Predicting future harm from gambling over a five-year period in a general population sample: a survival analysis.

BACKGROUND: There is little longitudinal evidence on the cumulative risk of harm from gambling associated with excess spending and frequency of play. The present study sought to assess the risk of gambling problems over a five-year period in adults who exceed previously derived low-risk gambling limits compared to those who remain within the limits after controlling for other modifiable risk factors. METHODS: Participants were adults (N = 4212) drawn from two independent Canadian longitudinal cohort studies who reported gambling in the past year and were free of problem gambling at time 1. Multivariate Cox regression was employed to assess the impact over time of gambling above low-risk gambling thresholds (frequency ≥ 8 times per month; expenditure ≥75CAD per month; percent of household income spent on gambling ≥1.7%) on developing moderate harm and problem gambling. Covariates included presence of a DSM5 addiction or mental health disorder at time 1, irrational gambling beliefs, number of stressful life events in past 12 months, number of game types played each year, and playing electronic gaming machines or casino games. RESULTS: In both samples, exceeding the low-risk gambling limits at time 1 significantly increased the risk of moderate harm (defined as ≥2 consequences on the Problem Gambling Severity Index [PGSI]) within 5 years after controlling for other modifiable risk factors. Other significant predictors of harm were presence of a mental disorder at time 1, cognitive distortions about gambling, stressful life events, and playing electronic gaming machines or casino games. In one sample, the five-year cumulative survival rate for moderate harm among individuals who stayed below all the low-risk limits was 95% compared to 83% among gamblers who exceeded all limits. Each additional low-risk limit exceeded increased the cumulative probability of harm by 30%. Similar results were found in models when the outcome was problem gambling. CONCLUSIONS: Level of gambling involvement represents a highly modifiable risk factor for later harm. Staying below empirically derived safe gambling thresholds reduces the risk of harm over time.

Use of Self-control Strategies for Managing Gambling Habits Leads to Less Harm in Regular Gamblers.

There is little research on the control strategies used by the general public to self-manage gambling habits and avoid harmful consequences. The current study sought to identify the most common self-control strategies of people who gamble regularly, the characteristics of those who use them, and assess the effectiveness of limit-setting strategies in reducing gambling-related harm. We recruited a large sample (N = 10,054) of Canadian adults who reported gambling activity in the past 12 months. Participants completed a survey that assessed gambling habits, use of control strategies including quantitative limit setting, and gambling related harm. The most common control strategies were setting predetermined spending limits, tracking money spent, and limiting alcohol consumption. The number of self-control strategies used by gamblers was positively associated with gambling involvement, annual income, problem gambling severity and playing electronic gaming machines. Approximately 45% of respondents failed to adhere to self-determined quantitative limits for spending, frequency, and time spent gambling. People who stayed within their gambling limits were less likely to report harm even after controlling for other risk factors. However, the effectiveness of remaining within one's personal spending limit decreased for those whose limits exceed $200CAN monthly. The findings support public health interventions that promote lower-risk gambling guidelines aimed at helping gamblers stay within spending, frequency and duration limits.

Validation of a Comprehensive Patient Experience Survey for Addiction and Mental Health that was Co-designed with Service Users.

A rigorous survey development process was undertaken to design and test a novel, comprehensive patient experience measure that can be used across the full continuum of addiction and mental health programs. Service users were involved in all aspects of the measure's development, including the selection of items, pre-testing, naming of the scales, and interpretation of the results. Survey data was collected from 1222 patients in treatment in a variety of service settings across Alberta, Canada (89% outpatients; 60% female). An exploratory factor analysis identified five subscales-patient-centred care, treatment effectiveness, staff behaviour, availability and coordination of care, and communication. The subscales had high internal reliability (Cronbach's alpha = 0.77 to 0.85) and test-retest reliability ranged from 0.53 to 0.82 across the five scales. Scores on the new instrument were correlated with treatment outcomes. The assessment of patient experience should be integrated into a continuous, sustainable quality improvement process to be truly effective.

