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Concurrent Disorders

Concurrent disorders refers to the presence of co-occurring mental illness and addiction, for example, having both depression and problem gambling. It is essential to screen and monitor people experiencing gambling problems for a wide range of possible co-occurring issues.​

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Concurrent Disorders


Concurrent disorders refers to the presence of co-occurring mental illness and addiction, for example, having both depression and problem gambling. People with mental illnesses have higher rates of gambling disorders compared to people in the general population. Similarly, people with a gambling disorder have high rates of concurrent mental illness. Screening all clients with gambling problems for concurrent disorders and creating an integrated treatment approach are recommended as best practice. In this section, we will look at how mental illnesses (such as mood and anxiety disorders and psychotic disorders) intersect with problem gambling and discuss how you can implement effective screening tools, assessments and treatment strategies in your practice.

Key Concepts

Research shows that, in general, there is a strong link between problem gambling and concurrent mental illness. A complex mix of biological and environmental factors likely contributes to whether people develop problem gambling and/or substance use disorders, alongside a mental illness.

Gambling can influence mental illness and in turn, mental illness can influence gambling behaviours. Gambling excessively is also linked with higher rates of suicide. Research shows that there is a strong link between problem gambling and both suicidal thoughts and attempts. These risks increase in people who also have a co-occurring mental illness or substance use issue.

Therefore, it is essential to screen and monitor people experiencing gambling problems for a wide range of possible co-occurring issues. Screening can help identify the need to refer for psychiatric consultation or to a specialized mental health clinic.

Here are some key concepts about treatment of concurrent disorders:

  • Research on concurrent disorders highlights the importance of providing addiction and mental health treatment in an integrated fashion.
  • Aftercare programs and intensive case management support continuity of care and help prevent relapse for people with co-occurring mental illness and problem gambling.
  • Cognitive-behavioural therapy and motivational interviewing have been used successfully in the treatment of both mental illness and problem gambling.
  • Some research has shown that depression in people with problem gambling is often correlated with a history of traumatic events. Ensuring that all mental health and addiction services are trauma-informed is a recommended best practice.
  • Holistic therapies can help people with gambling problems and a co-occurring mental illness or substance use issue to manage their stress and cope with emotional triggers. These alternative, holistic modalities include massage, yoga, mindfulness and exercise.


Research Snapshot​

​​​What is the relationship between problem gambling and mental illness?

Research shows that, in general, the link between problem gambling and concurrent mental illness is quite strong. The connection between problem gambling and depression and anxiety is well documented (Dowling et al., 2015a; Lorains et al., 2011; Parhami et al., 2014; Toneatto & Pallai, 2016). Studies have also shown that there is a higher prevalence of impulsivity (e.g., attention-deficit/hyperactivity disorder [ADHD]) (Waluk et al., 2016), bipolar disorder (Dowling et al., 2015a; Lorains et al., 2011), personality disorders (Brown et al., 2016; Dowling et al., 2015b; Lorains et al., 2011) and psychotic disorders in the problem gambling population (Haydock et al., 2015). However, more research is needed to determine cause-and-effect relationships.

A complex mix of biological and environmental factors likely contribute to whether people develop problem gambling and co-occurring mental illnesses or substance use issues. The following diagram depicts how biological and environment factors can interact to create risk factors and protective factors for substance use, mental illness and problem gambling and how these concerns can influence each other (Moore et al., 2002).


Factors Contributing to Problem Gambling

Some notable research findings on problem gambling and mental illness

A meta-analysis conducted by Lorains and colleagues (2011) illustrates the prevalence rates of co-occurring disorders in problem gambling populations:

  • High prevalence for nicotine dependence (60.1%), alcohol use disorder (28.1%), illicit drug dependence (17.2%) and other substance use disorders (57.5%).
  • High prevalence for mood (37.9%) and anxiety (37.4%) disorders.
    • Mood and anxiety disorders often precede gambling problems, whereby gambling is used as a coping mechanism.
    • Mood disorders may manifest as secondary symptoms in response to the financial loss associated with problem gambling.
  • Prevalence of antisocial personality disorder is substantially higher (28.8%) than in the general population (0.6-3.6%).

Previous studies pertaining to the prevalence of co-occurring disorders in problem gambling have been largely based on people who are receiving treatment. However, the meta-analysis by Lorains and colleagues (2011) was based on population studies, providing crucial evidence about problem gambling populations at the community level.


Prevalence of Gambling and Concurrent Disorders

What is the relationship between problem gambling and suicide?

