Frequency and Correlates of Gambling Problems in Depressed and Bipolar Outpatients

Frequency and Correlates of Gambling Problems in Depressed and Bipolar Outpatients

Journal: The Canadian Journal of Psychiatry/La Revue canadienne de

psychiatrie

Manuscript ID: CJP-2009-163-OR.R1

Manuscript Type: Original Research

Date Submitted by the Author:

Complete List of Authors: Kennedy, Sidney; University Health Network, Psychiatry

Key Words: gambling, bipolar disorder, major depressive disorder

For Peer Review

The Canadian Journal of Psychiatry/La Revue canadienne de psychiatrie

DRAFT July 4, 2009

Submission to Canadian Journal of Psychiatry 1

Frequency and Correlates of Gambling Problems in Depressed and Bipolar Outpatients

Sidney H. Kennedy, MD, FRCPC 1*

Brenda R. Welsh, HBHSc 2

Kari Fulton, BA BScN RN2

Joanna K. Soczynska, HBSc.3

Roger S. McIntyre, MD, FRCPC 4

Claire O’Donovan, MD, FRCPC 5

Roumen Milev, MD, FRCPC 6

Jean-Michel le Melledo MD FRCPC 7

Jean-Claude Bisserbe MD FRCPC 8

Mark Zimmerman, MD 9

Neasa Martin BSc OT 10

1. Psychiatrist in Chief, University Health Network and Professor of Psychiatry, University

of Toronto, Toronto, ON, Canada

2. Research Coordinator, Mood Disorders Psychopharmacology Unit, University Health

Network, Toronto, ON, Canada

3. PhD Student, Institute of Medical Science, University of Toronto, Toronto, ON, Canada

4. Associate Professor of Psychiatry and Pharmacology, University of Toronto, Toronto,

ON, Canada

5. Associate Professor of Psychiatry, Dalhousie University, Halifax, NS, Canada

6. Head, Department of Psychiatry, Providence Care, Queen’s University, Kingston, ON,

Canada

7. Associate Professor of Psychiatry, University of Alberta, Edmonton, AB, Canada

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8. Clinical Director, Department of Psychiatry, Royal Ottawa Hospital, Professor of

Psychiatry, University of Ottawa, ON, Canada

9. Director of Outpatient Psychiatry, Rhode Island Hospital and Associate Professor,

Psychiatry & Human Behaviour, Brown University, RI, USA

10. Mental Health Consultant, Neasa Martin and Associates, Toronto, ON, Canada

Address for Correspondence: Sidney H. Kennedy, MD, FRCPC

EN8-222 - 200 Elizabeth Street

Toronto, Ontario M5G 2C4

Email: [email protected]

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ABSTRACT

OBJECTIVE: The primary objective of this study was to investigate the frequency of gambling

in individuals who have been diagnosed with major depressive disorder (MDD) or bipolar

disorder (BD). Secondary objectives were to examine: 1.) sex differences in the rates of

gambling behaviour, 2.) the temporal relationship between onset of mood disorders and problem

gambling, 3.) psychiatric comorbidities associated with problem gambling, and, 4.). the

influences of problem gambling on quality of life.

METHOD: Individuals (>18 years of age) who met criteria for lifetime DSM-IV-TR-defined

major depressive disorder (MDD) or bipolar I/II disorder (BD), confirmed by the Mini

International Neuropsychiatric Interview (M.I.N.I) were enrolled. Participants were recruited

from five sites in Canada and one in the United States. Prevalence of past-year problem

gambling was assessed with the Canadian Problem Gambling Index (CPGI). Associated

comorbidities with problem gambling are presented.

RESULTS: A total of 579 participants were enrolled (female: n = 379, male: n = 200).

