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Method
Individuals
seeking treatment for problem gambling were recruited from addiction and mental health
agencies, community mental health professionals, assessment and referral agencies,
credit counselling agencies, employee assistance programs as well as directly soliciting
participants through advertisements in major and local daily newspapers in Toronto,
Canada. Individuals who were referred to the study or responded to newspaper advertisements
were invited to participate in the baseline assessment procedure.
The severity
of the individual's gambling problem was measured using the Diagnostic and Statistical
Manual (DSM-IV) criteria for pathological gambling (American Psychiatric Association,
1994) and the South Oaks Gambling Screen (SOGS) (Lesieur & Blume, 1987), a widely
used screen for gambling problems. The Gambling Behavior Questionnaire (Toneatto,
unpublished) was used to assess the types and duration of gambling problems, previous
gambling treatment, family history of gambling, positive and negative perceptions
of gambling and negative consequences of pathological gambling.
Lifetime
use, problematic use and treatment history for up to11 psychoactive substances were
also measured. Recent use (during the month pre-treatment) and use during the year
following treatment were assessed. Substances were classified into two broad categories:
drugs (cannabis, cocaine, hallucinogens, inhalants, opiates, stimulants) and psychiatric
medications (anti-depressants, anxiolytics, sedatives, anti-psychotics). Prescription
opiates and alcohol were considered separately.
Gambling
treatment consisted of one of four modalities: cognitive-behavioural therapy, brief
motivational intervention, 12-step therapy and solution-focused therapy. As the treatments
were administered in separate geographic locations, random assignment was not possible.
All treatments were administered on an outpatient basis and averaged six sessions
except for the motivational intervention, which was one session.
Frequency
of gambling, money wagered and relapse (i.e. any gambling if the treatment goal was
abstinence; excessive gambling if participants did not choose abstinence as the treatment
goal) were assessed for the periods: a) 30 days prior to the baseline, b) six months
post-treatment and c) 12 months post-treatment. Relapse was assessed as any gambling
if the treatment goal was abstinence and as excessive gambling if participants did
not choose abstinence as the treatment goal. At the 12-month follow-up assessment,
use of psychoactive substances during the preceding year was assessed again. Additional
details describing the treatments and the study can be found in Toneatto, Dragonetti
and Brennan (unpublished).
Results
Sample characteristics
Table 1
describes the overall demographic and gambling-related characteristics for the sample
as a whole. The sample was primarily male, middle-aged, earning a middle income,
largely non-partnered, with some college education and generally employed. Almost
everyone met clinical criteria for pathological gambling according to DSM-IV or SOGS.
All subjects were included in the analysis, however, as these measures were not employed
as inclusion criteria, but rather as indicators of the severity of the gambling problem.
At the time
of seeking treatment, the individual's gambling problem was typically of several
years duration, associated with multiple negative consequences (including substantial
total estimated financial losses). Almost half of the sample had sought treatment
for gambling previously at Gamblers Anonymous (GA). Participation in other addiction
programs was not assessed.
Table 1
Description of sample
| Variable |
Total (n=200) |
| Demographic |
|
| Mean (SD) age in years |
41.3 (11.1) |
| % male |
74.9 |
| % married/common-law |
48.2 |
| % some college education |
30.3 |
| % full-/part-time employment |
61.9 |
| Mean (SD) income in thousands |
33.0 (23.0) |
Gambling-Related |
|
| Mean (SD) SOGS score |
12.1 (4.0) |
| % pathological gamblers, SOGS score > 4 |
96.0 |
| Mean (SD) DSM-IV symptoms |
6.9 (2.2) |
| % pathological gamblers, DSM-IV 5 symptoms |
84.9 |
| Mean (SD) years pathological gambling |
7.2 (7.6) |
| Mean (SD) lifetime financial loss in thousands |
90.0 (140.0) |
| % ever attended GA |
47.5 |
| Mean (SD) number of consequences1 |
6.2 (2.2) |
| Mean (SD) problem gambling behaviors2 |
2.4 (1.6) |
1 maximum
10 2 maximum 12
Gender and substance use patterns
Lifetime
use of psychoactive substances was extensive in this sample (see Tables 2 and 3).
The highest use rates were reported for certain psychiatric medications (i.e., anti-depressants
and anxiolytics), cannabis, cocaine and prescription opiates (see Table 2). Several
gender differences in psychoactive substance use were observed. Females were more
likely to report lifetime use of psychotropic medications, primarily anti-depressants
(62% vs. 22% for males; c 2 [1] = 27.3, p
< .0001), anxiolytics (50% vs. 22% for males; c 2
[1] = 14.9, p < .0001) and sedatives (28% vs. 13% for males; c 2 [1] = 5.7, p < .02).
The
women were also more likely to report drug use during the 12-month post-gambling
treatment follow-up period as well; anxiolytics (19% vs. 2% for males; c
2 [1] = 7.0, p < .01) and anti-depressants (37% vs. 14% for
males; c 2 [1] = 5.4, p < .05). There
were no gender differences in the proportion of individuals reporting lifetime use
of any specific drugs, history of drug problems or drug treatment, or drug use either
pre-treatment or during the 12-month follow-up.
