria for scratchcards4 than those who were only addicted to 5 scratchcardss ("unique" PSG) at both ti and t2. Moreover, the "combined" group also fulfilled moree DSM-IV criteria with respect to their addiction to other games of chance than with respectt to their addiction to scratchcards. Thiss study has several methodological limitations. The main methodological problem concernss the fact that only addicted and potential problematic scratchcard buyers were followed-up.. As a consequence, all incidence and prevalence estimates are dependent upon

33 "Unique" PSG is defined as meeting DSM-IV criteria for pathological scratchcard gambling but not forothe r formss of gambling.. "Combined" PSG is defined as meeting DSM-IV criteria of both PSG and pathological gamblingg on other games of chance. *Meann scores from cases at t]: SOGS-S= 7; DSM-IV=6 & Mean scores from cases at t2: SOGS-S= 16.5; DSM- IV^. . 55 Mean scores from cases at t,: SOGS-» 5.5; DSM-IV=5.7 & Mean scores from cases at t2 SOGS-S» 10.33; DSM-rV=5.5 5

51 1 Temporall Stability of PSG thee assumptions pertaining to the incidence of pathological scratchcard gambling in occasionall and recreational scratchcard gamblers. These assumptions were quite conservative andd if the main findings of this article (low prevalence, low public health risk and low incidence)) are biased by these assumptions they are more likely to overestimate than to underestimatee (see Appendix 3.1). A second limitation is related to the lack of evidence on the test-retestt reliability of the DIS-T. Consequently part of the temporal instability may reflect unreliabilityy instead of true changes in gambling problems. However, the fact that the SOGS totall score also had low temporal stability might be used in defence of a true temporal instabilityy interpretation. Additionally because the severity of PSG seems to wane over time, inter-rateinter-rate reliability might be a better indicator of the reliability than test-retest. Currently we aree conducting a qualitative research with the "unique" PSG to assess the reliability of their diagnosess among different clinicians (inter-rater reliability) and to investigate whether their problemss justify a DSM-IV diagnosis of PSG. A third limitation is the exclusion of under-age buyerss which might bias our prevalence rate when generalising to the total Dutch population. However,, we expect this bias to be limited. Adding under-age gamblers to our study will not onlyy increase the denominator of the prevalence estimate but also the numerator. Only under thee assumption that under-age players are more at risk to develop PSG would the net effect be ann increase in the prevalence estimate. Exclusion of persons under 18 years of age also impliess that our findings only pertain to adults and cannot be generalised to under-age gamblerss (DeFuentes-Merillas et al., 2003). Whenn interpreting these results, national differences in gambling opportunities must bee taken into account. The addiction potential of a specific game of chance is among others factorss a function of the accessibility/availability of other short payout intervals forms of gamblingg (e.g. slot machines, casinos, bets and bingo). Scratchcards might be more addictive inn a context where, compared to the Dutch situation, access to other short payout interval gamess is limited. Additionally, it is important to emphasise on the danger of generalising resultss about the dangers of gambling across all formats. As Dickerson (2003) pointed out the analysiss of the key structural characteristics of games of change in combination with the relatedd subjective and behavioural responses of regular players have the potential to reveal the psychologicall processes that maintain and erode control. Alll estimates pertain to adult scratchcard buyers. However, since the penetration rate off scratchcard in the Dutch general adult population in 1999 was approximately 19%, the one- yearr prevalence of pathological scratchcard gambling for the total adult population in the Netherlandss can be estimated to be approximately 0.046%. When comparing these prevalence estimatess with those of smoking related disorders, alcohol dependence and substance dependencee and pathological gambling to other forms of gambling (such as slot machines and casinoo games) scratchcards can not be considered an important issue from a public health perspective.. For example, the one-year prevalence of alcohol dependence or alcohol abuse amongg Dutch adults between 18-64 years of age was 8% (Nationale Drug Monitor, 2002). Thee public health impact of alcohol among Dutch adults is approximately 173 times the publicc health impact of scratchcards.

52 2 Chapterr 3

REFERENCES S

Aasvedd M.J., & Schaefer J.M. (1995) "Minnesota Slots": an observational study of pull tab gambling.. Journal of Gambling Studies 11, 311-341. Americann Psychiatric Association (APA) (1994) Diagnostic and statistical manual of mental disorders,disorders, 4th ed., Washington, DC: American Psychiatric Association. DeFuentes-Merillas,, L., Koeter, M.W.J., Schippers, G.M. & Brink, W. van den (2003). Are scratchcardss addictive? The prevalence of pathological scratchcard gambling among adult scratchcard buyerss in the Netherlands. Addiction, 98, 725-731. Dickerson,, M.G., Baron, E., Hong, S.-M., & Cottrell, D. (1996) Estimating the extent and degree off gambling related problems in the Australian Population: A National Survey. Journal of Gambling Studies,Studies, 4, 135-51. Dickerson,, M. (2003) The evolving contribution of gambling research to addiction theory. Addiction,Addiction, 98, 709. Dik,, J J. (1977) Approximation of confidence bounds, report number 77-09, Department of Mathematics,, University of Amsterdam). Emerson,, M.O., & Laundergan, J.C. (1996) Gambling and problem gambling among adults Minnesotans:: Changes 1990 to 1994. Journal of 'Gambling Studies, 12, 291-304. Griffiths,, M. (1995) Adolescent Gambling. London: Routledge. Griffiths,, M. (2000) Scratchcard gambling among adolescent males. Journal of Gambling Studies,Studies, 16,79-91. Gupta,, R. & Deverensky, J.L. (1998) Adolescent gambling behavior: a prevalence study and examinationn of the correlates associated with problem gambling. Journal of Gambling Studies, 14, 319-345. . Grim,, L. & McKeigue, P. (2000) Prevalence of excessive gambling before and after introduction off a national lottery in the United Kingdom: another example of the single distribution theory. Addiction,Addiction, 6, 959-966. Hendriks,, V.M., Meerkerk,G.-J., Oers, H.A.M., van & Garretsen, H.F.L. (1997) The Dutch instantt lottery: prevalence and correlates of at-risk playing. Addiction, 92, 335-346. IPMM Research en Advies (1993) Oriënterend onderzoek naar de wijze waarop instantloterijen in enkeleenkele landen zijn ingevoerd en naar de eventuele problemen die zich hierbij hebben voorgedaan. Rotterdam:: IPM. [Research oriented to the way in which instant lotteries had been introduced in some countriess and the eventually problems that may have occurred].

Lesieur,, H.R. & Blume S.B.(1987) The South Oaks Gambling Screen (SOGS): a new instrument forr the identification of pathological gamblers. American Journal of Psychiatry, 144,1184-1188.

Lesieur,, H.R. & Blume S.B.(1993) Revising the South Oaks Gambling Screen in different settings.. Journal of Gambling Studies, 9,213-223.

Lester,, D. (1994) Access to gambling opportunities and compulsive gambling. International JournalJournal of Addictions 29,1611-1616.

Pugh,, P. & Webley, P. (2000) Adolescent participation in the U.K. National Lottery Games. JournalJournal of Adolescence, 23,1-11.

53 3 Temporall Stability of PSG

Meyer,, G.(1992) The gambling market in the Federal Republic of Germany and the helpseeking off pathological gamblers. Journal of Gambling Studies, 8,11-20. Nationalee Drug Monitor (NDM) (2002) Nationale Drug Monitor: Jaarbericht 2002. Utrecht, Bureauu NDM [National Drug Monitor: Report from 2002). Nationall Opinion Research Center (NORC) (1999) Gambling Impact and Behavior Study: Report toto the National Gambling Impact Study Commission. Chicago: NORC. Shaffer,, H. J., Hall, M. N. & Vander Bilt, J. (1999) Estimating the prevalence of disordered gamblingg behaviour in the United States and Canada: A research synthesis. American Journal of PublicPublic Health, 9,1369-1376. Shepherd,, R.M., Ghodse, H. & London, M. (1998) A pilot study examining gambling behaviour beforee and after the launch of the National Lottery and scratch cards in the UK. Addiction Research, 6, 355-377. . Stinchfield,, R. (2002) Reliability, validity and classification accuracy of the South Oaks Gamblingg Screen (SOGS). Addictive Behaviour, 27,1-19. Stinchfield,, R. (2003) Reliability, validity and classification accuracy of a measure of DSM-IV diagnosticc criteria for pathological gambling. American Journal of Psychiatry, 160, 180-182. Volberg,, R. (1994) The prevalence and demographics of pathological gamblers: Implications for publicc health. American Journal of Public Health, 84,237-241. Wood,, R.T.A & Griffiths, M. (1998) The acquisition, development and maintenance of lottery andd scratchcard gambling in adolescence. Journal of Adolescence, 21,265-273.

54 4 Chapterr 3

APPENDIXX 31. Assumptions for the calculation of incidence for occasional and recreationall scratchcard gamblers.

Inn this study several assumptions were made about the two-year cumulative incidence of PSG amongg occasional and recreational scratchcard gamblers. These assumptions were necessary forr the calculation of the cumulative incidence, because those subgroups were not followed- up.. The rationale behind the assumptions can be summarised in two points: (1) the incidence off PSG will be mainly concentrated within those scratchcard gamblers that already encounteredd some scratchcard-related problems at tiF and (2) the incidence among those characterisedd as occasional and recreational scratchcard gamblers at ti will be lower than the prevalencee of PSG at ti. More specifically the incidence for occasional gamblers was assumed too be a quarter of the prevalence of PSG at ti (0.25* 0.0024 =0.0006) and the incidence of PSGG for recreational scratchcard gamblers was assumed to be half the prevalence of PSG at ti (0.50*0.0024=0.0012) )

Thiss appendix provides the arguments for the size of the assumed incidences and showss that these assumptions are rather conservative.

Att the ti prevalence study, from the 12,222 participants we have both SOGS and DIS-T dataa for 258 respondents (201 with a SOGS total score > 3 and 58 with a SOGS total score < 2,, DeFuentes-Merillas, et al., 2003). Using logistic regression the relation between DSM-IV PSGG and SOGS-total score at ti was estimated to be:

Logitt (PSG+lSOGS=x) = pVPiSOGS with p0= -3.222 and Pt = 0.231

Thesee 258 respondents, however, comprised a selected high prevalence subsample of the totall ti sample. In order to generalise this relation to the total ti sample, the Po parameter had to bee adjusted (pi is unbiased) using the following formula p0 «dj = Po + ln[P/(l-P)] - ln[p/(l-p)] withh P = prevalence in total sample and p = prevalence in the subsample in which the logistic regressionn estimates were made. In our case 28 of the 258 respondents were PSG+ (p=0.1081),, the prevalence in the total sample of 12,222 respondents was 0.0024. Using these figuress Po»dj =-7.142.

Whenn logit (PSG+|SOGS=x)= -7.142+0.23 lx the prevalence of PSG+ among occasional andd recreational scratchcard gamblers can be estimated using the logistic relation between P(PSG+)) and SOGS-total score P(PSG+|SOGS=x) = 1 / [l-exp(-7.142+0.23lx)]

P(PSG+|| SOGS=0) = 1/ [1+ e -(-7.142 + 0.231 x 0)] = 0.00079. P(PSG+|| SOGS=l) = 1/ [1+ e -(-7.142 + 0.231 x 1)] = 0.0010. P(PSG+|| SOGS=2) = 1/ [1+ e -(-7.142 + 0.231 x 2)] = 0.0012.

55 5 Temporall Stability of PSG

Alll occasional scratchcard gamblers had a SOGS total score of '0'. The distribution of thee SOGS total score in the recreational gamblers was as follows: '0'=57.7%; *1' = 30.7%; and'2'== 11.6%

Combiningg P(PSG+|SOGS=x) and relative frequency of SOGS total score among occasionall and recreational scratchcard gamblers the prevalence at ti of PSG+ can be estimatedd as using

2%% with fj = relative frequency SOGS total score 'i' and p( = P(PSG+|SOGS='i'). The prevalencee of the potential problematic scratchcard gamblers (SOGS3+) was established empiricallyy (28/201)

Prevalence e Occasional l 0.00079 9 Recreational l 0.00090 0 PPSG G 0.13930 0 PPSGG compared to Decisional ' '6; RR ppgo compared to recreational — 155

Thee only assumption we were making to legitimate our incidence assumptions is that thee ratio between the prevalences (i.e. the RR's) at ti is approximately the same as the ratio betweenn the cumulative incidences at t2.. Making this assumption and considering the fact that: : CIPPSG== 0.0672; Cloccasionai== CIPPSG : 176 = 0.00038, and CIrecreationall = CIppsQ : 155 = 0.00043.

Thesee calculations indicate that the assumptions made in this paper Cloccasionai = .25* prevalencee tt and CIreCreationai - 0.5* prevalence ti (respectively 0.0006 and 0.0012) are somewhatt conservative.

56 6 Chapterr 3

APPENDIXX 3II. Procedure to adjust prevalence estimates taking into account stability of thee diagnosis over time.

Althoughh only respondents with a SOGSti total score > 3 were followed-up at t2, the

prevalencee of pathological scratchcard gambling at t2 could be estimated based on some assumptions.. This appendix describes the procedure and assumptions made in order to achievee these adjustment prevalence estimates.

Tablee A.1 Estimates prevalence study (n= 12,222) X X P(X[buyer)' ' R+ + Regularr scratchcard gamblers 0.2840 0 R-- Occasionall scratchcard gamblers 0.7160 0 S+ + SOGSS total score tj £ 3 = non recreational gamblers'1 0.0268 8 s-- SOGSS total score tf ^ 3 = recreational gamblers 0.9732 2 c+ + DSM-IVV case (DIS-T +) 0.0024 4 c-- DSM-IVV case (DIS-T -) 0.9876 6 )) Probabilities were taken from prevalence report (probabilities are adjusted for samplin gg design). Alll probabilities pertain to scratchcards buyers (DeFuentes-Merillas et al, 2003). 2)) S+ comprises bom PPSG (2.44 % = 0.0244) and PSG (0.24 % = 0.0024)

Estimatingg transition probabilities.

Forr the incidence study we divided the 201 Sti+ responders into two different groups. Thee initial cases, which comprised the 28 respondents that fulfilled the DSM-IV criteria for pathologicall scratchcard gambler at tj and the potential problematic scratchcard gamblers comprisingg the 162 respondent which at tj were experiencing scratchcard-related problems, butt did not fulfil the criteria for pathological scratchcard gambling. At follow-up two years laterr we were able to interview 18 of the 28 initial cases and 134 of the 173 PPSG.

Basedd on these data, transition probabilities were estimated as follows: A = P(caset2+|caseti+); CC = P(caset2+|caseti-) and their complements B and D (Table 3.2).

Tablee A.2 Transition matrix addiction probabilities tit2

t2 2 casee + Case - tii case + A A B B case-- C C D D

Celll A

Off the 18 caseti+ interviewed at t2 only 2 fulfilled the DSM-IV criteria for pathological scratchcardd gambling 2 years later. Making the conservative assumption that all 10 ti cases

thatt refused to participate in the t2 interview are still PSG:

P(caset2+|case+)== 12/28=0.4286 = A.

CellB B BB = (1- A) or (1 - 0.4286) = 0.5714

57 7 Temporall Stability of PSG

CellC C Thiss cell is a combination of caseu- people that were S+ at ti and casen- people that were S- at ti. .

CaseCasetJtJ -andSti+ people (= PPSG) 66 of the 134 (Su+ and caseti-) fulfilled the DSM-IV criteria for pathological gambling adapted fortt scratchcards at t2= 0,045. Assuming non-differential loss to follow-up, this is an approximationn of P(casee+| caseti- and Sti+).

C,rC,r and Su-people Thiss subgroup comprises 8,664 persons, comprising 5,893 (R- and S-) people (68 % = 0.68) andd the 2,771 (R+ and S-) people (32 % = 0.32). Although we do not have follow-up data for thesee persons, we can approximate the probability that they will develop pathological scratchcardd gambling. Given the fact that for diseases like addiction the incidence in general iss much lower than the prevalence, we can make a range of probability estimates making moree and less conservative assumptions.

TwoTwo assumptions need to be made, one for the occasional scratchcards gamblers at ti P(caset2+|| Rti-) and one for the recreational scratchcard gamblers at ti P(caset2+|R+ and S-) In thee more optimistic estimates we assumed P(caset2+|Rti-) = 0. As a more pessimistic estimate wee assumed P(caset2+|Sti-) to be 0.50 times the prevalence estimate at ti. Combining assumptionss for P(caset2+jRti-) and P(caset2+|Sti-) results in two estimates for P(casetz+| caseti- andd Sti-).

OptimisticOptimistic estimate

-- P(caseö+|Rti-) = 0 Incidencee of pathological scratchcard playing in the tit2 interval for occasional scratchcard gamblerss = 0.

-- P(caseü+| Sti -) < 0.25* P(caseu+) = 0.25*0.0024=0.0006 Incidencee of pathological scratchcard playing in the tit2 interval for recreational scratchcard gamblerss was less or equal to 0.25 times the prevalence of pathological scratchcard playing at ti. . Thesee assumptions lead to the following estimate for P(caset2+| caseti- and Sti-): 0.68*0 + 0.32*0.000666 = 0.000192

PessimisticPessimistic estimate

-- P(caset2+|Rti-) - P(caset2+| R+ and SOGSu total score < 3) <, 0.50 P(caseu+) Incidencee of pathological scratchcard playing in the tit2 interval for occasional scratchcard gamblerss was the same as the incidence of pathological scratchcard playing in the tit2 interval

** P(caseu+) * 0.25 = 0.0024 * 0.25 - 0.0006

58 8 Chapterr 3 forr recreational scratchcard gamblers and was less or equal to half the prevalence of pathologicall scratchcard playing at t\.

Thesee assumptions lead to the following estimate for Pfcasea+lcaseu- and Sti-): 0.68*0.0012 ++ 0.32*0.0012 = 0.0012.

Estimatee for cell C7

P(casec+|caseti-)) = P(Sti+ and caseu-)* P(caset2+| casea- and Stj+) + P(Sti- and caseti-)* P(caset2+|| caseti- and Sti-)

P(casea+|| case,i-) Optimistic c 0.0013 3 Mostt conservative 0.0023 3 CellD D DD = (l-C) Fillingg in the cell probabilities in the transition matrix gives several transition matrices conditionall on caseti (ie. row probabilities sum to 1.00)

Transitionn matrices: conditional on DSM-lVn

Transitionn matrix addiction probabilities tit2 conditional on ti optimistic ti i case++ case- T|| case + .4286 6 .5714 4 case-- .0013 3 .9987 7

Transitionn matrix addiction probabilities M2 conditional on ti conservative

t2 2 casee + case - tjj case + .4286 6 .5714 4 case-- .0023 3 .9977 7

Unconditionall transition matrices

Multiplyingg the conditional probabilities by the ti probabilities gives unconditional cell probabilities: :

P(A)=P(caset2+|caseti+)*P(caseti+);P(B)=[l-P(caset2+|caseti+)]*P(caseti+); ;

P(C)=P(caset24.|case,i-)*P(case,i-);; P(D)=[1- P(caset2+|caseti-)]*P(caseti-)

Transitionn matrix addiction probabilities tit2: optimistic

t2 2 case++ case- tii case + 0.0010 0 0.0014 4 case-- 0.0013 3 0.9963 3

77 Example optimistic estimate 0.0013= 0.0244*0.045+0.9732*0.000192

59 9 Temporall Stability of PSG

Transitionn matrix addiction probabilities t^: conservative

t2 2 case++ case- tii case + 0.0010 0 0.0014 4 case-- 0.0023 3 0.9853 3

Estimatess based on the 12,222 sample. Prevalencee estimate based on prevalence and incidence data. Prevalence at t2 was a combinationn of pathological scratchcard gamblers at ti still addicted at t2 + recreational and occasionall scratchcard gamblers at ti that became addicted in the tit2 interval.

Ptcaseü+y y 95%% CI Optimistic c 0.0023 3 0.0015-0.0033 3 Conservative e 0.0033 3 0.0023-0.0045 5 (caset2+)) was calculated by adding the column of t2 case + at the different transitionn matrix (i.e. Optimistic P(caseQ+) = 0.0010 + 0.0014 = 0.0024).

Thee 95% confidence interval was calculated using the estimation formula by Dik (1977).. Lower bound (>/z-.98)2; upper bound (V(z+l)+.98)2 with z = number of pathological gamblerss at t2. This number was estimates by P(caset2+)* 12,222. Upper and lower bound weree converted to proportions by dividing by 12,222. (example optimistic estimate: z=.0023** 12,222 = 28, z^» = 18.6, Zap,» = 40.5 Transforming to proportions gives respectivelyy 18.6/12,222 = 0.0016 and 40.5/12,222=0.0033.

60 0 Chapterr 4

CHAPTERR 4

AA CLINICAL RE-EVALUATION OF THE DSM-IV CRITERIA FOR PATHOLOGICALL SCRATCHCARD GAMBLING1

ABSTRACT T AimsAims To examine the effects of the DSM-IV criterion for clinical significance (CCS) on the numbernumber of positive diagnoses of pathological scratchcard gambling (PSG) based on the DSM-IVDSM-IV symptom criteria. MethodsMethods In a previous prevalence study with a non-proportional stratified random sample of 12,22212,222 adult scratchcard buyers in the Netherlands, 28 participants were identified as pathologicalpathological scratchcard gamblers (PSG) using the DSM-IV Diagnostic Interview Schedule (DIS-T)(DIS-T) adapted for scratchcards. These 28 PSG were approached for an in-depth face-to- faceface interview two years later. Ten (35.71%) agreed to participate: 5 cases were 'unique' PSGPSG and 5 were combined PSG (i.e. PSG in combination with pathological gambling for otherother games of chance). Based on the transcripts of the in-depth interviews, two psychologistspsychologists experienced in the treatment of pathological gambling independently rated the clinicalclinical significance of the PSG diagnoses. ResultsResults The clinicians agreed in 60% of the cases on the question whether or not the gamblinggambling problems fulfilled CCS. In 3 cases both rated the problems as endorsing the CCS andand in 3 cases both agreed the problems did not reach clinical significance. The clinicians agreedagreed on the classification of all 5 'unique' PSG cases and on only 1 of the 5 combined PSG cases.cases. Compared to the outpatient clinician, the inpatient clinician used a higher threshold forfor clinical significance. When a lenient (Le. outpatient) threshold is taken into account, 7 of thethe 10 PSG cases (2 unique and 5 combined) endorsed the DSM-IV criterion for clinical significancesignificance (CCS). When a more severe (i.e. in-patient) threshold is applied, only 3 of the 10 casescases (2 unique and 1 combined) endorsed the CCS. ConclusionConclusion When the DSM-IV CCS is applied, the previously reported prevalence of unique PSGPSG among a representative population of Dutch scratchcard gamblers (0.09%) is likely to bebe an overestimation of the actual prevalence.

INTRODUCTION N

Betweenn 1999 and 2002, The Amsterdam Institute for Addiction Research conducted a large- scalee social-epidemiological study to assess the potential negative effects of scratchcard gamblingg using a sample of 12,222 adult scratchcard players in the Netherlands. The study providedd prevalence figures on the nature and extent of scratchcard-related problems in the generall population (DeFuentes-Merillas, et al., 2003). In addition, this study provided data on thee temporal stability of scratchcard-related problems and on the characteristics of those sufferingg from pathological scratchcard gambling (PSG) (DeFuentes-Merillas, et al., 2004).

