ABSTRACT

Aim: To identify co-morbid disorders of problem gamblers and their use of GPs.

Method: Data from 50 diagnosed pathological gamblers seeking help from a specialist gambling clinic were analysed for degrees of depression, anxiety, alcohol abuse, and reasons for presentation to their GPs during the 12 month period prior to first attending the gambling clinic.

Results: Elevated depression (22 per cent severe), anxiety, alcohol use (24 per cent hazardous, 32 per cent probably dependent) was found. Only one gambler had disclosed a gambling problem to his GP. Of the 28 pathological gamblers who presented to a GP in the preceding 12 months, 25 per cent presented for anxiety related reasons, 18 per cent for depression, and others for stress problems possibly associated with their gambling. Problem gamblers' presentations to their GP exceeded general population presentations for anxiety and depression related reasons.

Conclusion: GPs may be providing treatment for symptoms of a presenting disorder without awareness of the underlying gambling problem. GPs could screen and intervene for problem gambling.

• Problem gamblers may present to their GPs for depression and anxiety disorders rather than the underlying gambling problem
• GPs can be a suitable first intervention point for problem gamblers
• Alcohol abuse is common amongst problem gamblers
• The estimated problem gambling prevalence of 3 per cent may be increasing with increased gambling opportunities

INTRODUCTION

Pathological gambling is a progressive disorder that develops from occasional lapses in control of time or money spent, to a pathology that results in destructive behaviour that affects both the gambler and his or her family, and is generally accompanied by alcohol abuse, anxiety, mood and personality disorders (1,2,3).

The current prevalence of pathological gambling is generally estimated at between 1 per cent and 3 per cent of the adult population, while a nation-wide New Zealand study previously estimated the prevalence at 1.2 per cent with a further 2.1 per cent exhibiting some problem gambling behaviour (1,4,5).

However the incidence of this disorder may be increasing as a result of the worldwide trend of growth in the gambling industry (5) and may be more rapidly acquired than most other addictions (6).

METHODS

Data was collected from the assessment of 50 problem gamblers self-presenting for the first time to the Problem Gambling Foundation (formerly the Compulsive Gambling Society of New Zealand Inc, 'CGS'), a specialist voluntary treatment provider for problem gambling, at their day treatment clinic in Auckland.

From a random date in the latter part of 1995, all presenting gamblers thereafter contributed data until a total of 50 sets was reached. The gamblers provided relevant information (demographics, health) and completed the clinic's usual screens for gambling problem severity, depression, anxiety, and alcohol abuse followed by an assessment session with a psychologist or an addiction therapist.

Screening Tests
The following screens were used:

1. The South Oaks Gambling Screen (SOGS) (7)
2. The South Oaks Gambling Screen (SOGS) (7)
3. Spielberger State Trait Anxiety Inventory (STAI):  A shortened version of the STAI was employed to meet time restraints (9)
4. The Beck Depression Inventory (BDI) (10)

Additional information obtained included whether the gambler had attended their doctor in the previous 12 month period and the general purpose of the visit/s. Rate of presentation and reason for attending their GP were compared with similar data from a large New Zealand survey (11).

Previous research has indicated that problem gamblers are careless of their health needs and are unlikely to volunteer problems around gambling, either because of a failure to associate the behaviour with their health, or because of feelings of shame or guilt (12,13).

Males appear to be at greater risk for gambling pathology at the ratio of four to one (1,4) and the gender proportion of subjects chosen during the randomly selected period appeared to support this contention.

Table 1: Alcohol, depression and anxiety screen results of diagnosed pathological gamblers attending an outpatient gambling treatment clinic (n=50) compared with pathological gamblers identified in a New Zealand general population study (Abbott & Volberg, 1992)

RESULTS

Nine female (18 per cent) and forty one male (82 per cent) problem gambles completed the screens and assessments, with the average age for each being similar (female 31.8 years, male 32.8 years). All 50 presenting gamblers were assessed by trained clinicians as meeting the DSMIV criteria for pathological gambling. (1) All female gamblers disclosed a problem with video gambling machines, while males disclosed more variation with 56.1 per cent having similar problems with video gambling machines, 31.7 per cent with horse gambling, 9.8 per cent with both gambling machines and horses, and one with instant scratch tickets. Gamblers were generally specific in their gambling preference.

Ninety six per cent of the gamblers regularly purchased Lotto (state lottery tickets) compared with the general population where 32 per cent purchase tickets weekly, and 60 per cent at least monthly (14).

