Comorbidity of mental disorders and substance use: a brief guide for the primary care clinician
11.2 Comorbidity with gambling
11.2.1 Gambling and substance abuse
- There is a high prevalence of current and lifetime substance use amongst people who are affected by problem gambling, exceeding that of the general population(426, 428, 431, 432, 435-437, 443, 459-462).
- There is also a strong correlation between the severity of substance use and the severity of problem gambling, with higher rates and severity of substance use being predictive of more severe gambling problems and vice versa(23, 365, 367, 428, 429, 433, 463).
- Substance use can be a significant discriminator between people with problematic versus nonproblematic gambling. The greater the number of substances used the more severe the gambling problems experienced(367, 463, 464).
- Problem gambling is often associated with increased impulsivity, antisocial tendencies as well as the inability to control anger(426, 465-468).
- Gambling at an earlier age increases the risk of multiple addictions and risky behaviour(437).
- People with comorbid substance use and gambling problems experience increased impulsivity which leads to further poor decision making(428).
- Impaired impulse control and poor risk assessment occurs with both gambling and substance use disorders(365, 428).
- Failure to treat comorbid substance use disorders in gambling may lead to higher gambling relapse rates(428).
- People with comorbid substance use and gambling problems are more likely to report other psychiatric histories(433).
11.2.2 Gambling and mental disorders
- Increased gambling is associated with reduced mental health status(469). The majority of people with problem gambling have more than one psychiatric disorder(459).
- The causative relationship between comorbid problem gambling and other mental disorders has not been clearly established:
- Gambling may be pursued to relieve anxiety(428) and depression(429).
- Early onset problematic gambling is associated with pre-existing depression(470).
- Mental disorders such as depression and anxiety may develop or be exacerbated by gambling(428).
- People most at risk for problem gambling are those with major mental disorders who often experience significant social isolation and separation(429).
- Use of psychiatric medication has shown a decline following behavioural and motivational treatment of problem gambling(464). This suggests that anxiety and depression may be secondary to gambling, at least in some people.
- Women are more likely than men to have additional mood or anxiety disorders and use gambling to escape depressed moods(428, 431, 471). Women with problem gambling are also significantly more likely to seek treatment for their mood or anxiety disorder(431).
- Affective disorders are more common amongst people who are affected by problem gambling compared to the general population(428, 429, 432, 434, 437, 440, 459, 462, 465, 466, 469, 471-478).
- Gambling is more common amongst people with bipolar disorder than the general population(462, 479).
- Higher rates of anxiety are also correlated with more severe gambling problems(23, 480).
- There are also increased rates of obsessive compulsive disorders in people with problem gambling(427, 428, 438, 459, 460, 481).
- As mentioned above, problem gambling is also highly correlated with personality disorders, particularly antisocial, borderline and obsessive compulsive personality disorders(428, 435, 437, 465, 470, 471, 482, 483).
- Problem gambling is associated with high comorbidity of other impulse control disorders (including kleptomania, impulsive shopping and impulsive sexual behaviour), as well as purging type eating disorders(364-367, 432, 462, 484).
11.2.3 Gambling and suicide
- Problem gambling is often associated with increased suicidal ideation and attempts compared to the general population(427-429, 432, 437, 472, 476, 477, 485.
- Early onset problem gambling increases lifetime risk of suicide470).
- However, gambling-related suicide attempts are usually made by older people with problem gambling(485).
- Both comorbid substance use(432, 433) and comorbid mental disorders increase the risk of suicide in people with problem gambling(485).
11.2.4 General management approaches to comorbidity
- A history of past substance use and mental disorders does not lessen the effectiveness of current treatment for gambling(464).
- People with current substance use as well as problem gambling must avoid replacing one addiction with the other(436).
- People with problem gambling and bipolar spectrum disorder show significant improvement on gambling thoughts, urges and behaviour as well as in manic behaviour while taking lithium***(486).
- SSRIs as a combined treatment may be effective in treating co-occurring anxiety and gambling*(487) as well as depression.