Prevalence of problem gambling did not differ significantly between MDD (12.6%) and BD

(12.3%) group. There was a significant difference in the prevalence of problem gambling

between males (19.5%) and females (7.8%) in the BD group (χ2

=8.695, P = 0.003). Amongst

individuals meeting criteria for problem gambling, the mood disorder was the primary onset

condition in 71% of cases. Individuals with a mood disorder with comorbid current panic

disorder (OR = 1.96, 95% CI 1.02 to 3.75), obsessive-compulsive disorder (OR = 1.86, 95% CI

1.01 to 3.45), specific phobia (OR = 2.36, 95% CI 1.17 to 4.76), alcohol dependence (OR = 5.73,

95% CI 3.08 to 10.65) or lifetime substance dependence (OR = 2.05, 95% CI = 1.17 to 3.58), had

a significantly increased odds of problem gambling. Problem gambling across MDD and BD

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populations was also associated with lower quality of life ratings.

CONCLUSION: These results reaffirm a higher prevalence of gambling in both BD and MDD

populations compared to previously published community samples. The study also identifies risk

factors for gambling behaviours within these populations.

Key Words: gambling, bipolar disorder, major depressive disorder

Word count: ABSTRACT: 328

BODY TEXT: 3627

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Clinical implications

- Clinicians should assess gambling problems in patients who have a mood disorder and

include this in their comprehensive treatment programs.

- Problem gambling in individuals with a mood disorder contributes to diminished quality

of life and is a detractor from a full functional recovery.

- Routine screening for suicide risk is warranted as problem gamblers are more than twice

as likely to report suicidal ideation

Study Limitations

- The cross-sectional design cannot infer causality

- Not all psychiatric diagnoses were assessed

- The sample was predominantly Caucasian

- The temporal relationship scales have not been validated

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INTRODUCTION

Problem gambling involves a pattern of repeated gambling behaviour that disrupts the

individual’s life including, but not limited to, family life, occupational functioning, finances, and

personal well-being1. The prevalence of problem gambling in Canada is estimated at

approximately 2%2, while a further 3% of Canadians are at low risk for problem gambling3.

Studies have shown that problem gamblers frequently exhibit symptoms of mood disorders.

Despite the significant association between mood disorders and problem gambling, there have

been few explorations of the temporal relationship and comorbid risk factors of problem or

pathological gambling in psychiatric populations. Extant studies evaluating MDD and BD are

limited by the small sample size, failure to consider the temporal relationship between gambling

problems and mood disorders, or inconsistent findings on the comorbidities or determinants of

gambling behaviours4-6. There is little research that explores the risk of gambling in mood

disorder populations and the contribution of psychiatric comorbidity to treatment outcome or

quality of life.

Through a unique partnership involving the Mood Disorders Society of Canada, the

Canadian Network for Mood and Anxiety Treatments and Brown University, USA, the mutually-

defined primary objective of this study was to investigate the frequency of gambling problems in

individuals who have been diagnosed major depressive disorder (MDD) or bipolar disorder

(BD). The secondary objectives were to examine; (i) sex differences in the rates of gambling

behaviour; (ii) the temporal relationship between the onset of mood disorders and problem

gambling in the two groups; (iii) the influence of anxiety and substance use comorbidity on

gambling behaviours in both MDD and BD populations; (iv) the influence of gambling

behaviours on quality of life in MDD and BD populations.

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METHOD

Study Design

This was a single-visit, multi-site study involving five sites in Canada (University Health

Network in Toronto, Walter C. Mackenzie Health Sciences Centre in Edmonton, Queen

Elizabeth II Health Sciences Centre in Halifax, the Providence Continuing Care Centre in

Kingston, and the Royal Ottawa Hospital in Ottawa) and one site in the United States (Rhode

Island Hospital, Rhode Island). Over 60% of subjects were recruited from the three sites in

Ontario (see Table 1). Prior to initiation of any site, an inter-rater reliability session was held for

all study coordinators and standardised instructions for questionnaire administration were

provided for use at each centre.

Sample

Individuals (N = 606; > 18 years of age) meeting criteria for lifetime MDD or BDI/II

defined according to the Diagnostic and Statistical Manual of Mental Disorders, 4th

Edition

(DSM-IV-TR)7 were recruited from outpatient mood disorder and general psychiatric clinics and

advertisements posted in local hospitals. Posters invited participants who had a diagnosed mood

disorder to complete interviews and questionnaires on lifestyle and mood symptoms. Subjects

were excluded from the study if they met criteria for schizophrenia or other psychotic disorders.

