co-occurring mental illness and problem gambling

Co-occurring Mental Illness and Problem Gambling

The Victorian Statewide Problem Gambling and Mental Health Partnership Program 2009-2011

Presenters:

Karen HarrisonProject Officer, Training and Education

Mick FieldSenior Clinician, Clinical Services

Partnerships

Training Modules

Module 1 Module 2 Module 3

Pathways to treatment

Module

Case studies: How do they present?

• Defining

• Classification

• Phases of Gambling

• Types of Gamblers

• Understanding co-morbidity

• Co-morbidity in practice

• Current research in co-morbidity

• Models of co-morbidity

• Models of treatment

• Identifying

• Screening

• Assessment

•“Now what do I

do?”

• The Curious Case

of Mr. B

• One thing looks

like another

• Discussion

What is Problem Gambling?

PG & MI : A partnership for trouble

Module 1What is Problem Gambling?

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Overview

Defining problem gambling DSM-IV classification of

problem/pathological gambling Understanding the problem gambler Phases of gambling Types of problem gamblers

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Gambling

“To stake money or risk anything of value on the outcome of something involving chance”.

Dictionary.com website: http://dictionary.reference.com/browse/gamble

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Defining “Problem Gambling”

Problem Gambling refers to the situation when a person’s gambling activity gives rise to harming the individual player, and/or his/her family, and may extend into the community.

Victorian Casino & Gaming Authority (1998)

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In order to be diagnosed, an individual must have at least 5 (or more) of the following symptoms: - Impulse Disorder (312.31)

Preoccupation. Preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble.

Tolerance. As with drug tolerance the subject requires larger or more frequent wagers to experience the same “rush”.

Withdrawal. Restlessness or irritability associated with attempts to cease or reduce gambling.

Escape. The subject gambles to improve mood or escape problems.

Chasing. The subject tries to win back gambling losses with more gambling.

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DSM-IV definition of Pathological Gambling

Lying. The subject tries to hide the extent of his or her gambling by lying to family, friends, or therapists.

Loss of control. The person has unsuccessfully attempted to reduce gambling.

Illegal acts. The person has broken the law in order to obtain gambling money or recover gambling losses. This may include acts of theft, embezzlement, fraud, or forgery.

Risked significant relationship. The person gambles despite risking or losing a relationship, job, or other significant opportunity.

Bailout. The person turns to family, friends, or another third party for financial assistance as a result of gambling. The gambling behaviour is not better accounted for by a Manic Episode

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition. Washington DC: American Psychiatric Association.

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DSM-IV definition of Pathological Gambling (cont)

Understanding the Problem Gambler

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Phases of Gambling

Winning Losing Desperation Hopelessness

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Phases of Gambling

Start gambling

Winning

Losing

Desperation

Hopelessness

Presentationto service

Treatmentpathway

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Winning Phase

Gambling episodes occur more frequently but still may be widely spaced apart.

Person experiences gambling episodes as positive and fun events.

Person starts to view gambling as an important behaviour

in their lives.

An increased acceptance and rationalization of gambling. There may be a period without negative economic

consequences.

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Winning Phase (cont’d)

The person may adopt an identity as a gambler. They accept gambling as part of their personal image and share stories of winning with others.

If the person is winning or breaking even, there may be a feeling that they are talented as a gambler or have a special gift for the type of action they engage in.

There are few or no negative consequences to the gambling. Spouses and family members may encourage the behaviour during this time.

This phase may last for many years or can be quite brief to some or non-existent for others (especially for slot machine players).

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Losing Phase Gambling episodes occur more frequently, and may be

regular and habitual.

Chasing losses begins; wager size increases. Gambling becomes a primary behaviour and replaces other

hobbies and interests. Occupation and family may suffer from neglect.

Increased anxiety and depression resulting from financial pressures. Loans are often sought from banks or credit cards, then from family and friends.

Symptoms of pathological gambling begin to appear.

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Losing Phase (cont’d) Juggling of finances ("creative financing") to pay for

gambling may occur.

Minimization and hiding of the gambling behaviour starts.

First bailout may occur.

Initial effort to cut back or quit gambling may follow a particularly bad loss.

A lack of recognition that gambling is causing problems may be evidenced.

Problem severity may be minimized by the person trying to "handle it myself”.

