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 Harrison Project Officer, Training and Education Mick Field Senior Clinician, Clinical Services

Partnerships

Training Modules Module 2 Module 3 Pathways to treatment Module Case studies: How do they present? Module 1 PG & MI : A partnership for trouble What is Problem Gambling? • 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

Module 1 What is Problem Gambling? Module 1

Overview Module 1 • Defining problem gambling • DSM-IV classification of problem/pathological gambling • Understanding the problem gambler • Phases of gambling • Types of problem gamblers

Gambling Module 1 “To stake money or risk anything of value on the outcome of something involving chance”. Dictionary.com website: http://dictionary.reference.com/browse/gamble

Defining “Problem Gambling” Module 1 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)

DSM-IV definition of Pathological Gambling Module 1 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.

DSM-IV definition of Pathological Gambling (cont) Module 1 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.

Module 1 Understanding the Problem Gambler

Phases of Gambling Module 1 • Winning • Losing • Desperation • Hopelessness

Phases of Gambling Module 1 Desperation Presentation to service Winning Start gambling Treatment pathway Losing Hopelessness

Winning Phase Module 1 • 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.

Winning Phase (cont’d) Module 1 • 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).

Losing Phase Module 1 • 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.

Losing Phase (cont’d) Module 1 • 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”.

Desperation Phase Module 1 • 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.

Hopelessness Phase Module 1 • 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.

Types of Problem Gamblers Module 1 • Action Problem Gambler • Escape Problem Gambler • Internet Problem Gambler

Action Problem Gambler Module 1 • 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.

Understanding the “Action” Module 1 • 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.

Escape Problem Gambler Module 1 • 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.

Behind the “escape” Module 1 • 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.

Behind the Escape (con’t) Module 1 • 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.

Internet Problem Gambler Module 1 • 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.

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

Overview Module 2 • Understanding co-morbidity • Co-morbidity in practice • Current research in co-morbidity and problem gambling • Models of co-morbidity • Models of treatment

What does co-occurring mean? Module 2 • Often referred to as co-morbid illness or co-morbidity • Can mean multi-occurring or multi-morbidity • Important for: • Assessment • Treatment • Recovery

Common co-occurring illnesses in MI & PG: Module 2 • Depression + • Anxiety + • Substance abuse +

Statistics of co-morbidity amongst Problem Gamblers Module 2 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

Co-morbidity and pathological gambling:Epidemiological data Module 2 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 disorder 60.8% had a personality disorder Petry et al (2005)

Anxiety disorders and Problem Gambling: Module 2 • 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.

Depression and Problem Gambling: Module 2 • 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.

Alcohol abuse and dependence and Problem Gambling Module 2 73.22% of problem gamblers have been found to have a co-morbid alcohol use disorder (Petry et al 2005). In Victoria, the Department of Justice (2009) reported that compared with non-problem gamblers, using the CAGE 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)

Not so common co-occurringMI & PG (or are they?): Module 2 • Schizophrenia + • Bi-polar + • Personality disorder + • PTSD +

Co-morbidity Problem Gambling and “serious mental illness” (SMI) Module 2 • 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%)

Effects of PG on SMI Module 2 • 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

A significant proportion (up to 80%) of problem gambling clients have a mental health problem May be referred on to mental health services Many more may have subclinical symptoms Rule rather than the exception in treatment settings Module 2

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 Module 2

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 Module 2

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 Module 2

How do clients present to Health Services? Module 2 • Depression - suicidal • Anxiety - panic attacks & agoraphobia • Agitation & anger • Headaches • Sleep problems • Alcohol or drug problems • Personal/family/employment problems

The hidden problem Module 2 • 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

Barriers to help-seeking Module 2 • 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

Problem Gambling & Suicide Module 2 • 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 Productivity Commission (2009) Gambling, Draft Report, Canberra.

Problem Gambling & Suicide Module 2 • 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.

Problem Gambling and Suicide: MAPrc-Alfred Psychiatry Study 2009 Module 2 • 50% of clients report being suicidal before they had gambling problems • 50% of clients reported being suicidal after they had gambling problems

Problem Gambling and Suicide: MAPrc-Alfred Psychiatry Study 2009 Module 2 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.

Co-occurring Mental Illness and Problem Gambling