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Introduction
Gender has been a determinant of many health-related
behaviors, such as treatment utilization, substance use, and psychiatric
symptoms and diagnoses (Robins & Regier, 1991; Verbrugge, 1985).
Males tend to have earlier and higher mortality rates(Verbrugge,
1985) and use substances (alcohol, tobacco and street drugs)more
than females (Robins & Regier, 1991). Females tend to use physical
and mental health services more (Verbrugge, 1985) and use more prescribed
drugs than males (Verbrugge, 1985). Gender is also important in psychiatric
disorders, where males tend to have higher rates of disordered substance
use, with the exception of prescription drug use (Robins & Regier,
1991) and females tend to have more psychiatric disorders, especially
in the anxiety and mood disorder cluster(Robins & Regier,
1991).
Historically, in studies of the prevalence of gambling
disorders, males have significantly outnumbered females. Volberg (1994),
in a paper summarizing prevalence studies from five states in the United
States, estimated males to be 76% of pathological gamblers in the community.
The most current diagnostic manual states that females comprise only
33% of pathological gamblers (American Psychiatric Association, 2000).
However, the expansion of legalized gambling in the United States has
changed this ratio. The most recent U.S. national survey of gambling
behavior, completed in 1999, shows gambling disorders more equally distributed
by gender. Although the National Opinion Research Center (1999) found
higher prevalence rates of problem and pathological gambling among men
than women male lifetime rates: problem 1.6%, pathological 0.9%;
female lifetime rates: problem 1.0%, pathological 0.7% in their
initial (RDD) survey, the differences were not statistically significant.
Studying the patterns of comorbid disorders can lead
to better treatment and understanding of the causal factors in the disorder.
Additional disorders of all types have implications for treatment. The
presence of comorbid diagnoses makes it more likely that the patient
will seek treatment (Andrews, Slade & Issakidis, 2002; Noyes, 2001).
The presence of comorbid diagnoses also increases the likelihood of treatment
failure in many psychiatric disorders: depression (Bagby,
Ryder & Cristi, 2002), bipolar disorder (Frangou, 2002), obsessive-compulsive
disorder (Ruppert, Zaudig, Hauke, Thora & Reinecker, 2001), generalized
anxiety disorder (Noyes, 2001), post-traumatic stress disorder (Breslau,
1999) and panic disorder (Mennin & Heimberg, 2000). The presence
of comorbid diagnoses affects cognitive-behavioral therapies (Mennin & Heimberg,
2000), inpatient treatment (Haettenschwiler, Rueesch & Modestin,
2001) and pharmacotherapy (Bagby et al., 2002).
The National Comorbidity Survey (Kessler et al., 1994)
was the first survey to administer a structured psychiatric interview
to a national probability sample of non-institutionalized people in the
United States. The study found that psychiatric morbidity was highly
concentrated in one-sixth, or approximately 16% of the adult population
with a lifetime history of three or more comorbid disorders.
The most well-studied comorbid relationships among psychiatric
disorders are the (misnamed) dual disorders, or the association between
substance use disorders and psychotic, anxiety and mood disorders. The
interactions can be very complex. To generalize: 1) the two disorders
may occur by chance, 2) substance use may cause or exacerbate the psychiatric
disorder, 3) the psychiatric disorder may cause or increase the severity
of the substance use, 4) both disorders may be caused by a third condition,
and 5) substance use or withdrawal may mimic the psychiatric disorder.
Studies of dual disorders often attempt to determine
the temporal relationship of the onset of the different disorders to
clarify causation. However, the comorbidity pattern can differ by the
substance used and the specific other psychiatric disorder or disorders
as well as by the population studied. For example, the National Comorbidity
Study found that alcohol use problems and dependence consistently occurred
after the onset of the psychiatric disorder (Kessler et al., 1997). However,
nationwide studies of psychiatric comorbidity and both alcohol and drug
use disorders in six countries found that only anxiety disorders consistently
preceded substance use disorders; mood disorders and substance use disorders
had no consistent temporal pattern (Merikangas et al., 1998). Despite
the theoretical complexity, the temporal relationship among comorbid
disorders can be useful clinically, in deciding which of several disorders
is primary, which have implications for treatment priorities and plans.
