Gambling, Problem Gambling, and Mental Illness: Have the Conversation

1. Gambling, Problem Gambling, and Mental Illness: Have the Conversation Loreen Rugle, Ph.D., NCGC-II Program Director, Maryland Center of Excellence on Problem Gambling Lrugle@psych.umaryland.edu

2. Maryland Center of Excellence on Problem Gambling Mission Statement The Maryland Center of Excellence on Problem Gambling promotes health and informed choices regarding gambling and problem gambling through treatment, prevention, training and education, outreach and public awareness, research and public policy. It does so by working closely with appropriate state stakeholders and bringing together experts from a variety of disciplines including psychiatry, medicine, epidemiology, social work, law and others. Funded by DHMH/BHA

3. Overview • Defining Terms • Why Bother? Evidence on the impact of gambling • Maryland based research on screening for problem gambling in SUD setting • Technology Transfer: Research to Practice • Developing a “GBIRT”

4. What is Gambling? • If you bet on a horse, that’s gambling. • If you bet you can make three spades, that’s entertainment. • If you bet cotton will go up three points, that’s business. • If you play bingo at your church, that’s charity. • What’s the difference? • Gambling is any activity or game where you risk something of value or money on an outcome that is not guaranteed.

5. Why Do People Gamble? Excitement Entertainment Escape (forget about their problems for a while) Economics (they want the money) Ego (the person’s pride or reputation is on the line) 5

6. Question: HOW MANY How many adults in Maryland have a gambling problem? 6 Funded by DHMH/BHA

7. WHAT DOES THIS REPRESENT? + Funded by DHMH/BHA

8. WHAT DOES + REPRESENT? Capacity 71,008 x 2= 142,016 Representsless than the 154,400Adult Problem Gamblers in MD Another 397,900 classify as At Risk Funded by DHMH/BHA

9. Risk Factors (Maryland 2011 Study) • Male • Single • African American • Individuals who have ever gambled in lifetime compared to non-gamblers more likely • To be smokers • Have higher alcohol intake • Use drugs with higher frequency Funded by DHMH/BHA

11. Defining Terms Gambling: the act of risking something of value, including money and property, on an activity that has an uncertain outcome Gambling Disorder: Current DSM5 diagnosis Pathological Gambling: DSM- IV diagnosis Problem Gambling: Characterized by difficulties in limiting money and/or time spent on gambling [impaired control] which leads to adverse consequences for the gambler, others, or for the community. (Neal, 2005).

12. At Risk Gambler:someone who is at risk for becoming a problem or pathological gambler because: a) they evidence some adverse consequence(s) from gambling but no symptoms of loss of control; OR b) they evidence some symptoms of loss of control but no adverse consequences; OR c) they evidence some adverse consequences and loss of control, but not at a level sufficient to meet criteria for problem or pathological gambling; OR d) they have a gambling frequency and/or expenditure that is significantly above average (especially in the context of their employment status, income, and debt). Recreational Gambler : someone who is able to maintain control over amounts of time and money spent gambling and who does not experience any adverse effects from gambling.

13. Diagnostic Changes DSMIV to DSM5

14. DSM 5 • Reclassified under: Substance-Related and Addictive Disorders • So far only “Non-Substance-Related Disorder included • Renamed: Gambling Disorder Funded by DHMH/BHA

15. Gambling Disorder A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period.

16. Diagnostic Criteria • Needs to gamble with increasing amounts of money in order to achieve the desired excitement • Is restless or irritable when attempting to cut down or stop gambling • Has made repeated attempts to control, cut back, or stop gambling • Is often preoccupied with gambling (etc)

17. Diagnostic Criteria • Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed) • After losing money gambling, often returns another day to get even (“chasing one’s losses”) • Lies to conceal the extent of involvement with gambling • Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling • Relies on others to provide money to relieve desperate financial situations caused by gambling.

18. Specifiers • Episodic: • Met criteria at more than time pt. with sx’s subsiding in between for several months • Persistent • Continuous sx’s for multiple years • Early Remission: no criteria for 3-12 mos. • Sustained Remission: no criteria for 12 or more mos. • Severity • Mild: 4-5 Criteria • Moderate: 6-7 Criteria • Severe: 8-9 Criteria

19. Differential Diagnosis • Nondisordered Gambling • Professional Gambling • Social Gambling • Manic Episode • Key – Not better explained • Person may exhibit manic like behavior during gambling episode • Personality Disorders • Other Medical Conditions