The study was approved by local Research Ethics Boards at each of the recruiting sites. All

enrolled subjects provided written informed consent.

Primary Measures

Psychiatric diagnoses were confirmed using the short version of the Mini International

Neuropsychiatric Interview, version 5.0.0 M.I.N.I.PLUS8 for DSM-IV. The structured interview

was administered by a trained research coordinator, and included modules for mood and anxiety

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disorders, current suicide risk, alcohol and other substance dependence and abuse. The

researchers at the Rhode Island Hospital site applied the Structured Clinical Interview for DSM

diagnoses (SCID-P) in place of the M.I.N.I. The M.I.N.I. has been validated against the

Structured Clinical Interview for DSM diagnoses (SCID-P)8 as well as the Composite

International Diagnostic Interview for ICD-10 (CIDI)9. At the time of interview, depressive and

hypo/manic symptom severities were assessed respectively using the clinician-rated Hamilton

Depression Rating Scale 7-item (HAM-D-7)10 and the Young Mania Rating Scale (YMRS)11 .

The prevalence of problem gambling was assessed with a self-report questionnaire; The

Canadian Problem Gambling Index (CPGI)1. The CPGI is a 9-item self-report questionnaire

scored using a 4-point Likert scale that assesses problem gambling severity in the past year. The

CPGI divides scores into categories to indicate four severity levels of gambling (O = Non-

problem Gambler, 1-2 = Low risk gambler, 3-7 = Moderate risk gambler, 8 -27 = Problem

Gambler). This study classified individuals scoring >3 on the CPGI as problem gamblers. The

decision to collapse ‘moderate risk’ and ‘problem gambler’ categories was performed to increase

sample size as has been done previously10,12.

Sociodemographic data were collected and included age, sex, ethnicity, marital status,

education and income. Other measures included the Quality of Life Enjoyment and Satisfaction

Questionnaire (Q-LES-Q), a 16-item self-report questionnaire, was used to evaluate current

quality-of-life13; The NEO-FFI Personality Inventory14, a 60-item self report questionnaire, was

used to assess personality according to the Five Factor (Neuroticism, Conscientiousness,

Extraversion, Openness, Agreeableness) model; The Trimodal Anxiety Questionnaire (TAQ)15 is

a 36-item self-report questionnaire that was used to separately assess the cognitive, somatic, and

behavioural domains of anxiety; The Quick Inventory of Depressive Symptomatology (QIDS-

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SR16)16 is a 16-item self-report scale that was used to assess severity of depression, and has been

applied in many depression treatment trials: In order to capture the temporal relationship

between mood disorder and gambling, two scales were developed based on the DSM-IV-TR

criteria7 for MDD and Pathological Gambling Disorder; The Temporal Assessment of Mood

(TAM) and the Temporal Assessment of Gambling (TAG). These two scales provide a

chronological account of milestones for onset of mood disorder and onset of gambling problems.

Mean age scores were calculated for the TAM and the TAG and subsequently used in the

analysis of temporal relationship between mood and gambling pathology.

Statistical Analysis

The analysis herein focuses on past-year problem gambling, which is defined as moderate

risk or severe problem gambling (i.e., CPGI a score of >3). Analyses were first conducted for:

any mood disorder (including all subjects) and then separately for major depressive disorder

(MDD) and bipolar I/II disorder (BD) populations. The chi-square statistic was employed to

compare demographic characteristics, rates of problem gambling and psychiatric comorbidity.

Logistic regressions were performed to identify risk factors associated with problem gambling.

The independent t-test was implemented to compare mean scores between gamblers and non-

gamblers on continuous variables such as the HAM-D-7, YMRS, QIDS, TAQ, NEO-FFI.

