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
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.
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
To learn about problem gambling-related screening and assessment tools read this
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.
Substance use disorders
Mood and anxiety disorders
Attention-deficit/hyperactivity disorder (ADHD)
Psychotic disorders, general mental health symptoms and overall functioning
Handouts for clients
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.)
Download video transcript
Click to show references
- Health Canada. (2002).
Best practices: Concurrent mental health and substance use disorders. Ottawa. Available: http://www.hc-sc.gc.ca/hc-ps/alt_formats/hecs-sesc/pdf/pubs/adp-apd/bp_disorder-mp_concomitants/bp_concurrent_mental_health-eng.pdf. Accessed April 2, 2019.
- Lorains, F.K., Cowlishaw, S. & Thomas, S.A. (2011). Prevalence of comorbid disorders in problem and pathological gambling: Systematic review and meta-analysis of population surveys.
Addiction, 106(3), 490–498. doi:10.1111/j.1360-0443.2010.03300.x
- Sagoe, D., Pallesen, S. & Hanss, D., Leino, T., Molde, H., Mentzoni, R. A., et al. (2017). The relationships between mental health symptoms and gambling behavior in the transition from adolescence to emerging adulthood.
Frontiers in Psychology,8, 478. https://doi.org/10.3389/fpsyg.2017.00478
- Brooker, I.S., Clara, I.P. & Cox, B.J. (2009). The canadian problem gambling index: factor structure and associations with psychopathology in a nationally representative sample.
Canadian Journal of Behavioural Science,
41(2), 109–114. doi:10.1037/a0014841
- BC Ministry of Health. (2012).
Integrated models of primary care and mental health & substance use care in the community: Literature review and guiding document. Available: www.health.gov.bc.ca/library/publications/year/2012/integrated-models-lit-review.pdf. Accessed April 2, 2019.
- Black, D.W. & Moyer, T. (1998). Clinical features and psychiatric comorbidity of subjects with pathological gambling behavior.
49(11), 1434–1439. doi:10.1176/ps.49.11.1434
- Dowling, N.A., Cowlishaw, S., Jackson, A.C., Merkouris, S.S., Francis, K.L. & Christensen, D.R. (2015). Prevalence of psychiatric co-morbidity in treatment-seeking problem gamblers: A systematic review and meta-analysis.
The Australian and New Zealand Journal of Psychiatry,49(6), 519–539. doi:10.1177/0004867415575774
- Moore, K., Wagner, C., Peters, R. & Hills, H. (2002).
Co-Occurring Disorders Problem Gambling Integrated Treatment Manual. Available: http://www.ct.gov/dmhas/lib/dmhas/pgs/cooccuringmanual.pdf. Accessed April 2, 2019.
- Centre for Addiction and Mental Health.
Concurrent Disorders. Available: https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/concurrent-disorders. Accessed April 2, 2019.
- Skinner, W. (2005).
Treating Concurrent Disorders: A Guide for Counsellors. W. Skinner (Ed.). Toronto: Centre for Addiction and Mental Health.
- Parhami, I., Mojtabai, R., Rosenthal, R.J., Afifi, T.O. & Fong, T.W. (2014). Gambling and the onset of comorbid mental disorders: A longitudinal study evaluating severity and specific symptoms.
Journal of Psychiatric Practice,
20(3), 207–219. doi:10.1097/01.pra.0000450320.98988.7c
- Toneatto, T. & Pillai, S. (2016). Mood and anxiety disorders are the most prevalent psychiatric disorders among pathological and recovered gamblers.
International Journal of Mental Health and Addiction,14(3), 217–227. doi:10.1007/s11469-016-9647-5
- Momper, S.L., Delva, J., Grogan-Kaylor, A., Sanchez, N. & Volberg, R.A. (2010). The association of at-risk, problem, and pathological gambling with substance use, depression, and arrest history.