The study of other psychiatric diagnoses occurring with
gambling disorders is early in its development. The Harvard Division
of Addictions gambling disorder prevalence meta-analysis (Shaffer, Hall & VanderBilt,
1997) established psychiatric comorbidity as a risk factor for gambling
disorders. Their analysis established significantly higher prevalence
rates for gambling disorders among samples of adults with psychiatric
or substance dependence disorders and those in prison than among community
samples of adults. The relative risk varies from four to seven, depending
on the population studied (Shaffer et al., 1997).
Comorbidity patterns change based on the population studied
and site of assessment (Berkson, 1946). Clinical studies of patients
in treatment with gambling disorders have found that other psychiatric
disorders occur consistently. Ibañez et al. (2001) found comorbidity
in 43% of gamblers seeking treatment. There have been more studies of
treatment populations than community populations in the study of comorbid
disorders in gambling. However, the number of subjects studied is usually
small, especially in studies of anxiety and personality disorders. Clinically
useful information, such as the nature and relevance of the specific
comorbidity associations, is limited. See Table 1 for a summary of the
relevant studies.
Table 1
Summary table of research on comorbid diagnoses
in community and treatment samples
Disorder |
Total number of studies
|
Community studies
|
|
Treatment studies
|
|
|
|
Number
|
Total subjects
|
Number
|
Total subjects
|
Mood disorders |
20
|
3
|
9,100
|
17
|
3,200
|
Anxiety disorders |
5
|
1
|
7,200
|
4
|
250
|
Antisocial personality disorder |
2
|
1
|
7,200
|
1
|
109
|
Substance use disorders |
12
|
2
|
9,200
|
10
|
3,200
|
Substance dependency has been relatively well established
as a significant comorbidity with pathological gambling (Crockford & el-Guebaly,
1998; Ibañez et al., 2001; National Research Council, 1999; Shaffer
et al., 1997). Approximately 50% of pathological gamblers will have a
substance use or dependency diagnosis. Affective symptoms have also been
found to be associated with pathological gambling (Crockford & el-Guebaly,
1998; Maccallum & Blaszczynski, 2002; National Research Council,
1999; Shaffer et al., 1997); however, the results have been inconsistent.
One analysis proposed that affective disorders were a significant comorbidity
in only a subgroup of problem gamblers (Crockford & el-Guebaly, 1998).
Personality disorder comorbidity has also been studied, with antisocial
personality disorder being the strongest association (Crockford & el-Guebaly,
1998; Ibañez et al., 2001). However, the strong association between
substance use disorders and antisocial personality disorder confounds
the association between gambling disorders and antisocial personality
disorder (National Research Council, 1999).
There are many unanswered questions about the influence
of comorbid psychiatric disorders in problem gamblers. Because of the
historical predominance of males in populations with gambling disorders,
the effect of gender on comorbidity patterns in gambling disorders is
unstudied. In addition, since treatment populations for any psychiatric
disorder are more likely to have other psychiatric disorders (Berkson,
1946), the clinical relevance of comorbid disorders in problem gambling
has been minimally studied. Only one study has determined that comorbid
disorders increase the severity of the gambling disorder (Ibañez
et al., 2001). But do the comorbid disorders only add to disease burden
and make it more likely for the patient to seek treatment or do they
directly affect the gambling behavior and need to be considered in the
formulation of treatment plans for problem gamblers?
The objectives of this study were to assess (1) the effect
of gender on comorbid problems and (2) treatment-seeking behavior of
gamblers in treatment and (3) the interactive effects of the comorbid
problems on the participants' gambling.