Stepwise multiple logistic regressions were performed to identify a set of significant and unique

correlates of problem gambling behaviour. Variables included in the multiple logistic regressions

were first identified as significant individual covariates associated with problem gambling. Two

separate multiple logistic regressions were applied (i) MDD; and, (ii) BD. The variables included

in the MDD group included educational attainment, lifetime alcohol dependence, current

obsessive-compulsive disorder, risk for suicide in the past month, HAM-D-7 score, TAQ total

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score, Q-LES-Q, and the personality factors of neuroticism, openness, agreeableness, and

conscientiousness. The variables included in the BD group were sex, ethnicity, lifetime alcohol

dependence, lifetime substance dependence, current specific phobia, HAM-D-7, TAQ-somatic

subscale, Q-LES-Q, and the personality factors of agreeableness and conscientiousness. The

QIDS was excluded from the logistic regression because it was highly correlated with the HAM-

D-7. All tests were two-tailed with statistical significance set at alpha <0.05.

RESULTS

A total of 606 respondents were enrolled, of whom 27 withdrew consent, leaving a

sample of 579 (female: n = 379, male: n = 200) for analysis (mean age = 44.8, SD = 12.1). A

positive diagnosis for lifetime bipolar disorder (BD) was confirmed in 52.5% (BD-I = 227, BD-

II = 77) of the subjects; 5.3% (n = 16) of bipolar subjects met criteria for a current manic or

hypomanic episode at the time of interview, and 29.5% (n = 86) met criteria for a major

depressive episode. 47.5% (n = 275) of subjects met diagnostic criteria for major depressive

disorder (MDD) and 55.5% presented in a current major depressive episode at the time of

interview.

The prevalence of low risk problem gambling was 11.0% (n = 61), moderate risk 7.0% (n

= 39) and problem gambler 5.4% (n = 30). The prevalence of problem gambling as defined by

greater than 3 on the CPGI for the total mood disorder sample was 12.4% (n = 69). The

prevalence of problem gambling was significantly higher in three Canadian sites: Ottawa,

Toronto, and Edmonton (Ottawa = 19.6%, Toronto = 17.8%, Edmonton = 16.0%) compared to

the other three sites (Kingston = 10.0%, Halifax = 4.3%, Rhode Island = 4.1%) (χ2 =19.054, df =

5, P = 0.002) (see Table 1). There were no significant differences in the prevalence rates of

problem gambling by the type of mood disorder diagnosis (see Table 2).

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Sex differences were identified in the BD group; a significantly higher prevalence of

problem gambling was identified in males (19.5%) versus females (7.8%) with BD (χ2 =8.695, P

= 0.003). No significant sex differences with respect to problem gambling were found in the

MDD group.

The prevalence of problem gambling was significantly associated with several

sociodemographic characteristics in individuals with a mood disorder (see Table 3). Individuals

with MDD and problem gambling were significantly more likely to lack any post-secondary

education compared to non-gamblers (37.5% vs. 15.4%; χ2 = 9.26, P = 0.01); this was not the

case for individuals with BD. Individuals with BD and problem gambling were significantly

more likely to be of non-Caucasian ethnicity compared to non-gamblers with BD (36.1% vs.

14.5%; χ2 = 10.43, P = 0.001). The presence of problem gambling was not significantly

associated with annual income, employment status, or marital status in the MDD or BD groups.

Temporal assessment of problem gambling

The temporal assessment of problem gambling questionnaire identified that the onset of

the mood disorder preceded the onset of gambling pathology in 80.6% of females, and 57.7% of

males (χ2 =3.83, P =0.05). In the MDD group, the onset of mood disorder preceded the onset of

gambling pathology in 77.3% of females, and 25.0% of males (χ2 = 6.903, P =0.009). In the BD

group, the onset of mood disorder preceded the onset of gambling pathology in 85.7% of females

and 72.2% of males, though the difference was not statistically significant.

