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Review of Problem Gambling and Comorbid Disorders and Behaviours: Final Report

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Review of Problem Gambling and Comorbid Disorders and Behaviours: Final Report Review of problem gambling and comorbid disorders and behaviours: Final Report Nigel E. Turner, Ph.D. Peter Ferentzy, Ph.D. Address for correspondence: Nigel Turner, Ph.D. Social, Prevention and Health Policy Research Department The Centre for Addiction and Mental Health 33 Russell St. Toronto, Ontario, Canada M5S 2S1 Tel: (416) 535-8501 ext 6063; Fax:(416) 595-6899 E-mail: [email protected] Table of Contents Abstract Executive Summary Acknowledgements Introduction Method Literature Reviewed Summary of the papers reviewed Results Part 1: Substance abuse Part 2: Comorbid psychiatric disorders Part 3: Smoking Part 4: Suicide Key informants research Method Part 5: Comorbidity survey of counsellors Appendix 1: Substance abuse – details Appendix 2: Psychiatric comorbidities – details Appendix 3: Smoking – details Appendix 4: Suicide – details Conclusions References Tables Table 1: Type of disorder by type of study Table 2: Means and standard deviations for percentage of problem gamblers who are smokers. Table 3: Summary of Suicidal thoughts and Suicide attempts by the type of study. Table 4: Approach to assessing comorbid disorders (percent). Table 5: Percentage of respondents that scan for various disorders. Table 6: Percentage of agencies that endorse different approaches. Table 7: Treatment approaches and techniques used by each agency. List of appendices Appendix 1: Substance abuse – details Appendix 2: Psychiatric comorbidities – details Appendix 3: Smoking – details Appendix 4: Suicide – details Acknowledgements This report was funded by a grant from the Ontario Problem Gambling Research Centre. In addition, support to Centre for Addiction and Mental Health (CAMH) for salary of scientists and infrastructure has been provided by the Ontario Ministry of Health and Long Term Care (OMHLTC). The ideas expressed are those of the authors and do not necessarily reflect those of either the Ontario Problem Gambling Research Centre, the Centre for Addiction and Mental Health, Correctional Service of Canada (CSC), the Parole Board of Canada, or The University of Toronto. Abstract This paper was initiated in response to an RFA identifying a need to summarize the literature regarding the comorbidities of problem gambling. Currently a lot of information exists on the topic of comorbidities, but it had not been summarized in a convenient manner that would facilitate further exploration in this area. The objective of the proposed study was to provide a review and synthesis of available knowledge on the association between problem gambling and workplace absenteeism, suicide, mental health disorders, and addictions (in particular smoking). In this paper we report on the number of papers that have examined evidence regarding the link between problem gambling and four major areas of comorbidities: (1) smoking, (2) substance abuse, (3) psychiatric comorbidities, and (4) suicide. We were unable to find very much information of work absenteeism. In addition, the project also involved contacting various treatment centres in order to determine the extent to which assessment and/or treatment of problem gambling takes into account comorbid disorders and behaviours. Key words: problem gambling; comorbidity; concurrent disorders; literature review. Executive Summary This paper was initiated in response to an RFA noting a need to summarize the literature regarding the comorbidities of problem gambling. Currently a lot of information exists on the topic of comorbidities, but it has not been summarized in a convenient manner that would facilitate further exploration in this area. The objective of this study was to provide a review and synthesis of available knowledge on the association between problem gambling and workplace absenteeism, suicide, mental health disorders, and addictions (in particular smoking). In this study, we report on the number of papers that have examined evidence regarding the link between problem gambling and four major areas of comorbidity: (1) smoking, (2) substance abuse, (3) psychiatric comorbidities, and (4) suicide. We were unable to find very much information on work absenteeism. In addition, the project involved contacting various treatment centres in order to determine the extent to which assessment and/or treatment of problem gambling takes into account comorbid disorders and behaviours (N = 40). SUD findings. We examined 137 articles on substance abuse. 67 of these studies examined treatment samples. 41 were studies of the general population (e.g., telephone surveys). 