Method
Participants
An anonymous, voluntary questionnaire was distributed
to all state gambling disorder treatment sites and Gamblers Anonymous
meeting sites in the state of Louisiana in January of 1999 as part of
a study on the social cost of gambling (Ryan et al., 1999). Seventy-eight
questionnaires were returned in time for statistical analysis.
Materials
Participants completed a survey that included a screen
for gambling disorders, demographic questions, and questions about types
and frequency of gaming activities, quantifiable consequences of gambling
disorders, comorbid conditions, illicit substance use, gambling career
and treatment-seeking history. Questions covered gambling behavior and
work and legal and other consequences of disordered gambling based on
Lesieur's model (Lesieur, 1998). Gender differences in these behaviors
are under study. The questionnaire inquired about the types of other
mental health and substance use problems that the participants had experienced.
The questionnaire specifically asked, "Did any of these problems ever
make your gambling problems worse?" Each participant's history of gambling,
substance use disorder and psychiatric treatment was also reported.
Design and procedure
Chi-square analyses were performed on the types of comorbid
problems, total number of comorbid problems, types of mental health or
substance use treatment sought and the response to whether or not gambling
had been worsened by comorbid problems. A one-way ANOVA was performed
on total number of comorbid problems by gender. The chi-square on each
comorbid condition was analyzed separately by gender and by the dichotomous
variable that reflected their worsening of the gambling problem.
Results
Previous treatment
Males reported larger treatment costs for gambling treatment
and more substance abuse treatments. Females reported significantly more
outpatient mental health treatment (χ2 (1, N = 78) = 5.198, p < .05).
Comorbid problems
Sixty-one of the 78 respondents (78%) reported other
substance use or mental health problems. A total of 168 comorbid problems
in 11 categories were reported by the sample. Twice as many males (30.7%
of the total sample) as females (16.7%) had one or no other comorbid
problems. See Table 2 for the distribution of the number of comorbid
problems by gender. More females (32%) than males (20.6%) had two or
more comorbid problems. A one-way ANOVA on total number of comorbid problems
by gender showed that females (mean 2.42) had more comorbid problems
than did males (mean 1.6) (F (1,76) = 3.948, p < .05).
Table 2
Total number of comorbid problems by gender with
percentages of total sample
Number of comorbid problems
Count/per cent of total |
Males
|
Females
|
0 |
14
|
17.9%
|
7
|
9.0%
|
1 |
10
|
12.8%
|
6
|
7.7%
|
2 |
7
|
9.0%
|
10
|
12.8%
|
3 |
2
|
2.6%
|
3
|
3.8%
|
4 |
3
|
3.8%
|
6
|
7.7%
|
5 |
2
|
2.6%
|
3
|
3.8%
|
6 |
2
|
2.6%
|
3
|
3.8%
|
Table 3 presents the percentages of males and females
reporting specific problems. Males reported significantly more alcohol
problems (χ2 (1, N = 78) = 5.641, p < .05) and
problem use of other drugs (χ2 (1, N = 24) = 4.8, p < .05)
than females and showed tendencies to greater marijuana use (χ2 (1, N = 78) = 3.486, p = .062). Females reported significantly
higher problems with overeating (χ2 (1, N = 78) = 7.453, p < .01),
eating disorders (χ2 (1, N = 78) = 4.438, p < .05),
compulsive shopping (χ2 (1, N = 77) = 16.896, p < .001)
and tranquilizer use (χ2 (1, N = 24) = 10.667, p < .001).