Gender and alcohol use patterns
Males
were more likely than females to drink alcohol in the month prior to seeking treatment
for gambling (64.3% vs. 26.0%, respectively; c 2
[1] = 22.7, p < .0001) as well as during the 12-month follow-up period
(59.7% vs. 24.2%, respectively; c 2 [1] = 8.3,
p < .005) (See Table 2.) Males also consumed significantly more alcohol
drinks (M [SD] = 4.4 [6.0]) on any one day in the month prior to treatment
than did females (M [SD] = 1.5 [4.3]; F [1: 197] = 9.6, p
< .005). This margin of difference decreased in the month prior to the 12-month
follow-up assessment (M [SD] = 3.6 [6.3] vs. M [SD] =
1.3 [3.1], for males and females, respectively; F [1: 91] = 4.0, p
< .05). There were no significant differences in the proportion of males (12.9%)
and females (9.1%) who reported a current alcohol problem.
Females
also reported more days of abstinence in the month pre-treatment (M = 28.4,
SD = 4.3) than did males (M = 23.9, SD = 8.1; t [197]
= -3.72, p < .0001). The same was true in the month prior to the 12-month
follow-up assessment (M = 28.4, SD = 4.8 vs. M = 23.7, SD
= 8.7 for females; t [91] = -2.82, p < .01). There were no gender
differences, however, in the lifetime rates of alcohol problems or treatment-seeking
for problem gambling.
In
addition, there was no significant gender effect of either alcohol use on gambling
behaviour (21.0% of males vs. 10.0% of females reported increased gambling when drinking
alcohol) or gambling on alcohol consumption (14.4% of males and 12.0% of females
reported increased alcohol use when gambling).
Table 2
Patterns of use for individual psychoactive substances, by gender
| Substance |
|
Ever
used |
Ever a
problem |
Ever
treated |
Used in 30 days pre-treatment |
Used during follow-up period1 |
| |
|
M2 |
F3 |
M |
F |
M |
F |
M |
F |
M |
F |
| Alcohol |
%
n |
na4
na |
na
na |
26
22 |
24
8 |
12
10 |
22
7 |
664.3
97 |
26
13 |
59.7
37 |
24.2
8 |
| Cannabis |
%
n |
67
100 |
54
27 |
15.3
23 |
12
6 |
6
9 |
6
3 |
8.7
13 |
8
4 |
1.3
2 |
4
1 |
| Cocaine |
%
n |
30
45 |
22
11 |
8
12 |
10
5 |
4
6 |
18
2 |
0.7
1 |
4
2 |
0.7
1 |
0
0 |
| Opiates |
%
n |
7
11 |
10
5 |
2.7
4 |
4
2 |
1.3
2 |
2
1 |
1.3
2 |
0
0 |
2
1 |
0
0 |
| Hallucinogens |
%
n |
31
46 |
24
12 |
6.7
10 |
6
3 |
3.3
5 |
4
2 |
0
0 |
0
0 |
0
0 |
0
0 |
| Inhalants |
%
n |
5
7 |
6
3 |
0.7
1 |
0
0 |
0
0 |
0
0 |
0
0 |
0
0 |
0
0 |
0
0 |
| Stimulants |
%
n |
21
31 |
22
11 |
6
9 |
10
5 |
1.3
2 |
8
4 |
1.3
2 |
2
1 |
0
0 |
0
0 |
| Anti-depressants |
%
n |
22
33 |
62
31 |
1.3
2 |
6
3 |
0
0 |
0
0 |
14.7
22 |
34
17 |
14
7 |
37
10 |
| Anxiolytics |
%
n |
22
32 |
50
25 |
4
6 |
14
7 |
1.3
2 |
10
5 |
4.7
7 |
22
11 |
2
1 |
19
5 |
| Antipsychotics |
%
n |
4
6 |
12
6 |
0
0 |
0
0 |
0
0 |
2
1 |
2.7
4 |
8
4 |
8
4 |
15
4 |
| Sedatives |
%
n |
13
20 |
28
14 |
3.3
5 |
16
8 |
0.7
1 |
8
4 |
4
6 |
10
5 |
6
3 |
15
4 |
| Prescribed opiates |
%
n |
33
49 |
46
23 |
4
6 |
16
8 |
1.3
2 |
8
4 |
9.3
14 |
10
5 |
6
3 |
15
4 |
1n = 93 2
Males, n = 149-150 3Females, n =
50
4Lifetime
use of alcohol not assessed.
