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Concurrent Disorders

The terms ”concurrent disorders” and ”co-occurring disorders” refer to a diagnosis that includes more than one disorder, such as having a mental health disorder and addictive disorder.1 An example of this is when a person has a gambling disorder and depression. Screening and monitoring of people with gambling problems for the presence of concurrent disorders is recommended to ensure they get the most effective treatment.2

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Concurrent Disorders

The term “concurrent disorders” refers to the presence of multiple disorders, for example, a mental illness and an addiction.1 People with mental illnesses have higher rates of gambling problems than the general population.3

Similarly, people with gambling problems have higher rates of other mental health problems, such as major depression, anxiety, and other addictive problems. In addition, people with gambling problems have a higher risk of suicide ideation and self-harm attempts.2,4

Screening your clients with gambling problems for concurrent disorders is a best practice that allows you to create an integrated treatment plan.2,5

This webpage gives an overview of the interaction between mental illnesses (such as mood, anxiety, and psychotic disorders) and problem gambling, as well as how to implement screening, assessment, and treatment for concurrent disorders in your practice. This information for providers of mental health and addiction services is based on a review of the literature and was reviewed by an expert in the field of mental health and addictions.

About concurrent disorders

Research shows there is a strong link between problem gambling and other mental illnesses.6 It is estimated that approximately seventy-five per cent of people who seek treatment for gambling problems have at least one other psychiatric diagnosis.7

A complex mix of biological and environmental factors can increase the risk of concurrent disorders in people with gambling problems.8

Gambling problems and concurrent disorders can present in a variety of ways. They can be active at the same time or at different times, they can develop suddenly or over time, and they can have different levels of symptom severity and intensity.9

The image below shows the relationship between problem gambling and concurrent disorders.10

A Dimensional Approach to Mental Illness & Gambling

What does the evidence say

The image below presents the findings by Lorrains et al. (2011) of the most common disorders seen in people with gambling problems.2 As seen in the image, substance use disorders are the most common types of problems seen in clients with problem gambling.

The interaction between problem gambling and both depression and anxiety has been well documented.2,7,11–13 There is also a higher prevalence of impulsivity (e.g., attention-deficit/hyperactivity disorder [ADHD])14, bipolar disorder2,7, personality disorders2,15,16 and psychotic disorders documented for people with problem gambling.17 In addition, it was demonstrated that people with schizophrenia and schizoaffective disorders have higher risks of problem gambling.18

Several studies suggest that in some people with mood or anxiety disorders and problem gambling, the mental illness may have preceded their gambling.19 These findings suggest that some of these individuals may have used gambling to relieve depression and/or boredom. The authors noted, however, that financial losses may have worsened depression and anxiety in some study participants, leading to continued gambling.19

There is a strong link between excessive gambling and suicide.20–22 This link is especially strong in people with concurrent disorders.20 Ongoing screening for suicidality and suicide ideation for all clients experiencing gambling problems is an important part of clinical support. Learn more about problem gambling and suicide.

Research shows that problem gambling and mental health disorders may influence each other thus causing less definitive diagnoses. More research is needed to confirm this relationship.

Prevalence of Gambling and Concurrent Disorders

Putting the evidence into practice

Research on concurrent disorders highlights the importance of integrating primary care with addiction and mental health treatment and supports.1 Such integrated care helps ensure that the unique needs of the individual are met and the services and supports they receive are optimal.5 Therefore, when working with a client who has concurrent disorders, it is important that you collaborate with other service providers to ensure they receive integrated care. For an example, see the ‘Clinical Simulation Video’ below.

To develop a tailored treatment plan, screen and monitor clients with gambling problems for concurrent disorders and, conversely, screen and monitor people with mental health or substance use disorders for gambling problems.2,5 Screening, through psychiatric consultation or referral, can help identify the person’s eligibility to receive other mental health services. Learn more about the different screening tools that are available.

Ongoing assessment can also detect changes in mood or behaviour and help monitor safety risks over time, so that you can provide your client with adequate support.2 The mental status examination (MSE), endorsed by the American Psychiatric Association, is an example of a clinical assessment tool that you can use with your problem gambling clients to identify the presence of a concurrent mental health disorder.23,24

Research indicates that suicide risk assessment tools yield low predictive reliability and greater possibility of false positive or false negative results.25–28 The limitations of these tools can be mitigated by combining them with a clinical interview and by building a strong therapeutic relationship.29 Learn more about suicide risk assessment.

A meta-analysis summarized six studies that examined the effectiveness of treatment interventions for persons with problem gambling and psychiatric disorders. Two studies focused on concurrent substance use, and found support for modified dialectical behaviour therapy as well as a combination of cognitive behavioural therapy and naltrexone.30

Additionally, research indicates variability in the effectiveness of disorder-appropriate medication (e.g., lithium for concurrent bipolar disorder).7,30 Studies of medication efficacy have shown mixed results due to the difficulty of testing a single medication with clients who may have an untreated concurrent disorder. Therefore, the presence of concurrent disorders should be considered when prescribing medication to clients with problem gambling.7

List of screening tools

To learn about problem gambling-related screening and assessment tools read this Evidence-informed Practice.

There are numerous screening tools to help you identify and monitor addictions and mental health problems, and to determine the need for further psychiatric assessment and consultation. Below is a selection of these tools.

Handouts for clients

Concurrent Disorders:

This handout provides general information about concurrent disorders for clients with problem gambling as well as treatments and supports.

Clinical simulation video

This scenario depicts a fictitious therapy session where the client (Joseph) who is dealing with problem gambling has already completed a screening questionnaire for a suspected concurrent disorder. The screening questionnaire identified that the client has been experiencing depressive symptoms. In the session, the therapist discusses what the client has been feeling and ways to support him, including referral to a psychiatrist for an assessment.

In this case, the psychiatrist is on the same clinical team as the therapist and can make a direct referral. However, the referral process may be different for a community psychiatrist. (Depending on the jurisdiction, psychologists and other health professionals may be able to make mental health diagnoses.)

 

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References

Last modified: April 15, 2019

What is evidence-informed practice?

This information is intended to help clinicians in their use of evidence-informed practice (EIP) when screening, assessing, and treating clients with behavioural addiction(s). Evidence-informed practice, sometimes called evidence-based practice, is a client-centred approach to clinical decision making. It’s a way to solve problems by integrating the best available research evidence with the clinician’s experience, the client’s preferences and values, and the organizational and cultural context.1,2,3,4