20. Risk and Prognostic Factors • Early Onset • Psychiatric and Substance Use risk factors • Genetic and Physiological • Family history of gambling problems • Family history of substance use disorder • Culture-Related • Cultural gambling preferences • Higher prevalence among African Americans and indigenous populations • Gender-Related • More males, females catching up • Gender gambling preferences

21. Lifetime Co-morbidityKessler et al., 2008 (National Comoribidty Survey Replication)

22. Why Bother? Impact on Treatment and Recovery of Serious Mental Illness 19% of individuals in treatment with diagnosis of schizophrenia or schizoaffective disorder met criteria for problem or pathological gambling PG associated with depression, alcohol use problems, greater legal problems and higher utilization of MH treatment (this associated with recreational gambling as well) (Desai & Potenza, 2009) • Health Problems and Medical Utilization with Gambling Disorders • Gambling even 5 times a year (at risk) is associated with adverse health consequences, increased medical utilization and health care costs. • At risk gamblers more likely to be diagnosed with hypertension, receive ER treatment, experienced severe injury, be obese, have history of mood or anxiety disorder, have an alcohol use disorder and nicotine dependence. • At risk group comprises 25% of the population. • National Epidemiologic Survey on Alcohol and Related Conditions (Morasco et al, 2006) 22

23. Why Bother? Canadian Epidemiological Study • The more severe the past year substance use disorder, the higher the prevalence of gambling problems • Individuals with a lifetime history of a mental health disorder have 2 – 3 times the rate of problem gambling (PG). (Rush et al, 2008) • PG in Methadone Maintenance • 28% met criteria for problem or pathological gambling • PG group more likely to have positive tox screen for cocaine • 45.5% PG group dropped out early compared to 17.6% of non-gambling group • Ledgerwood et al, 2002 Individuals with PG and SUD – double the rates of admission for detoxification and significantly greater admissions for psychiatric stabilization • (Kaplan & Davis, 1997) 23 Funded by DHMH/BHA

24. DSM-5 GAMBLING DISORDER 75.2% identified as Moderate or Severe Gambler Funded by DHMH/BHA

25. Most common types of gambling • Lottery Tickets (81.1%) • Scratch Offs (71.8%) • Games of Skill (40.5%) • Casino (9.2%) Funded by DHMH/BHA

26. Few people discussed gambling with their health provider (6.5%) • Those with a DSM-5 Gambling Disorder were significantly more likely to discuss gambling with health provider compared to those without (12% vs. 2%, p<0.05) Funded by DHMH/BHA

27. Lifetime Co-morbidityKessler et al., 2008 (National Comoribidty Survey Replication) • Although nearly half (49%) of those with lifetime pathological gambling received treatment for mental health or substance abuse problems, none reported treatment for gambling problems

28. PROBLEM GAMBLING AMONG CLIENTS DIAGNOSED WITH A SERIOUS MENTAL ILLNESS WHAT DEFINES A PROBLEM GAMBLER AMONG THE MENTALLY ILL OFTEN SOMEONE WHO GAMBLES VERY LITTLE MONEY BUT WHOSE SELF-ESTEEM AND SELF-WORTH ARE COMPROMISED BY THE GAMBLING

29. PROBLEM GAMBLING AMONG CLIENTS DIAGNOSED WITH A SERIOUS MENTAL ILLNESS WHAT THE CHRONICALLY MENTALLY ILL PERSON LONGS FOR AND THINKS GAMBLING WILL BRING TO HER/HIM: LOOKING FOR A “CURE” THAT WILL MAKE THE PAIN GO AWAY FOR GOOD. PROVIDES PARADOXICAL SENSE OF REGULATING EMOTIONS AND PAIN (COMPARISON TO CUTTING) RELIEVES INTRUSIVE THOUGHTS

30. PROBLEM GAMBLING AMONG CLIENTS DIAGNOSED WITH A SERIOUS MENTAL ILLNESS IT’S NOT ABOUT THE AMOUNTS OF MONEY GAMBLED; IT’S ABOUT SEEING YOURSELF AS NORMAL AND IT’S ABOUT CONNECTING WITH THE REST OF THE POPULATION ON EQUAL FOOTING. PROVIDES “SAFE” SOCIALIZING, ILLUSION OF ACCEPTANCE AND BELONGING, RELIEVES LONELINESS AND BOREDOM. CAN SEEM LIKE A SUBSTITUTE FOR EMPLOYMENT. FEELING USEFUL AND PRODUCTIVE PROVIDES STRUCTURE FOR LIFE. SOMETHING TO DO WITH TIME