'Thiss chapter has been submitted for publication: DeFuentes-Merillas, L., Schippers, G.M., Koetcr, M.W.J., Brink,, W., van den. A clinical re-evaluation of the DSM-IV criteria for pathological scratchcard gambling

61 1 Criteriaa for clinical significance

Thee study's main findings were: (1) that PSG has a low prevalence (0.24%) among Dutch adultt scratchcard buyers; (2) that both the estimated two-year cumulative incidence (0.24%) andd the temporal stability (between 11-43%) of PSG were low; and (3) that the prevalence of PSGG is stable over time. Furthermore, the study showed that only one third of the 0.24% meetingg the DSM-IV criteria for PSG (0.09%) was addicted uniquely to scratchcards. The remainingg two thirds (0.15%) were also addicted to other games of chance. (For a detailed descriptionn of the findings of this prospective study we refer to the above-mentioned publications). . AA limitation of this study is related to the application of the DSM-IV criteria used to identifyy PSG. The DSM-IV criteria for pathological gambling are considered the international standardd for researchers and treatment professionals (National Opinion Research Center, NORC,, 1999; Stinchfield, 2003), and their ultimate goals are to help clinicians and researcherss to improve diagnostic accuracy, minimising the likelihood of false positives and falsee negatives and also to improve reliability by minimising criterion variance among studies (Spitzerr & Wakefield, 1999). Despite this fact, there is still a lack of evidence regarding the reliabilityy and validity of the diagnosis of pathological gambling in DSM-IV (APA, 1994) and thee pathological gambling section of the DSM-IV Diagnostic Interview Schedule (DIS-T, APA,, 1994). As a consequence, part of the reported prevalence and temporal stability estimatess may reflect unreliability and validity problems of the assessment procedure used. Thee question, therefore, arises whether the identified 'cases' of PSG in our earlier studies can bee considered pathological, i.e. in the sense of having reached the level for clinical significancee comparable to that of other forms of pathological gambling or substance dependence.. This seems a legitimate concern given the rather special characteristics of the uniquee pathological scratchcard gamblers: middle-aged women spending relatively small amountss of money on scratchcards (DeFuentes-Merillas et al, 2003). Accordingly, the appropriatenesss of the DSM criteria for PG applied to this particular form of gambling needs too be further investigated. Ass a general rule, the DSM-IV attempts to deal with the false positives problem by addingg the DSM-IV "criterion for clinical significance" (CCS) to all DSM-IV symptoms and too the total syndrome or diagnosis. This CCS requires that the individual exhibits "[..] clinicallyclinically significant distress or impairment in social, occupational or other important areas ofof functioning*. (American Psychiatric Association, 1994, page 7). The criterion is also meant too "help establish the threshold for the diagnosis of a disorder in those situations in which the symptomaticsymptomatic presentation by itself (particularly in its milder forms) is not inherently pathological"pathological" (American Psychiatric Association, 1994, page 7)-. Thus, the CCS might be helpfull to distinguish between mild and more severe consequences of gambling. A distinction thatt might be related to the specific type of hazard game one plays (i. e. loss of control may indicatee more severe problems when playing roulette than playing scratchcards). The clinical significancee criterion is used in this study to assess the accuracy of DSM-symptom criteria andd the DSM diagnosis applied among scratchcard players. Too this end a small qualitative study was conducted. In this study in-depth interviews weree conducted with a sub-sample of 10 of the 28 identified PSG from the population-based

62 2 Chapterr 4 studyy mentioned above (DeFuentes-Merillas et al., 2003, 2004). The purpose of the present qualitativee study was to investigate the validity of the DSM-IV diagnosis of PSG using a fece- to-facee structured interviewed and the DSM-IV criterion for clinical significance as assessed byy two independent clinicians (concurrent validity).

METHODS S

Sample e Twenty-eightt participants from a non-proportional stratified random sample of 12,222 adult scratchcardd players interviewed for a prevalence study2 were identified as suffering from PSG,, i.e. they met the DSM-IV criteria adapted for PSG in the year preceding the assessment. Fourteenn of them were addicted uniquely to scratchcards and 14 were also addicted to other gamess of chance. The DSM-IV symptom criteria were assessed with an adapted version of the gamblingg section of the DSM-IV Diagnostic Interview Schedule (DIS-T). Two years later 10 respondentss (35.7% of the original 28 PSG cases) agreed to participate in the present extensivee in-depth interview. Informed consent to have the interview audiotaped was obtained fromfrom all participants and confidentiality and anonymity were warranted. Participants received €€ SO as a compensation for the time invested in the study.

Tablee 4.1 Demographics and participation in games of chance for the PSG identified at initial assessmentt and for the PSG participating in the in-depth interviews. Prevalencee assessment In-depthh interview PSG(n=28) ) PSG(n=10) ) Combined d Unique e Combined d Unique e N-14 4 n-14 4 n-5 5 n-5 5 Men n 71.4% % 42.9% % 60.0% % 40.0% % Women n 28.6% % 57.1% % 40.0% % 60.0% % Meann age 36.9 9 43.6 6 39.4 4 55.8 8 Dutch h 42.9% % 64.3% % 40.0% % 80.0% % Scratchcardss previous month Frequencyy of playing (median) Amountt of money spent (median) 15.5 5 21 1 15 5 25 5 €€ 85.08 €51.05 5 €90.76 6 €€ 45.38 Otherr games of chance previous month' Frequencyy of playing (median) Amountt of money spent (median) 2 2 1 1 2 2 1 1 €€ 159.70 €€ 14.50 €160.64 4 €19.97 7 Slott machines Lotto/toto/otherr lotteries 50.0% % 7.14% % 40.0% % 0 0 Casinoss (excl. slot machines) 71.4% % 50.0% % 80.0% % 60.0% % Otherr games of chance1 28.6% % 0 0 20.0% % 0 0 35.8% % 32.2% % 30.0% % 40.0% % 11 Other games of chance includes a combination of several short-payout interval games (Le. participation in cardss games for money outside the home, bingo, internet garriblmg, hc*se^rac* betting, and chance). .

22 A detailed description of the original sample and of the results ofu^rwevalence study have been published elsewheree (DeFuentes-Merillas et al., 2003).

63 3 Criteriaa for clinical significance

Off the 10 PSG respondents, 5 were addicted uniquely too scratchcards, the remaining 5 weree also addicted to other games of chance. Table 4.1 displays the demographic and gamblingg characteristics at initial assessment (ti) of these groups in comparison with the originall group of 28 pathological scratchcard gamblers.

Instrumentss and procedure Pathologicall gambling and pathological scratchcard gambling (PSG) were defined as fulfillingg the Diagnostic and Statistical Manual 4th edition (DSM-IV) criteria for pathological gambling.. Both were assessed with the Pathological Gambling Section of the DSM-IV Diagnosticc Interview Schedule (DIS-T, APA, 1994), although for the assessment of PSG an adaptedd version of the DIS-T interview was used (the adaptation basically meant the replacementt of the word 'gambling' by 'scratchcard gambling'). An example of this adaptationn has been reported in the previous two studies (DeFuentes-Merillas et al., 2003, 2004).. A mania screener based on Section F of the DSM-IV Diagnostic Interview Schedule (DIS-F,, APA, 1994) was used to exclude subjects with a current manic episode. Participants weree defined as pathological scratchcard gamblers if they met the DSM-IV criteria for pathologicall gambling, i.e. presence of at least five of the defining criteria during the year priorr to the assessment and were not suffering a mania episode. Thee DSM-IV criterion for clinical significance (CCS; see the introduction section), servedd as an additional criterion for PSG. The assessment of the CCS was made in two phases:: an in-depth interview with the 10 PSGs and a coding phase. Thee Gambling Problems Severity Scale (GPSS, Koeter, et al., submitted) was included inn this study to assess the severity of the gambling-related problems among PSG. The GPSS comprisess 20 items in four 5-item subscales, covering the following domains: Psychological andd Emotional Health (PEH), Family and Social Relations (FSR), Financial Consequences (FC)) and Work and Education (WE). The total scale as well as the four subscales fulfilled the criteriaa of the Rasch model. This implies among others characteristics that 1) they are one- dimensional,, and 2) interval severity scores can be obtained using a relatively simple transformation.. The psychometric properties of the total scale, as well as, each of its sub- scaless are good (Koeter et al., submitted).

In-depthIn-depth interview Thee aim of the current face-to-face in-depth interview was to explore in more detail the scratchcard-relatedd behaviours and problems that the participant had referred to in the diagnosticc interview using the DIS-T at initial assessment (ti). The nature of the gambling behaviourr and the problems mentioned then were extensively explored, and illustrative exampless of the symptoms were sampled. The interviewer focused in a retrospective manner onn all the DIS-T items that the participant had endorsed. The interviews were conducted by twoo experienced lay interviewers. They had attended a one-day training course and worked withh a detailed semi-structured protocol to ensure the integrity of the interview in terms of intervieww content, the use of a coding sheet and interview techniques like the use of a retrospectivee timeframe, open questions and different confronting techniques, in case that the

64 4 Chapterr 4 participantt reported contradictory information during this in-depth interview. The interviews weree conducted at the participant's home and took an average of 90 minutes. All ten interviewss were tape-recorded. After every interview feedback was given to the interviewer in aa supervision session to minimize drift during the study.

InterviewInterview coding Alll interviews were transcribed. Two clinicians with extensive clinical experience (16 and 13 yearss of practice in addiction treatment, including gambling problems) were approached to independentlyy code the ten verbatim interview transcriptions using a coding sheet. Since the thresholdd for clinical significance may differ when it is assessed by clinicians working in differentt contexts, one coder was selected from an inpatient clinic whilst the other was recruitedd from an outpatient treatment centre. The coding sheet and coding instructions were developedd to instruct the coders on how to make use of the coding sheet and to ensure comprehensionn of the DSM-IV CCS. The coding sheet was piloted independently by the first twoo authors. The coding instructions covered every DSM-IV symptom with the question whetherr or not participants fulfilled the CCS on the basis of the behaviours, problems and circumstancess that the interviewee presented in relation to this symptom. More precisely, clinicianss were asked to evaluate if participants met one or both of the following conditions at symptomm level: (a) whether the symptom limited or impeded the proper fulfilment of a role functionn or whether it affected the person's performance (i.e. caused clinically significant distresss or impairment in social, occupational, or other important areas of functioning) QL (b) whetherr the symptom referred to a subjective experience of "not feeling well". Participants weree considered a clinically significant case if at least one of the clinicians considered the participantt to meet the DSM-IV case of PSG at a clinically significant level, i.e. had a minimumm of five clinically relevant positive scores out of the ten DSM-IV symptoms.

RESULTS S

Basedd on the CCS, the outpatient clinician classified 7 of the 10 PSG as clinical significant PSG,, whereas the inpatient clinician classified only 3 of the 10 cases as clinically significant. Thesee results suggest that the inpatient therapist used a higher threshold in the assessment of clinicall significance. Thee clinicians agreed in 60% of the cases on the question whether or not the gambling problemss fulfilled CCS. In 3 cases both rated the problems as endorsing the CCS and in 3 casess both agreed the problems did not reach clinical significance. The clinicians agreed on all 55 unique PSG cases and on only 1 of the 5 combined PSG cases. Compared to the outpatient clinician,, the inpatient clinician used a higher threshold for clinical significance. When using thee more lenient (i.e. outpatient) threshold, 7 of the 10 cases (2 unique and 5 combined) endorsedd the DSM-IV criterion for clinical significance (CCS). Using a more severe (in- patient)) threshold, only 3 of the 10 cases (2 unique and 1 combined) endorsed the CCS.

65 5 Criteriaa for clinical significance

Althoughh clinicians agreed in 60% of the cases whether or not participants were a clinicallyy significant case (diagnostic level), a comparison between the mean number of clinicallyy significant criteria a patient endorsed showed that they differed on their judgement off CCS at symptom level. With the exception of the withdrawal and lies/deception symptoms, thee outpatient clinician always coded more DSM symptoms as endorsing CCS than the inpatientt clinician. These results provide additional support for the fact that outpatient and inpatientt clinicians use different threshold levels in the assessment of clinical significance. Tablee 4.2 presents the ratings per clinicians for the DSM-IV CCS at symptom level for thee ten PSG cases (Table 4.2). For both clinicians the most prevalent symptom of PSG was preoccupationn (outpatient n=10; inpatient n=8) and the least prevalent PSG symptom was illegall acts (outpatient n=l; inpatient n=0). At symptom level, total agreement was only reachedd for the PSG symptom lies/deception. For the unique PSG group total concordance betweenn coders at symptom level was found for the following DSM-IV criteria: escapism, lies/deception,, illegal acts and family/job disruption. For the combined PSG group total concordancee between coders at symptom level was found for the following DSM-IV criteria: preoccupationn and lies/deception. The largest discrepancy was found for the criterion tolerance. . Tablee 4.3 shows several demographic characteristics, the number of endorsed DSM-IV symptomss according to the DIS-T, the number of clinically significant DSM-IV symptoms accordingg to the clinicians and the severity of the gambling problems according to the self- reportt GPSS for the 5 unique PSGs.

Tablee 4.3 Demographic characteristics, DIS-T, GPSS and CCS scores for the unique PSG Tl l CCS S DIS-T T GPSS S Case e Group p Age e Gender r A A B B W&E E FC C FS S PEH H Total l 1 1 U* * 66 6 M° ° 9* * 7* * 6 6 0 0 0 0 5,2 2 6,2 2 4,1 1 2 2 U U 46 6 W W 4* * 1* * 6 6 0 0 0 0 0 0 5,2 2 3,0 0 3 3 U U 66 6 M M 3* * 3* * 5 5 0 0 0 0 4,3 3 3,4 4 3,0 0 4 4 u u 41 1 W W 4* * 0* * 5 5 0 0 3,4 4 0 0 3,4 4 2,5 5 5 5 u u 60 0 W W 9* * 8* * 6 6 0 0 5,2 2 3,4 4 5,2 2 4,1 1 ** U= unique PSG group and C = combined PSG group. bb A = outpatient clinician and B = in-patient clinician. cc M = man and W = woman ** Agreement between coders at diagnostic level.

Whenn the three instruments used to assess the participants' situation (DIS-T, GPSS andd CCS) are compared, it is clear that both clinicians identified more DSM-IV symptoms as clinicallyy significant than when the DIS-T was applied. In addition, the two unique cases that bothh clinicians classified as CCS cases scored above 4 on the GPSS. This seems to indicate thatt the total score of the GPSS is more in line with the clinician's CCS ratings than the DIS- T. .

66 6 Chapterr 4

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§ Ï&'BS S c2o o2 Q Q O Ou uo oo o n n TT T II I ai i 3 3 iii s es s 11 1 H H 67 7 Criteriaa for clinical significance

DISCUSSION N

Thee current study shows that about one-third of the PSG cases fulfilled the DSM-IV CCS usingg a severe (inpatient) threshold and two-thirds fulfilled the DSM-IV CCS using a more lenientt (outpatient) threshold. The picture differs for unique and combined PSGs. Of the uniquee PSGs 40% fulfilled the DSM-IV CCS (irrespective of the threshold used) whereas ii 00% of the combined cases fulfilled the CCS using the lenient threshold and 20% using the moree severe threshold. These results indicate that the diagnosis 'unique' PSG based on the DSM-IVV criteria as assessed with the DIS-T in the majority of cases does not represent clinicallyy significant psychopathology. On the other hand, following the same procedure, the diagnosiss for 'combined' PSG does seem to represent clinically significant psychopathology inn many if not all of the cases. Ass a consequence, the current findings suggest that the previously reported prevalence ratee of unique PSG (0.09%) is likely to be an overestimation of the 'real' prevalence of this addictionn among scratchcard players. This is probably not the case for combined PSG (0.15%)) (DeFuentes-Merillas et al., 2003). However,, it is important to be cautious with statements about the potential overestimationn of our previous prevalence rates, since the results of this qualitative study are onlyy based on a sub-sample of 10 of the 28 PSGs identified at the initial assessment. Moreover,, the retrospective character of the in-depth interviews may have caused underreportingg of the scratchcard-related problems suffered two-years earlier in the participants,, particularly given the high recovery rate of PSG found in the two-year follow-up (DeFuentes-Merillass et al., 2004). However, this concern of potential underreporting during thee in-depth interviews does not seem to apply to the two unique pathological scratchcard gamblerss that were identified as clinically significant cases, because the clinicians identified moree DSM-IV symptoms as clinically significant than the number of symptoms identified by thee DIS-T. Thee outpatient clinician was always more lenient in the application of the DSM CCS thann the inpatient clinician. Variables like the clinician's background and/or the co-morbidity off PSG with a primary pathological gambling disorder may explain the low level of agreementt between the clinicians for the 'combined' group. These results lend support to the hypothesiss that there are different threshold levels, in terms of clinical significance at inpatientt and outpatient settings; a phenomenon also observed in other disorders. On the other hand,, the perfect rater agreement at the diagnostic level between both clinicians for the uniquee PSG may be explained by the fact that unique PSGs either fall into the upper clinical rangee (>7 symptoms for both clinicians) or into the lower sub-clinical range (<3 for the inpatientt clinician). Thee application of a lenient (i.e. outpatient) criterion of CCS may underestimate the falsee positive problem. However, in our opinion, if a person fulfils the DSM-IV CCS from an outpatientt setting point of view, he/she is a true case. Inn summary, when a lenient threshold is used, 70% of the identified 'cases' of PSG are too be considered pathological, in the sense of reaching the level for clinical significance

68 8 Chapterr 4

However,, for unique PSG the bias is probably much larger. In this group only 40% reached thee criterion for clinical significance As a consequence, the previously reported prevalence of 'unique'' PSG among a representative population of Dutch scratchcard gamblers (0.09%) is likelyy to be an overestimation of the actual prevalence.

REFERENCES S

Americann Psychiatric Association (APA) (1994) Diagnostic and statistical manual of mental disorders,disorders, 4th edn. Washington, DC: APA DeFuentes-Merillas,, L., Koeter, M. W. J., Schippers, G. M, & Brink, W. v. d. (2003) Are scratchcardss addictive? The prevalence of pathological scratchcard gambling among adult scratchcard buyerss in the Netherlands. Addiction, 98, 725-731. DeFuentes-Merillas,, L., Koeter, M. W. J., Schippers, G. M, & Brink, W. v. d. (2004) Temporal stabilityy of pathological scratchcard gambling among adult scratchcard buyers two years later. Addiction,Addiction, 99, 117-127. Koeter,, M. W. J., DeFuentes-Merillas, L., Borsboom, D., Schippers, G. M., & Brink, W. v. d. (submitted)) The Gambling Problems Severity Scale (GPSS): A new multi-domain instrument with Raschh properties to assess the severity of gambling related problems. Nationall Opinion Research Center (NORC) (1999) Gambling Impact and Behavior Study: Report toto the National Gambling Impact Study Commission. Chicago: NORC. Spitzer,, R.L.& Wakefield, J. C. (1999) DSM-IV diagnostic criterion for clinical significance; Doess it help to solve the false positives problem? American Journal of Psychiatry, 156, 1856-1864. Stinchfield,, R. (2003) Reliability, validity and classification accuracy of a measure of DSM-IV diagnosticc criteria for pathological gambling. American Journal of Psychiatry, 160, 180-192.

ACKNOWLEDGEMENTS S Thee authors would like to thank the clinicians Mr. H. Nelissen and Mr. J. J. Schijf for their ratingss of the interviews.

69 9 Criteriaa for clinical significance

APPENDIXX 4 L CASE STUDIES

Thiss appendix briefly illustrates the 2 cases of unique pathological scratchcard gamblers. Theyy are selected from those for which both clinicians agreed that the scratchcard-related problemss reached the DSM-IV criterion for clinical significance (CCS) based on the DSM-IV symptomm criteria for pathological scratchcard gambling (PSG) (Cases 1 and 2).

Casee 1 Thee participant is a 66-year-old man, married, and living from his pension (between € 900 andd € 1350 a month). During the in-depth interview, he reported that two years ago he was addictedd to scratchcards. For several months, the drive to buy scratchcards was so high that he neglectedd his allotment because he preferred to spend his time playing scratchcards. Duringg an average month he spent between € 40 and € 60 on scratchcards. However, duringg this in-depth interview he recognised that during his worst scratchcard period he used too spend € 5 to € 10 a day (€ 150-300 a month). He always bought the scratchcards in the samee shop because it was where he used to buy his cigarettes, and because this shop sold once aa scratchcard with a price of € 50.000. Bothh clinicians agreed that he scored the following DSM-IV criteria when considering thee CCS: preoccupation, loss of control, withdrawal, escapism, lies/deception, and family and jobb disruption (See Table 4.2, page 67, Case 1 of the unique PSG). In the following paragraphss we illustrate these symptoms with quotes from his in-depth interview. Preoccupationn and chasing: "I was continuously thinking about going back to the shop toto buy more scratchcards, to get the losses back [..] You think that you will win your money back,back, that you keep in playing, but the wins never happens. That is the misery of it!" Losss of control: "Before I went to the shop, I planed to spend € 10 in 8 scratchcards, butbut you go and buy 4 or 6, and you don't win anything. Then, you buy a couple more, and a couplecouple more Well, that is how it goes! [...] You think very frequently, lam not going back to thatthat shop to buy this "nonsense ", but the day after you are there again ". Withdrawal:: "When I couldn't buy them I was not feeling good, nervous or even irritable,irritable, and those feelings disappear after buying [...] even when I was on vacation in BelgiumBelgium I went to the shops seeking that 'rubbish' (scratchcards) ". Escapism:: "Ifyou buy and play, you think in the money that you are going to earn and allall the things that you can do with that money, of course, you forget your current problems. YeahYeah that is it! You don't think in your problems only in the prices". Lies/deceptionss and family disruption: "My wife complains a lot about it, she hates thatthat game. We had several fights about it. Of course, 1 continue playing and then you feel very miserable.miserable. I hid it! I make up stories in order to buy or scratch them in secret".

Casee 2 Thee participant is a 60-year-old woman, living alone and with a social benefit as income (betweenn € 450 and € 900). During the in-depth interview, she reported that, two years ago, thee scratchcard-related problems were so severe that she spent all her money on scratchcards,

70 0 Chapterr 4 andd at the end of the month she needed to borrow money to buy her food. In her own words: "It"It was a real disaster". Shee regularly followed the same pattern of spending 2 scratchcards, 6 to 7 times a week.. Although, she recognised that she used to have a "peak" in her playing behaviour aroundd the 20th of every month, and then she will bought until all her money was gone. She spentt around € 140 a month, when she should not have spent more than € 25, in order to avoid financiall problems. Bothh clinicians agreed that she scored the following DSM-IV criteria when consideringg the CCS: preoccupation, loss of control, withdrawal, escapism, lies/deception, familyy and job disruption and financial bailout (See Table 4.2, page 67 Case 5 of the unique PSG).. In the following paragraphs, we will illustrate these symptoms with quotes from the transcriptionss of the in-depth interview with her. Preoccupation:: "I was thinking all the time in wining, wining, wining" [...] "and then, whenwhen I was back home, I was feeling bad because I did not do other thing that buying scratchcardsscratchcards and thinking about that next time I will buy and win ". Losss of control: "/ tried to stop, I really tried, but well, yeah...I did not succeed, I cannotcannot do anything about it... I say to myself 'don't buy, don't buy', but still you go and buy ". Withdrawal:: ""Other people smoke or drink which are very bad things to do. I do somethingsomething less bad, I keep in buying scratchcards. [...] I feel a bit restless when I don't have moremore money to buy them, this unpleasant goes with the time, but it comes back too ". Escapism:: "When I buy and play scratchcards, I forget my problems, I am just excited aboutabout the wining, and I enjoy that feeling, no worries, just winning". Chasing:: "I have many times feeling guilty, but still the next day, I need to go and buy scratchcards,scratchcards, always hoping I will win. For example this morning, I thought, if I win now I willwill get my money back. You are constantly thinking about it". Lies/deceptionss and family disruption: "No, I never tell to nobody. If they know they willwill never lean me money. It is my own secret, if my sons will know, they will get angry. Once II mentioned that I bought one and they called me gambler \ [...] If someone will ask about it, I willwill deny it or change the conversation. If they know I will get problems ". Financiall bailout: "Yes, I have money problems at the end of the month because of the scratchcards,scratchcards, and if you don't have money, then you cannot buy food, ...I had that for almost 33 years... Then, you borrow money to buy food, or when you are hungry you just visit family oror friends around dinner time. Of course you feel awful about it, but I couldn 't help it".