People who gamble excessively experience higher rates of suicide, suicidal thoughts and attempts. These risks increase in people who have co-occurring mental illnesses or substance use issues (Cook et al., 2015; Hodgins et al., 2006). This is why it is important to perform ongoing screening for suicidality and suicide ideation with all clients experiencing gambling problems. Learn more about problem gambling and suicide.


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Putting It into Practice​

​​​Supporting people with problem ga​mbling and concurrent disorders

Why is it important to understand the relationship between problem gambling and concurrent mental illness?

  • Problem gambling and mental illness frequently co-occur.
  • Problem gambling can influence mental illness and mental illness can influence gambling behaviours.
  • Problem gambling may worsen symptoms of existing mental illness.
  • Problem gambling behaviours can mimic symptoms of mental illness.
  • Problem gambling can mask mental illness that already exists.

A Dimensional Approach to Mental Illness & Gambling


Importance of screening

Since people with problem gambling are at increased risk of experiencing concurrent mental illness, it is essential to screen and monitor for a wide range of possible co-occurring issues. Screening can help identify whether a client should be referred for psychiatric consultation or to a specialized mental health clinic. Learn more about screening tools.

Importance of ongoing assessment

Ongoing monitoring and assessment is always important, especially for people who have concurrent mental illness. Ongoing assessment can detect changes in mood or behaviour and help monitor safety risks, ultimately supporting the person in their recovery journey.

The mental status examination (MSE) is an ongoing clinical assessment of the person's psychological state and is a useful tool in practice.

When to refer for psychiatric consultation or specialized mental health services?

Refer for psychiatric consultation or to a specialized mental health service in the following cases:

  • when there is an acute risk of self-harm or suicide
  • when screening detects the possibility of undiagnosed/untreated mental illness or when the person self-reports mental illness
  • when there are significant changes to the person's mental status or a marked change in their daily functioning
  • when there is an unclear clinical picturea psychiatric consultation can clarify differential diagnoses (symptoms that are clinically similar or a missed diagnosis)
  • when a person is responding inadequately over time to available treatment and mental illness may be affecting treatment
  • when psychiatric medication is ineffective or needs re-evaluation (e.g., causing harmful side effects, etc.)
  • when unresolved medical issues are present (some mood/anxiety disorders can induce or mimic medical conditions and vice versa)
  • when the person remains unresponsive to gambling treatment and there is no clear explanation for why the treatment is not working
  • when there is a feeling that something is "off" or different about the person when they interact with their counsellor or others
  • when there is a need for further psychoeducation on specific mental illnesses.

Please note this list is not exhaustive and other situations may warrant referral for psychiatric consultation or specialized mental health services.

Suicide assessment

Perlman and colleagues (2011) report that the current suicide assessment tools yield low predictive reliability and often result in false positive and false negative outcomes. If you chose to use these assessment tools, they should be used with caution and must be incorporated within the overall clinical interview with your client. The Centre for Addiction and Mental Health (CAMH) has developed an extensive resource in suicide assessment entitled the Suicide Prevention and Assessment Handbook. Learn more about the handbook.

Importance of integration of services

Research on concurrent disorders highlights the importance of providing integrated addiction and mental health treatments. As such, if you are referring a client for another service, it is important to work collaboratively with other service providers in providing care for the client.


Screening tools to use with clients

Mental health screening tools can help to monitor for possible symptoms and determine the need for further psychiatric assessment and consultation. Below are some screening tools from other organizations that assess for specific addictions and mental health issues:

Substance use disorders

Alcohol
Nicotine

Mood and anxiety disorders

Depression
Anxiety

Suicide

If results indicate that a client is at moderate to high risk, consider one of the following interventions:

  • Clinical consultation with your supervisor.
  • Referral on an urgent basis back to the family doctor.
  • Accompany client to the closest emergency department for assessment.

Attention-deficit/hyperactivity disorder (ADHD)

Personality disorders

Psychotic disorders, general mental health symptoms and overall functioning

Problem gambling*

*Clients can complete these problem gambling questionnaires on their own, print off their results and bring them to their health care provider if they have concerns. Learn more about problem gambling assessment.



Handout for clients

  
  
Concurrent Disorderscd-handout
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Clinical simulation video​

 

Download video transcript

This video clip shows a fictitious therapist and client session for teaching purposes.

The scenario depicts a therapy session where the client (Joseph) who is dealing with problem gambling has already completed a screening questionnaire for suspected concurrent disorders. The screener 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 a direct referral can be made. However, the referral process may be different for a community psychiatrist.

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L​ast updated: October 26, 2018