Screen results for alcohol use, depression and anxiety were categorised as to severity for male and female gamblers, and compared with an earlier epidemiological study of the general population (13) (Table 1).

Alcohol usage was high, and in 32 per cent of the gamblers (32 per cent males, 33 per cent females) met the criteria in the Audit screen for probable alcohol dependence, with a further 24 per cent meeting the criteria for hazardous alcohol consumption. This use of alcohol by pathological gamblers supported the findings of the earlier general population study13, with no difference found between pathological gamblers' alcohol use in this and the previous study (X21=.21, p=.65).

Some gamblers (n=5) recording low scores disclosed in the subsequent counselling session that they had previously had problems with alcohol and had ceased drinking after attending Alcoholics Anonymous or treatment programmes. However this inquiry was not pursued for all respondents with low Audit scores.

Beck depression scores averaged 12.4 for males and 11.6 for females (moderate range 8 to 15), with 22 per cent of both male and female gamblers meeting the screen level of severe depression. Depression screen scores were significantly higher for the clinic subjects (X22=34.7, p<.0001) when compared with those pathological gamblers identified in the earlier general population study (13).

Anxiety scores (STAI) were high, with 51 per cent of males and 44 per cent of females scoring in the 90th percentile or above of the most anxious members of society (trait anxiety), with current exhibited (state) anxiety high at the time of presentation (44 per cent of both male and female gamblers scored in the 90th or above percentile).

The very high trait anxiety scores were supported in subsequent assessment sessions. Reports of panic attacks (with or without agoraphobia) were common. Inability to concentrate, intolerance of boredom, and polarised emotions were disclosed, with suppressed anger and fear the most common emotion reported. Heavy smoking behaviour was the norm amongst most gamblers.

Suicidal ideation was high, with 56 per cent of females and 60 per cent of males reporting having at least considered suicide as a solution to their gambling problems, and 10 per cent of males and 11 per cent of females reporting having attempted suicide stating gambling problems as the reason. Suicidal ideation was seldom disclosed voluntarily, and a screen question asking for details around such thoughts was followed by further questions during the assessment.

Those with high anxiety and/or depression were encouraged to present to their GP for advice regarding medication and eight of 20 reporting attending.

Attitudes commonly expressed regarding reluctance to consider medication for anxiety and depression were discussed and gamblers were asked to consider medication as a temporary tool that would accompany counselling, and that might expedite recovery. Fear of becoming reliant on medication, of being perceived as 'mentally ill', and of side effects of medication were all addressed during this assessment session, and were re-addressed in subsequent sessions if the gambler had not presented and still appeared to be suffering from stress or depression.

Pathological gamblers reported attending their GPs within the previous 12 months at a lower rate that the general population (56 per cent vs 79 per cent15), but presenting problems rated high in stress and depression when compared with the WaiMedCa study11 (Table 2).

One gambler disclosed a gambling problem to his GP, seven reported presenting for anxiety, stress or nervousness, while five reported attending for depression.

Other presenting problems included headaches/tiredness, feeling run down, skin rashes, asthma and migraine.

Table 2: A comparison of self reported presenting disorders of problem gamblers to their GPs during the 12 months prior to seeking assistance at a specialist gambling clinic, and rates of GP identified disorders of patient/GP encounters in a general patient study (WaiMedCa11)

* number of surgery presentations ranged from 1 to 25
** no similar category

DISCUSSION

The majority of the pathological gamblers sampled exhibited alcohol abuse or dependence, high levels of anxiety, depression and suicidal ideation.

Alcohol Abuse
The rate of alcohol abuse in the clinic sample was high, but regarded by gamblers as unrelated and inconsequential compared with their gambling. The perception seemed to be that such concern was effectively 'labelling' them with an additional problem, a further insult to their self-esteem, and that alcohol abuse or dependence was a 'lesser' disorder for which they had not presented. It was uncommon for those who scored as hazardous or possibly dependent drinkers to consume alcohol in quantity during gambling sessions (often stating it dulled the effect, or interfered with the concentration required), but instead they tended to resort to alcohol after such sessions. When referral for alcohol use counselling was covertly or overtly resisted over time, information and alcohol counselling was introduced into sessions.