71 1

PARTT III

THEE ASSESSMENT OF GAMBLING-RELATED D PROBLEMS S

Chapterr 5

CHAPTERR 5

PREVALENCEE OF PATHOLOGICAL GAMBLING: VALIDITYY OF THE DUTCH VERSION OF THE SOUTH OAKS GAMBLINGG SCREEN1

ABSTRACT ABSTRACT AimsAims To estimate the prevalence of pathological gambling (PG) in a community sample of youngyoung adults (12-35 years old) in the Netherlands and to test the validity of the South Oaks GamblingGambling Screen (SOGS) as a screener for pathological gambling. MethodsMethods A representative sample of 5830 young adults were assessed for PG using a two- stagestage sampling design with the SOGS as the stage-1 screening instrument and the PG section ofof the Diagnostic Interview Schedule (DIS-T) as the diagnostic instrument for stage-2. SensitivitySensitivity and specificity of the SOGS with DIS-T as a criterion for PG were estimated using bothboth stage 1 and stage 2 data. These estimates were used to obtain an adjusted prevalence estimateestimate ofPG. ResultsResults The SOGS had good sensitivity (.94) and specificity (.99), using a cut-off score of 5. Stage-1Stage-1 and adjusted stage-2 prevalence estimates for PG among males were 2.9% and 2.0%,2.0%, respectively, for the general population, 4.6% and 3.2% for males playing games of chance,chance, and 6.7% and 4.6% for males playing short-payout interval games (e.g. slot machine,machine, casino games, etc.). The positive predictive value (PPV) of the SOGS as a screener forfor DSM-III-R PG, using a threshold value of 5, was 65%. The probability of being a pathologicalpathological gambler at any given SOGS total score is presented. ConclusionsConclusions SOGS is a good screening questionnaire for pathological gambling. However, asas a consequence of the relatively low prevalence ofPG in the general population, the SOGS considerablyconsiderably overestimates the prevalence ofPG in community samples.

INTRODUCTION N

Thee increasing availability and social acceptance of gambling has, inevitably, resulted in higherr rates of problem and pathological gambling among players, especially among young adultss and adolescents (Fisher, 1993; NORC, 1999; Duvarci and Varan, 2000; Gotestam and Johansson,, 2003). A substantial part of society sees hazardous games of chance as a pleasant leisuree time activity, whereas some consider it a risky, and even morally inferior, behaviour. Inn many countries gaming laws are developed to canalise gambling behaviour. In the Netherlands,, the gaming law has three main aims: the prevention of pathological gambling, thee protection of gamblers by assuring fair games of chance and the prevention of criminality byy cracking down on illegal providers of gambling. New developments (like Internet or SMS

11 This chapter has been submitted for publication: DeFuentes-Merfflas, L.t Koeter, M.W.J., Schippers, G.M., Brink,, W., van den. Prevalence of Pathological Gambling: Validity of the Dutch version of the South Oaks Gamblingg Screen.

75 5 Prevalencee of Pathological Gambling

gaming)) require both the adaptation of the existing gaming law and the development of new gamingg legislation. Reliablee and valid screening instruments for the general population are needed to assess,, monitor and evaluate the effects of existing gaming policy and to keep track of new developmentss as to the extent and character of the gambling possibilities offered. As Ladouceurr et al. (2000) pointed out, the accuracy with which the prevalence of pathological gamblingg is estimated has important implications for both empirical research and for the widerr political debate concerning the desirability of having more forms of gambling available inn society. Reportedd prevalence estimates for pathological gambling vary substantially over differentt studies. For instance, prevalence estimates for the general population vary from 0.77%% to 3.4% pertaining to the USA (Shaffer et al., 1999; NORC, 1999; Volberg & Bank, 2002;Weltee et al., 2002), from 0.25% to 1.73% in Australia (Dickerson et al., 1996; Productivityy Commission, 2002; Sakurai and Smith, 2003), and from 0.9% to 1.5% in New Zealandd (Abbott and Volberg, 1996). Reported European estimates of pathological gambling were:were: 0.6% in Norway (Gotestam and Johansson, 2003), 1.2% in Sweden (Volberg, et al., 2001),, 1.5% in Spain (Becona, 2002) and between 0.13% to 1.3% for the Dutch population (Brink,, van den et al, 1998). Theree are at least three explanations for these variations among studies. First, the characteristicss of the samples on which these estimates were based may have been responsible forr the different outcomes. Second, the methods used to estimate the prevalence varied per study,, and finally, there was great diversity in the case criteria or definitions used to identify pathologicall gamblers, as well as in the time frames applied (lifetime, last-year or last-month prevalence). . Ass regards the first issue, it has been shown that some groups are more at risk than otherss groups. For instance, relatively higher prevalence rates have been found among young adultss (age group 18-29, Abbott & Volberg, 1996; Gotestam and Johansson, 2003), adolescentss (Gupta & Derevensky, 1998; Stinchfield et al., 1997) and adults undergoing treatmentt for mental health and substance abuse (Shaffer et al., 1999; Potenza and Kosten, 2001).. Most epidemiological surveys also reported that men are more at risk of pathological gamblingg than women (Gotestam and Johansson, 2003; Abbott and Volberg, 1996, etc.) and thatt level of education, employment and marital status are related to problematic gambling (Abbottt and Volberg, 1996). Ass mentioned, the methods and case definitions used to estimate prevalence varied acrosss studies. Many of the epidemiological studies on pathological gambling used diagnostic interviewss and/or self-report screening questionnaires to gather their prevalence estimates. In ourr opinion, the most appropriate instrument, in terms of validity, is a structured psychiatric intervieww like the DIS-T (Pathological Gambling Section of the Diagnostic Interview Schedule).. However, in the case of relatively rare diseases, like pathological gambling, large sampless are needed to get precise prevalence estimates. In this situation structured psychiatric interviewss are very time consuming and expensive (non cost-effective). As a consequence self-reportt screening questionnaires are frequently preferred in general population surveys

76 6 Chapterr 5 sincee they enable researchers to study relatively large populations fast and conveniently. One off the most widely used screening questionnaires in general population studies is the South Oakss Gambling Screen (SOGS, Lesieur and Blume, 1987; Volberg and Abbott, 1994; Emersonn and Laundergan, 1996). The original SOGS, however, has never been validated with aa two-stage design in Europe. Screeningg instruments always generate misclassification (false positives and false negatives).. In case of a low prevalence disorder like pathological gambling, even a screener withh excellent specificity like the SOGS will produce a substantial number of false positives, andd as a consequence overestimate prevalence. This may be an important explanation for the variancee in reported prevalence estimates. Mostt methodological limitations mentioned can be overcome by the application of a cost-effectivee two-stage sampling design (Lesieur and Blume, 1987; Volberg and Abbott, 1994;; Abbott and Volberg, 2001). In the first stage a self-report screening questionnaire is usedd to identify the people at risk of pathological gambling in a large and representative samplee of the target population. In the second stage, all screener positives and a random samplee of the screener negatives are given a structured diagnostic interview to assess whether orr not they meet the diagnostic criteria for pathological gambling. This design will produce a moree accurate prevalence estimate at considerably lower cost. This design also allows the sensitivity,, specificity, positive predictive value and the negative predictive value of the SOGSS to be tested in a target population. Thee present study used a two-stage design and aimed (1) to assess the one-year prevalencee of pathological gambling in a Dutch sample of individuals within the age range of 122 to 35 years, (2) to establish the validity of the Dutch version of the SOGS as a screener for pathologicall gambling in the general population using the DIS-T (APA, 1987) as criterion, andd (3) to provide positive predictive values of the SOGS with respect to DSM-HI-R criteria forr pathological gambling. Additionally, two procedures are discussed to adjust biased (populationn survey) prevalence estimates.

METHODS S

Participants s AA two-stage sampling procedure was used. In the first stage, a self-report questionnaire was mailedd to a self-weighting stratified random sample of 11,000 inhabitants of the Netherlands agedd between 12 and 35 years. The sample was drawn from the municipal registers of a randomlyy selected sample of Dutch cities. For the participants under the age of 18 years, the surveyy was addressed to the parents with a cover letter explaining its purpose and requesting thee parents' to give their consent. The parents were instructed to hand the questionnaire to theirr son or daughter in the enclosed closed envelope. The Medical Ethics Committee of the Academicc Medical Centre of the University of Amsterdam approved the procedures and designn used in this study. AA total of 5,830 (53%) questionnaires were filled out and sent back. The main characteristicss of this first-stage sample were: male 47.5%, mean age 20.9, 82% between 18

77 7 Prevalencee of Pathological Gambling andd 35 years of age. Non-response was not related to gender, age, socio-economic status or urbanisationn level. The achieved sample at stage-1 was representative of the Dutch population22 for this age group (12-35) in terms of demographic characteristics. Basedd on the SOGS total score and using a threshold value of 3 all first-stage respondents weree classified as either "possible problem players" (SOGS total score £ 3) or "recreational players"" (SOGS total score < 3). To enhance the efficiency of our design a non-proportional stratifiedd sampling strategy was used for the second stage. In this second stage all probable problemm players (n = 135) and a random sample from the recreational players (n=391) were askedd to participate in an individual diagnostic psychiatric interview (DIS-T, APA). A total of 1633 respondents were actually interviewed, 112 (35%) of the recreational players (SOGS total scoree < 3) and 51 (38%) of the probable problem players. First-stage socio-demographic and gamblingg behaviour (SOGS) data were used to test for differential selection bias in the second-stagee sample. The people who refused participation in the second-stage of this study didd not differ from the participants in gambling variables, age, educational level or employmentt status. Ass a consequence of the non-proportional random stratification the sample had a strongg overrepresentation of screener positives. To get unbiased estimates, all second-stage dataa were weighted back, using the reciprocate of the inclusion probability as weight factor.

Instruments s Thee first-stage self-report questionnaire had two versions, one for adolescents (age 12-17) andd the other for adults (age 18-35). Both versions comprised sections on socio- demographics,, leisure time activities, and type and frequency of involvement in games of chance.. The main differences between the two versions concerned the socio-demographic questions:: where young adults were questioned about the status and nature of their employment,, adolescents were asked about their school situation. Prevalencee of pathological gambling in the first-stage sample was estimated with the Southh Oaks Gambling Screen (SOGS, Lesieur and Blume, 1987), a 20-item self-report screeningg questionnaire based on DSM-m criteria for pathological gambling. This instrument correlatess well with the DSM-ÜI-R criteria (Lesieur and Blume, 1993), and recently the SOGS'' reliability, validity and classification accuracy were examined against the DSM-IV criteriaa (Stinchfleld, 2002). The SOGS is the most commonly used screening instrument to identifyy lifetime gambling problems and has good psychometric properties. The SOGS total scoree ranges from 0 to 20. A SOGS score below 3 indicates no problem with gambling, a scoree of 3 to 4 implies possible problem gambling and a cut-off score of 5 is frequently used too identify probable pathological gamblers. Originally, the SOGS has a lifetime time-frame. Inn accordance with several other studies (Emerson and Laundergan, 1996; Dickerson et al, 1996;; etc.) we changed this into a one-year time-frame both to make it more suitable as an indicatorr of the number of people in the population who are currently experiencing gambling-

22 The stage-1 sample was compared with the data from the Dutch Central Bureau for Statistics (CBS), the government'ss official statistics agency.

78 8 Chapterr 5 relatedd problems and to make our results comparable with those of the other studies. To minimisee the number of false negatives a cut-off score of 3 was used to identify possible problemm gamblers for the second-stage sample. Thee Pathological Gambling Section of the DSM-IE-R Diagnostic Interview Schedule (DIS-T,, APA, 1987) was used during the second stage of this study. According to DSM-IE-R aa pathological gambler is "a person who is chronically and progressively unable to resist impulsesimpulses to gamble and for whom gambling compromises, disrupts or damages family, personalpersonal and vocational pursuits". For the DSM-HI-R diagnosis 'pathological gambling' a personn has to fulfil at least 4 of the 9 criteria (e.g. preoccupation, loss of control, tolerance, withdrawall symptoms, chasing, social/job disruption, etc).

Statisticall analysis Inn addition to the prevalence estimate of pathological gambling based on SOGS (i.e. the proportionn of respondents with a SOGS total score £ 5 at the first stage), a prevalence estimatee of pathological gambling based on the combined SOGS and DIS-T data was calculatedd using the following procedure: (1) All second-stage respondents were given a weightt factor equal to the inverse of their inclusion probability, (2) sensitivity and specificity off the SOGS as a screener for DSM-III-R pathological gambling (using a threshold value of 5)) were assessed based on the weighted-back stage-2 data, (3) prevalence of pathological gamblingg in the stage-1 sample was estimated using the following formula: prev = (S+spec- l)/(sen+spec-l)) with S = proportion of respondents in stage 1 with a SOGS total score > 5; specificityy and sensitivity values were calculated from the SOGS5+ as screener for DSM-HI- RR pathological gambling. Positive predictive values (PPV) for pathological gambling for all differentt SOGS scores were calculated using the following procedure: (a) P(DSM+|SOGS=x) == l/(l+(-exp(poadj+Pi*SOGS total score)), (b) Po and Pi parameter estimates were obtained fromm a logistic regression analysis with DIS-T caseness as dependent and SOGS total score as independentt variable on stage-2 data, (c) since po depends on the prevalence of the population (pii is independent of prevalence population) and since the prevalence in the stage-2 sample differss from the prevalence in stage-1, po had to be adjusted using the following formula: fWj == Po + ln(P/(l-P) - In (p/(l-p) with P = prevalence stage-1 sample (the estimated prevalence usingg weighted stage-2 data described above was used) and p = prevalence stage-2 sample (observedd prevalence of the stage-2 sample was used).

RESULTS S

Prevalencee estimates for potential problematic gambling based on the SOGS total score using aa threshold value of 5 were 1.6% for the total population, 2.8% for players and 4.5% for high- riskk players. The term players refers to participants that played any game of chance (e.g. lotteries,, bingo, casino, etc.). High-risk players refers only to those participants that played short-payoutt interval games or continuous games of chance (e.g. fruitmachines, casino, scratchcards,, etc.). Prevalence estimates for potential problematic gamblers stratified on

79 9 Prevalencee of Pathological Gambling genderr and age are presented in Table 5.1. Both adolescents and adult males were more at risk thann females since the former reported more gambling-related problems. In the same way, playerss of short-payout interval games were clearly more at risk than players of games of chancee in general. However, since the SOGS is a screening instrument, an above-threshold scoree may indicate an increased risk for pathological gambling but it is not equivalent to the diagnosiss 'pathological gambling'. SOGS prevalence estimates comprise both false positives (SOGS++ and DSM-) and false negatives (SOGS- and DSM+).

Tablee 5.1 Prevalence estimates of potential problematic gamblers (SOGS ^ 5) Agee 12-17 Agee 18-35 Total l Men n Women n Men n Women n Totall sample .009 9 .002 2 .034 4 .005 5 .016 6 Players' ' .031 1 .010 0 .048 8 .008 8 .028 8 High-riskk players2 .031 1 .013 3 .073 3 .015 5 .045 5 l>l> Players refers to participants that played games of chance in general (e.g. lotteries, bingo, casino, etc.) 2)) High-risk players refers only to participants that played short-payout interval games of chance (e.g. fruitmachines,, casino, scratchcards, etc.)

Twentyy of the 163 respondents of the second-stage sample fulfilled the DSM-HI-R criteriaa for pathological gambling. All were adult males. This implies a limited generalisibility off the combined first and second-stage data to women and to males under the age of 18. Therefore,, the results based on the combined stage-one and stage-two data will be presented forr young adult males only (18-35 years of age). Sensitivity,, specificity and positive and negative predictive value of the SOGS total scoree for DSM-IH-R pathological gambling were assessed using the inverse of the inclusion probabilityy as a weight factor (see Table 5.2). In the general population sample, the SOGS had ann excellent sensitivity (.94) and specificity (.99) among young adult males. However, as a consequencee of the relatively low prevalence, the positive predictive value was only .65, meaningg that approximately 65% of the participants with a SOGS total score > 5 met DSM- III-RR criteria for pathological gambling.

Tablee 5.2. Validity of SOGS and prevalence of DSM-IH-R pathological gambling using combinedd stage 1 and stage 2 data (males 18-35). Sensitivity y Specificity y PPV1 1 NPV' ' SOGSS 5+ DSM-IO-R+2 2 Totall sample (2769) .944 4 .990 0 .654 4 .999 9 .029 9 .020 0 Players'' (1651) .944 4 .984 4 .671 1 .998 8 .046 6 .032 2 High-riskk players4 (1008) .944 4 .975 5 .680 0 .997 7 .067 7 .046 6 JPPVV = positive predictive value = P(DSM+|SOGS+); NPV = negative predictive value = P(DSM-|SOGS-). 2)) DSM-EI-R+ = (S + Spec - l)/(Sens + Spec -1) with S = observed prevalence SOGS5+ in first-stage sample: SOGSS 5+. 3)) Players refers to male participants that played games of chance in general (e.g. lotteries, bingo, casino, etc.) 4)) High-risk players refers only to male participants that played short-payout interval games of chance (e.g. fruitmachines,, casino, scratchcards, etc.)

80 0 Chapters s

Whenn the prevalence of SOGS5+ in the first-stage sample and the sensitivity and specificityy estimates of the combined first and second-stage sample were combined, the prevalencee of DSM-1H-R pathological gambling among males (18-35 years old) in the total populationn was estimated to be .020, while the prevalence for players and high-risk players wass .032 and .046, respectively. Thee relationship between the SOGS total score and DSM-III-R caseness was assessed amongg young adult males at stage two. Logistic regression analysis with caseness as dependentt and SOGS totals score as independent variable resulted in a po of -4.822 and a Pi off .732, which was equivalent to an OR (odds ratio) of 2.08 (p<. 01). After adjustment of the Poo estimate (see statistical section) this model could be used to calculate the probability of beingg categorised as a 'pathological gambler' at any given SOGS total score. These results are presentedd in Table 5.3. This table clearly shows that although most studies use SOGS thresholdd values of 3 or 5, the risk of caseness for people of the general population with such SOGSS total scores is fairly low.

Tablee 5.3 Relationship between the SOGS total score and DSM-ITI-R diagnostic criteria for Pathologicall Gambling for Men. SOGSS total score Positivee predictive value2 0 0 .0010 0 1 1 .0021 1 2 2 .0043 3 3 3 .0089 9 4 4 .0184 4 5 5 .0374 4 6 6 .0748 8 7 7 .1439 9 8 8 .2590 0 9 9 .4209 9 10 0 .6018 8 11 1 .7586 6 12 2 .8673 3 13 3 .9314 4 14 4 .9658 8 15 5 .9833 3 16 6 .9919 9 17 7 .9961 1 18 8 .9981 1 19 9 .9991 1 20 0 .9996 6 11 Players refers to male 22 The probability of meeting DSM-III-R Diagiw^ccrtteria for PG given any specific SOGS total score (positive predictivee value).

SI I Prevalencee of Pathological Gambling

DISCUSSION N

Thiss study confirmed that the Dutch version of the SOGS, when applied to the general population,, is a valid screener for pathological gambling according to the DSM diagnostic criteriaa for PG. Although the SOGS has been widely used in epidemiological studies, to our knowledge,, ours was the first community study in Europe that used a two-stage design to test thee SOGS validity against the DSM diagnostic criteria. It needs to be noted that the present studyy provides sensitivity and specificity figures of the SOGS for the Dutch general population.. Nevertheless, the specificity (0.99) found in this study is comparable to the results reportedd in other studies, whereas the sensitivity rate of 0.94 is considerably higher in our samplee than those observed in other general populations. For instance, the figures reported in aa Minnesotan sample were a specificity of 0.99 and a sensitivity of 0.67 (Stinchfield, 2002) andd a National Survey in New Zealand (Abbott and Volberg, 1996) yielded comparable results.. Since, in this study, the specificity of the SOGS is higher than 0.95, it is justified to concludee that the SOGS is a good screener for pathological gambling when applied in general populationn studies. However,, even with this excellent specificity, the SOGS overestimates the prevalence off pathological gambling in community samples. In our study, the number of false positives wass relatively high compared to the number of true positives. After combining the stage-1 and stage-22 data, an adjusted prevalence estimate was made that was approximately 40% lower thann the SOGS prevalence estimate. Our findings are in line with other studies. A meta- analysess of prevalence studies comparing all the studies that used a two-stage methodology withh the SOGS and the DSM diagnostic criteria revealed that the number of pathological gamblerss positively screened by the SOGS is approximately twice as high as the cases obtainedd with the DSM criteria (Shaffer et al., 1999). Recently, in a Minnesota general populationn sample a false positive rate of 50% was found (Stinchfield, 2002). These findings suggestt that all community studies solely using the SOGS to estimate the prevalence rate generatee an overestimation of the true prevalence of pathological gambling. Besidess the dichotomous approach to evaluate the SOGS as a reliable screener for PG, thiss study has also provided new data that may contribute to the current debate on the predictivee values of the SOGS in relation to the DSM diagnostic criteria (continuous approach).. In other words, we examined the probability of fulfilling the DSM-IH-R diagnostic criteriaa for pathological gambling given any SOGS total score. Our analyses show that one cann be fairly confident that the respondent is a pathological gambler when his/her SOGS total scoree lies between 8 and 20. Notwithstanding its proven reliability, one should be aware that onlyy a SOGS total score > 8 has a substantial positive predictive value for pathological gambling.. Additionally, our results show that although most studies use threshold values of 3 orr 5, the likelihood of caseness for people with such SOGS total scores is quite low. Similar resultss were found in other studies (Duvarci et al., 1997; Stinchfield, 2002; Battersby, 2002). AA Turkish study (Duvarci et al., 1997), for instance, also demonstrated that the cut-off score thatt yielded the lowest false negative and false positive rates was 8. The issue of overestimationn of gambling problems in community surveys has received a great deal of

82 2 Chapterr 5 criticall attention. More specifically, in their Australian studies Dickerson and colleagues foundd that a cut-off of 10 (rather than 5) identifies individuals who are likely to have gamblingg problems similar to those who apply for treatment (Dickerson, et al., 1996). On the otherr hand, Stinchfield pointed out that "a SOGS score of 5 remains the best cut-off score in termsterms of maximising the hit rate and balancing false positive and false negative errors" (Stinchfield,, 2002, page. 12). Thee low response rate at both sampling stages (stage 1 = 53% and stage 2 = 36.5%) mayy be seen as a limitation of the present study. This is a typical problem in studies investigatingg sensitive topics such as gambling and the amount of money spent in games of chance.. However, it is important to emphasise that, first, the sample at stage 1 was representativee of the Dutch population for this age group (12-35) in terms of demographic characteristics,, and second, that first-stage socio-demographic and gambling behaviour data weree used to test for differential selection bias in the second-stage sample and that non- responsee was non-differential on all these characteristics. Additionally, our response rates are comparablee to the response rates reported by previous addiction surveys conducted in the Netherlandss and gambling prevalence studies carried out elsewhere (59,8% RR in home interviews,, (Legarda, 1992); 66% RR in telephone interviews, (Abbott and Volberg, 1996); 47%% RR in telephone interviews among a Norwegian sample (Gotestam and Johansson, 2003). . Anotherr issue we need to address is the fact that the positive predictive values of the SOGSS with respect to the DSM-TU-R criteria could only be calculated for young adult men (18-35).. The relationship between SOGS total score and pathological gambling may be differentt for adolescents and women. In both subgroups none of the SOGS5+ cases fulfilled thee DSM-EI-R criteria for pathological gambling, whereas among adult males this was approximatelyy 63%. Our results are in contrast with other studies that showed that adolescents havee a higher prevalence of PG than adults (Gupta and Derevensky, 1998, Fisher, 2000). Additionally,, retrospective studies have shown that the majority of male pathological gamblerss started gambling in their teens (e.g. Fisher, 1993). Possibly, given that it takes, on average,, 3.5 years to become a pathological gambler, it is likely that the group of adolescents wouldd need more time to develop the full range and intensity of this disorder (Meyer, 1992). Moreover,, it must be taken into account that the gaming law in the Netherlands is quite restrictedd in terms of accessibility/availability of games of change to persons under the age of 188 years. Wee believe that the most accurate case criterion to estimate prevalence of pathological gamblingg is the use of a diagnostic, structured interview like the DIS-T. Nevertheless, the use off this method implicates high human, economic and time investments. The DIS-T, as a face- to-facee interview, requires a trained interviewer and up to an hour and a half for each participant,, which implies that this method is unlikely to be applied in large-scale studies. In thesee circumstances is recommend the two-stage design as used in this study, i.e. initial applicationn of the SOGS as a screener to identified possible case positives (stage-1), followed byy the DSM diagnostic interview (DIS-T, stage-2) to identify pathological gamblers. Despite thee limitations of this study, we have provided evidence that the SOGS can indeed be used as

83 3 Prevalencee of Pathological Gambling

thee initial screener in a two-stage methodology in order to estimate the prevalence of PG at communityy level. However, additional studies are necessary to further test the validity of the SOGSS for use in general populations. There is a clear need for an instrument that can accuratelyy assess the prevalence of gambling problems in the general population. The SOGS appearss to be a valid and reliable screening instrument for general populations with a "reasonablee professional agreement" at international level, which facilitates comparisons of prevalencee and incidence estimates at both the national and international level. Althoughh we strongly advise to use a two-stage methodology to estimate the prevalencee of PG in future studies, if the resources for a two-stage study are lacking, one couldd use the sensitivity and specificity figures of two-stage studies on comparable populationss to adjust first-stage estimates using the formulae proposed in this study.