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Desperation Phase Increased depression, shame and guilt.

The chase leads to being "jammed up," where the options for obtaining cash are depleted. May sell possessions, float checks, engage in illegal acts, do things that they never would have considered before the addiction started.

Debt related anxiety often increases further.

Physical health and sleep patterns may be affected.

Isolation from family and friends may increase.

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Hopelessness Phase

20% of pathological gamblers will attempt suicide, almost all pathological gamblers seriously consider suicide.

60% will commit a criminal offense.

20% will appear before the judicial system.

Although a person in this phase essentially gives up, they may still seek or return to treatment.

Adapted from material written by R. Custer, M.D., R. Rosenthal, M.D., L. Rugle, Ph.D. and S. Wexler.

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Types of Problem Gamblers

Action Problem Gambler

Escape Problem Gambler

Internet Problem Gambler

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Action Problem Gambler

Can be characterized as highly competitive, domineering, controlling, manipulative and egotistical.

See themselves as friendly, sociable, gregarious and generous. They are energetic, assertive, persuasive and confident.

Usually have low self esteem.

May have started gambling at an early age, often in their teens, by placing small bets on sporting events or playing cards with friends or relatives.

Progress through the four phases of the disorder over a ten to thirty year time span.

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Understanding the “Action”

Typically gamble primarily at "skill" games such as poker or other card games; craps or other dice games; horse and dog racing and sports betting.

Both legal and illegal sports betting is dominated by these gamblers.

Gamble to beat other individuals or the "house" and often believe they can develop a system to achieve this goal.

During the desperation phase of the disease, many action gamblers often begin to gamble specifically for escape, medicating the pain they are feeling from the destruction created by their gambling with the narcotic-like effect of slot or, more likely, video poker machines.

Adapted from material written by Don Hulen, AZCCG.

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Escape Problem Gambler

Typically play games that do not require high levels of skills or knowledge such as handicapping.

They tend to choose games such as slot machines, video poker, cherry masters, bingo, keno, pull tabs, etc.

May go into a "trance like" state and spend extensive amounts of time "lost" in their gambling.

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Behind the “escape”

Most have been nurturing, caring responsible people for most of their lives.

Most are not egotistical, have no indications of narcissism and are not out-going.

They appear to be "normal" and have an almost exact opposite character profile than that of the action problem gambler.

During their lives, various psychological traumas have occurred and commonly suffer from undiagnosed PTSD

Frequently suppress those negative feelings and do not deal with them. As time goes by and the traumas increase, a single traumatic event may take place which causes situational or clinical depression.

Are prone to use drugs, food, sex, alcohol or gambling as a way to self-medicate.

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Behind the Escape (con’t)

Most escape gamblers begin by visiting a casino with friends or family once or twice as a social event.

may quickly step over the line into escape problem gambling. They rapidly fly through what is often referred to as the "winning" phase.

may or may not have a big monetary win.

enter PG phase two, chasing their loses, almost immediately and reach the third phase of desperation and fourth phase, hopelessness, within two to three years.

often seek professional counselling prior to attending their first self help meeting.

Adapted from material written by Don Hulen, AZCCG.

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Internet Problem Gambler

Internet gambling is the placing, receipt, or other transmission of a bet or wager which involves the use of the Internet.

This type of gambling is available 24-hours a day.

The internet problem gambler can be more capable of concealing harmful activity from friends and loved ones.

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Module 2Problem Gambling and Mental Illness: A partnership for Trouble

Overview

Understanding co-morbidity Co-morbidity in practice Current research in co-morbidity and

problem gambling Models of co-morbidity Models of treatment

Module 2

What does co-occurring mean?

