Characteristics of Problem Gambling in a Canadian Context: A Preliminary Study Using a DSM-IV–Based Questionnaire

Carole M Beaudoin, MSc1, Brian J Cox, PhD2


Objective: To develop a self-report instrument to assess diagnostic criteria and associated features of pathological gambling in order to learn more about the characteristics of individuals who seek treatment for gambling problems in a Canadian setting.

Method: Fifty-seven adults seeking treatment for gambling problems at the Addictions Foundation of Manitoba were assessed.

Results: There was substantial variation in the endorsement of  Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) symptoms. Lying to family members or friends and “chasing” previous gambling losses were frequently reported, while more serious consequences (for example, relationship breakup, job losses) were less frequent. DSM-IV ratings were correlated (r = 0.59) with the South Oaks Gambling Screen. Many individuals reported gambling as a way to alleviate dysphoric mood, and 30% reported receiving mental health services in the past. Approximately 50% reported suicidal ideation, although recent suicide attempts were not common.

Conclusion: These preliminary results of Canadian adults seeking treatment for gambling problems suggest a somewhat different profile from many United States studies, which often rely on older male pathological gamblers. More systematic investigation of the presence of major depression and other psychiatric disorders is warranted. Consistent with demographic data collected at the Addictions Foundation of Manitoba, it appears that video lottery terminals play a major role in the type of problem gambling experience seen in Canadian settings.

(Can J Psychiatry 1999;44:483–487)

Key Words: pathological gambling, problem gambling, assessment, depression

It seems likely that the increased availability of legalized gambling in recent years in several parts of Canada has been associated with an increase in the number of individuals with serious gambling problems. In support of this position, Canadian epidemiological data collected in Edmonton in the 1980s estimated the lifetime prevalence of pathological gambling to be 0.42% (1). However, more current prevalence rates of pathological gambling have been estimated to approach 2% in different areas in Canada (2).

Unfortunately, research into gambling problems has not kept pace with this increase. While a promising cognitive-behavioural therapy program has been developed (3), the nature of problem gambling in Canada remains poorly understood. Almost all of the research in this area comes from United States (US) samples, yet there is evidence that the Canadian experience is relatively unique. For example, it is not uncommon for US studies of problem gambling (4,5) to rely on older male samples. A report released by the Addictions Foundation of Manitoba (AFM) on the demographics of individuals seeking treatment for gambling problems indicated that approximately one-third of the clients were women and 43% were between the ages of 18 and 34 years (6). In contrast to the stereotype of a “high-roller” casino gambler, the vast majority of AFM clients reported that their preferred type of gambling activity was daily or weekly use of video lottery terminals (VLTs) at local hotels, and almost 40% said that they had never been to a casino (6).

One area that could be advanced, particularly in the Canadian context, is assessment. To our knowledge, no structured clinical interview assesses pathological gambling. Instead, the most commonly used assessment instrument is the South Oaks Gambling Screen (SOGS) (7). The SOGS is a 20-item, self-report measure and is based on Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (8) criteria for pathological gambling. Scores can range from 0 to 20, and a cutoff score of 5 is used to indicate “probable pathological gambling.” However, a score of 5 is not differentiated from a higher score, and almost everyone seeking treatment for gambling problems at institutional settings scores above 5. There is a perceived need for an assessment instrument that will provide additional information on the individual differences within this type of sample. Further, the SOGS is based on DSM-III criteria, and important changes were made in the diagnostic criteria and associated features for pathological gambling in the DSM-III-R (9) and DSM-IV (10). For example, the DSM-IV now recognizes that some individuals may gamble as a way of relieving dysphoric mood.

Therefore, the purpose of the present investigation was to develop a self-report instrument designed to capture the diagnostic criteria and associated features of pathological gambling and to administer it to a Canadian sample of individuals seeking treatment for gambling problems. Obviously, a self-report instrument cannot be used to generate a formal psychiatric diagnosis; nor was it our intention to develop a cutoff score for a “probable” diagnosis. In fact, this is one reason we use the term “problem” instead of “pathological” gambling. The diagnostic threshold for pathology may be seen as somewhat arbitrary, and most individuals seeking treatment for gambling problems do not undergo a formal diagnostic interview. Rather, it was hoped that the information assessed in this type of instrument could further our understanding of the nature of problem gambling in a Canadian setting and stimulate future research in this relatively neglected area.