REFERENCES S

Abbottt M, Volberg RA. (1996) The New Zealand National Survey of problem and pathological gambling.. Journal ofGambling Studies, 12, 143-160. 1996. Americann Psychiatric Association (APA) (1987) Diagnostic and statistical manual of mental disorders.disorders. 3rd ed., Revised ed. Washington: American Psychiatric Association. Battersbyy MW, Thomas LJ, Tolchard B, Esterman A. (2002) The South Oaks Gambling Screen: a revieww with reference to Australian use. Journal of Gambling Studies, 18,257-271. Beconaa E. (2002) Prevalence surveys of problem and pathological gambling in Europe: The cases off Germany, Holland, and Spain. In: Marotta JJ, Cornelius J A Eadington WR, editors. The Downside: ProblemProblem and Pathological Gambling, Reno, Nevada: Institute for the Study of Gambling and Commerciall Gaming Institute, 259-270. Brinkk W vd, Koeter M, Derks J&PN. (1994) Een gokje wagen of gewaagd gokken. Journal of Alcohol,Alcohol, Drugs and other Psychotropic Substances, 3,137-147. Cullentonn RP. (1989) The prevalence rates of pathological gambling: A look at methods. Journal ofof Gambling Studies, 5, 22-41. Dickersonn MG, Baron E, Hong SM, Cottrell D (1996). Estimating the extent and degree of gamblingg related problems in the Australian Population: A National Survey. Journal of Gambling Studies,Studies, 4, 135-151. Duvarcii I, Varan A, Cockunol H, Ersoy MA. (1997) DSM-IV and the South Oaks Gambling Screen:: Diagnosing and assessing pathological . Journal of Gambling Studies, 193-206. . Duvarcii I, Varan A. (2000) Descriptive features of Turkish pathological gamblers. Scand. J. Psychol,,Psychol,, 41, 253-260. Emersonn MO, Laundergan JC. (1996) Gambling and problem gambling among adult Minnesotans: Changess 1990 to 1994. Journal of Gambling Studies, 13,291-304. 1996. Fisherr S. (1993) Gambling and pathological gambling in Adolescents. Journal of Gambling Studies,Studies, J Gambl Stud 9, 277-288. Fisherr S. (2000) The South Oaks Gambling Screen Revised for Adolescents (SOGS-RA): Further psychometricc findings from a community sample. US: Kluwer Academic, 2000. Gotestamm KG, Johansson A. (2003) Characteristics of gambling and problematic gambling in the Norwegiann context. A DSM-IV-based telephone interview study. Addictive Behavior, 28, 189-197.

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Guptaa R, Derevensky JL. (1998) Adolescent Gambling Behavior: A Prevalence Study and Examinationn of the Correlates Associated with Problem Gambling. Journal of Gambling Studies, 14, 319-345. . Guptaa R, Derevensky JL. (1998) Adolescent gambling behavior: A prevalence study and examinationn of the correlates associated with problem gambling. Journal of Gambling Studies 14, 319-345. . Kaminerr V, Petry NM. (1999) Gambling behaviour in youths: why we should be concerned. Psychiatrr Serv, 50, 167-168. Ladouceurr R, Bouchard C, Rheaume N, Jacques C, Ferland F, Leblond J. (2000) Is the SOGS an accuratee measure of pathological gambling among children, adolescents and adults? Journal of GamblingGambling Studies, 16, 1-24. Legardaa JJ, Babio R, Abreu JM. (1992) Prevalence estimates of pathological gambling in Seville (Spain).. British Journal of Addiction, 87,767-770, Lesieurr HR, Blume SB. (1987) The South Oaks Gambling Screen (SOGS): a new instrument for thee identification of pathological gamblers. American Journal of Psychiatry, 144,1184-1188. Lesieurr HR, Blume SB. (1993) Revising the South Oaks Gambling Screen in different settings. JournalJournal of Gambling Studies, 9,213-223. Meyerr G. (1992) The gambling market in the Federal Republic of Germany and the helpseeking of pathologicall gamblers. Journal of Gambling Studies, 8,11-20. Nationall Opinion Research Center (NORC, 1999) Gambling Impact and Behavior Study. Final reportt to the National Gambling Impact Study Commission. Chicago: NORC. Potenzaa MN, Kosten TR, Rounsaville BJ. (2001) Pathological gambUng. JAMA , 286,141-144. Productivityy Commission (2002) The Productivity Commission's gambling inquiry: 3 years on. 02 Octt 21; Presentation to the 12th Annual Conference of the National Association for Gambling Studies, Melbourne:: Productivity Commission, Canberra. Sakuraii Y, Smith R. (2003) Gambling as a motivation for the Commission of Financial Crime, http://www.aic.gov.auu No. 256. Australian Institute of Criminology. Shafferr HJ, Hall MN, Vander-Bih J. (1999) Estimating the prevalence of disordered gambling behaviorr in the United States and Canada: a research synthesis. American Journal of Public Health, 89,1369-1376. . Stinchfieldd R, Cassuto N, Winters KC, Latimer W. (1997) Prevalence of gambling among Minnesotaa public school students in 1992 and 1995. Journal of Gambling Studies, 13, 25-48. Stinchfieldd R. (2002) Reliability, validity, and classification accuracy of the South Oaks Gambling Screenn (SOGS). Addictive Behavior, 27, 1-19. Volbergg RA, Abbott MW, Ronnberg S, Munck IME. (2001) Prevalence and risks of pathological gamblingg in Sweden. Acta PsychiatScand., 104,250-256. Volbergg RA, Abbott MW. (1994) Lifetime prevalence estimates of pathological .. International Journal of Epidemiology, 23,976-983. Volbergg RA, Banks SM. (2002) A new approach to understanding gambling and problem gamblingg in the general population. In: Marotta JJ, Cornelius JA, Eadington WR, editors. The Downside:Downside: Problem and Pathological Gambling. Nevada: Institute for the Study of Gambling and Commerciall Gaming, 309-323. Weltee JW, Barnes GM, Wieczorek WF, Tidwell MC, Parker J. (2002) Gambling participation in thee U.S.-results from a national survey. Journal of Gambling Studies, 18, 313-337.

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CHAPTERR 6

THEE GAMBLING PROBLEMS SEVERITY SCALE (GPSS): AA NEW MULTI-DOMAIN INSTRUMENT WITH RASCH PROPERTIES TOO ASSESS THE SEVERITY OF GAMBLING RELATED PROBLEMS1

ABSTRACT T AimsAims To describe the development and psychometric properties of a new multi-domain instrumentinstrument to measure the severity of gambling related problems: the Gambling Problems SeveritySeverity Scale (GPSS). DesignDesign A three-stage procedure was used to develop the instrument. The first stage comprisedcomprised a literature study and a focus group meeting and resulted in an initial item pool of 4646 items. The second stage focused on the identification of severity dimensions and allocation ofof items to these dimensions. In the third and last stage, a latent variable model (Rasch) basedbased on latent trait theory was used to construct the final 20 items GPSS. ParticipantsParticipants For the third-stage analysis we used a sample covering the whole range of gamblinggambling problem severity comprising 299 recreational gamblers, 173 potential problematic gamblersgamblers and 136 problem gamblers (patients treated for gambling-related problems). FindingsFindings The resulting 20 item GPSS comprises four 5-item subscales 'work and education', 'family'family and social relations', 'financial consequences' and 'psychological and emotional health'.health'. The total scale as well as the 4 subscales fulfill the criteria of the Rasch model. This impliesimplies among others 1) validation of the one-dimensionality of the scales and 2) after a relativelyrelatively simple transformation the total and subscale severity scores have interval level properties.properties. The scale or subscales have good psychometric properties, e.g. a normal distributiondistribution in a treated patients, good reliability and one dimensionality. ConclusionsConclusions The multi-domain character as well as the interval character of the GPSS gives itit several advantages over existing instruments like the SOGS as an evaluation instrument. TheThe self-report character makes it easy and cheap to administer.

INTRODUCTION N

Inn 1980, pathological gambling was formally recognized as a mental disorder by the APA in DSM-HII and classified as an impulse-control disorder not elsewhere classified (American Psychiatricc Association, 1980). The diagnostic criteria for pathological gambling have since beenn revised twice, and the current standard is DSM-IV (American Psychiatric Association, 1980;; American Psychiatric Association, 1987; American Psychiatric Association, 1994). Accordingg to the DSM-IV criteria a pathological gambler is defined as a person who is chronicallyy and progressively unable to resist impulses to gamble and for whom gambling

11 This chapter has been submitted for publication: Koeter, M. W.J., DeFuentes-Merillas, L., Borsboom, D., Schipperss G.M., Brink, W., van den. The Gambling Problems Severity Scale (GPSS): A new multi-domain instrumentt with Rasch properties to assess the severity of gambling related problems.

87 7 Gamblingg Problems Severity Scale compromises,, disrupts or damages family, personal and vocational pursuits. DSM-IV criteria includee preoccupation, loss of control, tolerance, withdrawal, chasing, illegal acts, family and/orr job disruption, etc. A person is considered a pathological gambler if he fulfils at least 5 off the 10 criteria. These criteria are a product of clinical experience, research results, expert groupp consensus, and possible cultural and political biases (National Opinion Research Center,, NORC, 1999; Stinchfield, 2003). The polythetic format of DSM-IV (i.e. an optional sett of criteria is provided and only a subset is needed for diagnosis) is consistent with clinical reality,, but it also results in substantial diagnostic heterogeneity. The diagnostic requirement off any 5 out of 10 criteria theoretically allows for 252 different symptom combinations. Mostt of the instruments developed to assess gambling-related problems are grounded inn the diagnostic symptoms reported in the DSM. The most well known is the South Oaks Gamblingg Screen (SOGS, Lesieur & Blume, 1987) and its derivatives such as the SOGS-R, SOGS-RA,, the SOGS-TC; the Cumulative Clinical Signs Measure (CCSM, Culleton, 1988); thee Massachusetts Gambling Screen (Shaffer & Hall, 1996; National Opinion Research Center)) a DSM screen for gambling problems (NORC, NODS, (National Opinion Research Center,, NORC, 1999); Diagnostic Interview for Gambling Severity (DIGS, Lesieur et al., 1987;; Winters, Specker, & Stinchfield, 2002); Diagnostic Interview Schedule (DIS, Welte, Barnes,, Wieczorek, Tidwell, & Parker, 2001; Welte, Barnes, Wieczorek, Tidwell, & Parker, 2002);; DSM-IV Diagnostic Criteria for PG (Stinchfield, 2003); DSM-IV-based interview (Gotestamm & Johansson, 2003; Lesieur et al., 1987). In concordance with DSM-IV, all these self-reportt screening instruments or diagnostic interviews classify subjects within a categorical,, mostly dichotomous approach (problematic or pathological gambler yes or no). Thiss categorical approach, a consequence of the disease entity assumption in psychiatry,, has been increasingly questioned as evidence has accumulated that prototypical mentall disorders such as mood and anxiety disorders seem to merge imperceptibly into anotherr and into normality (Kendler & Gardner, 1998) with no demonstrable boundariess or zones of rarity in between (Kupfer, First, & Regier, 2002). Furthermore both geneticc and environmental factors underlying these syndromes are often nonspecific (Kendler, 1996;; Brown, Marten, & Barlow, 1998). In the research agenda for DSM-V, Rounsaville et al. (2002)) argue that, although the DSM is becoming the world standard, certainly for research andd therefore increasingly so for clinical discourse, there are several limitations in the current DSMM system. They mention 6 topics for the DSM-V revision process and the fourth of these is:: "determining whether a dimensional approach should be substituted for the current categoricalcategorical approach to diagnosis". A dimensional approach has the additional advantages of supplyingg both a severity measure and a way of assessing change at a more refined level than aa transition from case to no case and vice versa. Althoughh there is no clear evidence that the number of problems endorsed is directly relatedd to the severity of gambling problems, screening instruments are frequently used as a dimensionall measure of problem severity. The problem with this approach is, that unless an instrumentt is specifically developed as a severity measure, one does not know what the total scoree stands for. The same number of criteria at baseline and follow-up does not mean that a personn did not change, it could be 5 different criteria, implying considerable change

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(deteriorationn or amelioration) in problem severity. For the same reason a change in total scoree does not necessarily imply a change in severity. Assuming an item hierarchy solves this problem.. In other words the probability that a person endorses a specific item is assumed to bee related to the severity of his gambling addiction, consequently some items are endorsed at aa lower severity level than other items. In this case a higher total score implies more severe gamblingg problems. Soo far, only two gambling severity instruments have been developed e.g. the Problem Gamblingg Severity Index (Ferris & Wyne 2001) and a 6 item Rasch version of the SOGS (Strong,, Breen, Lesieur, & Lejuez, 2003). Both instruments, however, are one-dimensional: thee former is only an ordinal scale (which basically means that a higher score only indicates a personn to be more severe, however, the extend of the scale differences is not related to the extendd of the differences in severity which makes ordinal scales problematic to measure change)) and the latter mainly focuses on financial problems. Latentt trait theory can be used to develop an instrument, assuming item hierarchy, that validlyy assesses the severity of gambling problems. The main advantages of scales based on latentt trait analysis are their population independence (i.e. the fact that, contrary to scales basedd on classical test theory, the psychometric properties do not depend on the characteristicss of the study population) and the interval character of the scale scores. Using latentt trait theory draws upon the clinical experience that, although the syndrome does not assumee a chronological progression of symptoms, there is evidence that some symptoms are moree likely to occur earlier in the development of pathological gambling than others (Toce- Gerstein,, Gerstein, & Volberg, 2003), suggesting that symptoms may vary in relation with the severityy of the gambling problem. For example, whereas the great majority of pathological gamblerss may manifest impaired control over gambling behavior, only those with more severee dependence may show symptoms of tolerance and withdrawal. AA valid multi-domain severity instrument would enable clinicians to tailor treatments, assesss domains for which help is most needed, assess the effect of interventions and compare differentt interventions on their ability to ameliorate consequences on specific severity domains. . Thee main focus of this paper are 1) description of the development of a multi-domain gamblingg severity scale, the Gambling Problems Severity Scale (GPSS), using latent trait theory,, and 2) description of it is psychometric properties.

METHOD D

Sample e Too cover the range of gambling severity, the Item Response Theory (IRT) analyses were performedd on a combination of three samples: (1) a sample of 299 recreational gamblers (RG),, comprising a subsample of 241 persons playing only long payout interval games (e.g. lottery)) and a subsample of 58 scratchcards players with a SOGS total score < 3; (2) a sample off 173 potential problematic gamblers (PPG) comprising scratchcards players with a SOGS

89 9 Gamblingg Problems Severity Scale totall score > 3 but not fulfilling the DSM-IV criteria for pathological gambling; and (3) a samplee of 136 problem gamblers (PG) comprising patients treated for gambling problems in addictionn treatment centers. RGG were screened from a large panel study representative of the Dutch general population.. To be eligible for the RG sample respondents had to fulfill the following three screeningg criteria: 1) not playing scratchcards the year preceding the screening , 2) engaged < 22 times in the preceding year in any short payout intervals game such.as slot machines, casinoss games, betting on horses or bingo, 3) played > 3 times long payout intervals games (i.ee national lottery) in the year previous to the screening. The first criterion is not relevant for thiss study but necessary to make this group a valid comparison group in the incidence study, thee rationale behind the last two criteria was to exclude people who are morally against gamblingg and never participate in games of chance and people playing more than occasionally high-riskk games. Participants fulfilling these criteria were asked to participate in a face to face homee interview. The RG sample comprises those 241 subject who agreed to participate in this intervieww and a random sample of 58 regular scratchcard players with a SOGS total score < 3 Thee PPG sample resulted from a large epidemiological study on scratchcard addiction (DeFuentes-Merillas,, Koeter, Schippers, & Brink, 2003). In this study a total of 12,222 scratchcardd buyers were approached at 246 outlets, 1.2% (n=148) were not eligible (younger thann 18 years old, foreign resident, or insufficient command of the Dutch language), 23.2% (n == 2,839) refused to participate. Of the remaining 9,235 scratchcard buyers 3,342 fulfilled the criteriaa for regular scratchcard gambling (i.e. purchased £ 10 scratchcards in the month prior too the screening). The SOGS-S2 was filled out by all regular scratchcard gamblers, 340 were PPGG (i.e. had a SOGS-S total score £ 3). All 340 were asked to participate in a face to face homee interview to assess the extend and specific characteristics of their gambling problems. 2011 agreed to participate, 28 of them fulfilled the DSM-IV criteria for pathological gambling. Thee PPG sample comprises the 173 scratchcard participants with a SOGS total score > 3 that nott fulfilled the DSM-IV criteria. Fiftyy one of the 242 consecutive persons admitted to outpatient treatment for their gambling-relatedd problems during the study period in the following 4 addiction treatment centers:: "Jellinek" Amsterdam, 'Tarnassia" the Hague, "de Brijder" Haarlem, and "Game over"" Rotterdam met one or more of the following exclusion criteria: 1) < 18 years of age, 2) gamblingg problems not primary problem, 3) started treatment immediately after a treatment forr drug or alcohol dependence, 4) insufficient command of the Dutch language. The remainingg 191 patients were asked by their clinician to participate in this study. Fifty five refused.. The PG sample comprises the 136 patients who agreed to participate.

Instrument t AA three-stage procedure was used to develop the initial instrument.

Thee SOGS adapted for scratchcards by replacing the word 'gambling' by 'scratchcards' or 'playing scratchcards' '

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Stagee 1: Development of the initial item pool. This stage comprised drawing up an inventoryy of existing instruments for the assessment of severity of addiction in general. At thatt time, no instruments pertaining to the severity of problem gambling addiction were available.. However, several instruments for the assessment of the severity of drug and alcohol dependencee were identified. Most of them were based on the dependence syndrome (Edwards && Gross, 1976). This syndrome comprises 5 dimensions 1) impaired control, 2) salience, 3) tolerance,, 4) withdrawal and 5) compulsion. In addition several categories of alcohol related problemss are distinguished, such as a) physical, b) psychological and c) social. Some of the existingg severity instruments focused only at one dimension (e.g. short opiate withdrawal scale;; Gossop, 1990), others on addiction related problems (Alcohol Problems Questionnaire, Williamss & Drummond, 1994). Almost all severity instruments comprised DSM criteria. Resultss of this literature search were discussed in a focus group meeting with 4 experiencedd clinicians and two researchers experienced in gambling(addiction) research. The mainn target of this focus group was to get a better understanding of the concept of severity of gamblingg addiction as well as it's clinical manifestation. What do clinicians use as indicators forr severity? The following potential indicators were mentioned: gamble until all money is lost;; borrow money to gamble, percentage of income gambled, loss of social contacts, gamblingg related quarrels, endangering work and social life, neglecting hobbies, avoiding sociall contacts, omit appointments (report sick), loss of self-esteem, affective complaints whenn not able to gamble and amount of time gambling. Basedd on both the literature search and the focus group meeting a list of 46 potential severityy items was constructed; the initial item pool.

Stagee 2: Finding clinical relevant domains Three experienced clinicians and 4 gamblingg addiction researchers were asked to allocate the 46 severity items to one or more domains.. Based on the focus group and literature study the following domains were suggested:: 1) work and education, 2) financial consequences, 3) family and social relations, andd 4) psychological and emotional health. However, clinicians and researches were also allowedd to make up their own domains and allocate items to these new domains. Theree was general consensus on the allocation of 42 items over the following 4 domains: workk and education (5 Hems); financial consequences (10 items), family and social relations (133 items) and psychological and emotional health (14 items). These items were used in the IRTT analyses. Onn the remaining 4 items raters agreed less than 50% on the allocation to a domain (lostt housing because of gambling; stealing or practiced fraud to get money to gamble; in contactt with police because of gambling (e.g. steal money or became aggressive); more than onee unsuccessful attempt to decrease gambling).

Statisticall analysis Too develop the final scales and assess their psychometric quality an hem response theory (IRT)) model based on a latent variable approach was used in stage 3 (Hambleton & Swaminathan,, 1985; Mellenbergh, 1994). The "modern" IRT techniques have several

91 1 Gamblingg Problems Severity Scale advantagess over the "classical test theory" (Lord & Novick, 1968). The most important limitationss of classical test theory compared to IRT are (1) classical test theory fails to assess uni-dimensionalityy whereas IRT can assess uni-dimensionality (Borsboom & Mellenbergh, 2003)) and (2) results from classical test theory are population dependent (Mellenbergh, 1996) whichh severely limits the generalizability of the results whereas scales resulting from IRT analysiss are population independent. IRTT models attempt to model the dependence of observed variables (in our case the responsee to the GPSS hems) on a latent variable (the severity of gambling addiction). In the parametricc model used for this article this dependence is modeled in the item characteristic functionn (ICC; item characteristic curve). This is a logistic regression function, which regressess the binary item responses on the continuous latent trait. Figure 6.1 shows the ICC forr 5 items. The ICC is characterised by 2 parameters, (1) the hem difficulty which is defined ass the point on the latent trait (i.e. the problem severity) where the probability to endorse the itemm equals .50 (the difficulty of item 1 is about -2.1 and of item 5 about +2.0), items with a higherr difficulty have trace lines more located to the right (i.e. hem 5 compared to item 1) indicatingg a higher problem severity needed to endorse the hem and (2) discriminative power whichh is defined as the slope of the ICC, items that discriminate poorly between different latentt trait levels have a relatively flat ICC and low slope whereas items that discriminate sharplyy between different latent trah levels have a steep ICC and high slope. The one parameterr hem response model (Rasch model) used in this analysis assumes all hems to have equall slopes.

Figuree 6.1 Item difficulty

Latentt trait

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Ann important quality of Rasch scales is that they allow for the construction of an intervall scale. This is important because commonly used sum scores cannot be on an interval scalee if they are composed of dichotomous responses. The reason for this is that because the itemss are nonlinearly related to the latent trait the sum score is also nonlinearly related to the latentt trait. If a Rasch model fits the data, however, a simple function of the sum score (the logg odds function, (Bond & Fox, 2001) does yield equal intervals and is therefore on an intervall scale. Let'S' be the interval severity score and 'p' the proportion of endorsed items onn the (sub) scale, then S=ln[p/(l-p)]. Forr example say a person has a sum score of 4 on a 5 item Rasch scale his interval severityy score S is ln(.80/.20)=1.39. Note that S scores for people endorsing 0% or 100% of thee items are - infinity and + infinity, this is because people scoring none or all items are literallyy 'off the scale'. For subsequent analysis however, one may set the estimates for these scoress at -4.75 and 4.09 respectively which will match the trait estimates as given by OPLM computerr program (Verhelst, Glas & Verstralen, 1995). Finally the theoretical minimum of eachh scale is set to '0' by adding 4.75 to each scale score setting the range for both total score andd subscale scores from 0 to 8.84.