Often referred to as co-morbid illness or co-morbidity

Can mean multi-occurring or multi-morbidity

Important for: Assessment Treatment Recovery

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Common co-occurring illnesses in MI & PG:

Depression + Anxiety + Substance abuse +

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Statistics of co-morbidity amongst Problem Gamblers

Epidemiological data:

alcohol use disorder (44.5%-73.2%) drug use disorder (23.3%-38.1%) major depression (8.8%-37%,) mania (3.1%- 22.8%) generalized anxiety (7.7%- 11.2%) panic disorder (3.3%- 23.3%) agoraphobia (5.1%-13.3%) phobia (10%-23.5%) obsessive-compulsive disorder (3.9%-16.7%)

Bland, Newman, & Stebelsky, 1993; Cunningham-Williams, Cottler, Compton, & Spitznagel, 1998;

Petry, 2005

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Co-morbidity and pathological gambling: Epidemiological data

43,093 US adults participated in face-to-face interviews in the 2001-2002 survey:

73.2% of pathological gamblers had an alcohol use disorder 38.1% had a drug use disorder 60.4% had nicotine dependence 49.6% had a mood disorder 41.3% had an anxiety disorder60.8% had a personality disorder

Petry et al (2005)

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Anxiety disorders and Problem Gambling:

Kessler et al 2008 found that 60.3 per cent of problem gamblers had an anxiety disorder (odds ratio = 3.1).

Petry et al (2005) reported the prevalence rate to be 41.3% with an odds ratio of 3.4.

The Victorian Department of Justice (2009) survey found 46.36% of problem gamblers reporting anxiety compared with 7.4% of non-problem gamblers.

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Depression and Problem Gambling:

Volberg et al (2006) reported 37% of problem gamblers in their general population survey also had experienced depression in the last year.

Similar results were found by Kessler et al (2008) who found 38.6% of problem gamblers have co-morbid depression

Petry et al (2005) found that 36.99 % of problem gamblers have a major depressive disorder in their lifetime.

The Victorian Department of Justice (2009) surveyed found just over half of problem gamblers reporting past year depression.

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Alcohol abuse and dependence and Problem Gambling

73.22% of problem gamblers have been found to havea co-morbid alcohol use disorder (Petry et al 2005). In Victoria, the Department of Justice (2009) reportedthat compared with non-problem gamblers, using theCAGE alcohol screen:

problem gamblers were significantly more likely to report signs of clinical alcohol abuse (OR=2.56, p<.01)

problem gamblers were significantly more likely to report a high level of clinical alcohol abuse (OR=22.94, p<.001)

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Not so common co-occurringMI & PG (or are they?):

Schizophrenia + Bi-polar + Personality disorder + PTSD +

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Co-morbidity Problem Gambling and “serious mental illness” (SMI)

McIntyre et al (2007) Bipolar Affective Disorder (6.3% problem gambling)

• Desai & Potenza (2009) Psychotic disorders (19% problem/pathological

gambling 10% pathological gambling)

Cunningham-Williams et al (1998) Schizophrenia (3.9%)

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Effects of PG on SMI

Financial stress Relationship difficulties Increased rates of depression & anxiety Impaired vocational & social functioning Increased substance use Non-adherence to prescribed medication Increase in psychiatric symptoms Suicide risk Increase use of services Homelessness Crime

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A significant proportion (up to 80%) of problem gambling clients have a mental health problemMay be referred on to mental

health servicesMany more may have subclinical

symptoms• Rule rather than the exception in

treatment settings

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Clients with co-morbid problem gambling and mental health problems have:

• Poorer prognosis• Higher risk of harm• Greater likelihood of relapse to both

disorders• Greater use of health services

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Co-morbidity in Practice Co-morbidity is the norm

In both mental health and problem gambling services

BUT

Client group is very different in each service

Substance abuse / dependence will be a complicating issue for a majority of clients

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Co-morbidity in Practice

In Mental Health Services; Mostly psychotic disorders with range of Problem

Gambling issues

In Problem Gambling Services: Mostly high prevalence disorders: anxiety and

depression Often not able to refer to Mental Health Services Often have subclinical symptoms: often go

undetected

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How do clients present to Health Services? Depression - suicidal Anxiety - panic attacks & agoraphobia Agitation & anger Headaches Sleep problems Alcohol or drug problems Personal/family/employment problems

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The hidden problem Clients with active gambling problems often seek help not

for their gambling but for related symptoms such as: Depression, Anxiety, Sleep disturbances With relationships, school or job.

12% of problem gamblers studied reported that they wanted treatment but did not seek help independently due to stigma

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Barriers to help-seeking The desire among gamblers to handle their own problems;

Shame, secrecy, embarrassment, pride and fear of stigma;

An unwillingness to admit or a minimisation of the problems associated with gambling;

Concern about what goes on in treatment / lack of knowledge regarding treatment options, and practical issues around attending treatment;

Not wanting to stop or to give up the financial, social or emotional benefits of gambling; and

Difficulty in sharing problems or talking about personal issues.