Table 3
Per cent of sample reporting comorbid problems
by gender
|
Per cent of total sample
|
Disorder |
Males
|
Females
|
Alcohol use |
20.5**
|
7.7
|
Overeating |
12.8
|
26.9**
|
Eating disorder |
0
|
5.1*
|
Compulsive shopping |
1.3
|
19.5***
|
Depression |
28.2
|
30.8
|
Any drug use |
14.1
|
14.1
|
|
Per cent of drug users
|
Substance |
Males
|
Females
|
Marijuana |
39.1
|
17.4
|
Tranquilizers |
8.3
|
41.7***
|
Stimulants, "uppers" |
8.3
|
8.3
|
LSD |
4.2
|
0
|
Narcotics |
8.3*
|
4.2
|
Other drugs |
16.7
|
0
|
Note: * p < .05; ** p < .01; *** p < .001
Effect of comorbid problem on gambling
Forty-nine per cent of those reporting comorbid problems
(38.5% of the total sample) indicated that a comorbid problem had increased
the severity of their gambling behavior. Eleven different types of comorbid
problems were reported. Only two, depression and problem drinking, were
identified as exacerbating gambling behavior. Females were significantly
more likely than males to report that problem drinking (χ2 (1, N =
34) = 5.13, p < .05) had increased the severity of their gambling. About
the same percentage of males and females reported depression had increased
the severity of their gambling. Chi-square analyses on depression by
gender and by the variable that measured a worsening of gambling problems
found that depression exacerbated gambling problems independent of gender.
Both males (χ2 (1, N = 38) = 5.546, p < .01) and
females (χ2 (1, N = 34) = 5.903, p < .01) reported
that depression significantly worsened their gambling problems.
Discussion
Many of the comorbid and treatment-seeking behaviors
reported by this sample are consistent with well-known and studied gender
differences in health behaviors. Males reported more alcohol and drug
use problems and females reported more psychiatric problems, tranquilizer
use and outpatient psychiatric treatment, which is consistent with previous
reports (Kessler et al., 1994; Robins & Regier, 1991; Verbrugge,
1985).
The majority of the gamblers in this treatment sample
from Louisiana had other psychiatric or substance use problems in addition
to their gambling disorder. Comorbid problems were the rule rather than
the exception in this population of gamblers in treatment. However, only
a minority of patients with comorbid disorders answered positively to
the question that the comorbid disorder had ever increased the
severity of their gambling. This study partially supports the findings
of Ibañez et al. (2001) that comorbid disorders increase the severity
of gambling problems.
One finding of this study is that, from the participants'
viewpoint, only two of the multiple comorbid problems reported had ever
affected the severity of their gambling. Unfortunately, the effects were
inconsistent: only about half of the patients with comorbid problems
identified that depression or problem drinking had increased their gambling
behavior. Most of the males with comorbid problem drinking and some of
the participants with depression did not identify these problems as ever
negatively affecting their gambling.
Although preliminary, this study provides more evidence
of the need for careful attention to diagnosing and investigating the
interactions of comorbid alcohol (Maccallum & Blaszczynski, 2002)
and affective disorders. Clinicians should further investigate the interaction
of the comorbid disorder with gambling behavior and the order of onset
of the disorders. For example, a patient who developed depressive symptoms
after the onset of pathological gambling in response to financial, legal
or marital problems should be treated differently than a patient who
developed depressive symptoms, and later, found that gambling temporarily
relieved the symptoms of depression. In this example, the clinical approach
should be different, even if both patients reported that their depressive
symptoms increased their desire to gamble or their gambling behavior.
In addition, this study provides some perspective on
the inconsistent results of pharmacological treatments for gambling disorders.
Inconsistent and possibly gender-related effects of comorbid disorders
may be confounding the results of these trials. Several agents that affect
mood and alcohol use behavior have shown inconsistent, mixed results
in treatment trials. It may be necessary to sub-type gambling populations
in treatment trials by both the presence and type of comorbid disorders
as well as the effect of the comorbid disorder on the gambling behavior.
This study needs to be replicated with larger numbers
and independent confirmation of comorbid diagnoses, rather than self-report
alone. Family or other collateral information on the interaction of the
comorbid disorders and the gambling would also be useful to supplement
the patient's perceptions of the interactions. In addition, information
on the onset of the comorbid disorders in relation to the gambling disorder
would be crucial to determine causality. Further, more targeted studies
are needed to clarify the clinical relevance of comorbid disorders for
gamblers in treatment programs and to determine the role of these disorders
in the development of gambling disorders.
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