31. PROBLEM GAMBLING AMONG CLIENTS DIAGNOSED WITH A SERIOUS MENTAL ILLNESS IT’S ABOUT FEELING STIGMATIZED AND DISENFRANCHISHED BY A CONSUMER ORIENTED, “HEALTHY” ORIENTED SOCIETY THAT DIMINISHES THE UNHEALTHY AND THE POOR

32. “You know one if you see one” ---Director of Substance Abuse Treatment Program, Detroit VA Funded by DHMH/BHA

33. PG Screening Good News Lie/Bet BBGS NODS-CLiP NODS-PERC SOGS 33 Funded by DHMH/BHA

34. Have you ever felt the need to bet more and more money Have you ever had to lie to people important to you about how much you gambled Lie BetJohnson, Hamer, Nora et al., 1997

35. Loss of Control: Have you ever tried to stop, cut down, or control your gambling? Lying: Have you ever lied to family members, friends or others about how much you gamble or how much money you lost on gambling? Preoccupation: Have there been periods lasting 2 weeks or longer when you spent a lot of time thinking about your gambling experiences, or planning out future gambling ventures or bets? NODS CLiPToce-Gerstein, Gerstein & Volberg, 2009

36. The NODS-PERC

37. Brief Bio-social Gambling Screen (BBGS) 1. During the past 12 months, have you become restless, irritable or anxious when trying to stop/cut down on gambling? 􀂀 Yes 􀂀 No 2. During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled? 􀂀 Yes 􀂀 No 3. During the past 12 months, did you have such financial trouble that you had to get help from family or friends? 􀂀 Yes 􀂀 No • BBGS Scoring: Answering ‘Yes’ to one or more questions indicates likely pathological • gambling. Source: Gebauer, L., LaBrie, R. A., & Shaffer, H. J. (2010). Optimizing DSM-IV • classification accuracy: A brief bio-social screen for gambling disorders among the • general household population. Canadian Journal of Psychiatry, 55(2), 82-90

38. PG Screening Bad News Screens don’t work well in clinical practice Give illusion of addressing issue 38

39. Typical Results of Use of Brief Screens What happens in actual clinical practice Use screen No one endorses items What does counselor think None of my clients have any gambling problems Don’t care about the research, my clients are different NIMBY (Not in my back yard or treatment program)

40. Screening Issues Self-report How you ask as well as what you ask Need to ask multiple times and in multiple contexts Decrease defensiveness Involve family/significant others

41. Assessing Impact on Recovery • Beyond diagnosis and labeling • In what ways does gambling support or detract from mental health or substance abuse recovery? • In what ways does gambling support or detract from life goals?

42. Integrated Assessment Incorporating into existing assessments How might you ask questions related to gambling in each of these sections of your intake or assessment? Medical Financial Family History Substance Use Psychiatric Recreation

43. Stages of Change and Motivation Substance Use Disorder Mental Health Disorder Problem Gambling Contemplation Action Precontemplation 43

44. Feedback Score = 0 Score = 0 Score = 1-2 Score = 2-3 Score > 3

45. Brief Education Low and High Risk Gambling Risk Factors High Risk Situations Life Goals – Discrepancy Analysis Cost Benefit Analysis Establishing personal guidelines

46. Low Risk Gambling is Done: As a form of recreation, not to make money or make up for previous losses. With limits on time, frequency, and duration. In a social setting with others not alone. With money you can afford to lose. High Risk Gambling – Situations When You Are: Coping with grief, loneliness, anger or depression. Under financial pressure and stress. Recovering from mental health or substance use disorders. Using alcohol or other drugs. Under legal age to gamble. Maryland Center of Excellence on Problem Gambling

47. KEEP GAMBLING FUN AND PROBLEM FREE Set a limit on how much time and money you will spend and stick to it Don’t view gambling as a way to make money Balance gambling with other leisure activities If you gamble and spend more time and money than you can afford, a good strategy is to take a break and look at your gambling. Consider seeking help if this is a concern. Problem Gambling Helpline, Toll-Free, Confidential, 24/7 1-800-522-4700 or www.mdproblemgambling.com

48. RESOURCES: Md. Problem Gambling Helpline 1-800-Gambler www.mdproblemgambling.com www.baltimoregambler.org www.facebook.com/BaltimoreGambler www.baltimoredicezombies.org www.gamblesafewomen.org www.aboveallodds.org Lori Rugle: Lrugle@psych.umaryland.edu

49. Thank You Anyone can slay a dragon, he told me, but try waking up every morning and loving the world all over again. That’s what takes a real hero. 49 Funded by DHMH/BHA