Suuravali, Cordingley, Hodgins & Cunningham. (2009) Comprehensive review of help-seeking studies

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Problem Gambling & Suicide

Evans and Delfabbro (2005) study of 77 problem gamblers: 61 (79%) sought professional help only after a crisis situation.

Gambling Care (2007-2008) study of 249 active clients: 87 (34%) had indicated they had seriously considered suicide and 17 (7%) had attempted suicide as a result of their problems with gambling.

Studies have reported levels ranging from 17%- 80% for suicidal ideation and 4%- 23% for suicide attempts

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Productivity Commission (2009) Gambling, Draft Report, Canberra.

Problem Gambling & Suicide

Penfield et al (2006) study of attempted suicide &/or self harm episodes screened for problem gambling in A&E Dept. of Auckland Hospital reported 17.1% had gambling problem.

MAPrc-Alfred Psychiatry study (2006 & 2009), CATT presentations: 17.2% screened positive for problem gambling.

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Problem Gambling and Suicide: MAPrc-

Alfred Psychiatry Study 2009

50% of clients report being suicidal before they had gambling problems

50% of clients reported being suicidal after they had gambling problems

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Problem Gambling and Suicide: MAPrc-Alfred Psychiatry Study 2009

80% of participants had been gambling for more than 10 years.

55% of participants had spoken to their GP about problem gambling while 100% had spoken to their GP about suicide.

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Problem Gambling and Suicide: MAPrc-Alfred Psychiatry Study 2009

Problem Gambling impacts as high as 21.4% (17.2% + 4.2%) amongst psychiatric patients which is 20 times higher than reported in the community

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Which came first?Problem Gambling or Mental Illness

Models of co-morbidity

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The secondary problem gambling model

The secondary psychopathology model

The bi-directional model

The common-factor model

The no-relationship model

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The secondary problem gambling model suggests that

mental health problems lead to problematic gambling.

Mental health

problems

Problem gambling

leads to

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The secondary psychopathology model suggests that

problematic gambling triggers mental health problems.

Problem gambling

Mental health

problems

leads to

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The bidirectional model suggests that multiplefactors may serve to trigger and maintain mental health problems and gambling problems.

Mental health problems

Problem gambling

leads to

leads to

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The common-factor model suggests that there are one

or more underlying factors that lead to an increased risk of

both conditions.Mental health problems

Problem gambling

Underlying factors

leads toleads to

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The no relationship model suggests that the twoconditions are unrelated and co-occur by

coincidence.

Problem gambling

Mental health problems

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Implications in treatments

A person does not need to have a specific, diagnosed mental health disorder to gain benefit from an intervention to address mental health symptoms, regardless of the cause of those symptoms. If the client is showing signs of MI and PG, both disorders should be addressed.

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Models of treatment

1. Sequential treatment

2. Parallel treatment

3. Integrated treatment

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Sequential treatment

offers the client treatment for both the mental health and gambling issues. The client is treated for one problem first (treatment for the problem gambling) and then the second problem (often the mental health problem).

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Parallel treatment

Occurs when both mental health and gambling problems are treated simultaneously, with the client receiving treatment for their mental health symptoms from a different service or treatment provider than that which is providing treatment for their gambling problem.

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Integrated treatment

approaches offer clients simultaneous treatment for both their mental health and gambling problems, provided by the same service or treatment provider. This approach allows the client to explore for themselves the relationship between their mental health and gambling problems, and to examine the links to current distress and impairment from both mental health and problem gambling treatment perspectives..

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Module 3

Pathways to treatment

IdentifyScreen Assess

GPPsychiatry

Gambler’s Help

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Now what do I do?

Identifying problem gamblers

Gamblers will commonly present with: depression anxiety headaches sleep difficulties heavy alcohol use or other drug problems indigestion back and neck pains

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Identifying problem gamblers

Broaching the subject of gambling:

Enquire about leisure time Frame as health issue Relationship issues Finances Stress levels

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Screening

Who do you ask? What do you ask? Why do you ask?

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Who do you ask?