Method

Participants

The study sample comprised 57 adults (38 men, 19 women) seeking treatment for gambling problems at the AFM. The mean age of the sample was 37.7 years (SD 10.5), with a range of 24 to 62 years. The self-reported mean age at which gambling began was 30.1 years (SD 12.1). Approximately 60% of the sample was either married or living common-law. The demographics of this sample are very similar to the typical gambling client seen at the AFM (6). All of the participants were in the assessment phase at the AFM’s gambling unit and provided written informed consent. In a large sample of problem gamblers from this unit (6), 87% reported they used VLTs daily or weekly, and only 2.4% reported never using VLTs.

Measures

A measure was developed to assess the frequency of DSM-IV diagnostic criteria for pathological gambling (Table 1). Questions were also developed to assess the associated features of pathological gambling noted in the DSM-III-R and DSM-IV (Table 2). Finally, questions were developed to assess whether participants had previously sought help for gambling problems and to assess levels of suicidal ideation and attempts (Table 2). In addition, SOGS (7) data were obtained from client files for 45 of the participants.

Table 1. Frequency of DSM-IV diagnostic criteria reported by sample (n = 57)




Never
(0)

Yes, at some time in my life (1)

Yes, in the past year
(2)

Yes, in the past month
(3)


Mean score (SD)

1. Have you ever tried to cut down or stop gambling, and then found that you couldn’t?

5

9

19

24

2.09 (0.97)

2. Have you ever tried to cut down or stop gambling, and found that you were restless or irritable?

11

10

13

23

1.84 (1.16)

3. Do you ever gamble as a way of escaping from problems in life or as a way of getting rid of unpleasant feelings?a

9

11

18

18

1.80 (1.07)

4a. Have you ever lost a job or got into trouble at work because of gambling?

42

5

6

4

0.51 (0.95)

4b. Have you ever jeopardised or lost a marriage or other significant relationship because of gambling?

29

11

7

10

0.96 (1.164)

5. Have you ever committed a crime to get money for gambling (ie, stealing, forgery, fraud, etc)?

37

7

10

3

0.63 (0.96)

6. Do you find yourself thinking often about gambling, such as reliving past gambling experiences, planning your next gambling venture, or thinking of ways to get money with which to gamble?

4

15

14

24

2.02 (0.99)

7. Do you find you need to gamble with increasing amounts of money in order to get the desired level of excitement?

12

15

13

17

1.61 (1.13)

8. Do you find yourself gambling in an attempt to recover your previous gambling losses?

1

14

16

26

2.18 (0.87)

9. Have you ever lied to family, friends, or others about your gambling?

3

13

14

27

2.14 (0.95)

10. Have you ever turned to family or friends to help you with financial problems that were caused by your gambling?

16

13

12

16

1.49 (1.18)

an = 56.

Results

Table 1 breaks down the endorsement of symptoms that comprise the diagnostic criteria for pathological gambling in the DSM-IV. Although the DSM-IV dichotomizes symptoms into presence–absence, Table 1 shows substantial variation in the presence of symptoms with regard to time frame (that is, lifetime, past year, past month). Lying to family members or friends and “chasing” previous gambling losses were frequently reported, while more serious consequences such as job losses, relationship breakups, and criminal activity were less frequently reported. The DSM-IV requires the presence of at least 5 of these symptoms to establish a diagnosis of pathological gambling. Based on self-report, 84% of our sample endorsed a lifetime presence of at least 5 symptoms (questions 4a and 4b were combined for this analysis). The DSM-IV symptom ratings were significantly correlated with SOGS scores (r = 0.59, P < 0.001). All of the SOGS scores (mean 11.91, SD 3.65) were above the cutoff score of “probable pathological gambling.”

Table 2 presents participants’ endorsement of items relating to the associated features and consequences of gambling. Almost all participants reported feeling guilty because of gambling. Although almost three-quarters of the sample reported that they were easily bored in general, only one-third reported that they were generally risk-takers. Approximately 30% of the sample reported receiving mental health services in the past, most commonly for depression. Approximately one-half of the sample reported suicidal ideation in the past year, although only a small number reported actual attempts.

Table 2. Frequency of DSM-III-R and DSM-IV associated features endorsed by sample (n = 57)

 

Yes (%)

No (%)

1. I always gamble only with friends, family, or coworkers, and never by myself.

3.5

96.5

2. If I decide in advance how long I will gamble for, I can usually stick to that time limit.

10.5

89.5

3. I usually decide before I start gambling how much money I can lose.

45.6

50.9

4. Have you ever felt guilty because of your gambling?

96.5

1.8

5. Have you ever felt detached from your surroundings while gambling, as though in a trance?

73.7

26.3

6. Do you take a lot of risks in life?

33.3

64.9

7. Do you see money as the solution to almost all your problems?

71.9

26.3

8. Would you describe yourself as a “big spender”?

45.6

50.9

9. Would you describe yourself as a competitive person?

64.9

29.8

10. Would you say that in general you are easily bored?

73.7

24.6

11. Would you describe yourself as a “workaholic”?

24.6

68.4

12. Do you feel that in general you are too concerned with receiving the approval of other people?

52.6

43.9

13. Do you feel you have restructured your life to revolve around gambling?

59.6

36.8

14. Have you ever been seen by a mental health professional for any psychological problems?

29.8

70.2

    If yes, what type of problem did you have?