Anxiety
The high levels of anxiety indicated by the screen in almost half of the pathological gamblers was often not apparent until a history was taken prompted by screen results. Anxiety may have contributed to a reluctance to disclose a gambling problem to their doctor. Only one gambler in the study had advised his doctor, and reluctance to seek help for gambling problems has been previously reported. (13)

Depression
Severe depression scores were evident in almost one in four problem gamblers with a further one in two meeting the screen criteria for moderate depression. Gamblers' negative perceptions may reduce motivation to change their gambling behaviour. Indeed, the perception by some treatment providers is that the escape from stress provided by gambling for pathological gamblers is a form of self medication to counter depression and anxiety that may involve adrenergic and endorphin processes. (16) This hypothesis might apply whether or not the depression existed prior to the problem gambling behaviour, or developed as a consequence of their losses and isolation resulting from gambling. Relief for those who are depressed and participate in gambling may be due to short term escape from dysphoric moods. The brief relief from depression caused by the longer term effects of the very same behaviour may indicate the complexity of the disorder, and contribute towards an explanation of the apparent contradictory behaviour of contribution of gambling despite increasing losses and accompanying social and emotional costs. Such relief, if the hypothesis were to be supported, would indicate a powerful and immediate change in mood when gambling, in order to reinforce behaviour that would be followed by negative consequences as losses (or reinvested 'wins') resulted.

Some gamblers indicated a history of depression prior to problematic gambling, although most indicated that feelings of depression followed their gambling. However, whether depression preceded the gamblers' problem gambling behaviour, or was a reaction to it, cannot be determined accurately from retrospective self-reports. Longitudinal studies are required to clarify this important issue.

Clinic gamblers were significantly more depressed than pathological gamblers identified in a general population study (13), perhaps suggesting that pathological gamblers are reluctant to seek help until co-morbid disorders are relatively severe.

Notwithstanding, the immediate relief from dysphoria provided by gambling (albeit temporary) appears to be a far more powerful behavioural determinant than the negative consequences experienced later in time, as is suggested by theories of reinforcement. (17)

Suicidal ideation and behaviour
The level of attempted suicide was more than 30 times the level found in the general New Zealand population. (18) A recent study of suicidal ideation in pathological gamblers found similar results (74 per cent suicidal ideation, 10 per cent had attempted suicide) to those in this study. (3)

DISCLOSURE TO THEIR GP

Many of the gamblers had presented to their GPs with symptoms of anxiety and/or depression during the 12 months prior to attending the gambling treatment clinic; however, as stated, only one gambler had disclosed a gambling problem to his GP. Either the gamblers were uncomfortable in disclosing such problems, or they had difficulty perceiving that their health could be affected by their gambling behaviour. As discussed, the behavioural determinant, the expectation of winning, may have been replaced through experience with a need to escape from external problems (creditors, family criticism) and internal cognitions (guilt, shame, loneliness), together with undetermined biochemical effects.

If this were so, problem gamblers who gave up gambling would be denying themselves the control over relief from stress, however transitory. The need for GPs to understand the possibility of this apparent conflict underpinning the problem gamblers' behaviour in the face of continued losses, in monetary, as well as emotional and environmental terms, is important in effecting a successful intervention.

CAUTION IN INTERPRETING RESULTS

The results of screens must be treated with caution as they are by nature likely to identify false positive cases of the screen disorder (4). However this was reduced by the subsequent clinical assessment where additional information supported high screen results in anxiety or depression, although gamblers tended to defend against the findings of the alcohol screen, especially when indicating alcohol dependence. The relatively small number of subjects (9 female, 41 males) may affect the generalisation of the findings which may be restricted to a subgroup of people with this disorder. In light of previous information that problem gamblers are unlikely to seek help (4,5,12,) it may well be the case that the subjects of this study were experiencing higher dysphoria (from gambling and co-morbid disorders) which compelled them to seek help for their gambling behaviour.

The self-reported reasons for presenting to their GPs were open to errors of recollection, are somewhat vague in description, and future studies would benefit from direct comparison with GP records.

CONCLUSIONS

The relatively small numbers of patients participating in the study mitigate against too much weight being placed upon findings; however strong trends can provide some support for further inquiry by GPs during consultations.

The findings are indicative of high levels of anxiety and symptoms of depression, significantly above those recorded for pathological gamblers in the New Zealand nationwide study (13). The effectiveness of this dysphoria as an indicator of possible pathological gambling may vary in health settings: in London and elsewhere, around 15 per cent of GP consultations diagnose mental disorders such as depression or anxiety (19) compared with those of the WaiMedCa study where 3.8 per cent of patients presented for psychological reasons or counselling, and 4.4 per cent were diagnosed with psychological disorders (11).