Psychiatric comorbidities

Individuals with a mood disorder who met CPGI criteria for problem gambling had

significantly increased odds of current panic disorder (OR = 1.96, 95% CI = 1.02-3.75), current

specific phobia (OR = 2.36, 95% CI 1.17 to 4.76), current obsessive-compulsive disorder (OCD)

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(OR = 1.86, 95% CI 1.01 to 3.65), current (OR = 5.73, 95% CI 3.08 to 10.65) as well as lifetime

(OR = 3.02, 95% CI 1.80 to 5.07) alcohol dependence, lifetime substance dependence (OR =

2.05, 95% CI 1.17 to 3.58), and risk for suicide in the past month (OR = 2.06, 95% CI 1.18 to

3.58). An increased odds of current OCD (OR = 2.67, 95% CI 1.13 to 6.31) as well as current

(OR = 2.92, 95% CI 1.05 to 8.09) and lifetime (OR = 2.12, 95% CI 0.99 to 4.51) alcohol

dependence, and risk for suicide (OR = 2.52, 95% CI 1.06 to 5.72) remained significant for

individuals with MDD. Individuals with BD had a significantly increased odds of current

specific phobia (OR = 2.96, 95% CI 1.08 to 8.15) as well as current (OR = 9.33, 95% CI 4.12 to

21.13) and lifetime (OR = 4.34, 95% CI 2.04 to 9.23) alcohol dependence and current (OR =

4.00, 95% CI 1.40 to 11.44) and lifetime (OR = 2.89, 95% CI 1.39 to 6.00) substance

dependence. Psychiatric comorbidities are shown in Table 4.

Quality of Life

Individuals meeting criteria for problem gambling reported lower quality of life on the Q-

LES-Q compared to non-problem gamblers both for the MDD (M = 22.94, SD = 8.85 vs. M =

31.47, SD = 11.65; t = 4.95, p < 0.001) and BD (M = 29.69, SD = 13.32 vs. M = 35.29, SD =

13.47; t = 2.334, P = 0.02) groups.

Anxiety Symptoms

Individuals with MDD who met criteria for problem gambling scored significantly higher

on self-reported anxiety as measured with the total TAQ score (M = 154.94, SD = 51.45 vs. M =

123.59, SD = 54.14; t = -3.127, P = 0.002) and all of its subscales: behavioural (M = 53.73, SD =

17.43 vs. M = 42.73, SD = 20.25; t = -2.964, P = 0.003), cognitive (M = 42.21, SD = 12.53 vs.

M = 32.30, SD = 14.59; t = -3.707, P < 0.001) and somatic (M = 59.00, SD = 29.00 vs. M =

48.56, SD = 26.63; t = -2.080, P = 0.04) as compared to non-problem gamblers. In the BD

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group, problem gamblers scored significantly higher on the somatic subscale only (M = 57.49,

SD = 26.80 vs. M = 46.43, SD = 30.26; t = -2.053, P = 0.04).

Personality

Individuals with MDD meeting criteria for problem gambling scored significantly higher

on the NEO-FII factor of neuroticism (M = 33.64, SD = 5.87 vs. M =29.82, SD = 8.36; t = -

2.532, P = 0.01), and lower on openness (M = 25.24, SD = 5.54 vs. M = 28.02, SD = 6.32; t =

2.394, P = 0.02), agreeableness (M = 27.85, SD = 6.57 vs. M = 31.71, SD = 5.87; t = 3.482, P =

0.001), and conscientiousness (M = 23.91, SD = 6.69 vs. M = 28.08, SD = 7.71; t = 2.951, P =

0.003) as compared to non-problem gamblers. Individuals with BD who met criteria for problem

gambling had significantly lower scores on the agreeableness (M = 26.31, SD = 6.66 vs. M =

31.65, SD = 6.59; t = 4.549, P < 0.001) and conscientiousness subscales (M = 25.17, SD = 7.44

vs. M = 28.61, SD = 7.85; t = 2.482, P = 0.01) as compared to non-problem gamblers. There

were no significant findings for the NEO-FFI factor of extraversion in either mood disorder

group.