    Depression 76.5 % (25% of total sample)

    Other 23.5 %

   
15. Do you have any current medical problems?

    If yes, what type of problem did you have?

    Depression 44.4 % (14% of total sample)

    Other 55.6 %

31.6

64.9

16. In the past year have you thought a lot about death?

50.9

49.1

17. In the past year have you felt like you wanted to die?

63.2

36.8

18. In the past year have you felt so low at times that you thought about committing suicide?

50.9

49.1

19. Have you ever attempted suicide?

5.3

94.7

20. Have you ever attempted suicide at some other time in your life?

    Were these thoughts or feelings of suicide due to problems related to your gambling?

15.8

68.6

82.5

31.4

21. I gamble on a regular basis.

    I gamble on a binge basis.

56.1

43.9

43.9

56.1

22. Do you gamble because (you may check more than one)

    I gamble for excitement

    I gamble to make money

    I gamble to get rid of unpleasant feelings

    I don’t know why I gamble

    Other reason

  

63

72

40

35

11

      

Discussion

This preliminary study yielded some interesting results that are better suited for generating hypotheses for future study than for reaching definitive conclusions. To date, there has been little research on the Canadian gambling experience, particularly in relation to VLTs, and relying on US studies of mostly older male pathological gamblers is problematic. Evidence of the VLT experience comes from the finding that almost three-quarters of the sample reported feeling “detached from your surroundings while gambling, as though in a trance.” As noted earlier, the typical profile of the problem gambler seen at the AFM is an individual who uses VLTs daily or weekly at local hotels (6). Similarly, several of the assumptions or “associated features” listed in the recent editions of the DSM may not readily apply to these individuals. For example, only one-third of the sample reported taking a lot of risks in life, and contrary to an assumption made in the DSM-IV, more individuals reported they gambled to “make money” than for the excitement. The DSM-IV diagnostic threshold also may or may not be appropriate for these Canadian VLT gamblers. In this study, 16% of participants did not endorse the minimum number of symptoms specified by the DSM-IV for establishing a diagnosis of pathological gambling, even though they were seeking treatment. Finally, instruments such as the SOGS, which is based on DSM-III criteria, may not fully capture the nature of the gambling experience for these individuals. For example, more than 80% of this sample reported they gambled as a way to relieve dysphoria or to escape from life’s problems. This characteristic, introduced in the DSM-IV, is not contained in the SOGS. Regardless, the SOGS is most often used simply to generate a cutoff score, and the questionnaire items developed for the present study may be more useful in understanding distinguishing features of these gamblers.

Some investigators have suggested that a subset of problem gamblers is characterized by the presence of depression and the use of gambling as a coping mechanism (11,12). There was evidence to support this view in the present study. In addition to the majority of individuals who gambled to relieve dysphoria, approximately 30% of the sample reported being seen by a mental health professional in the past (most commonly for depression). Further, suicidal ideation was quite pronounced in this sample, and although few individuals reported recent suicide attempts, 16% reported past attempts. These results suggest that depression should be more formally investigated in individuals seeking treatment for gambling problems. In their recent review of psychiatric comorbidity in pathological gambling, Crockford and el-Guebaly concluded that a significant comorbidity with mood disorders is “probable,” but serious methodological shortcomings in the research to date prevent firm conclusions (13). A structured diagnostic interview could help determine the prevalence of major depression and other psychiatric disorders in these individuals as well as the temporal course of such disorders in relation to gambling. Similarly, a structured clinical interview for pathological gambling, perhaps modelled after the Structured Clinical Interview for the DSM-IV (SCID) (14), would likely benefit the field. Our research group is currently working on such endeavours.

There are several limitations to the present study, including reliance on self-report data, the use of an institutional rather than a community-based setting, and the fact that the sample was not a particularly large one. Until replicated at other sites, these findings might be limited to a Manitoban rather than Canadian context (VLTs were widely introduced in Manitoba in the early 1990s). However, this study identifies several avenues for future research and contributes some much-needed empirical data to the ongoing discussion of problem gambling in the Canadian context.