RESULTS S

Scalee construction Basedd on IRT analysis we identified 20 items that adequately fitted a Rasch model (x2(76) = 95.33,, n.s.). None of the individual items showed a significant departure from the model. Givenn that the Rasch model is the most restrictive of all IRT models, this yields substantial supportt for the validity of severity of gambling as a psychological construct. Table 6.1 shows thee items that make up the Rasch scales and their respective difficulties. Thesee items are allocated to each of the 4 domains (Work and Education (WE); Familyy and Social Relations (FSR); Financial Consequences (FC), and Psychological and Emotionall Health (PEH) defined in the second stage of the scale construction. The subset of itemss for each domain also fitted the Rasch model. Figuree 6.2 shows that different gambling related problems correspond to different severityy levels (remember that the item difficulty corresponds to the severity level at which 50%% of the people endorse the item). Item PEH-1 (felt guilty or ashamed because of your gambling)) discriminates at the lower end of the gambling addiction severity continuum, item FC-44 (got behind in paying your rent or mortgage due to gambling) in the middle and item WE-55 (failed exams, got suspended, got fired or missed a job opportunity due to gambling) discriminatess at the end of the gambling addiction severity continuum. Thee findings depicted in Figure 6.2 suggests that a person who becomes addicted first encounterss feelings of guilt and small interpersonal problems, when addiction becomes worse financialfinancial problems start and interpersonal problems become more severe, when financial problemss become worse so do psychological problems, (feeling lonely, withdrawal effects).

93 3 Gamblingg Problems Severity Scale

Thee most severe stages of gambling addiction are characterized by irreversible social and workk problems (broke up with partner, lost job etc).

Tablee 6.1 Difficulties GPSS items stratified by subscale Inn the past month/year Problemm severity (Standardd error) WorkWork and education (WE) 1.. Have you experienced any concentration problems at school, work or during studies due 1.188 (.25) too gambling? 2.. Has your work, school, or study results suffered due to gambling? 1.999 (.27) 3.. Have you more than once stayed away from work, skipped school or studies due to 2.811 (.31) gambling? ? 4.. Have you experienced problems at work (with colleagues or your employer) or at school 3.899 (.41) (withh teachers) due to gambling? 5.. Have you failed exams, been suspended, been fired or missed a job due to gambling? 4.188 (.44)

FamilyFamily and social relations (FS) 1.. Has anyone more than once told you, that you had a gambling problem -0.355 (.23) 2.. Have you more than once lied to your partner, parents, family members or friends about -0.244 (.23) yourr gambling 3.. Have you more than once quarreled or had conflicts with your partner, family members) .566 (.24) orr friends about gambling 4.. Have you lost friends or acquaintances due to gambling 2.566 (.29) 5.. Have you broken up with your partner due to gambling 3.544 (.37)

FinancialFinancial consequences (FQ 1.. Have you had any debts with your parents, partner, friends or family members due to 0.422 (.24) gjwnhling g 2.. Have you had any debts caused by gambling that were too large to settle within a 0.744 (.24) reasonablee period of time 3.. Have you fallen behind with payments for standing orders other man your rent or 1.055 (.25) mortgagee (e.g. gas, water, electricity bills, health insurance, etc) due to gambling 4.. Have you fallen behind with payments for your rent or mortgage due to gambling 1.355 (..25) 5.. Have you been unable to pay for necessary maintenance or reparations for your house or 1.733 (.26) changee of housing due to gambling

PsychologicalPsychological and emotional keakk (PEH) 1.. Have you felt guilty or ashamed about your gambling -1.911 (.25) 2.. Have you more than once had a period of time in which you were preoccupied with 0.00** (-) gamblingg even when you were actually doing other things* 3.. Have you felt lonely due to gambling 0.599 (.24) 4.. Have you become (more) apathetic as a result of gambling 0.80(24) ) 5.. Did you experience any unpleasant physical sensations when you were unable to gamble 1.733 (.26) (e.g.. sweating, shakes etc) )) Item PE-2 is arbitrarily used as reference item to fix the latent scale; therefore it is not estimated and has no standardd error.

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Figuree 6.2

Gamblingg Problem Severity ID*== Item difficulty, for graphical reasons we added +2 to all difficulties reported in Table 6.1. This makes that alll difficulties positive, but does not affect the relation between difficulties. Itemm numbers are in concordance with Table 6.1.

Reliability y Usingg both last month and last year data, the six month test retest correlation in the patient samplee is relatively low, as it should, given they are treated patients. The 2 year test retest correlationn for the PPG is somewhat higher, but still moderate, reflecting a relatively low problemm severity with changes over time (Table 6.2).

Tablee 6.2 Test-retest reliability (produc tt moment correlation) Patientt sample' PPG' ' (n=104) ) (n=134) ) Lastt month Lastt year Lastt month Lastt year WE E .21 1 .44 4 .25 5 .67 7 FC C .39 9 .53 3 .48 8 .53 3 FSR R .34 4 .38 8 .64 4 .59 9 PEH H .27 7 .35 5 .31 1 .66 6 Totall score .31 1 .51 1 .64 4 .67 7 UU 55 — * ~ - * 3

Tablee 6.3 Reliability GPSS total score and subscales (cronbach alpha) Patientt sample PPG G Combinedd sample' (n=136) ) (n=173) ) (636) ) Scale e WE E .74 4 .73 3 .77 7 FSR R .65 5 .78 8 .77 7 FC C .82 2 .83 3 .87 7 PEH H .66 6 .82 2 .81 1 Total l .87 7 .92 2 .93 3 )) Including 299 recreational gamblers. Tablee 6.3 shows the population dependence of classical test measures. Reliability definedd as true score variance divided by total variance depends on the scale variance in the

95 5 Gamblingg Problems Severity Scale

Bothh patient sample and PPG sample have less variance than the combined sample (which alsoo includes the 'recreational gamblers'). Consequently reliability figures are best in the combinedd sample. It should be noted, however, that even in the patient sample all scales have alphass > .65 and that the total score has good reliability in all samples.

Validity y Bothh using a last month and last year timeframe, the GPSS shows good discriminant validity, itt clearly discriminates between recreational gamblers, problem gamblers and treated patients (Tablee 6.4). The mean severity score for recreational gamblers was almost zero, i.e. at the bottomm end of the scale range (0 - 8.84), while the mean severity score for treated patients wass about 4.

Figuree 6.3

GPSSS total score 500 T

40' '

30' '

20' '

>,, . _ SS 10. a1 1 ££ o ~~\ I— »—ii }—^—i—B—L—|—i—a—I—__l—„—I ,—1 m m 1 , 2,88 3,5 4,2 4,9 5,6 6,3 7,0 7,7 8,4 9,1 tll total score GPSS (year data)

Severityy measures frequently have a heavily skewed distribution in treated samples, makingg them less applicable as an evaluation instrument. In the patient sample, the GPSS totall score, however, was approximately normal distributed, covering almost the entire theoreticall range of the GPSS total score (0-8.84), making the instrument sensitive enough to discriminatee between treated patients based on the severity of their gambling problems (Figuree 6.3).

96 6 Chapterr 6

Tablee 6.4 GPSS total and subscale scores (mean, sd) stratified by problem group Recreationall gamblers PPG G Patientt sample (299) ) (173) ) (136) )

Lastt month data WE E 0.011 (.25) 0.37(1.23) ) 1.44(2.21) ) FC C 0.022 (.27) 0.533 (1.61) 3.31(3.02) ) FS S 0.077 (.51) 0.944 (1.92) 3.13(2.35) ) PEH H 0.111 (.66) 1.311 (2.25) 4.23(2.19) ) Totall score 0.088 (.48) 1.04(1.65) ) 3.500 (1.66) Lastt year data WE E 0.066 (.60) 0.544 (1.53) 3.088 (2.54) FC C 0.088 (.66) 0.733 (1.84) 5.300 (2.32) FS S 0.133 (.81) 1.422 (2.27) 4.900 (1.70) PEH H 0.188 (.86) 1.611 (2.44) 5.677 (1.78) Totall score 0.166 (.74) 1.388 (1.82) 4.822 (1.00) ')) Recreational gamblers = long payout interval games players + scratchcard players with SOGS total score < 3. 2)) Potential problematic gamblers = scratchcard players with SOGS total score £ 3 (excluding persons fulfilling DSM-IVV criteria pathological gambler). 3)) pathological gamblers = sample of persons treated for gambling problems in an addiction treatment center

Relationn with the SOGS Sincee the majority of recreational gamblers have a total score of zero both on the GPSS and thee SOGS the relation between GPSS and SOGS is only assessed in the patient and the PPG samplee (Table 6.5). The correlation between GPSS total score and SOGS total score in both sampless is substantial indicating that both instruments measure a similar construct. However, theree is still considerable variance in GPSS total scores given the SOGS total score. This is displayedd in Figure 6. 4 and by the fact that the product moment correlation is not really high (sayy > .80, Table 6.5). In the patient sample with more severe gambling problems the correlationn between GPSS subscales and SOGS total score is only of medium strength.

Tablee 6.5 Relation SOGS total score and GPSS total and subscale scores (pm correlation) GPSS S WE E FC C FSR R PEH H totall score Patientss (n=136) ,45 5 .48 8 ,54 4 ,44 4 ,69 9 PPGG (n=173) ,60 0 ,66 6 ,64 4 ,67 7 ,71 1

Inn Figure 6.5 one can see that the PEH severity score for subgroup of people with a SOGSS total score of 6 ranges from 3 to 8.84, the same PEH range applies to the subgroup of peoplee with a SOGS total score of 12. The multi-domain approach thus clearly offers additionall information to the SOGS total score for the psychological and emotional health problems.. The same holds for the GPSS total score (Figure 6.4)

97 7 Gamblingg Problems Severity Scale

Figuree 6.4

Figuree 6.5 Treatedd patients (N=136) Treatedd patients (N=136)

18. .

16. .

14. .

12. .

10. .

8, , s s 6. . S S (J J 4-- O O

G G 2. . G G S S S S 0. . -2 2 22 3 4 5 00 2 4 6 8 GPSSS total score Psychologicall and emotional health

Sensitivityy to change Comparingg baseline and follow-up scores of a treated patient sample and a general population PPGG sample gives an indication of the sensitivity to change of the GPSS. For evaluation purposess the last month timeframe seems more appropriate than the last year timeframe. Six monthh after the start of their treatment the patients show a clinical and statistical significant dropp in problem severity on all GPSS scales. The PPGs started with considerable lower mean scoress and after two years only a small decrease in problem severity was found on all scales withh the exception of the PEH subscale, where the decrease was statistical significant (Table 6.6).. Changes in SOGS total score are only weakly related to changes in GPSS total score (productt moment correlation one month time-frame r = .11; one year time-frame r=.47).

Tablee 6.6 Sensitivity to change: mean and (standard deviation)

1 1 ti i T2 2 P P Patientt sample (n=104) WE E 3.455 (1.67) 2.033 (1.89) <.001 1 FSR R 1.47(2.28) ) 0.822 (1.76) .012 2 FC C 3.066 (2.94) 1.59(2.58) ) <001 1 PEH H 3.15(2.32) ) 1.622 (2.29) <001 1 Total l 4.17(2.27) ) 2.333 (2.45) <001 1 Potentiall problem gamblers (n=134) ' ' WE E 0.933 (1.51) 0.71(1.37) ) .059 9 FSR R 0.222 (.094) 0.18(0.86) ) .678 8 FC C 0.444 (1.44) 0.39(1.22) ) .641 1 PEH H 0.822 (1.76) 0.47(1.34) ) .004 4 Total l 1.211 (2.77) 0.977 (2.02) .139 9 )) Only respondents with both a t, and t2 score; Time-frame 'last month'; fa patient sample 6 month after start treatment,, follow-up PPG sample 2 year after t,.

98 8 Chapterr 6

DISCUSSION N

Too our knowledge, there exists no multi-domain instrument to assess the severity of gambling problemss yielding interval level severity scores. The Gambling Problem Severity Scale (GPSS)) presented in this article is such an instrument. Several characteristics make it a potentiall useful instrument for the assessment of gambling problem severity and treatment evaluation.. First its' multi-domain character. This makes it possible to identify subgroups of problemm gamblers with different problem profiles. These profiles can be used to focus treatmentt at the most problematic areas and moreover, to evaluate treatment at a more specific level.. Moreover they can be used to assess whether the severity and character of the "gamblingg addiction" is related to the game of chance played. Are the severity and character off gambling problems of people addicted to scratchcards comparable to those of people addictedd to slot machines or horse racing? Second, the fact that the GPSS scales fit the Rasch modell implies that they are truly one-dimensional and can be relatively easy converted into severityy scores with interval properties. These two characteristics make them useful for the assessmentt of gambling problem severity and changes in gambling problem severity. Most existingg instruments SOGS (Lesieur et al., 1987), NODS (National Opinion Research Center, NORC,, 1999) only offer severity scores with ordinal scale properties, which makes changes difficultt to interpret. Recently Strong et al. (2003) presented a 6 item Rasch scale based on the SOGS.. In contrast to the GPSS this scale, however, is not a multi-domain scale and mainly focusess on financial problems. Third the GPSS is a short (20 items) self-report questionnaire whichh is easy to complete and requires no training. The respondent only has to indicate whetherr on not he has experienced a specific problem in the last month or last year. This makess the GPSS a relatively cheap research instrument. Fourth, the GPSS total score has a relativelyy normal score distribution in treated populations. Combined with its interval propertiess this allows the use of parametric tests. Fifth, the GPSS has good discriminant validity.. Sixth the instrument is clinically grounded, the initial item pool is based on a consensuss meeting with clinicians experienced in the treatment of gambling problems. Thee most used instrument in gambling research today is the South Oaks Gambling Screen.. The SOGS is basically developed as a screening instrument although the SOGS total scoree is sometimes used as an indicator for the severity of gambling problems. The correlation betweenn GPSS total score and SOGS total score is of medium strength only (.70). Contrary to thee SOGS the GPSS offers several subscale scores, which correlate less with the SOGS total score,, especially in the patient sample. The problems with the ordinal character of the SOGS totall score become more visible in the low correlation between changes in severity as assessed withh the SOGS and the GPSS. Onee may wonder whether it makes sense to use domain scores since the total scale fits thee Rasch model and consequently is one dimensional and the domains are subsets of this one dimensionall construct. We believe that even in case of a one dimensional construct domains mayy offer additional information. A good example is the general concept of arithmetic skills

99 9 Gamblingg Problems Severity Scale wheree the domains can be interpreted as specific skills like division, multiplication, addition etc.. that make up this general skill. Althoughh this study indicates that the GPSS is sensitive to change, this is yet to be provenn since no external change criterion has been available in this study to validate its sensitivityy to change. InIn summary, the GPSS is a promising instrument, however, more research has to be donee to corroborate our findings and to assess its usefulness as both a severity indicator and treatmentt evaluation instrument.

REFERENCES S

Americann Psychiatric Association (APA)(1980). Diagnostic and statistical manual of mental disorders.disorders. Washington.: American Psychiatric Association. Americann Psychiatric Association (APA) (1987). Diagnostic and statistical manual of mental disorders.disorders. Washington: American Psychiatric Association. Americann Psychiatric Association (APA)(1994) Diagnostic and statistical manual of mental disorders.disorders. (4th ed.) Washington,DC. Bond,, T. G. & Fox, C. M. (2001) Applying the Rasch model: Fundamental measurement in the socialsocial sciences. Mahwah, NJ: Lawrence Erlbaum Associates. Borsboom,, D. & Mellenbergh, G. J. (2002) True scores, latent variables, and constructs: A commentt on Schmidt and Hunter. Intelligence, 30, 505-514. Brown,, T. A., Marten, P. A., & Barlow, D. H. (1998) Empirical evaluation of the panic symptom ratingss in DSM-III-R panic disorder. In T.A.E. Widiger, A. J. E. Frances, & H. A. E. Pincus (Eds.), DSM-IVDSM-IV Sourcebook (pp. 209-215). Washington, DC: American Psychiatric Association. DeFuentes-Merillas,, L., Koeter, M. W. J., Schippers, G. M, & Brink, W. v. d. (2003) Are scratchcardss addictive? The prevalence of pathological scratchcard gambling among adult scratchcard buyerss in the Netherlands. Addiction, 98, 725-731. Edwards,, G. & Gross, M. M. (1976) Alcohol dependence: provisional description of a clinical syndrome.. British Medical Journal, 1,1058-61. Ferriss & Wyne (2001) The Canadian Problem Gambling Index: Final Report. Canadian Center on Substancee Abuse. User Manual, www.ccsa.ca Gossop,, M. (1990) The development of a Short Opiate Withdrawal Scale (SOWS). Addictive Behaviors,Behaviors, 15,487-90. Gotestam,, K. G. & Johansson, A. (2003) Characteristics of gambling and problematic gambling in thee Norwegian context - A DSM-IV-based telephone interview study. Addictive Behaviors, 28, 189- 197. . Hambleton,, R. K. & Swaminathan, H. (1985) Item Response Theory: Principles and applications. Boston:: Kluwer-Nijhoff. Kendler,, K. S. (1996) Major depression and generalised anxiety disorder: same genes, (partly) differentt environments - revisited. British Journal of Psychiatry, 168,68-75. Kendler,, K. S. & Gardner, C. O. (1998) Boundaries of major depression: an evaluation of DSM- IVV criteria. American Journal of Psychiatry, 155,172-177.

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Kupfer,, D. J., First, M. B., & Regier, D. E. (2002) Introduction. In DJ.Kupfer,, M. B. First, & D. A.. Regier (Eds.), A research agenda for DSM-V(pp. XV-XXOT). Washington: American Psychiatric Association. . Lesieur,, H. R. & Blume, S. B. (1987) The South Oaks Gambling Screen (SOGS): a new instrumentt for the identification of pathological gamblers. American Journal of Psychiatry, 144, 1184- 1188. . Lord,, F. M. & Novick, M. R. (1968) Statistical theories of mental test scores. Addison-Wesley Publishingg Company. Mellenbergh,, G. J. (1994) Generalized Linear Item Response Theory. Psychological Bulletin, 115, , 300-307. . Mellenbergh,, G. J. (1996) Measurement precision in test score and item response models. PsychologicalPsychological Methods, 1, 293-299. Nationall Opinion Research Center (NORC) (1999) Gambling Impact and Behavior Study: Report toto the National Gambling Impact Study Commission^ Chicago: NORC. Rounsaville,, B. J., Alarcon, R. D., Andrews, G., Jackson, J. S., Kendell, R. E., & Kendler, K. (2002)) Basic nomenclature issues for DSM-IV. In DJ.Kupfer, M. B. First, & D. A. Regier (Eds.), A researchresearch agenda for DSM-V (pp. 1-30). Washington: American Psychiatric Association. Shaffer,, H. J. & Hall, M. N. (1996) Estimating the prevalence of adolescent gambling disorders: A qualitativee synthesis and guide toward standard gambling nomenclature. Journal of Gambling Studies, 12,193-214. . Stinchfield,, R. (2003) Reliability, validity and classification accuracy of a measure of DSM-IV diagnosticc criteria for pathological gambling. American Journal of Psychiatry, 160,180-192. Strong,, D. R„ Breen, R. B., Lesieur, H. R., & Lejuez, C. W. (2003) Using the Rasch model to evaluatee the South Oaks Gambling Screen for use with nonpathological gamblers. Addictive Behaviors,Behaviors, 28,1465-72. Toce-Gerstein,, M., Gerstein, D. R., & Volberg, R. A. (2003) A hierarchy of gambling disorders in thee community. Addiction, 98,1661-1672. Verhelst,, N.D., Glas, C.A.W., & Verstralen, H.H.F.M. (1995). One-parameter logistic model: OPLMM [computer program] Chicago: Scientific Software. Welte,, J., Barnes, G., Wieczorek, W., Tidwell, M. C, & Parker, J. (2001) Alcohol and gambling pathologyy among US adults: Prevalence, demographic patterns and comorbidity. Journal of Studies of Alcohol,Alcohol, 62,706-712. Welte,, J. W., Barnes, G. M., Wieczorek, W. F., Tidwell, M. C, & Parker, J. (2002) Gambling participantionn in the U.S. -Results from a National Survey. Journal of Gambling Studies, 18, 313-337. Williams,, B. T. & Drummond, D. C. (1994) The Alcohol Problems Questionnaire: reliability and validity.. Drug Alcohol Depend., 35,239-43. Winters,, K. C, Specker, S., & Stinchfield, R. (2002) Measuring pathological gambling with the Diagnosticc Interview for Gambling Severity (DIGS). In J.J.Marrotta, J. A. Cornelius, & W. R Eadingtonn (Eds.), The Downside: Problem & Pathological Gambling (pp. 143-148). Nevada: Institute forr the Study of Gambling and Commercial Gaming Institute.

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PARTT IV

GENERALL DISCUSSION ANDD SUMMARY

Chapterr 7

CHAPTERR 7

GENERALL DISCUSSION

Inn this final chapter, the major findings regarding the addictive potential of scratchcards and thee assessment of gambling-related problems are summarised, discussed and placed within the contextt of recent scientific developments. Furthermore, methodological issues that are key to ann accurate interpretation and extrapolation of our findings are addressed. Finally, several recommendationss are made from a public health perspective and suggestions for future researchh are given.

OVERVIEWW OF THE RESULTS

Prevalencee and temporal stability of pathological scratchcard gambling Thee current findings provide strong scientific evidence that pathological scratchcard gambling (PSG)) is a rare phenomenon among Dutch adult scratchcard buyers. The last-year prevalence off scratchcard-related problems was 2.68% and only a small minority (0.24%) of the scratchcardd gamblers met the DSM-TV criteria for pathological gambling adapted for scratchcardss (see Chapter 2). The estimated two-year cumulative incidence also was 0.24%. Inn addition, the stability (or chronicity) of PSG was low (between 11.1 and 42.9% -best- and worst-casee scenarios). This means that even in the "worst-case scenario" more than half of the pathologicall gamblers no longer fulfilled the adapted DSM-IV criteria two years after the first assessment.. When the 2-year follow-up stability and incidence data were taken into account, thee adjusted last-year prevalence estimate for PSG among scratchcard buyers was somewhere betweenn 0.23 and 0.33% (Chapter 3). All these figures show that, over time, some new cases willl appear (incidence) and some of the pathological scratchcard gamblers will recover, resultingg in an overall stable and low PSG prevalence. The disorder can thus be said to be a raree phenomenon among Dutch adults scratchcard buyers. The present prevalence estimates pertainn to adult scratchcard buyers only. If we take into account that in 1999 the penetration ratee of scratchcards in the Dutch general adult population was 19%, the prevalence of PSG for thee general adult population can be estimated at 0.046% (0.029% for the 'combined' and .017%% for the 'unique'1 group of pathological scratchcard gamblers, see Chapter 2). Thee available studies in the literature, including the findings of this thesis (Chapters 3 andd 4), provide evidence that many people with gambling-related problems recover without treatmentt intervention (natural recovery; see Koeter, & Brink, 1996; Abbott, M. W., Williams,, M M., & Volberg, R. A, 1999; Hodgins, D. C, Wynne, H., & Makerchuk, K., 1999;; Hodgins, D. C, 2001; Hodgins, D. C, Makarchuk, Karyn, El Guebaly, N., & Peden, N.,, 2002; Wiebe, Jamie., Single, E., & Falkowski-Ham, A., 2003). Recovery rates across the

11 'Unique' PSG is defined as meeting DSM-IV criteria for pathological scratchcard gambling but not for other fotmss of gambling. 'Combined' PSG is defined as meeting DSM-IV criteria for both PSG and pathological gamblingg involving other games of chance.