17 included other types of samples. High correlations between PG and SUD are well established. The relationship has been shown in PG samples, SUD samples, as well as studies of other clinical populations. PGs with SUD are often more severe cases. Alcohol appears to be the most common SUD amongst gamblers. The percentage of alcoholic comorbidity is particular strong in the US where alcohol is served for free to problem gamblers. Psychiatric Comorbidities We examined a total 116 papers that addressed the relationship between problem gambling and various comorbid psychiatric disorders. 55 were studies of clinical populations. 41 were studies of the general population. 20 were other types of samples. The most frequently studied comorbidity was depression, which was found in 64 of the papers. Nearly all studies that examined depression found a positive relationship with PG. 43 studies examined impulsivity in one form or another; of these 6 examined ADHD. Evidence for bipolar or manic disorder was examined in 14 papers. Anxiety was examined in 34 studies. In nearly all cases the relationship was positive. OCD was examined in 15 studies, but the results were mixed with some studies finding no link. Personality disorders were examined in 19 studies. The most frequently cited personality disorder correlated with problem gambling was antisocial personality disorder. Evidence for comorbidities in general are very strong, but the strength of the findings depends on how many studies examined a particular issue; the link with depression and anxiety for example are well documented, but the evidence is weaker for some other disorders (e.g., ADHD, psychosis). Smoking findings We examined a total of 54 studies examining smoking and PG. 18 studies of clinical samples 26 studies of the general population 9 studies of other types of samples (e.g., recruited through advertisements, prison studies, casino employees) A great deal of our information came from comorbidity studies that did not target smoking directly. Smoking amongst problem gamblers is more common than in the general population. Smoking is also more common among persons with SUD and other comorbid conditions associated with PG, so it would be premature to identify a strict relation between smoking and PG. Suicide In total 51 papers discussed the relationship between gambling problems and suicide. These papers were divided into four general types. We found 8 papers on actual cases of suicides. We found 29 studies that examined suicidal thoughts or suicide attempts with clinical and helpline samples. We found 11 studies of suicidal thoughts in the general population. We found 3 studies of statistics on suicide rates in a given area that examined if suicide rates were higher in areas with casinos. The results depend on whether or not one includes visitors in the population. In most clinical and general population papers a link between suicide and gambling was found. However, a small number of papers reported no link. In the papers reviewed in this study, the average number of problem gamblers reporting suicidal thoughts ranged from 2% to 81% with an average of 39.7% (SD = 22.0%). Suicide attempts ranged from 3% to 40% with an average of 19.4% (SD = 12.9%). Clinical studies reported higher levels of suicidal thoughts and suicide attempts than general population studies. Survey results The results of the counsellor survey found that counsellors take a variety of approaches in dealing with problem gambling. Nearly all of the counsellors reported scanning1 for suicidal thoughts, depression, drug abuse and alcohol abuse. Very few reported scanning for ADHD. 1 Counselors do not necessarily use a formal screen, but will scan for signs of disorders during their assessment or treatment procedures. Most have specific plans for dealing with comorbidity and they take an individual approach to dealing with the problem. The most common approach was to refer the client to a specialist or other agency. All of the respondents endorsed teaching coping skills, relapse prevention, motivational interviewing, and solution focused problem solving. Twelve step and spiritual approaches were endorsed least often.. Summary The results indicate that problem gambling is related to a number of psychiatric comorbidities. Genetic and longitudinal twin research suggests that some of this comorbidity is linked to genetic vulnerability. The most common comorbidities appear to be alcoholism, nicotine dependence, and depression. It is likely that the cause and effect relationship for these various disorders is complex with some coming before problem gambling, and others resulting from the consequences of problem gambling. Comorbidities represent a very vulnerable population for developing problem gambling as well as a variety of other disorders. More research is needed to determine cause and effect relationships Introduction Purpose The purpose of this study was to organize and summarize information
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