Every patient, because: Research indicates that a person with a gambling

problem effects between 5 and 10 people in their immediate personal circle. This means that a partner, child/children, parents, close relative and friends can all be affected by a person’s gambling problems.

Australian estimates of 15-20% of children born to problem gamblers will also become problem gamblers.

12% of problem gamblers studied reported that they wanted treatment but did not seek independently due to stigma.

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How often do you gamble? Form of gambling ______________How long? ____________________

Has your gambling ever caused any financial difficulty for you or your household? Y/N (CPGI)

Has gambling ever created problems between you and any member(s) in your family? Y/N (MAGS)

What do you ask?M

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Basis for these questions

How often do you gamble? Type of gambling ______________How long? ____________________

Why are these important to know?

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Gambling ActivitiesFavourite Gambling Activity %

Pokies 72

Casino 38

Horses 24

Lottery 28

Dice games 10

Cards 4

Tables games 4

Stock Market 4

Bingo 4

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MAPrc-Alfred Psychiatry study (2009) Suicide and Problem Gambling

N=21

0-5 5 %

6-10 yrs 9 .5 %

11-15 yrs 52 %

16-20 yrs 19 %

21+ yrs 9.5 %

Number of years spent on Gambling

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N=21


Has your gambling ever caused any financial difficulty for you or your household? (CPGI)

Financial difficulties often pose a multitude of problems in a persons’ life and this can be a stress trigger to a psychiatric presentation. This is an opportunity to explore the level of gambling and the impact it may be having on a patients’ life.

Average weekly amount of $$ spent on gambling

< $100 33%

$100-500 57%

$ >500 23.8%

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N=21


Has gambling ever created problems between you and any member(s) of your family? Y/N (MAGS)

Males = 75% Financially supportive of friends, partners and parents

Females = 25% Partners and ex-husband that gambled

Clients (N=12) 33 % Schizophrenia

25% Mood disorders


Why do you ask? Current research estimates the prevalence of moderate to

severe problem gambling is 2.5% (410,000 people) of the general population in Australia, with a higher prevalence in high-risk groups.

Research indicates that people with mental illness are 18 times more likely to develop or have a gambling problem than people unaffected by MI.

Our own research indicated up to 21% of CATT/ ED admissions were affected significantly by problem gambling.

Current research reports that problem gamblers have significantly poorer health status than non-gamblers and a higher rate of lung disorders, obesity, depression, anxiety and other mental health issues (DOJ report, 2008)

Because if you don’t ask…they won’t tell

Module 4Case Presentations:What does Problem Gambling look like?

The Curious Case of Mr. B

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Mr. B is a 28-year-old single Asian male with no children. He is an only child and lives with his mother. His father committed suicide 15 years ago when Mr. B was 13 years old. Mr. B finished high school and completed one year of a three-year bachelor of arts degree before dropping out of academics because he felt "sad and directionless“. He is currently supported by his mother but does odd jobs for family friends. He declared bankruptcy last year.

Ever since his recent bankruptcy, Mr. B has been feeling sad and racked with guilt. Three months ago, he began to tell his mother that he sometimes thinks about “ending it all”. His motivation to look for work and maintain his hygiene dropped and he began to isolate himself at home. His mother would find Mr. B crying throughout the day. He barely ate and his mother watched him slowly waste away. Mr. B found he couldn't sleep well and would wake up in the mornings with a feeling of hopelessness about his future.

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One month ago, Mr. B took an overdose of benzodiazepines and antidepressant medication he found in his mother's medicine drawer. His mother found him unconscious at home and called for an ambulance. Luckily, Mr. B was able to be medically stabilized, and was then admitted for psychiatric observation. The psychiatrists at the hospital determined that Mr. B was suffering from a major depressive episode (MDE) and started him on an antidepressant.

They verified that he had no substance use disorders (such as alcohol dependence). He was kept in hospital for three weeks and was released to follow-up with his family doctor once his mood had stabilized.

Two weeks later he quit taking his medication, feeling that it did not help him. He quickly began to get into dark moods and was having suicidal thoughts, and thus returned on his own to the hospital emergency room.

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Discussion Thoughts?

Diagnosis?

Treatment plan?