105 5 Generall discussion aforementionedd studies ranged from 39% to 77%. For example, the prevalence study conductedd in New Zealand reported high recovery rates (77%) among problem gamblers over aa 7-year period (Abbott, M. W., Williams, M. M., & Volberg, R. A., 1999). The results of Wiebee and colleagues (2003) seem to indicate that, whereas high-risk gambling or moderate gamblingg problems appear to be transitory states, those gamblers suffering severe problems aree much more stable. However, the latter finding seems questionable given the results of our studyy reported in Chapter 3, which suggests that also PSG is a disorder with.low stability. On thee other hand, the findings discussed in Chapter 4 did reveal that the players diagnosed with PSGG that had recovered during the follow-up period were those that had reported less severe symptomss (GPSS) and fulfilled fewer symptom criteria (DIS-T) at the initial assessment than thosee players in the same group that did not recover. The differences in the recovery rates reportedd by these various studies may not only be accounted for by the severity of the gambling-relatedd problems but also by the heterogeneity in the groups of gamblers investigated.. More specifically, gamblers playing different games of chance were classified as gamblerss in general, thus disregarding the type of game as a potential variable influencing the severityy and development of gambling problems. The disparate findings point to the importancee of a further examination the effects the severity of gambling-related problems has, ass well as the role that specific forms of gambling (e.g. slot machines vs. scratchcards) play in thee stability of and recovery from gambling problems. InIn summary, the prevalence of pathological scratchcard gambling has been shown to bee low, stable over time and is associated with a high recovery rate (as assessed in a two-year follow-up).. When the DSM-IV criterion for clinical significance (Chapter 4), was taken into account,, it was concluded that the previously reported prevalence of 'unique' PSG among a representativee population of Dutch scratchcard gamblers (0.09%) is likely to be a serious overestimationn of the real prevalence.

Clinicall picture of pathological scratchcard gamblers Whatt are the characteristics of pathological scratchcard gamblers (PSG)? From those gamblerss identified as being afflicted by PSG, approximately two thirds (0.15%) were also addictedd to other hazard games like slot machines or casino games. This 'combined' PSG groupp resembles the demographic and gambling characteristics of pathological gamblers in generall (young men, mainly slot-machine players). The remaining one third (0.09%) were 'unique'' PSG with some very specific characteristics: this group mainly consisted of middle- agedd women who spent relatively small amounts of money on scratchcards (Chapter 2). Given thatt pathological gambling is generally more prevalent among men and that the group of uniquee PSG mainly consisted of women players, our finding corroborates the suggestion madee by Grupta and Deverensky (1998) that women are more specifically attracted to particularr games of chance such as scratchcards. With this unique PSG group, our study may havee identified a new group with very specific characteristics within the pathological gamblingg spectrum. Moreover, this unique PSG group is not to be found in treatment settings; thee only pathological scratchcard gamblers seen in the clinical practice belong to the

106 6 Chapterr 7 combinedd group, which makes the unique group even more exceptional2. This fact was also mentionedd in a German study (IPM, 1993). Combined PSG seems to be part of a more general pathologicall gambling problem, one that developed prior to the onset of the gambling problemss related to scratchcards. This finding suggests that scratchcard gambling is not a stepping-stonee towards other more harmful forms of gambling (Chapter 2). Additionally, the incidencee cases resemble the prevalence cases in terms of comorbidity of pathological scratchcardd gambling with an addiction to other games of change. Although both groups, uniquee and combined PSG, met the DSM-IV criteria for PSG, the gamblers in the combined groupp scored positive on more South Oaks Gambling Screen items and DSM-IV criteria for scratchcardss than those who were only addicted to scratchcards (unique PSG) at both prevalence,, and incidence assessments. Moreover, the combined group also fulfilled more DSM-IVV criteria with respect to their addiction to other games of chance than with respect to theirr addiction to scratchcards (Chapter 3). These results confirmed that the level of impairmentt or distress associated with their scratchcard-related problems was higher for the gamblerss in the combined group than it was for those in the unique PSG group. Ourr findings on PSG seem to lend support to one of the hypotheses presented by Toce-Gersteinn and colleagues that the DSM-IV criterion Illegal Acts relating to criminal behaviourr due to a person's gambling losses may demarcate the most severe level of pathologicall gambling. It should be noted, however, that our sample did not confirm their data thatt the symptom most reported by all players classified as PSG is Chasing but rather PreoccupationPreoccupation with gambling, followed by Escapism, Loss of control and Tolerance (Toce- Gerstein,, M., Gerstein, D. R, & Volberg, R. A., 2003). Despite our congruent results, the severityy of gambling problems needs to be more extensively tested with validated severity instrumentss like the GPSS and with larger samples before any definitive conclusions can be drawn. .

THEE ASSESSMENT OF GAMBLING-RELATED PROBLEMS

Ass pointed out in the introduction of this thesis (Chapter 1), if one wishes to establish whether andd to what extent a specific form of gambling is addictive, and thus potentially dangerous to thee player and his/her environment, it is essential that one has suitable, validated instruments att one's disposal that allow a reliable assessment of the consequences that playing such a gamee of chance has in the general population. It is equally important that within the group of problemm gamblers the severity of the gambling-related problems as well as the different life domainss affected by their adverse behaviours can be accurately evaluated. Therefore, this thesiss included the validation of the Dutch version of the South Oaks Gambling Screen (Chapterr 5) and the development of a new instrument to assess the severity of gambling problems,, i.e. the Gambling Problems Severity Scale (Chapter 6).

22 In January 2004, several treatment centres specialised in the treatment of addictions confirmed this finding.

107 7 Generall discussion

Validityy of the Dutch version of the South Oaks Gambling Screen Chapterr 5 confirmed that the Dutch version of the South Oaks Gambling Screen (SOGS) is a validd screener for pathological gambling according to the DSM diagnostic criteria for pathologicall gambling in the general population. Although the SOGS has been widely used in epidemiologicall studies, to our knowledge, this was the first community study in Europe to usee a two-stage design to test the SOGS validity against the DSM-HI-R diagnostic criteria. Thee specificity rate (0.99) reported in this study is comparable to the, ones reported in otherr studies, whereas the sensitivity rate (0.94) is considerably higher in our sample than thosee reported in other general population samples (Abbott, M. W. & Volberg, R. A., 1996; Stinchfield,, R., 2002; etc.). The positive predictive value (PPV) of the SOGS as a screener for DSM-III-RR PG, using a threshold value of 5, was 65%. However, due to the relatively low prevalencee of PG in the general population, the SOGS considerably overestimates the prevalencee of PG in community samples. Our adjusted prevalence estimate was approximatelyy 40% lower than the SOGS prevalence estimate. This finding is in line with otherr studies. A meta-analysis of prevalence studies, comparing all the studies that used a two-stagee methodology with the SOGS and the DSM diagnostic criteria, revealed that the numberr of pathological gamblers positively screened by the SOGS is approximately two timess higher than obtained with the DSM criteria (Shaffer, H. J., Hall, M. N., & Vander-Bilt, J.,, 1999; Stinchfield, R., 2002). These findings suggest that all community studies using only thee SOGS to determine the prevalence rate overestimate the true prevalence of pathological gambling. .

Assessmentt of gambling severity: the Gambling Problems Severity Scale (GPSS) Chapterr 6 described the development of a new screening tool, the Gambling Problems Severityy Scale and its sound psychometric properties fulfilling the Rasch model for both the totall gambling severity continuum (total scale) and for each of the assessed domains (4 sub- scales).. The results obtained in this study validated the concept of gambling as a continuum, assumingg item hierarchy. The main strengths of the GPSS are: (1) its population independence,, i.e. the properties of the scale do not change across populations; (2) its scores cann be easily converted into interval scales; (3) the GPSS has a good discriminate validity; andd finally, (4) the GPSS is a concise, clinically based self-report instrument that does not requiree training, which makes the questionnaire highly cost-effective. Ass an assessment tool, the GPSS has several advantages over the SOGS. Apart from itss sound psychometric properties, it derives its potency both from its ability to assess the severityy of gambling problems relative to different life domains and from the interval nature off its scales. Inn summary, the GPSS enables clinicians to tailor their treatments to individual clients, too assess the life dimensions for which help is needed most, to measure the effects of their interventionss and to compare different interventions as to their ability to ameliorate consequencess on severity dimensions. In addition, the GPSS can help researchers to establish whetherr the severity and nature of the gambling-related problems are indeed associated with thee game of chance played.

108 8 Chapterr 7

STRENGTHSS AND LIMITATIONS

Att this point, it is important to emphasise that at all stages of this socio-epidemiological study,, i.e. its preparation, execution and analyses, the utmost was tried at methodological and statisticall levels, to ensure that the estimates on the addictive potential of scratchcards were as accuratee as possible. Nevertheless, no study is without its limitations; these weaknesses will bee addressed in this section. But first we would like to call attention to several of its strengths. Thee present study is one of the largest prospective studies ever conducted to monitor thee prevalence of regular, potentially problematic and pathological gambling at the communityy level investigating one specific game of chance, i.e. scratchcards. A large nationwidee non-proportional stratified random sample (n= 12,222) was used and a cost- effectivee two-stage design was applied. Another of the study's strong points was its prospectivee nature with a follow-up period (2 years) that was long enough to detect changes inn the temporal stability of pathological scratchcard-related problems and the assessment of thee adverse effects of scratchcards at the community level. Additionally, in order to portray thee real impact of scratchcards on the general population as accurately as possible, our figures weree calculated always using the most conservative estimates and "best- and worst-case scenarios"" with confidence intervals at all times. This means that if our estimates should carry anyy bias, such a bias would be in the direction of an overestimation of this phenomenon (conservativee approach, Chapter 3). Next,, the various limitations of this study will be addressed in brief (for a more detailedd description of the shortcomings we refer to their discussion in the relevant chapters).Onee of the main limitations concerns the exclusion criteria of our sample and its potentiall bias. Indeed, excluding new, non-native residents who are not fully competent in Dutchh and under-age scratchcard buyers may have biased our prevalence rate. However, as explainedd in Chapters 2 and 3, the exclusion of respondents with an insufficient command of thee Dutch language is not likely to have seriously affected the prevalence estimates since the exclusionn criteria only applied to those unable to understand the questions. As to the second exclusionn criterion: only if one assumes that under-age players3 are more at risk of developing PSGG would the net effect have been an increase in the prevalence estimate. The exclusion of youthss under the age of 18 does, however, imply that our findings only pertain to adults and cannott be generalised to minors. Additionally, because the addictive potential of a specific gamee of chance is also a function of the accessibility/availability of other continuous forms of gamblingg (i.e.: slot machines, casinos, bingo, etc.), scratchcards might be more addictive in a contextt where, as compared to the Netherlands, access to other games of chance is very limited.. This means that caution should be used with any extrapolation of our findings to otherr countries. Similarly, it is important to emphasise on the danger of generalising specific resultss about the negative side effects of gambling across different games of chance. Thee main methodological problem in the incidence phase of this study (Chapter 3) concernedd the fact that only potential problematic scratchcard players and pathological

Thee gambling regulation in the Netherlands docs not allow the sale of scratchcards to minors (< 18 years).

109 9 Generall discussion scratchcardd gamblers were followed-up. As a consequence, all incidence and prevalence estimatess are dependent upon the assumptions pertaining to the incidence of PSG in occasionall and recreational scratchcard gamblers. These assumptions were quite conservative andd if they did bias the main findings of this paper (low prevalence, low public health risk and loww incidence) they are more likely to have led to an overestimation. Anotherr limitation is related to the lack of evidence on the test-retest reliability of the DIS-T.. Consequently, part of the alleged temporal instability may reflect unreliability instead off true changes in gambling problems. However, the fact that the SOGS total score also had loww temporal stability and the fact that the GPSS yielded lower severity scores at the follow- upp measurement both lend support to the true temporal instability interpretation. TwoTwo other important issues that deserve special attention are the self-perception of gamblerss and the reliability of self-reported gambling behaviours. Several studies showed greatt ambiguity in the self-perception of gamblers, especially concerning their participation in scratchcardd gambling and lotteries (Shepherd, R. M., Ghodse, H,, & London, M., 1998; Lange,, M. A., 2001). Playing these two games of chance is generally not perceived as gamblingg by the majority of the players, unless these items were purchased frequently. However,, this ambiguity is unlikely to have played a part in this study since every item in the questionnairee referred to scratchcards. As to the second issue, as mentioned in Chapter 4, self- reportss based on retrospective information may be subject to distortion and underestimation of thee gambling-related problems at initial assessment, particularly among those with a high recoveryy rate (Vitaro, F., Arseneault, L., & Tremblay, R. E., 1997). This last bias is likely to havee affected our findings because most of the players in thee unique PSG group experienced a recoveryy in the follow-up interval. Furthermore, the tentative nature of the Chapter 4 findings needss to be emphasized. It concerned an exploratory study with a retrospective design and a limitedd number of cases (n=10). Replication of these findings in a different gambling context andd among underage populations would be useful to clarify the addictive potential of scratchcards. .

RECOMMENDATIONSS FOR FUTURE RESEARCH

Thiss thesis has provided strong scientific evidence for the low addictive potential of scratchcardss in the Dutch adult population. However, replication of this study in other countries,, where the availability of this game is regulated differently, that would also include under-agee players is required to gain a more in-depth understanding of the addictive potential off scratchcards. Further qualitative research is needed to investigate the singularity of the exceptionall group of unique pathological scratchcard gamblers identified in this study. It wouldd be most interesting to compare the careers of unique pathological scratchcard gamblers withh the development of the gambling careers of other homogeneous groups of pathological gamblerss (e.g. unique pathological slot-machine gamblers) and to thus provide evidence as to thee specific addictive potential of these various games of chance.

110 0 Chapterr 7

Additionall research is recommended in order to further investigate the relationship betweenn the structural characteristics of different games of chance and its addictive potential. Regardingg the so-called "Kingma's risk profile", the question has been raised whether the structurall game characteristics have the same weight across the different games of chance in termss of their addictive potential and whether these characteristics can be simply applied to calculatee the risk profile of any form of gambling (Kingma, S., 1993, see chapter 1, page 17). Althoughh in the Netherlands this profile is frequently used by various key figures in the gamblingg field, as yet it remains to be proven that this 'Kingma's score' is a valid indicator of addictivee potential. The fact that scratchcards, according to this method, have a positive addictivee potential, while several articles presented in this thesis prove the contrary, are indicativee of certain validity problems. Too date, relatively few reports on pathological gamblers have been published that used methodologicallyy strong designs comprising prospective designs, large random samples, standardisedd definitions and internationally accepted instruments (like the SOGS and structuredd diagnostic interview schedules to define the population of pathological gamblers underr investigation), or appropriate time-frames. It is evident that these are all prerequisites forr the further enhancement of the scientific quality of epidemiological research which, when met,, will facilitate a more accurate assessment of the diverse variables that play a role in this disorderr and its severity in future community studies. Thee longitudinal character of prospective studies allows the prevalence of gambling- relatedd problems to be assessed at different points in time and facilitates the evaluation of the incidencee and the temporal stability of these problems. To assess the effects of the public availabilityy of games of chance or specific preventive measures in the general population effectivelyy does, however, require a follow-up interval of sufficient length. In order to reduce thee costs of large prospective studies we recommend the use of a cost-effective design like the two-stagee sampling procedure and the combined use of both screeners and diagnostic instrumentss that were employed in this thesis. Whenn comparing the results of the studies conducted in various countries, the variance inn the reported prevalence estimates could be explained by the difference in sample characteristics,, the diagnostic criteria employed and the assessment procedures used. In order too enhance the reliability and comparability of data sets about gambling-related problems acrosss countries, we advocate the use of validated and internationally accepted assessment instruments,, standard diagnostic criteria, and appropriate time-frames. Speciall attention should be paid to the methodology to identify players that have gambling-relatedd problems or are at high risk of developing such problems. The most widely usedd screening questionnaire in general population studies is the South Oaks Gambling Screenn (SOGS, Lesieur, H. R. & Blume, S. B., 1987; Potenza, Marc N. & Chambers, R. Andrew,, 2001; Shaffer, H. J., Hall, M. N, & Vander-Bilt, I, 1999; Stinchfield, R., 2002; Volberg,, R A. & Abbott, M. W., 1994). As the SOGS has been adapted and/or validated in moree than twenty languages, this screening tool is recommended to help ensure that the data collectedd on an international scale are comparable, although this does not mean that we do not acknowledgee its limitations (Dickerson, M. G, Baron, E., Hong, S.-M., & Cottrell, D., 1996;

111 1 Generall discussion

Cox,, B. J., Kwong, J., Mchaud, V., & Enns, M. W., 2000; Jacques, C, Ladouceur, R, & Ferland,, F., 2000). For this reason we would strongly advise to combine the use of the SOGS withh additional instruments such as the newly developed and promising GPSS or NODS (Koeter,, M. W. J., DeFuentes-Merillas, L., Borsboom, D., Schippers, G.M., & Brink, W. van den,, 2004; National Opinion Research Center, NORC, 1999). In addition, the DSM-IV diagnosticc criteria (American Psychiatric Association, 1994) are recommended to define pathologicall gambling. These DSM-IV diagnostic criteria for PG (American Psychiatric Association,, 1994) are generally considered the standard and have been internationally adoptedd as the new benchmark by researchers and treatment professionals (Stinchfield, R., 2003;; National Opinion Research Center, NORC, 1999)., Whenn both screeners and diagnostic instruments are employed, the emphasis should be shiftedd from a lifetime to a last-year prevalence to allow the evolution of gambling problems overr time to be further explored4. Lifetime prevalence appears to overestimate the problem andd thus does not allow for a sensitive assessment of the gambling situation over time (Jacques,, C, Ladouceur, R., & Ferland, F., 2000; Crockford, D. N. & elGuebaly, N., 1998). Thee strongest evidence for the efficacy of government regulations and preventive programmes targetedd at gambling-related problems would be the reduction of both their point prevalence andd incidence, measured within a time-frame that is sufficiently sensitive to assess any changess in gambling behaviour. By definition, lifetime prevalence cannot decrease over time. Futuree studies should not solely rely on the level of symptoms or the total score on self-reportt screeners to determine the severity of gambling problems, but rather use properly validatedd instruments like the Gambling Problems Severity Scale (GPSS, Chapter 6) to assess thee severity of this disorder. Epidemiologicall surveys of gambling and problem gambling have become an essential componentt in the monitoring of legal gambling internationally (Volberg, R. A, Abbott, M. W.,, Ronnberg, S., & Munck, I. M. E., 2001). Hence, it cannot be stressed enough that an enhancementt of the quality of the research designs would greatly contribute to a more accuratee picture of gambling problems and the different factors that play a role in this disorder. .

AREE SCRATCHCARDS ADDICTIVE?

Duringg the last few decades there has been a surge in the availability of and expenditure on legalisedd forms of gambling, which was accompanied by a corresponding increase in public concernn about the harmful impact thought to be associated with gambling. Governments and thee gambling industry itself have responded by funding research targeted at both the assessmentt and amelioration of these assumed effects. In 1994 scratchcards were introduced inn the Dutch legal gambling market. The introduction was preceded and accompanied by a

44 The time-frame selection is not only conditioned by research purposes, but also depends on whether PG is seen ass a chronic disease (with lapses and relapses) or as a disorder that can be cured. The most logical time-frame tor thee former will be lifetime prevalence whereas for the latter this would be last-year prevalence.

112 2 Chapterr 7 longg and often heated public debate about its addictive potential. The studies presented in this thesiss were conducted to shed new light on the addictive potential of scratchcard gambling. Ourr findings did not corroborate the concerns voiced that preceded and accompanied thee introduction of scratchcards in the Netherlands in 1994. In contrast to the assumed addictivee potential of scratchcards (although estimated as moderate, according to Kingma, S., 1993),, pathological scratchcard gambling (PSG) was found to be a rare phenomenon among adultt scratchcard buyers in the Netherlands. Both incidence and stability of the DSM-IV diagnosiss of PSG were low. The low prevalence estimate is in line with previous studies reportingg that most of the scratchcard players do not experience scratchcard-related problems (IPM,, 1993; Lester, 1994; Aasved, 1995; Hendriks et al., 1997). In addition, the present study clearlyy shows that scratchcard related problems are transient. Thee public health impact of scratchcard gambling can be put into perspective by weighingg it against the effects of another similarly low-prevalence phenomenon like heroin usee (0.1%) and against a high-prevalence phenomenon like alcohol consumption (86%). In orderr to compare these three "products" the following variables need to be taken into account: (1)) the number of 'users', (2) the addictive potential, and (3) the biopsychosocial consequences.. In 1999 the penetration rate of scratchcards for the Dutch general adult populationn was 19%, which means that there were approximately 2,280,000 scratchcard players,, from which only a small percentage (0.046%) got addicted to this game of chance. Sincee the severity of the addiction was generally low, the consequences of this disorder were alsoo minor. In comparison, the prevalence of heroin use in the Netherlands was estimated at 0.1%% (Nationale Drug Monitor (NDM), 2002), from which approximately 70% (27,000 people)) got addicted to this substance. The consequences of heroin addiction were severe. Clearly,, even though scratchcards are used more frequently, they are far less addictive and havee far fewer and far less severe consequences for both the user and society at large than heroin.. By contrast, the prevalence rate for alcohol use was estimated at 86% for the Dutch generall population in 2002 (CBS, 2002), from which 8% (185,000 people) suffered from alcoholl abuse or dependence. Although scratchcards are used far less frequently, again they aree far less addictive and have far fewer and less severe consequences than alcohol. Table 7.1 summarisess these comparative results.

Tablee 7.1 1 1 Prevalencee of users Addictivee potential Consequences s Alcohol l Veryy High Low w Severe e Heroin n Low w Veryy high Severe e Scratchcards s High h Veryy Low Moderate/low w

Thee public health impact of alcohol among Dutch adults is approximately 173 times thee public health impact of scratchcards. Additionally, scratchcard-related problems are also veryy rare in treatment settings and when presented are always in comorbidity with other forms off gambling (e.g. slot machines or casino games) which are the main focus of treatment. It cann therefore be concluded that under the current regulatory conditions, the social burden of scratchcardd gambling for the Dutch adult population is quite low.

113 3 Generall discussion

Itt needs to be noted that this does not mean to say that our findings can be extrapolated too other forms of gambling or that the same regulations will be equally effective in preventing thee harmful effects of other games of chance. One of the government's responsibilities is to protectt both the individuals and the community against potential addictive behaviours, while maintainingg a careful balance between the individual freedoms and the collective protection. Withh this intention, the Dutch Gaming Law endeavours to prevent gambling-related problems (consumerr protection) and at the same time keep illegal gambling under control, surely not an easyy task considering that nowadays almost everybody can have access to electronic casinos att the other side of the world. Researchh will continue to try and fulfil the demands for information from key audiencess such as policy-makers, journalist, the gaming industry, clinicians and community groups,, who are all concerned about the impact of legalised gambling and the introduction of novell forms of gambling (Volberg, R. A. & Banks, Steven M., 2002; Lesieur, H. R., 2002). Governmentss can and should make use of scientific knowledge as the basis for new legislation.. To be eligible for funding researchers should ensure that their studies fulfil a set of minimall methodological requirements, as outlined above. Only then will they have any chancee of success in unravelling the addictive potential of different gambling forms or succeedd in monitoring the effects of gambling availability and the efficacy of gambling regulationss aimed to promote responsible gaming at a community level. In addition, there is a clearr need for more research into the effectiveness of consumer protection measures (Banks, G.,, 2003) and the efficacy of treatment interventions for those who fall victim to uncontrolled andd pathological gambling as well as basic research into the underlying biological factors of pathologicall gambling in relation to other disorders associated with loss of control.

REFERENCES S

Abbott,, M. W. & Volberg, R A. (1996) The New Zealand national survey of problem and pathologicall gambling. Journal of Gambling Studies, 12,143-160. Abbott,, M. W., Williams, M. M., & Volberg, R A. (1999) Seven years on: A follow-up study of frequentfrequent and problem gamblers living in the community. New Zealand: The Department of Internal Affeirs. . Americann Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders. (4thh ed.) Washington,DC. Banks,, G. (2003) The Productivity Commission's gambling inquiry: 3 years on. WUSTL: Economicss Working Paper Archive. CBSS (2002) Central Bureau of Statistics, www.cbs.nl/nl/cijfers/statline [On-line]. Cox,, B. J., Kwong, J., Michaud, V., & Enns, M. W. (2000) Problem and probable pathological gambling:: Considerations from a community survey. Canadian Journal of Psychiatry, 45, 548-553. Crockford,, D. N. & elGuebaly, N. (1998) Psychiatric comorbidity in pathological gambling: A criticall review. Canadian Journal of Psychiatry, 43,43-50.