Clinical Implications

Limitations

Acknowledgements

The authors thank Addictions Foundation of Manitoba staff members Roberta Coulter, Gerry Kaplan, Gerry Kolesar, and Herb Thompson and staff from the gambling unit for their support in this project.

References

1. Bland RC, Newman SC, Orn H, Stebelsky G. Epidemiology of pathological gambling in Edmonton. Can J Psychiatry 1993;38:108–12.

2. Ladouceur R. The prevalence of pathological gambling in Canada. Journal of Gambling Studies 1996;12:129–42.

3. Sylvain C, Ladouceur R, Boisvert J-M. Cognitive and behavioral treatment of pathological gambling: a controlled study. J Consult Clin Psychol 1997;65:727–32.

4. Linden RD, Pope HG, Jonas JM. Pathological gambling and major affective disorder: preliminary findings. J Clin Psychiatry 1986;47:201–3.

5. McCormick RA, Russo AM, Ramirez LF, Taber JI. Affective disorders among pathological gamblers seeking treatment. Am J Psychiatry 1984;141:215–8.

6. Kaplan GS. AFM gambling clients: two profiles. Winnipeg (MB): Addictions Foundation of Manitoba; 1996.

7. Lesieur HR, Blume SB. The South Oaks Gambling Screen (SOGS): a new instrument for the identification of pathological gamblers. Am J Psychiatry 1987;144:1184–8.

8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington (DC): American Psychiatric Association; 1980.

9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Revised. Washington (DC): American Psychiatric Association; 1987.

10. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994.

11. Taber JI, McCormick RA, Russo AM, Adkins BJ, Ramirez LF. Follow-up of pathological gamblers after treatment. Am J Psychiatry 1987;144:757–61.

12. McCormick RA, Taber JI. Attributional style in pathological gamblers in treatment. J Abnorm Psychol 1988;97:368–70.

13. Crockford DN, el-Guebaly N. Psychiatric comorbidity in pathological gambling: a critical review. Can J Psychiatry 1998;43:43–50.

14. First MB, Spitzer RL, Gibbon M, Williams, JBW. Structured clinical interview for DSM-IV Axis I disorders. New York: New York State Psychiatric Institute; 1995.


Résumé

Objectif : Mettre au point un instrument d’auto-évaluation des critères diagnostiques et des traits associés au jeu pathologique afin de mieux connaître les caractéristiques des personnes qui cherchent un traitement pour leurs problèmes de jeu dans un établissement canadien.

Méthode : Cinquante-sept adultes de la Fondation manitobaine de lutte contre les dépendances désirant un traitement pour leurs problèmes de jeu ont été évalués.

Résultats : L’homologation des symptômes du Manuel diagnostique et statistique des troubles mentaux (DSM-IV) était considérablement variée. Mentir aux membres de la famille ou aux amis et « se refaire » quant aux pertes de jeu précédentes étaient fréquemment déclarés, alors que des conséquences plus graves (par exemple, la rupture d’une relation, les pertes d’emploi) étaient moins souvent avouées. Les cotes du DSM-IV étaient corrélées (r = 0,59) à l’aide du South Oaks  Gambling Screen (échelle du jeu de hasard de South Oaks). Nombre de personnes ont déclaré que le jeu était une façon de soulager une humeur dysphorique, et 30 % ont indiqué avoir reçu des services de santé mentale par le passé. Quelque 50 % ont avoué des idées suicidaires, mais les tentatives de suicide récentes n’étaient pas répandues.

Conclusion : Ces résultats préliminaires des adultes canadiens désirant un traitement pour leurs problèmes de jeu indiquent un profil plus ou moins différent de celui de nombre d’études américaines, qui portent souvent sur des joueurs pathologiques masculins plus âgés. Une recherche systématique de la présence de dépression majeure et d’autres troubles psychiatriques est justifiée. Conformément aux données démographiques recueillies à la Fondation manitobaine de lutte contre les dépendances, il semble que les appareils de loterie vidéo jouent un rôle de premier plan dans le type de problèmes de jeu qu’on rencontre dans les établissements canadiens.

Manuscript received April 1998, revised, and accepted October 1998.

1Research Associate, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba.

2Associate Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba.

Address for correspondence: Dr B Cox, PZ-430 PsycHealth Centre, 771 Bannatyne Avenue, Winnipeg, MB  R3E 3N4

email: coxbj@cc.umanitoba.ca

Can J Psychiatry, Vol 44, June 1999