Mood Symptom Severity

Individuals with MDD meeting criteria for problem gambling scored significantly higher

on depressive symptom severity as measured with the mean HAM-D-7 score as compared to

non-problem gamblers with MDD (M = 10.45, SD = 5.59 VS. M = 7.73, SD = 5.67, t = -2.585 P

= 0.010). This finding remained significant for individuals with BD (M = 7.67, SD = 5.29 vs. M

= 5.41, SD = 5.33; t = -2.386, P = 0.018). Within the BD group, there were no significant

difference between problem gamblers and non-gamblers in manic symptom severity as measured

with the mean YMRS score. Individuals with MDD meeting criteria for problem gambling had a

significantly higher mean score on the QIDS than those without problem gambling (M = 15.52,

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SD = 4.35 vs. M = 11.95, SD = 5.86; t = -4.198, P < 0.001). These results were not significant

for the BD group.

Predictors of problem gambling – results from a multiple logistic regression

Results from a multiple logistic regression indicate that for individuals with MDD, past-

year problem gambling was significantly predicted by having an educational attainment of high

school diploma or less (OR = 2.57, 95% CI 1.07 to 6.17), the personality factor of agreeableness

(OR = 0.92, 95% CI 0.86 to 0.90), and quality of life (OR = 0.94, 95% CI 0.90 to 0.98). For the

BD group, problem gambling was significantly predicted by being of non-Caucasian ethnicity

(OR = 2.82, 95% CI 1.21 to 6.57), lifetime alcohol dependence (OR = 4.20, 95% CI 1.85 to

9.50), and the personality factor of agreeableness (OR = 0.90, 95% CI 0.85 to 0.95).

DISCUSSION

This study confirmed a high prevalence of problem gambling in outpatients with a mood

disorder. The prevalence of past-year problem gambling was equally high in BD (12.3%) and

MDD (12.6%) populations. The rate of gambling was more than twice as high in men (19.5%)

compared to women (7.8%) with BD, although men and women did not differ significantly in

rates of gambling in the MDD population.

Problem gambling affects approximately 2% of individuals in the Canadian general

population2, which would suggest that individuals with a mood disorder are six more likely to

meet criteria for problem gambling.

Problem gamblers in this study were more likely to have had no post-secondary

education than were non-problem gamblers. This is consistent with a large epidemiological

survey in which problem gamblers had lower level of educational attainment and individuals

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with post-graduate degrees reported the lowest rates for gambling17.

There were also significant differences between gamblers and non-gamblers in several

areas of psychiatric comorbidity. Alcohol dependence conferred the highest risk for problem

gambling in individuals with BD and MDD. The problem gambling population was also more

than twice as likely to be at higher risk for suicide in the past month and have higher rates of

anxiety disorders such as OCD and specific phobias as compared to non-problem gamblers.

Using the Five-Factor Model of Personality, the study also showed a consistent profile of

high neuroticism, low openness, low agreeableness and low conscientiousness in the gambling

populations compared to non-gambling population, although the differences in neuroticism and

openness were largely accounted for by the MDD population. These findings have implications

for identifying individuals at high risk for gambling pathology, as well as generating hypotheses

regarding the etiology of gambling behaviour. For example, personality factors may mediate the

risk for substance dependence and gambling in patients with a mood disorder.

To our knowledge our study is the first to report on the temporal relationship between

onset of gambling behaviour and onset of mood disorders. Our investigation documents that

most (71%) individuals with a mood disorder experienced the problems with gambling following

the onset of mood disorder. The onset of problem gambling behaviour occurred earlier in men as

compared to women with MDD but not BD. These observations corroborate with a previous

report that documented an earlier age at onset of gambling problems in males18.

Individuals meeting criteria for problem gambling also had lower self-reported quality of

life, similar to Grant and Kim (2005)19, who reported that a diminished quality of life affects the

ability of individuals to interact socially, work effectively and manage their home life. The Banff

Consensus20, an expert panel invited by the Alberta Gambling Research Institute, concluded that

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quality of life is an important index of morbidity associated with gambling. This study confirms

that quality of life is indeed an important issue that needs to be addressed by clinicians for

individuals with problem gambling and mood disorders.

Individuals with MDD and problem gambling had higher self-reported anxiety

(behavioural, cognitive, and somatic) than non-problem gamblers, while individuals with BD and

problem gambling had higher anxiety as captured by the somatic subscale only. These results

substantiate the evidence from a previous report that anxiety is often a salient component of

problem and pathological gambling behaviour21.