114 4 Chapterr 7

Dickerson,, M. G., Baron, E., Hong, S.-M., & Cottrell, D. (1996) Estimating the extent and degree off gambling-related problems in the Australian Population: A National Survey. Journal of Gambling Studies,Studies, 4,135-151. Gupta,, R. & Deverensky, J.L. (1998) Adolescent gambling behavior: a prevalence study and examinationn of the correlates associated with problem gambling. Journal of Gambling Studies, 14, 319-345. . Hodgins,, D. C. (2001) Processes or changing gambling behavior. Addictive Behaviors, 7, 142. Hodgins,, D. C, Makarchuk, K., El Guebaly, N., & Peden, N. (2002) Why problem gamblers quit gambling:: A comparison of methods and samples. Addiction Research and Theory, 10, 203-218. Hodgins,, D. C, Wynne, H., & Makerchuk, K. (1999) Pathways to recovery from gambling problems:: Follow-up from a general population survey. Journal of Gambling Studies, 15, 93-104. IPMM Research en Advies (1993) Oriënterend onderzoek naar de wijze waarop instantloterijen in enkeleenkele landen zijn ingevoerd en naar de eventuele problemen die zich hierbij hebben voorgedaan. Rotterdam:: IPM. Jacques,, C, Ladouceur, R., & Ferland, F. (2000) Impact of availability on gambling: A longitudinall study. Canadian Journal of Psychiatry, 45, 810-815. Kingma,, S. (1993) Risicoanalyse kansspelen: Onderzoek naar de aard en omvang van gokverslavinggokverslaving in Nederland. Tilburg: Katholieke Universiteit Brabant. Koeter,, M. W. J. & Brink, W. v. d. (1996) Een gokje wagen of gewaagd gokken & (Vols. 2) Amsterdam:: Amsterdam Institute for Addiction Research (ALAR). Koeter,, M. W. J., DeFuentes-Merillas, L., Borsboom, D., Schippers, G. M., & Brink, W. v. d. (submitted)) The Gambling Problems Severity Scale (GPSS): A multi-domain instrument with Rasch properties s Lange,, M. A. (2001) "If you do not gamble, check this box": Perceptions of gambling behaviours. JournalJournal of Gambling Studies, 17, 247-254. Lesieur,, H. R. (2002) Epidemiological surveys of pathological gambling: Critique and suggestions forr modification. In J.J.Marotta, J. A. Cornelius, & W. R Eadington (Eds.), The Downside: Problem andand Pathological Gambling (pp. 325-388). Nevada: Institute for the Study of Gambling and Commerciall Gaming Institute. Lesieur,, H. R_ & Blume, S. B. (1987) The South Oaks Gambling Screen (SOGS): a new instrumentt for the identification of pathological gamblers. American Journal of Psychiatry, 144, 1184- 1188. . Nationall Opinion Research Center (NORC) (1999) Gambling Impact and Behavior Study: Report toto the National Gambling Impact Study Commission. Chicago: NORC. Nationalee Drug Monitor (NDM) (2002) Nationale Drug Monitor: Jaarbericht 2002. [National Drugg Monitor: Report from 2002]. Utrecht: Bureau NDM. Potenza,, M. N. & Chambers, R. A. (2001) Reliability and validity study of the Turkish version of thethe South Oaks Gambling Screen. Turkey: Turk Psikiyatri Dergisi Shaffer,, H. J„ Hall, M. N., & Vander-Bilt, J. (1999) Estimating the prevalence of disordered gamblingg behavior in the United States and Canada: a research synthesis. American Journal of Public Health,Health, 89, 1369-1376.

115 5 Generall discussion

Shepherd,, R. M, Ghodse, H., & London, M. (1998) A pilot study examining gambling behaviour beforee and after the launch of the National Lottery and scratch cards in the UK. Addiction Research, 6, 5-12. . Stinchfield,, R. (2002) Reliability, validity, and classification accuracy of the South Oaks Gamblingg Screen (SOGS). Addictive Behaviors, 27,1-19. Stinchfield,, R. (2003) Reliability, validity and classification accuracy of a measure of DSM-IV diagnosticc criteria for pathological gambling. American Journal of Psychiatry, 160, 180-192. Toce-Gerstein,, M, Gerstein, D. R, & Volberg, R A. (2003) A hierarchy of gambling disorders in thee community. Addiction, 98, 1661-1672. Vitaro,, F., Arseneauh, L., & Tremblay, R. E. (1997) Dispositional predictors of problem gambling inn male adolescents. American Journal of Psychiatry, 154, 1769-1770. Volberg,, R_ A. & Abbott, M. W. (1994) Lifetime prevalence estimates of pathological gambling in Neww Zealand. International Journal of Epidemiology, 23, 976-983. Volberg,, R. A., Abbott, M. W., Ronnberg, S., & Munck, I. M. E. (2001) Prevalence and risks of pathologicall gambling in Sweden. Acta Psychiatrica Scandinavica, 104, 250-256. Volberg,, R. A. & Banks, S. M. (2002) A new approach to understanding gambling and problem gamblingg in the general populations. In J.J.Marotta, J. A. Cornelius, & W. R Eadington (Eds.), The Downside:Downside: Problem and Pathological Gambling (pp. 309-323). Nevada: Institute for the Study of Gamblingg and Commercial Gaming Institute. Wiebe,, J., Single, E., & Falkowski-Ham, A. (2003) Exploring the evolution of problem gambling: aa one year follow-up study Ontario: Canadian Centre on Substance Abuse and Responsible Gambling Council. .

116 6

Summary y

SUMMARY Y

Inn the last two decades scratchcards or instant lotteries have been launched in more than 40 countries.. The introduction of scratchcards in the Netherlands in 1994 was preceded and accompaniedd by a long and often heated public debate about their potential negative side effectss in terms of excessive playing and pathological gambling. Opponents of the introductionn of scratchcards referred to the game's structural game characteristics, which they consideredd potentially addictive. The most important characteristics in this respect are low threshold,, short payout intervals and near misses. Based on the available studies (Chapter 1) it iss concluded that the empirical evidence is insufficient to draw firm conclusions as to the addictivee potential of scratchcards. The aim of this thesis was to scientifically evaluate the potentiall adverse effects of scratchcards at the community level, in order to assess the addictivee potential and the social burden of this form of gambling in the Netherlands (Part n, Chapterss 2, 3 and 4). However, it is impossible to know whether a specific form of gambling iss addictive or not without the aid of valid instruments. Therefore, the secondary goal of this thesiss was to investigate several of the unresolved issues in the assessment of gambling problemss in general, i.e. a validation of the South Oaks Gambling Screen (SOGS) in a communityy study, and the development of a new instrument to asses the severity of gambling problemss (Part m, Chapter 5 and 6, respectively). Before elaborating on the twofold purpose off this thesis, it is necessary to place the nature of gambling problems within its' historical, sociall and legal context (Part I, Chapter 1).

Partt I. Introduction Chapterr 1 presents a general introduction to briefly illustrate the role that gambling has played throughoutt history, describes the situation of legalised gambling in the Netherlands, particularlyy with regard to scratchcards, and reviews some important concepts in order to clarifyy the nature of gambling problems. Additionally, this introductory chapter describes the ' purposess and provides the outline of this thesis.

Partt n. The addictive potential of scratchcards Partt n investigates the addictive potential of scratchcards and the nature of the associated problemss within the Dutch context. To this end a large prospective socio-epidemiological studyy was conducted among adult scratchcard buyers in the Netherlands. This prospective studyy used a nationwide non-proportional stratified sample of 12,222 adult scratchcard buyers andd had three independent assessment phases: a prevalence phase (Chapter 2), an incidence phasee (Chapter 3) and a qualitative phase (Chapter 4). In all studies, pathological scratchcard gamblingg (PSG) was defined according to the DSM-IV criteria for pathological gambling (as assessedd by means of the Diagnostic Interview Schedule -DIS-T, APA 1994). Chapterr 2 describes the results of the first-phase study: a cross-sectional prevalence surveyy among a non-proportional stratified sample of 12,222 adult scratchcard buyers. Its mainn aim was to obtain a valid estimate of the addictive potential of scratchcard gambling by

119 9 Summary y

establishingg the one-year prevalence of occasional1 (71.61%), recreational (25.71%), problematicc (2.44%) and pathological scratchcard gambling (PSG, 0.24%) among a representativee sample of adult scratchcard buyers five years after the introduction of scratchcardss in the Netherlands2. Of this latter PSG group, one-third (0.09%) was uniquely addictedd to scratchcards whilst the remaining two-thirds (0.15%) were also addicted to other hazardouss games of chance. The findings show that scratchcards have a very low addictive potentiall among adults in the Netherlands. Chapterr 3 comprises the second phase of this socio-epidemiological study. The incidencee study investigates the temporal stability of PSG during a two-year follow-up interval.. A cost-effective design was used and only those scratchcard buyers (n=201) who had alreadyy reported some scratchcard-related problems at the prevalence phase were followed up. Thee estimated two-year cumulative incidence again was as low as 0.24%. In addition, this studyy also showed that the stability of PSG was also low (between 11.1 and 42.9% -best and worst-casee scenarios). This means that even in the "worst-case scenario" more than half of the pathologicall gamblers no longer fulfilled DSM-IV the adapted criteria for PSG two years afterr the first assessment. When the 2-year follow-up stability and incidence data were taken intoo account, the adjusted last-year prevalence estimate for PSG among scratchcard buyers rangedd between 0.23 and 0.33%. All these figures show that whereas, over time, some new casess will appear (incidence), other pathological scratchcard gamblers will recover, resulting inn an overall stable and low prevalence. Therefore, the present findings show that PSG is a raree phenomenon among Dutch adults scratchcard buyers (0.24%) and even more infrequent (0.046%)) for the general adult population. Chapterr 4 presents the final qualitative phase of this prospective study based on in- depthh face-to-face interviews aimed to explore the effect of the DSM-IV clinical significance criterionn on the number of false positive diagnoses of PSG and its consequences for the diagnosticc validity of the DSM-IV symptom criteria. Participants were those respondents that fulfilledd the DSM-IV criteria for PSG at the prevalence phase and had consented to take part andd have the interview recorded (n=10). The main finding of this chapter shows that only 40%% of the 'unique' pathological scratchcard gamblers met the DSM-IV criterion for clinical significance.. As a consequence, the previously reported prevalence of 'unique' PSG among a representativee population of Dutch scratchcard gamblers (0.09%) is likely to be a serious overestimationn of the factual prevalence.

11 Occasional gamblers were defined as those players who bought £ 10 scratchcards a month; recreational gamblerss as those that had bought > 10 scratchcards in the month prior to the initial assessment and had played scratchcardss for more than six month; potential problematic scratchcard gamblers (PPSG) had a total score £ 3 onn the South Oaks Gambling Screen (SOGS-S); and pathological scratchcard gamblers were those players that mett the DSM-IV criteria for PSG. 22 In contrast to the prevalence study, here the percentages of occasional, recreational, potential problemmatic and pathologicall scratchcard gambling were considered mutually exclusive and their sum is 100%. If these groups aree considered as mutually inclusive (i.e. when pathological scratchcard gamblers are included in the potential problemm group which are in turn included in the regular gamblers group) the percentages would be as follows: 71.61%% for occasional, 28.4% for regular, 2.68% for potential problem problematic gambling and 0.24% for PSG,, and, as a consequence, their sum exceeds 100%

120 0 Summary y

Partt HI. The assessment of gambling-related problems Partt III deals with relevant issues in the assessment of gambling problems in general. The focuss of the two chapters presented in this section is on the identification of individuals with gambling-relatedd problems (Chapter 5) and the measure for the severity of those problems (Chapterr 6). Chapterr 5 reports on the validation of the Dutch version of the South Oaks Gambling Screenn (SOGS) against the DSM-IH-R diagnostic criteria, using a two-stage sample design amongg a representative sample of 5,830 Dutch young adults (aged between 12 to 35 years). Thee results showed that the Dutch version of the SOGS is a valid screener for pathological gamblingg according to the DSM-III-R diagnostic criteria for pathological gambling in the generall population. However, due to the relatively low prevalence of PG in the general population,, the SOGS considerably overestimates the prevalence of PG in community samples.. The DSM-III-R adjusted prevalence estimate was approximately 40% lower than the SOGSS prevalence estimate. This finding is in line with other studies suggesting that all communityy studies using only the SOGS to determine the prevalence rate of PG overestimate thee true prevalence of pathological gambling as measured with a diagnostic interview (DSM). Chapterr 6 describes the development of a new severity questionnaire, the "Gambling Problemss Severity Scale" (GPSS). This severity instrument integrates the findings reported in thee scientific literature and experiences from clinical practice regarding the severity of gamblingg problems. A multi-sample study population of 636 adults covering the entire continuumm of gambling severity was used to develop the GPSS. The results underpin the excellentt psychometric properties of the GPSS fulfilling the Rasch model for both the total gamblingg severity continuum (total scale) and for each of the life-domains (4 sub-scales). The GPSSS thus enables clinicians to tailor their treatments to individual clients, to assess the functionall domains for which help is needed most, to measure the effects of interventions and too compare different interventions as to their strength to ameliorate consequences on severity dimensions.. Moreover, the GPSS can help researchers to establish whether the severity and naturee of the gambling-related problems are indeed associated with the game of chance played. .

Partt IV. General discussion Thee fourth and final part of this thesis comprises the general discussion. Chapter 7 integrates thee main findings of this thesis in terms of the addictive potential of scratchcards, and the use off the various assessment instruments to measure the prevalence (SOGS) and severity of gambling-relatedd problems (GPSS). In addition, methodological issues that are important for thee interpretation and extrapolation of our results are addressed. The public health impact of scratchcardss is put into perspective by a comparison with the effects of another low- prevalencee phenomenon (heroin use <1%) and the effects of a high-prevalence phenomenon (alcoholl consumption 86%). Based on these comparisons, it is concluded that the social burdenn of scratchcard gambling is quite low. Finally, several recommendations are made from aa public health perspective and suggestions for future research are provided.

121 1 Summary y

Inn conclusion, this thesis presents one of the largest prospective studies ever conducted too establish the prevalence of occasional, recreational, regular, potential problematic and pathologicall gambling at the community level investigating one specific game of chance, i.e. scratchcards.. The studies presented provide strong scientific support that pathological scratchcardd gambling is a rare phenomenon among Dutch adult scratchcard buyers and even moree infrequent for the general adult population in the Netherlands. In addition, the thesis establishess the validity of the Dutch version of the SOGS as a screener for pathological gamblingg in the general population. The thesis also represents a valuable contribution to the growingg understanding of the role that the severity of gambling-related problems may have in differentt life domains, and provides a suitable clinical and research tool (the GPSS) to properlyy assess the nature and severity of these problems as well as the effects of different treatmentt interventions.

122 2 Samenvatting g

SAMENVATTING1 1

Kraslotenn zijn in de afgelopen twintig jaar geïntroduceerd in meer dan veertig landen. In Nederland werdd deze introductie (in 1994) voorafgegaan door heftige debatten over de mogelijke negatieve effectenn van krasloten zoals overmatig gokken en gokverslaving. De tegenstanders van de introductie vann krasloten wezen op de kenmerken van het spel die het verslavingsrisico verhogen zoals de laagdrempeligheid,, de snelle uitbetaling en de 'bijna prijs'-loten. Op basis van bestaande onderzoeksgegevenss (Hoofdstuk 1) blijken er echter nog onvoldoende empirisch gegevens te zijn om nardee conclusies te kunnen trekken over het verslavingsrisico van krasloten. Het eerste doel van dit proefschriftt is dan ook om middels wetenschappelijk onderzoek naar de mogelijke negatieve effecten vann krasloten deze empirische gegevens te verzamelen en op basis van deze gegevens vast te stellen in welkee mate krasloten verslavend zijn en/of overlast voor de samenleving veroorzaken (Deel II, Hoofdstukkenn 2, 3 en 4). Echter, het is onmogelijk om vast te stellen in hoeverre een gokspel verslavendd is zonder deugdelijke screenings en diagnostische instrumenten. Het tweede doel van dit proefschriftt richt zich daarom op de onderzoeksinstrumenten en omvat de validering van de South Oakss Gambling Screen (SOGS) in een bevolkingsonderzoek en de ontwikkeling van een nieuw instrumentt waarmee de ernst van gokproblemen kan worden vastgesteld (Deel III, respectievelijk Hoofdstukk 5 en 6). Voorafgaand aan de uitwerking van de beide onderzoeksdoelen wordt in het kort eenn overzicht gegeven van de historische, sociale en juridische context van het gokken (Deel I, Hoofdstukk 1).

Deell I. Introductie Hoofdstukk 1 is een algemene inleiding. Het hoofdstuk begint met de rol van het gokken in de geschiedenis,, gevolgd door een beschrijving van de huidige situatie en status van het (legale) kansspelaanbodd in Nederland, met name van de krasloterij. Verder worden er enkele belangrijke kwestiess en begrippen besproken ten aanzien van de aard van gokproblemen. De introductie eindigt mett de doelstellingen van het onderzoek en indeling van het proefschrift.

Deell II. Het verslavingsrisico van krasloten Deell II beschrijft het onderzoek naar het verslavingsrisico van krasloten en naar de aard van de kraslot gerelateerdee problemen in Nederland. Voor dit onderzoek werd een grootschalige sociaal- epidemiologischee studie uitgevoerd onder 12222 volwassen kraslotkopers in Nederland. Het onderzoekk bestond uit drie fases: een prevalentiestudie (Hoofdstuk 2), een incidentiestudie (Hoofdstuk 3)) en een kwalitatieve studie (Hoofdstuk 4). Voor de definitie van 'pathologisch krassen / kraslotverslaving'' werd in alle drie de studies gebruik gemaakt van de DSM-TV-criteria voor pathologischh gokken, vastgesteld met behulp van de Diagnostic Interview Schedule (DIS-T, APA 1994). . Hoofdstukk 2 presenteert de resultaten van de eerste onderzoeksfase: een cross-sectionele prevalentiestudie.. In dit onderzoek werd een inschatting gemaakt van het verslavingsrisico van kraslotenn door het vaststellen van de 1-jaars prevalentie van incidentele (71.61%), regelmatige (25.71%),, problematische (2.44%), en pathologische (0.24%) deelname aan de krasloterij onder volwassenn kraslotkopers, vijf jaar na de introductie van dit kansspel in Nederland. Van de pathologischee kraslotspelers bleek eenderde deel (0.09%) uitsluitend aan krasloten verslaafd te zijn en

11 Translated from the English by Hans Kronemeijer and edited by Maarten Koeter.

123 3 Samenvating g

tweederdee deel (0.15%) daarnaast ook aan andere vormen van gokken. Op basis van deze resultaten wordtt geconcludeerd dat het verslavingsrisico van krasloten in Nederland, bescheiden is. Hoofdstukk 3 beschrijft de resultaten van de tweede fase van het onderzoek. Deze incidentiestudiee richtte zich op de temporele stabiliteit van kraslotverslaving gedurende een fbllowup- periodee van twee jaar. Uit kosteneffectiviteitsoverwegingen werden uitsluitend kraslotkopers in dit onderzoekk gevolgd die in de eerste fase al enige kraslotgerelateerde problemen meldden (n=201). De twee-jaarss cumulatieve incidentie van kraslotverslaving was eveneens 0.24%. De stabiliteit van pathologischh krassen bleek laag te zijn en lag tussen de 11.1 en 42.9%. Dat wil zeggen dat zelfs in het meestt negatieve scenario meer dan de helft van de gokverslaafden twee jaar na de eerste meting niet meerr voldeed aan de (aangepaste) DSM-IV-criteria voor pathologisch krassen. Op grond van deze gegevenss over de stabiliteit en de incidentie kan de aangepaste (1-jaars) prevalentie van kraslotverslavingg onder kraslotkopers worden geschat op 0.23 tot 0.33%. Dat alles bij elkaar betekent datt er weliswaar regelmatig nieuwe kraslotverslaafden bijkomen (incidentie), maar dat anderen hun verslavingg weer kwijtraken, met als gevolg een stabiele en lage prevalentie. Op grond van dit onderzoekk blijkt kraslotverslaving dus een tamelijk zeldzaam (0.24%) verschijnsel te zijn onder volwassenn kraslotspelers in Nederland en nog zeldzamer (0.046%) onder de gehele volwassen bevolkingg van Nederland. Hoofdstukk 4 presenteert de laatste, kwalitatieve fase van het onderzoek. Op basis van diepte- interviewss werd vastgesteld wat het DSM-IV-criterium 'klinische significantie' voor consequentie heeftt voor het aantal fout-positieve diagnoses van 'pathologisch krassen' en wat de consequenties hiervann zijn voor de diagnostische validiteit van de DSM-IV symptoomcntena Van de respondenten diee in de prevalentiestudie voldeden aan de DSM criteria voor kraslotverslaving was een aantal (n=10) bereidd om aan een diepte interview mee te doen. De belangrijkste uitkomst hiervan was dat slechts 40%% van de verslaafden aan (uitsluitend) kraslotspelen voldeed aan de voorwaarde van klinische significantie.. Dit betekent dat het eerder genoemde prevalentiecijfer (0.09%) van 'unieke' kraslotverslavingg onder Nederlandse kraslotspelers waarschijnlijk nog een forse overschatting is van dee werkelijke prevalentie.

Deell III. Het meten van gokproblemen Deell III van dit proefschrift heeft betrekking op het meten en beoordelen van gokproblemen in het algemeenn (dus niet meer alleen kraslot gerelateerde problemen). De twee hoofdstukken in dit deel behandelenn achtereenvolgens de identificatie van personen met gokproblemen (Hoofdstuk 5) en het metenn van de ernst van deze problemen (Hoofdstuk 6). Hoofdstukk 5 beschrijft de validering van de Nederlandse versie van de South Oaks Gambling Screenn (SOGS) als screener voor pathologisch gokken volgens DSM-ffl-R criteria. In dit onderzoek wordtt gebruik gemaakt van een steekproef van 5830 Nederlanders in de leeftijd van 12 tot 35 jaar. De uitkomstt hiervan is dat de Nederlandse versie van de SOGS een valide screener blijkt te zijn voor pathologischh gokken in de Nederlandse bevolking. Als gevolg van de relatief lage prevalentie van gokverslavingg in de algehele bevolking leidt het gebruik van de SOGS ondanks zijn goede sensitiviteit enn zeer goede specificiteit tot een flinke overschatting van de prevalentie in bevolkingsonderzoeken. Dee prevalentieschatting op basis van een gestructureerd diagnostisch interview bleek ongeveer 40% lagerr te zijn dan de schatting op basis van de SOGS. Deze uitkomst is in overeenstemming met andere onderzoekenn die eveneens concluderen dat bevolkingsonderzoeken waarbij alleen de SOGS wordt gebruiktt leiden tot overschatting van de prevalentie ten opzichte van onderzoeken met behulp van diagnostischee interviews.

124 4 Samenvatting g

Hoofdstukk 6 beschrijft de ontwikkeling van een nieuwe ernst-vragenlijst, de 'Gambling Problemss Severity Scale' (GPSS). Dit instrument combineert de uitkomsten van wetenschappelijk onderzoekk met ervaringen uit de klinische praktijk ten aanzien van de ernst van gokproblemen. Bij het testenn van de GPSS werd gebruik gemaakt van 636 volwassen uit verschillende steekproefgroepen die tezamenn het gehele ernstspectrum op het gebied van gokproblemen bestreken. De resultaten bevestigenn de uitstekende psychometrische eigenschappen van de GPSS waarbij zowel de gehele schaall als de subschalen voor elk van de vier leefgebieden in overeenstemming zijn met het Rasch Model.. Zodoende biedt de GPSS aan behandelaars de mogelijkheid om hun behandelingen af te stemmenn op individuele cliënten, om vast te stellen op welke gebieden het meest hulp nodig is, om de effectenn van hun behandeling te meten en om de resultaten van behandelmethoden op verschillende gebiedenn te vergelijken. Verder verschaft de GPSS aan onderzoekers de mogelijkheid om vast te stellenn of er een verband is tussen de ernst en aard van de gokproblemen enerzijds en de verschillende soortenn gokspellen anderzijds.