Journal of Gambling Issues, 24, 7–32. doi:10.4309/2010.24.3
- Waluk, O.R., Youssef, G.J. & Dowling, N.A. (2016). The relationship between problem gambling and attention deficit hyperactivity disorder.
Journal of Gambling Behavior,32(2), 591–604. doi:10.1007/s10899-015-9564-8
- Brown, M., Oldenhof, E., Allen, J.S. & Dowling, N.A. (2016). An empirical study of personality disorders among treatment-seeking problem gamblers.
Journal of Gambling Behavior,32(4), 1079-1100. doi:10.1007/s10899-016-9600-3
- Dowling, N.A., Cowlishaw, S., Jackson, A.C., Merkouris, S.S., Francis, K.L. & Christensen, D.R. (2015). The prevalence of comorbid personality disorders in treatment-seeking problem gamblers: A systematic review and meta-analysis.
Journal of Personality Disorders,29(6), 735-54. doi:10.1521/pedi_2014_28_168
- Haydock, M., Cowlishaw, S., Harvey, C. & Castle, D. (2015). Prevalence and correlates of problem gambling in people with psychotic disorders.
Comprehensive Psychiatry, 58, 122–129. doi:10.1016/j.comppsych.2015.01.003
- Desai, R.A. & Potenza, M.N. (2009). A cross sectional study of problem and pathological gambling in patients with schizophrenia/schizoaffective disorder.
The Journal of Clinical Psychiatry, 70(9), 1250–1257. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3695825/.
- Martin, N. (2004).
Mood disorders and problem gambling: Cause, effect or cause for concern? A review of the literature. Available: https://mdsc.ca/documents/Publications/Mood Disorders and Problem Gambling A Review of Literature.pdf. Accessed April 2, 2019.
- Hodgins, D., Mansley, C. & Thygesen, K. (2006). Risk factors for suicide ideation and attempts among pathological gamblers.
American Journal on Addictions, 15(4), 303–310. doi:10.1080/10550490600754366
- Petry N.M. & Kiluk B.D. (2002). Suicidal ideation and suicide attempts in treatment-seeking pathological gamblers. The
Journal of Nervous and Mental Disease, 190(7), 462-469. https://doi.org/10.1097/01.NMD.0000022447.27689.96.
- Maccallum F. & Blaszczynski A. (2003). Pathological gambling and suicidality: An analysis of severity and lethality.
Suicide and Life-Threatening Behavior, 33(1), 88–98.
- American Psychiatric Association, Steering Committee on Practice Guidelines. (2006).
American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006. Arlington: American Psychiatric Association.
- Silverman, J.J., Marc Galanter, C., Jackson-Triche, M., et al. (2016).
The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd Ed. Arlington: American Psychiatric Association.
- Perlman, C., Neufeld, E., Martin, L., Goy, M. & Hirdes, J.P. (2011).
Suicide Risk Assessment Guide: A Resource for Health Care Organizations. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute. Available: http://www.patientsafetyinstitute.ca/en/toolsResources/SuicideRisk/Documents/Suicide Risk Assessment Guide.pdf. Accessed January 4, 2019.
- Quinlivan L., Cooper J., Meehan D., et al. (2017). Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study. The British Journal of Psychiatry, 210(6), 429-436.
- Carter G., Milner A., Katie M., Pirkis J., Kapur N., Spittal M.J. (2017). Predicting suicidal behaviours using clinical instruments: Systematic review and meta-analysis of positive predictive values for risk scales. The British Journal of Psychiatry, 210(6), 387-395.
- National Collaborating Centre for Mental Health. (2012).
Self-Harm: The NICE Guideline on Longer-Term Management. Available: https://www.nice.org.uk/guidance/cg133/evidence/full-guideline-184901581. Accessed April 2, 2019.
- Fowler, J.C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments.
- Dowling, N.A., Merkouris, S.S. & Lorains, F.K. (2016). Interventions for comorbid problem gambling and psychiatric disorders: Advancing a developing field of research.
58, 21–30. https://doi.org/10.1016/j.addbeh.2016.02.012