Individuals meeting criteria for problem gambling also had higher levels of clinician-

rated depression, as quantified by the HAM-D-7 and self-reported levels of depression as

measured by the QIDS. This indicates the importance of exploring potential gambling behaviour

in individuals with depression and, in addition, to address the level of depression in individuals

with problem or pathological gambling.

There were a number of strengths to this study including the large sample size,

administration of ‘in-person’ interviews, the use of reliable and structured diagnostic instruments

and symptom scales. On the other hand, several methodological issues should be acknowledged.

First subjects were not randomly selected which limits generalizability of these findings to

indivividuals with a mood disorder in the general population. Second, the M.I.N.I.-PLUS was

shortened and did not include diagnoses for ADHD andpersonality disorders,andlifetime

incidence of anxiety disorders (with the exception of panic disorder and agoraphobia). Third,the

Temporal Assessment of Mood (TAM) and the Temporal Assessment of Gambling (TAG) scales

are not validated measures. The two scales include a series of subjective questions that mirrored

each other to ensure that a temporal onset could be extracted for comparisons. Fourth, causality

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of problem gambling cannot be inferred from the results of this study. Finally, the sample was

predominantly Caucasian, which limited exploration of increased gambling pathology in non-

Caucasian ethnic groups.

CONCLUSION

There is a higher prevalence of problem gamblers in both the BD and MDD populations

as compared to community populations in Canada. These results also identify that gambling in

mood disorder patients is highly comorbid with substance use and anxiety disorders, suggesting

that detection of one condition should trigger an assessment and relevant concomitant treatment

for all comorbid conditions. Problem gamblers suffer a diminished quality of life and this affects

their psychological, social, and occupational well being.

It is possible that individuals with depression engage in gambling in an attempt to

enhance their mood. Some individuals with problem gambling become depressed due to

decreased quality of life and financial ruin. Mood symptoms are certain to affect motivation to

gamble. The manic state involves pleasure-seeking and risk-taking with little regard for

consequences. Problem gambling can be viewed as sharing features with addictions and impulse-

control disorders, both of which affect individuals with depression and bipolar disorder more

frequently22,23.

The results of this study highlight the need for a greater focus on gambling problems in

the mood disorder population. It is recommended that clinicians initiate screening for problem

gambling in addition to substance disorders in their practice. These findings suggest that a

screening tool such as the CPGI can be used to help clinicians identify patients at higher risk for

problem gambling. Recommendations for future studies are to explore the temporal onset and

comorbities of problem gambling and mood disorders and also to differentiate between different

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gambling severities of risk.

FUNDING AND SUPPORT

This project was funded by the Ontario Problem Gambling Research Centre. The Mood

Disorders Society of Canada and the Canadian Network for Mood and Anxiety Treatments

provided administrative and financial project oversight.

ACKNOWLEDGMENTS

The authors recognize the contribution from the following research coordinators: Jessica

Ridgway, Julie Garnham, Janisse Khudabux-Der, Judy Joannette, and Mandi Peterson. Also, we

wish to acknowledge Dr. Gerald M. Devins and Dr. Anthony L. Vaccarino for their statistical

advice during this project.

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Table 1. Problem Gambling Rates by Study Site (CPGI)

Problem

Gamblers

Site Total N

N %

University Health Network,

Toronto, Ontario

197 35 17.7

Royal Ottawa Hospital,

Ottawa, Ontario

51 10 19.6

Dalhousie University, Halifax,

Nova Scotia

93 4 4.3

University of Alberta,

Edmonton, Alberta

50 8 16.0

Queens University, Kingston,

Ontario

90 9 10.0

Brown University, Rhode

Island, USA

74 3 4.0

Total 555 69

Missing CPGI 24

χ2=19.054, df=5, p=0.002

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Table 2. Prevalence of Problem Gambling in Major Depressive Disorder and