Deell IV. Discussie Hett vierde en laatste deel (Hoofdstuk 7) van het proefschrift bevat de 'discussie'. Hierin worden de belangrijkstee onderzoeksresultaten ten aanzien van de verslavingsrisico's van krasloten en ten aanzien vann het gebruik van de meetinstrumenten (SOGS en GPSS) met elkaar gecombineerd. Daarnaast wordenn nog enkele methodologische kwesties besproken die van belang zijn bij het interpreteren en generaliserenn van de resultaten. De mate waarin kraslotgokken schadelijk is voor de volksgezondheid wordtt in perspectief gezet door een vergelijking met de effecten van twee potentieel verslavende middelen,, de ene met eveneens een lage prevalentie (heroïnegebruik <1%), de andere met een hoge prevalentiee (alcoholconsumptie 86%). Op basis van deze vergelijkingen wordt de conclusie getrokken datt de maatschappelijke schade van gokken met krasloten laag is. Tenslotte volgen er nog een paar aanbevelingenn voor het gokbeleid en suggesties voor verder onderzoek. Hett kraslotonderzoek dat voor dit proefschrift is uitgevoerd vormt een van de meest uitgebreidee prospectieve studies ooit naar de prevalentie van incidenteel, regelmatig, problematisch en pathologischh gokken met één specifiek gokspel in de algemene bevolking. Het onderzoek toont duidelijkk en op wetenschappelijk verantwoorde wijze aan dat kraslotverslaving een zeldzaam verschijnsell is onder volwassen Nederlandse kraslotspelers en nog zeldzamer onder alle Nederlandse volwassenen.. Tevens is de validiteit vastgesteld van de Nederlandse versie van de SOGS als screener voorr gokverslaving in de algemene bevolking. In het proefschrift wordt een bruikbaar klinisch- en onderzoeksinstrumentt (de GPSS) gepresenteerd waarmee de aard en ernst van problemen en de effectenn van verschillende behandelmethoden kunnen worden gemeten. Dit instrument kan onze kenniss over de relatie tussen (de ernst van) gokproblemen en de effecten daarvan op verschillende leefgebiedenn vergroten.

125 5 Resumen n

RESUMEN1 1

Lass loterias instantaneas o "raspaditas" han sido introducidas en las dos ultimas décadas en mass de cuarenta paises. La comercialización de este tipo de loterias en los Paises Bajos fiie precedidaa de una fiierte polémica relacionada con los posibles efectos negativos que la legalizationn de esta nueva forma de juego podria producir en la sociedad en términos de juego excesivoo y/o ludopatia. Los oponentes de la implantation de las loterias instantaneas alegaron comoo argumento las caracteristicas estructurales de este juego como potencialmente adictivas. Entree estas caracteristicas se encuentran: su facil acceso, la posibilidad de poder jugar de formaa continuada y los Uamados "casi premio" (near misses). En base a los estudios disponibless (Capitulo 1) puede concluirse que no existe aün evidencia empirica suficiente paraa poder sacar conclusiones sobre el caracter adictivo de las loterias instantaneas. El objetivoo de esta tesis es, por tanto, evaluar a nivel cientifico los posibles efectos negativos que estee tipo de loterias puedan tener en la sociedad holandesa (Parte II, Capitulos 2, 3 y 4). Como laa evaluación del caracter adictivo de un juego no puede realizarse sin la utilización de instrumentoss de medida adecuados, el objetivo secundario de esta tesis es la investigation de algunoss problemas aün sin resolver en la evaluación de los problemas del juego. En concreto, laa validation del "Cuestionario de Juego Patológico South Oaks" (SOGS, "South Oaks Gamblingg Screen") en población general y la creation de un nuevo instrumento de medida quee sea capaz de evaluar la severidad de los problemas relacionados con el juego (Parte JU, Capituloss 5 y 6, respectivamente). Pero antes de desarrollar los ya mencionados objetivos de estaa tesis es necesario enmarcar los problemas asociados al juego dentro de un contexto histórico,, social y legal (Parte I, Capitulo 1).

Partee L Introduction Ell capitulo 1 presenta una breve introducción de caracter general que ilustra el papel que los juegoss de azar han tenido a lo largo de la historia. Asimismo, se describe la situation legal de loss distintos juegos de azar en los Paises Bajos, particularmente los relacionados con las loteriass instantaneas y se revisan algunos conceptos importantes que ayudan a clarificar la naturalezaa de los problemas relacionados con los juegos de azar. Finalmente, este capitulo introductorioo sintetiza los objetivos y la estructura de esta tesis.

Partee II. El Potencial Adictivo de las Loterias Instantaneas J-aa Parte JJ investiga el potencial adictivo de las loterias instantaneas y la naturaleza de los problemass asociados a este juego de azar dentro del contexto holandés. Con este objetivo, se disefióó un estudio socio-epidemiológico a gran escala de caracter prospectivo en los Paises Bajos.. En este estudio, que fue organizado en tres fases, se empleó una muestra no proporcionalmentee estratificada a nivel national que incluyó 12222 adultos compradores de loteriass instantaneas. En la primera fase, se estimó la prevalencia de los problemas relacionadoss con las loterias instantaneas (Capitulo 2), en la segunda fase, se estimó la

11 Editado por Vanesa Gongora.

126 6 Resumen n incidenciaa del juego patológico asociado a esta forma de juego (Capitulo 3) y, en la ultima de lass fases, se realizó un estudio cualitativo (Capitulo 4). En esta tesis, el juego patológico asociadoo a las loterias instantaneas fue definido conforme a los criterios especificos del diagnósticoo presentados en el "Manual Diagnóstico y Estadistico de los Transtornos Mentales"" (DSM-IV) bajo la entidad nosológica de "juego patológico" (APA 1994). Ell Capitulo 2 describe los resultados de la primera fase de este estudio. El principal objetivoo de esta fase fue obtener una estimación valida del potencial adictivo de las loterias instantaneass estableciendo la prevalencia del juego en el ultimo afio a nivel ocasional2 (71.61%),, recreacional (25.71%), problematico (2.44%) y patológico (0.24%) en una muestra representativaa de jugadores adultos de loterias instaneas. Esta medida se realizó cinco aflos despuéss de la introducción de este juego en los Paises Bajos3. Dentro del grupo identificado comoo jugadores patológicos se encontró que un tercio (0.09%) eran exclusivamente adictos a lass loterias instantaneas, mientras que los otros dos tercios (0.15%) eran adictos también a otross juegos de azar. En base a los resultados encontrados en esta fase puede concluirse que lass loterias instantaneas tienen un bajo poder adictivo en la población adulta de los Paises Bajos. . Ell Capitulo 3 integra los resultados de la segunda fase de este estudio socio- epidemiológico.. En esta fase de incidencia, se investiga la estabilidad temporal de la patologia presentadaa por los jugadores patológicos durante un periodo de seguimiento de dos aflos. Con estee objetivo se aplicó un diseflo costo-efectivo a aquellos compradores de loterias instantaneass (n=201) que manifestaron algun tipo de problema a consecuencia de su participaciónn en las mismas en Ia fase de prevalencia. La estimación de la incidencia acumuladaa durante estos dos aflos también fue baja 0.24%. Durante este seguimiento se demostróó que la estabilidad de la patologia "juego patológico" aplicada a las loterias instantaneass era también baja (entre 11.1 y 42.9% -considerando el mejor y el peor de los casoss respectivamente). Lo que quiere decir, que incluso en el peor de los casos, mas de la mitadd de los jugadores patológicos de loterias instantaneas, que füeron identificados durante laa fase de prevalencia, no satisfacen el mismo criterio de diagnóstico dos aflos después. Si combinamoss estas dos estimaciones, la estabilidad de la patologia y la incidencia de nuevos casoss durante los dos aflos de seguimiento, se puede estimar que la prevalencia ajustada de juegoo patológico durante el ultimo aflo se encuentra entre 0.23 y 0.33%. Estas estimaciones indicann que, aunque a través del tiempo, aparecen nuevos casos de juego patológico (incidencia),, otros jugadores se recuperaran de su patologia, haciendo que la prevalencia sea establee y baja. Los resultados del presente estudio muestran que el juego patológico asociado

22 Jugadores ocasionales fueron aquellos que compraron £ 10 loterias instantaneas al mes, recreacionales aquellos quee compraron > 10 loterias instantaneas en el mes anterior a la evaluation y que ademés las llevaran jugando porr mis de 6 meses. Los jugadores de loterias instantaneas potencialmente probleméticos fueron aquellos que tuvieronn £ 3 puntos en el test SOGS-S y jugadores patológicos de loterias instantaneas son los que cumplieron el criterioo del DSM-IV para juego patológico aplicado a loterias instantaneas. 33 En contraste a lo presentado en el estudio de prevalencia, aqui los porcentajes de jugadores ocasionales, recreacionales,, potencialmente probleméticos y patológicos fueron considerados mutuamente excluyentes y por loo tanto su sumatoria equivale a 100% Si se les considera mutuamente incluyentes los porcetajes en los distintos gruposs de jugadores seria los siguientes: 71.61% ocasionales, 28.4% regulates, 2.68% potencialmente probleméticoss y 0.24% patológicos, consecuentemente su sumatoria excederia 100%

127 7 Resumen n

aa las loterias instantaneas, es un fenómeno raro entre los compradores en la población adulta holandesaa (0.24%), e incluso mas infrecuente si consideramos la población general adulta (0.046%). . Ell Capitulo 4 presenta la fase cualitativa de este estudio sobre la base de entrevistas en profundidadd con los objetivos de: explorar los efectos del criterio de "significancia clinica" dell DSM-IV, estimar el numero de falsos positivos en el diagnóstico de jugadores patológicos dee loterias instantaneas e investigar sus consecuencias, en la validez del diagnóstico de los criterioss del DSM-IV "juego patológico" aplicados a loterias instantaneas. Se entrevistó a aquelloss sujetos que cumplieron los criterios del DSM-IV "juego patológico" a las loterias instantaneass durante la fase de prevalencia y que accedieron a ser entrevistados y dieron permisoo para grabar las entrevistas (n=10). De este capitulo, se puede concluir que solo el 40%% de los jugadores patológicos, adictos exclusivamente a las loterias instantaneas, cumpliann el criterio de significancia clinica del DSM-IV. Como consecuencia, la prevalencia dee jugadores patológicos exclusivamente adictos a las loterias instantaneas presentada anteriormentee (0.09%) es probablemente una sobreestimación de la prevalencia real.

Partee DL La medida de los problemas relacionados con los juegos de azar Laa Parte HI de esta tesis trata de resolver algunas de las cuestiones relacionadas con la evaluaciónn de los problemas de los juegos de azar. El objetivo de los dos capitulos presentadoss en esta sección es: la identificación de los sujetos que sufren problemas a consecuenciaa de los juegos de azar (Capitulo 5) y la medida de la gravedad o severidad de dichoss problemas (Capitulo 6). Ell Capitulo 5 describe la validación de la version holandesa del test de "Juego Patológico dee South Oaks" (SOGS) comparandolo con el criterio del diagnóstico del DSM-III-R. Con estee objetivo, se seleccionó por medio de un disefio en dos fases una muestra de la población holandesaa constituida por 5.830 sujetos entre 12 y 35 aflos. Los resultados indicaron que la versionn holandesa del SOGS puede ser utilizada en la identificación de problemas relacionadoss con los juegos de azar en la población general. Sin embargo, debido a la baja prevalenciaa del juego patológico en la población general, el SOGS sobreestima considerablementee la prevalencia de dicha patologia en dicha población. La prevalencia estimada,, con el criterio del DSM-IU-R, fue aproximadamente un 40% mas baja que la calculadaa con el SOGS. Estos resultados sugieren que todos los estudios llevados a cabo en poblaciónn general y que han utilizado el SOGS estan sobreestimando la verdadera prevalencia dell juego patológico en comparación con la obtenida a través de una entrevista de diagnóstico. . Ell Capitulo 6 presenta el desarrollo de un nuevo cuestionario para evaluar la severidad dee los problemas relacionados con los juegos de azar, el "Gambling Problems Severity Scale" (GPSSS -la Escala de Severidad de Problemas con el Juego-). Este nuevo instrumento integra loss conocimientos actuales sobre la severidad de los problemas relacionados con el juego en laa literature cientifica y los recogidos de la experiencia clinica adquirida por los profesionales especializadoss en esta patologia. Con el objetivo de desarrollar y evaluar el cuestionario GPSSS fiie seleccionada una muestra heterogénea de 636 adultos. Los resultados sefialaron que

128 8 Resumen n ell GPSS posee excelentes cualidades psicométricas satisfaciendo el modelo de Rasch en toda laa escala y en cada una de las cuatro sub-escalas. Por lo tanto, el GPSS es una herramienta que puedee permitir a los profesionales ajustar sus tratamientos a las necesidades individuales de cadaa cliënte, evaluar las carencias funcionales mas importantes en las distintas areas de la vida yy medir los efectos de sus intervenciones en la severidad de la problematica. Ademas, el GPSSS puede ayudar a los investigadores a establecer si la severidad y la naturaleza de los problemass con el juego estan relacionados con el tipo de juego de azar al que el cliënte es adicto. .

Partee IV. Discusión General Laa parte cuarta y final de esta tesis presenta la discusión general. El Capitulo 7 integra los resultadoss mas importantes de esta tesis, relacionados con el potencial adictivo de las loterias instantaneass y el uso de dos instrumentos de medida para evaluar la prevalencia (SOGS) y la severidadd (GPSS) de los problemas asociados a los juegos de azar. Se mencionan también distintoss aspectos metodológicos que son importantes a la hora de interpretar y extrapolar los resultadoss de estos estudios. La valoración del impacto de las loterias instantaneas, a nivel de laa salud püblica, se realiza comparando los efectos de las mismas con los de otros dos fenómenoss adictivos, uno de baja prevalencia (el uso de heroina <1%) y otro de alta prevalenciaa (consumo de alcohol 86%). Basados en estas comparaciones, se puede concluir quee el impacto social de las loterias instantaneas es bajo. Finalmente, se presentan los resultadoss desde la perspectiva de la salud püblica y se dan distintas recomendaciones para futuross estudios e investigaciones. Enn conclusion, esta tesis presenta uno de los estudios prospectivos mas grandes llevadoss a cabo para establecer la prevalencia del juego de las loterias instantaneas a nivel ocasionaL,, recreational, potencialmente problematico y patológico. Los estudios presentados proveenn un fuerte soporte cientifico de que el juego patológico provocado por las loterias instantaneass es un fenómeno raro entre los compradores adultos en Holanda y atin menos frecuentee entre la población general de los Paises Bajos. Esta tesis establece también la validezz de la version holandesa del SOGS como un test valido para identificar el juego patológicoo en la población general. Finalmente, aporta un valioso instrumento a nivel clinico yy de investigación (el GPSS) para evaluar la naturaleza y la severidad de los problemas relacionadoss con los juegos de azar.

129 9 Acknowledgements s

ACKNOWLEDGEMENTS S Thee completion of this thesis would not have been possible without the contribution of many people.. Now it is the time to thank all of those who have influenced and contributed to this process. Unfortunately,, it is impossible to mention everybody in a single page. Therefore, I would first like to thankk all those who I am not going to mention here, but that surely have supported and encouraged me,, either in my professional development or in my daily life. Thiss thesis would not have been possible without the contribution of the 12,222 participants, the manyy shopkeepers, and the NIPO interviewers coordinated by C. Janssen and F. van der Horst. Further,, I would like to thank "De Lotto", not only for funding this project but also for the informationn that T. Veenstra and E. van Zon provided us during these years. Of course, my thanks also too the Supervising Board, that is the representatives of the addiction treatment centres and the Ministriess of Health, Welfare and Sport and Justice, who warranted the scientific independence of this project.. Additionally, I would like to thank: Prof. Hoogduin for his valuable comments in the developmentt of the research protocol; A. Benschop for all the work that she invested at the beginning off this project; Prof. Bethlehem for his advice and assistance in the complex sampling design on the prevalencee and incidence phases; and D. Borsboom for taking care of the Rasch analyses. Thankss to my promoters and co-promoter, who offered me the chance to take over this project, andd gave me all the support, motivation, patience, criticism and experienced advice that led to this manuscript.. From you I got more than I could summarise in just a few lines. Wim van den Brink, I am stilll impressed with the thorough way in which you went through all the papers: "short, sharp and smart".. Your comments seriously contributed to the quality of the final product. Gerard Schippers, thankss a lot for always being there, making sure that I did not lose myself in the details and that the paperss had a general line and structure. Maarten Koeter, if I have to describe the quality of your day- to-dayy supervision in psychometric terms, based on, of course, continuous confirmatory analyses, I wouldd just say that it was excellent, with a very high validity and reliability (including weekends!). In short,, the three of you were my "dream team" and working with you has been a pleasure and a great learningg experience. Thanks a lot! II would like to specially thank Prof. Van der Staak and Prof. Schaap for giving me the opportunityy to come to the Netherlands and work at the KUN, and all the colleagues that I met there. Manyy thanks also to my colleagues at the Amsterdam Institute for Addiction Research and at K&II for making a "gezellig" and inspiring working environment. Special thanks to Hans Kronemeijer forr his editorial comments and kind, continuous assistance with my "small computer" problems, to Udoo Nabizt for his nice e-mail support, and to Andrea van der Pouw and Bep de Lange for all their helpp during the preparations of this PhD thesis. My thanks also go to the members of the JOO ("Junior Onderzoekss Overleg") for their fruitful comments on the draft of these papers and for sharing their methodologicall and scientific struggles. AA very big thanks to all my Spanish friends and colleagues, and to Pieter, Edith and Machteld forr their help and Dutch friendship. Eva and Vanesa, my dear "paranimfs", thanks a lot for always beingg by my side and giving the support and advice that I was looking for. Lastt but certainly not least, I would like to thank my parents, Hemi y Miguel Angel, because theyy were the first to encourage me to learn and who have supported and stimulated every decision in myy life. Moreover, they have also given me the best present I could wish for, two wonderful brothers, Diegoo and Fernando, of whom I am very proud. Guido,, there are many things I can thank you for because you are always supporting and have sharedd in all the decisions, even though that sometimes meant that you were alone when I was working onn this manuscript. Thanks for always checking with love whether I was "working hard or hardly workingworking ". 130 0 Aboutt the author

ABOUTT THE AUTHOR

Lauraa De Fuentes-Merillas was born in Valladolid, Spain, on the 19th of July 1975. In June 19977 she obtained her degree in Psychology fromth e 'Universidad Pontificia" of Salamanca. During herr psychology studies, she earned a European grant to spend the third year of her studies at the Universityy of Hertfordshire at the Psychology Department in Hatfield. A European post-graduate grant broughtt her to the Netherlands in October 1997 to work as a researcher for HSK being posted at the Departmentt of Clinical Psychology and Personality of the University of Nijmegen. From then on she hass stayed in the Netherlands to conduct research in the fieldo f addictive behaviours. Fromm 1998 until January 2000, she was involved in several alcohol research projects as a researchh fellow at the University of Nijmegen Research Group on Addictive Behaviours (UNRAB). Inn 2000, she was a lecturer in the course on Clinical Psychology and she was also appointed as aa researcher in a smoking cessation project (2000-2002), both at the Department of Clinical Psychologyy at the University of Nijmegen. Also in 2000, she acquired a position as a research fellow att the Department of Quality and Innovation at the Jellinek Clinic (Amsterdam), where she was involvedd in the process of developing treatment protocols for various addictions. Inn November 2000 she was appointed as a research fellow at the Amsterdam Institute for Addictionn Research (ALAR) to conduct a large-scale epidemiological project to evaluate the addictive potentiall of scratchcards, the results of which are described in this thesis. Besides she has been a peer reviewerr for several international journals forgambling-relate d manuscripts. Fromm January 2003 until today, she has combined the completion of this thesis with her appointmentt as coordinator of a European project in Amsterdam aimed to explore, in nine European cities,, the treatment needs of at-risk opiate users and to identify the barriers that prevent diem from enteringg the treatment system (Risk Opiate users Study Europe -ROSE). Currently,, she holds a post-doc position at Novadic-Kentron (Network for Addiction Treatmentt Services) where she, in collaboration with the NISPA (Nijmegen Institute for Scientists- Practitionerss in Addictions) and five treatment clinics, investigates whether the Community Reinforcementt Approach combined with the use of vouchers can be successfully implemented with poly-drugg cocaine users in the Netherlands. In addition, she is completing her post-graduate training to becomee a registered cognitive behavioural therapist.

131 1 PUBLICATIONS S

DeFuentes-Merillas,, L., Koeter, M.W.J., Schippers1 G.M., & Van Den Brink, W. (2004). Temporall stability of pathological scratchcard gambling among adults sciatchcard buyers two years later.. Addiction, 99, 117-127. DeFuentes-Merillas,, L., Koeter, M.W.J., Bethlehem, J., Schippers'G.M., & Van Den Brink, W. (2003).. Are scratchcards addictive?: The prevalence of pathological scratchcard gambling among adultt scratchcard buyers in the Netherlands. Addiction, 98, 725-731. DeFuentes-Merillas,, L., & Koeter, M.W.J. (2002). Are scratchcards addictive?: Two-year cumulativee incidence and stability of pathological scratchcard gambling among Dutch scratchcard buyers.. Amsterdam: The Amsterdam Institute for Addiction Research. DeFuentes-Merillas,, L, DeJong, C.A.J. & Schippers, G.S.(2002). Reliability and Validity of the Dutchh Version of the Readiness to Change Questionnaire, Alcohol and Alcoholism, 37, 93-99. Schippers,, G.M., Aken, M. van, Lammers, S.M.M. & Fuentes-Merillas, L. de (2001).The role off expectations in the socialization of alcohol drinking. In: Houghton, E. & Roche, A. (Eds.) LearningLearning about drinking. International Centre for Alcohol Policies, Washington DC, Schippers,, G.M., Maker, N. & Fuentes-Merillas, L. de (2001). Social skills training, prosocial behaviour,, and aggressiveness in adult incarcerated offenders. International Journal of Offender TherapyTherapy and Comparative Criminology, 45, 244-251. Merillas,, L. & Schippers, GS. (2003). Literatuurstudie: Crisisinterventie. In A. Diepraam & A.M.. Smeerdijk. Crisis Module: Kortdurende Klinische Crisisinteventie. Resultaten Scoren, pp 42- 83. . Schippers,, G. M., & de Fuentes-Merillas, L. (2001). Interventies bij werkenden met alcoholproblemen.. In Handboek Verslaving. Bohn Stafleu Van Loghum, pp B 3060-3-19. Fuentes-Merillas,, L. de & Bijl, D. A. (2000). De relatie tussen alcohol en werk: een literatuuroverzicht.. In J. A. Walburg & Dijk, A. A. van, eds. Alcohol en Werk. Cure & Care, pp 17- 36. . Schippers,, G. M., & de Fuentes-Merillas, L. (2000). Interventies bij werkenden met alcoholproblemen.. In J. A. Walburg & Dijk, A. A. van, eds. Alcohol en Werk Cure & Care, pp 48-61.

Submittedd publications: DeFuentes-Merillas,, L., Koeter, M.W.J., Schippers'G.M., & Van Den Brink, W. (Submitted). Prevalencee of pathological gambling: Validity of the Dutch version of the South Oaks Gambling Screen. . DeFuentes-Merillas,, L.; Schippers'G.M.; Koeter, M.W.J.; & Van Den Brink, W. (Submitted) Clinicall re-evaluation of the DSM-IV criteria applied for pathological scratchcard gambling. Koeter,, M.W.J.; DeFuentes-Merillas, L.; & Borsbcom, D. (Submitted) Clinical re-evaluation of thee DSM-IV criteria applied for pathological scratchcard gambling. Breteler,, M.H.M., DeFuentes-Merillas, L., & Plas, A.G.M. (Submitted) Physician-guided smokingg attempts with the aidd of Bupropion compared to quitting during a mass media campaign in thee Netherlands: Outcome and its predictors.

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