However, that 25 per cent of gamblers in this study presented to their GP for anxiety distress, and a further 18 per cent for depression appears to considerably exceed even the presentation rate in London, and might provide an indicator of an underlying gambling problem.

Other research has indicated self-reported health problems of gamblers, with depression and alcohol abuse especially a problem. (2,4,12)

The degree of anxiety in many problem gamblers has not been highlighted before, yet may be a critical factor in effective treatment of the disorder. The Abbott/Volberg13 study supports the high correlation between pathological gambling and alcohol abuse and to some extent depression, as well as psychological disturbance more generally.

Overall, relatively little research has been done in the field of co-morbidity, and the present study supports and expands upon the categories of health problems that may be common amongst those gamblers who are suffering from an advanced gambling pathology.

This study and others suggest that further inquiry regarding the patients' gambling behaviour may be appropriate when patients present with symptoms of depression, anxiety and alcohol abuse or stress related disorders. The intervention may require considerable empathy and tact, together with some knowledge concerning the process of gambling pathology, in order to gain a patient's confidence and their disclosure.

Doctors provide unique opportunities to intervene early in the development of this disorder and may offer a gateway for the problem gambler to access help during brief 'windows of opportunity'.

The confidential nature of a GP's intervention, the ability for a gambler to externalise the disorder as an illness and so lower defences, and availability of medical support for co-morbid anxiety and depressive symptoms, all contribute to an environment whereby problem gamblers could address their problem at an early stage.

GPs can lead the way with awareness of problem gambling in their patient population, proactive inquiry, and through the learning of brief intervention skills, in what appears to be a growing incidence of a progressive and potentially life-threatening disorder.

Acknowledgement
We thank the Problem Gambling Foundation for its participation in this study.

References

(1) American Psychiatric Assoc. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington DC: APA, 1994.
(2) Lesieur H, Blume S, Zoppa R. Alcoholism, drug abuse, and gambling. Alcoholism: clinical & experimental research 1985; 10:33-8.
(3) Bergh C, Kuhlhorn E. Social, psychological and physical consequences of pathological gambling in Sweden. J Gambling Studies 1994; 10:275-85.
(4) Abbott M, Volberg R. The New Zealand national survey of problem and pathological gambling. J Gambling Studies 1996; 12:143-160.
(5) Volberg R, Abbott M. Lifetime prevalence estimates of pathological gambling in New Zealand. Int J of Epidem 1994; 23:976-83.
(6) Compulsive Gambling Society. Annual Clinical Report 1996. Auckland: CGS, 1997.
(7) Lesieur HR, Blume DB. The South Oaks Gambling Screen (the SOGS): a new instrument for the identification of pathological gamblers. Am J Psych 1987; 144:1184-8.
(8) Bohn MJ, Babor TF, Kranzler HR. The alcohol use disorders identification test (AUDIT): validation of a screening instrument for use in medical settings. J Stud. Alcohol 1995; 56:423-32.
(9) Spielberger CD, Gorsuch RL, Lushene RE. Manual for the State-Trait Anxiety Inventory (Self Evaluation Questionnaire). Palo Alto, Ca: Consult Psycholog Press, 1970.
(10) Beck AT, Ward CH, Mendelsohn M, Mock J, Erbaugh H. An inventory for measuring depression. Arch Gen Psych 1961; 4:561-71.
(11) McAvoy B, Davis P, Raymont A, Gribben B. The Waikato Medical Care (WaiMedCa) Survey. NZ Med J 1994; 107 (2 Suppl): 386-433.
(12. Daghestani AN. Why should physicians recognise compulsive gambling. Postgrad Med 1987; 85:253-63.
(13) Abbott MW, Volberg R. Frequent gamblers and problem gamblers in New Zealand. Research Series No 14. Wellington: Dept of Internal Affairs, 1992.
(14) Dept of Internal Affairs. Overview of gambling and gambling issues present and future 1995. Wellington: Dept Int Affairs, 1995.
(15) Statistics NZ & Ministry of Health. A picture of health. Wellington: Statistics NZ & Ministry of Health, 1993.
(16) Blaszczynski AP, Winter SW, McConaghy N. Plasma endorphin levels in pathological gamblers. J Gambling Behaviour 1986; 2:3-14.
(17) Skinner BF. Contingencies of reinforcement. NY: Appleton-Century-Crofts, 1969.
(18) Sullivan S. Why compulsive gamblers are a high suicide risk. Community Mental Health in NZ 1994; 8:40-7.
(19) Abas M, Broadhead J. Mental disorders in the developing world. BMJ 1994; 308:1052.