Q/A

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Take another look…

The Curious case of Mr. B: The Missing Pieces of the Puzzle

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Screening questions

How often do you gamble? Form of gambling ______________ How long? ____________________



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How often do you gamble? Regularly

Form of gambling: Casino (Blackjack) How long? 6years

Mr. B has been a regular at his local casino, where he has played blackjack for the last six years, which has overtaken most of his life. Starting about two months ago, he found that gambling no longer brought him any pleasure, although gambling used to help him deal with stress and sad emotions.

He has been unable to stop gambling despite his best efforts. He had been chasing his losses with increased betting, which resulted in his financial situation.

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Has your gambling ever caused any financial difficulty for you or your household? Y/N YES

He declared bankruptcy last year after racking up gambling debts of $60,000.

Mr. B has great shame over this, especially after borrowing

money from his mother for food.

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Has gambling ever created problems between you and any member(s) in your family? Y/N

28 yrs old, supported and cared for by mother.

Mother feels helpless, still responsible for son.

Mr. B holds a lot of guilt and shame, feels helpless and hopeless.

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Ballon, B. (April, 2006) The case of the bleak blackjack better: Clinical depression and pathologicalgambling. Journal of Gambling Issues; Issue 16.


Diagnosis?

Treatment plan?

Q/A

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Some things to consider:

Misunderstanding the chronic nature of depression and pathological gambling often leads to poor, uncoordinated treatment and to stigmatizing the person, who is seen stereotypically as being solely to blame for not getting "better." Instead, it is vital to realize that the system needs to provide the care suitable to a chronic disorder.

Clinical depression and pathological gambling are linked for any given individual. Treatment can then be adjusted accordingly.

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Four possible scenarios for co-occurring depressive and gambling symptoms are:

1. Clinical depression leading to pathological gambling, or

2. pathological gambling leading to clinical depression, or

3. both conditions occurring because of an underlying third

cause (e.g. trauma issues), or

4. none of the above.

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And finally… Concurrent disorders require concurrent treatment.

Chronic conditions such as pathological gambling and major depressive disorder will require chronic care, matching treatment intensity to the person's intensity of need.

Depressive symptoms in the context of pathological gambling are often judged as merely the just consequences of the gambler's actions. If a person has met criteria for an MDE, his or her depressive symptoms should be treated as an MDE.

Gambling behaviours can sometimes be thought of as only a maladaptive coping mechanism a person uses to self-treat depressive symptoms. This is often jumping to conclusions and can gravely affect the treatment outcome.

Clinicians need to be aware of the presentation and manifestation of pathological gambling and mood disorders in order to provide the proper assessment and treatment plans.

Ballon, B. (April, 2006) The case of the bleak blackjack better: Clinical depression and pathological gambling. Journal of Gambling Issues; Issue 16.

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Case Presentation #2

One thing looks like another

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Ms. S is a 44-year-old Caucasian woman, married for twelve years with no children. She finished high school and took a year of college courses. She is a homemaker, although she used to do clerical work until she married. She is supported by her husband's income. She has had no legal problems in her past.

Ms. S reported spending sprees, staying up all night, agitation, mood instability, and depression, her family doctor thought she might have bipolar disorder. She consulted with a psychiatrist who also thought this was the case, and she was started on a variety of mood stabilizing, antipsychotic, and antidepressant medications.

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She quickly developed a variety of side effects from the meds and so she wanted to know if she really needed them all. The medications also did not seem to have any impact on her moods.

When asked to explain her symptoms in further detail, Ms. S described staying up for one to two days at a time without sleep. Her moods were never so low that she ever felt the urge to self-harm (i.e., to cut herself, etc.) or to contemplate suicide. Her appetite has remained unchanged through the last few years.

She denied spending money on items such as fancy clothes, extravagant phone bills, or food. Her mood instability connected to all the stresses of financial debt, ongoing difficulties keeping the debt secret from her husband, and concerns about what she was doing with her life.

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Ms. S’s early history includes a chaotic family upbringing. She had difficulty with relationships, often failing to develop close intimacy. She married her husband to get away from her family, but for her this relationship also seemed to lack intimacy. She felt cut off from the world and alone.

She denied any problematic substance use history. Family history was negative for bipolar or other mental health or addiction issues.

Recent blood work done by her family doctor demonstrated normal blood and electrolyte indices. Her thyroid functions were also normal. A urine toxicology screen was negative for substances of abuse (e.g., amphetamines, cocaine, etc.).