Bipolar Disorder

Mood

Disorder

MDD BD

N = 579 N = 275 N = 304

χχχχ2222 p-

value

CPGI n % n % n %

1 - 2 – low risk 61 11.0 31 11.8 30 10.3 0.78 0.86

3 - 7 – moderate risk 39 7.0 20 7.6 19 6.5

≥ 8 – problem gambler 30 5.4 13 4.9 17 5.8

CPGI (missing n = 24)

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Table 3. Demographic and socioeconomic characteristics for past-year problem

gamblers with a mood disorder as measured with the Canadian Problem Gambling

Index (CPGI)

Non-

gambler

Problem

Gambler

N= 486† N= 69†

Age M SD M SD t-test p-value

44.9 12.1 42.9 11.5

N= 486 N= 69 χχχχ2222 p-value

Sex n % n %

Males 166 34.2 31 44.9 3.06 0.08

Females 320 65.8 38 55.1

Educational Level N=470 N=64

Less than high school 39 8.3 7 10.9 10.50 0.005

High school diploma 69 14.7 19 29.7

Some college or more 362 77.0 38 59.4

Income N=460 N=65

Less than 19,999 154 33.5 31 47.7 6.61 0.25

20,000 – 39,999 97 21.1 11 16.9

40,000 – 59,999 75 16.3 7 10.8

60,000 – 79,999 54 11.7 9 13.9

80,000 – 99,999 31 6.7 3 4.6

>100,000 49 10.7 4 6.2

Employment status N=471 N=66

Full-time employed 131 27.8 16 24.2 7.74 0.46

Part-time employed 56 11.9 11 16.7

Unemployed 51 10.8 7 10.6

Full-time student 21 4.5 0 0.0

Part-time student 5 1.1 1 1.5

Homemaker 14 3.0 1 1.5

Retired 42 8.9 3 4.6

Disability 151 32.1 27 40.9

Marital status N=465 N=66

Single 168 36.1 33 50.0 8.19 0.23

Married 159 34.2 15 22.7

Cohabitating 28 6.0 5 7.6

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Separated 29 6.2 6 9.1

Divorced 75 16.1 7 10.6

Widowed 6 1.3 0 0.0

Ethnicity N=457 N=62

African Can/Am 11 2.4 6 9.7 10.19 0.006

Caucasian 422 92.3 51 82.3

Other 24 5.3 5 8.1

†Missing data points excluded from analysis - denominator varies according to available

data.

Missing CPGI n = 24

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Table 4. Psychiatric Comorbidities in Problem Gamblers as defined by

the CPGI criteria (score >=3)

Results Predicting Problem

Gambling

Any Mood Disorder

OR 95% CI p-value

Anxiety Disorders

Panic Disorder Lifetime 1.27 0.76 2.13 0.36

Panic Disorder Current 1.96 1.02 3.75 0.04

Agoraphobia Lifetime 1.07 0.38 1.80 0.79

Agoraphobia Current 1.40 0.81 2.44 0.23

Social Phobia Current 1.31 0.76 2.26 0.33

Specific Phobia Current 2.36 1.17 4.76 0.02

Obsessive Compulsive Disorder

Current

1.86 1.01 3.45 <0.05

Post Traumatic Stress Disorder

Current 1.19 0.60 2.39 0.62

Generalized Anxiety Disorder

Current 1.25 0.73 2.13 0.42

Substance Use Disorders

Alcohol Dependence Current 5.73 3.08 10.65 <0.001

Alcohol Abuse Current 2.13 0.57 7.95 0.26

Alcohol Dependence Lifetime 3.02 1.80 5.07 <0.001

Alcohol Abuse Lifetime 0.71 0.27 1.84 0.48

Substance Dependence Lifetime 2.05 1.17 3.58 0.01

Substance Dependence Current 2.34 0.96 5.70 0.06

Substance Abuse Current 0.87 0.11 7.03 0.89

Suicide risk in the Past Month

Suicide risk present (low or higher) 2.06 1.18 3.58 0.01

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Frequency and Correlates of Gambling Problems in Depressed and Bipolar Outpatients

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