Gender and aggregated psychoactive substance use patterns
Table
3 describes the relationship of gender and aggregated substance use patterns. More
females reported lifetime use of psychiatric medications (c
2 [1] = 16.7, p < .0001), abuse of medications (c
2 [1] = 10.2, p < .005), treatment for abuse of medications
(c 2 [1] = 17.0, p < .0001), medication
use at the time of seeking treatment for the gambling problem (c
2 [1] = 17.8, p < .0001) and medication use during the 12-month
follow-up period post-treatment (c 2 [1] =
10.9, p < .001). Frequencies for the use of psychiatric medications also
showed similar, significant gender differences. There were no gender differences
in the patterns or frequency of drug use.
Table 3
Lifetime, current and follow-up drug and medication use, by gender
| Variable |
Males |
Females
|
| Mean (SD) number of: |
% n |
% n |
| Drugs1 ever used |
70.5 (106) |
60.0 (30) |
| Drugs ever a problem |
24.0 (36) |
22.0 (11) |
| Drugs ever treated for |
9.3 (14) |
10.0 (5) |
| Drugs used in 30 days pre-treatment |
10.0 (15) |
10.0 (5) |
| Drugs used during follow-up period2 |
6.5 (4) |
3.0 (1) |
| Medications ever used3 |
38.7 (58) |
72.0 (36) |
| Medications ever a problem3 |
7.3 (11) |
24.0 (12) |
| Medications ever treated for3 |
1.3 (2) |
16.0 (8) |
| Medications used in 30 days pre-treatment3 |
18.0 (27) |
48.0 (24) |
| Medications used during follow-up period2,3 |
14.5 (9) |
46.0 (15) |
1excluding alcohol 2n
= 93
3chi-square significant at p < .0001 4chi-square
significant at p < .005
Discussion
No
study has systematically assessed gender differences in substance use patterns, problematic
substance use and substance treatment history among pathological gamblers. The results
of the present study suggest that female problem gamblers reported significantly
greater lifetime use of psychiatric medications, in particular anti-depressants,
anxiolytics, and sedatives, than male problem gamblers.
This
pattern parallels the relationship observed between gender and psychiatric medications
in the general Canadian population. In a survey of drug use among Canadians (McKenzie,
1997), more women used tranquilizers (5.3%), sedatives (5.4%) and anti-depressants
(4.2%) in the past year than did men (3.4%, 3.7%, 1.7%, respectively).
While
the lifetime prevalence of illicit drug use in the Ontario population (e.g., cannabis,
26.8%, cocaine, 4.9%, heroin, 1.1%) is considerably lower than that for legal substances
(e.g., nicotine, alcohol) and prescribed medications, the rates are generally twice
as high for males as for females (Van Truong, Williams, Timoshenko, 1998; Adlaf,
Ivis, Ialomiteanu, Walsh, Bondy, 1997). The present study found the same relationship
wherein illicit drug use was higher in males, although not significantly so. While
the relationship between gender and substance use appears to be consistent with what
is found in the general population, the rates are considerably higher among problem
gamblers seeking gambling treatment.
There
were no gender differences in the reported rates for problems with, or treatment
for, drug, medication or alcohol use. Furthermore, very little drug use was reported
at the time that participants were seeking gambling treatment. None of the participants
reported that their current substance use was problematic. Nor was there any evidence
that gambling behaviour was substituted by increased use of psychoactive substances
as a result of treatment, since there was no change in the use of psychoactive substance
during the post-treatment period compared to substance use prior to entering gambling
treatment.
The
relatively high rates of medication usage among treatment-seeking female gamblers
suggest higher levels of psychological dysfunction, sufficient to warrant psychopharmacological
intervention. It is well-documented that women tend to suffer from mood and anxiety
disorders at rates higher (approximately two to three times) than men in the general
population and they are also more likely to seek treatment for anxiety and depression
(Kessler, et al. 1994; Ross, 1995). Medications would frequently be a component of
such treatment.
Problem
gamblers have been shown to suffer considerably from concurrent psychiatric symptomatology.
Reviews of the literature show that affective disorders and anxiety disorders are
particularly common (Lesieur & Blume, 1991; McCormick, Russo, Ramirez & Taber,
1984; Linden, Pope and Jonas, 1986). Specker, Carlson, Edmonson, Johnson and Marcotte
(1996) found that almost all of a sample of 40 problem gamblers had had a lifetime
mood disorder and most female (but not male) problem gamblers had been diagnosed
with an anxiety disorder during their lifetime. In general, this literature has not
examined psychopathology by gender.
The
results of this study suggest that substance use among treatment-seeking problem
gamblers, while highly prevalent over the course of the lifetime for both genders,
does not seem to be a relevant clinical issue. However, the elevated rates of psychotropic
drug use, especially among female problem gamblers, suggest that there may be considerable
psychiatric comorbidity in this population, which is consistent with other research
in this area.
It
is not clear from the study whether such psychopathology is functionally associated
with the gambling behaviour. The finding that neither gender changed greatly in their
use of antidepressants and anti-anxiety medications in the year following treatment
for gambling may indicate an independent psychiatric syndrome. Additional research
is needed to evaluate the impact of concurrent medication use and/or psychopathology
on the outcome and long-term effect of treatments for problem gambling.
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