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Diagnosis?

Treatment plan?

Q/A

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A second look:

Add the missing pieces…

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Screening questions

How often do you gamble? Form of gambling ______________ How long? ____________________



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How often do you gamble? Form of gambling ______________How long? ____________________

Ms. S has been gambling on slot machines for the last five years, starting when a casino opened near her home.

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Has your gambling ever caused any financial difficulty for you or your household? Y/N

Husband is sole income. Ms. S currently owes $11,000 in

gambling debts.

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Has gambling ever created problems between you and any member(s) in your family? Y/N

She says she started gambling to "escape" and feel alive.

She relates her mood instability to all the stresses of financial debt.

She has kept her gambling a secret from her husband.

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Effects on symptomatology

The medications did not seem to have any impact on her moods or gambling behaviours.

When asked to explain her symptoms in further detail, Ms. S described staying up for one to two days at a time without sleep when absorbed in gambling on slot machines. Her spending sprees were all in the pursuit of getting tokens to play the slots.

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Is it Problem Gambling or Bipolar Disorder?

Behaviours (and their consequences) arising from PG can "mimic" other mental health issues, e.g., staying up all night to indulge in gambling, committing illegal acts such as stealing for money to gamble, spending their money only on gambling, emotional reaction to losses, dealing with relationships that are impacted by the gambling, and other problems. Often this may lead to depressive symptoms and, for those vulnerable, a major depressive episode.

When gambling problems are treated usually many "psychiatric" symptoms vanish as well. If the symptoms do not resolve, or they get worse, then it becomes clear that there is a co-occurring/underlying psychiatric condition to be dealt with.

The clinician needs to look at all mental health issues and behaviours and see if they always manifest within or due to the gambling behaviours, or are occurring outside of them as well.

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Co-occurring problem gambling and bipolar disorder:How does it present? Starting with a pathological gambling disorder: Pathological

gambling behaviours are ongoing, but there are discrete episodes of hypomania, mania, or major depression occurring when a history is carefully taken. It could be during these episodes that the gambling behaviour worsens, but other symptoms of bipolar disorder are also present.

Starting with a manic episode: A person with the potential for gambling difficulties enters into a manic episode and takes up gambling as part of the illness. Once the episode begins to decrease in intensity, the person continues to gamble. If the person starts to slip towards a major depressive episode, he or she may increase the gambling behaviour as a way to self-medicate their mood.

Starting with a major depressive episode: The person starting to develop a depressive episode begins to "treat" him- or herself with the "highs" of gambling and develops the pathological gambling disorder due to a vulnerability to that condition. The gambling continues but worsens when a manic episode arrives.

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As clinicians, what do we need to know? Behaviours inside and outside the gambling environment Onset and pattern of gambling and psychiatric symptoms,

and how they relate to each other temporally (it helps to draw this out as a chart). This chronology of symptoms can include developmental history, periods of abstinence, etc.

Addiction conditions (either ruled out or, if present, put into the temporal relationship chart)

Medical conditions (either ruled out or, if present, put into the temporal relationship chart)

Medication use—is it helping with any of the symptoms? General functioning in the following domains:

1. School/Vocational functioning2. Family functioning3. Social/Peer relationships4. Leisure activities

Family history of mental health issues, e.g., mood disorders, anxiety disorders, gambling problems, addiction problems, etc.

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Being misdiagnosed with bipolar disorder when instead the condition is pathological gambling has serious implications:

The person has to endure the "label" and the consequences that go with it

Would-be parents must consider the possibility of having children who inherit a psychiatric condition

The person must maintain a certain lifestyle to prevent triggering an episode (i.e., going to bed on time, medication regimen, etc.)

The pathological gambling often can be overlooked and "lumped" into being only a manifestation of a manic episode, and thus the person does not receive the proper treatment for PG

The person may be put on medications which can cause unwanted side-effects and possible long-term problems induced by the medication

This also speaks to the question of whether most mental health clinicians are aware of the presentation and manifestation of pathological gambling to help prevent misdiagnosing BP.

Ballon, B. (2005) The case of the sleepless slot-machine supplicant: Bi-polar disorder and pathological gambling. Journal of Gambling Issues; Issue 14.

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co-occurring mental illness and problem gambling

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