A research plan to define Canada's first low-risk gambling guidelines.

From a public health perspective, gambling shares many of the same characteristics as alcohol. Notably, excessive gambling is associated with many physical and emotional health harms, including depression, suicidal ideation, substance use and addiction and greater utilization of health care resources. Gambling also demonstrates a similar 'dose-response' relationship as alcohol-the more one gambles, the greater the likelihood of harm. Using the same collaborative, evidence-informed approach that produced Canada's Low-Risk Alcohol Drinking and Lower Risk Cannabis Use Guidelines, a research team is leading the development of the first national Low-Risk Gambling Guidelines (LRGGs) that will include quantitative thresholds for safe gambling. This paper describes the research methodology and the decision-making process for the project. The guidelines will be derived through secondary analyses of several large population datasets from Canada and other countries, including both cross-sectional and longitudinal data on over 50 000 adults. A scientific committee will pool the results and put forward recommendations for LRGGs to a nationally representative, multi-agency advisory committee for endorsement. To our knowledge, this is the first systematic attempt to generate a workable set of LRGGs from population data. Once validated, the guidelines inform public health policy and prevention initiatives and will be disseminated to addiction professionals, policy makers, regulators, communication experts and the gambling industry. The availability of the LRGGs will help the general public make well-informed decisions about their gambling activities and reduce the harms associated with gambling.

Comorbid Problem Gambling and Major Depression in a Community Sample.

Major depression is among the most common comorbid conditions in problem gambling. However, little is known about the effects of comorbid depression on problem gambling. The present study examined the prevalence of current major depression among problem gamblers (N = 105) identified from a community sample of men and women in Alberta, and examined group differences in gambling severity, escape motivation for gambling, family functioning, childhood trauma, and personality traits across problem gamblers with and without comorbid depression. The prevalence of major depression among the sample of problem gamblers was 32.4%. Compared to problem gamblers without depression (n = 71), problem gamblers with comorbid depression (n = 34) reported more severe gambling problems, greater history of childhood abuse and neglect, poorer family functioning, higher levels of neuroticism, and lower levels of extraversion, agreeableness, and conscientiousness. Furthermore, the problem gamblers with comorbid depression had greater levels of childhood abuse and neglect, worse family functioning, higher neuroticism, and lower agreeableness and conscientiousness than a comparison sample of recreational gamblers with depression (n = 160). These findings underscore the need to address comorbid depression in assessment and treatment of problem gambling and for continued research on how problem gambling is related to frequently co-occurring disorders such as depression.

Validity of the Problem Gambling Severity Index interpretive categories.

The Problem Gambling Severity Index (PGSI) is a widely used nine item scale for measuring the severity of gambling problems in the general population. Of the four gambler types defined by the PGSI, non-problem, low-risk, moderate-risk and problem gamblers, only the latter category underwent any validity testing during the scale's development, despite the fact that over 95% of gamblers fall into one of the remaining three categories. Using Canadian population data on over 25,000 gamblers, we conducted a comprehensive validity and reliability analysis of the four PGSI gambler types. The temporal stability of PGSI subtype over a 14-month interval was modest but adequate (intraclass correlation coefficient = 0.63). There was strong evidence for the validity of the non-problem and problem gambler categories however the low-risk and moderate-risk categories showed poor discriminant validity using the existing scoring rules. The validity of these categories was improved with a simple modification to the scoring system.

Developing and validating lower risk online gambling thresholds with actual bettor data from a major Internet gambling operator.

OBJECTIVE: To help individuals avoid potential negative consequences associated with their gambling, researchers have developed lower risk limits for time and financial involvement among populations of land-based gamblers. The present study extended these efforts to online gambler populations with prospective longitudinal data. METHOD: We used receiver operating characteristic curve analysis and logistic regression models predicting a positive Brief Biosocial Gambling Screen (BBGS; Gebauer et al., Canadian Journal of Psychiatry, 55, 2010, 82-90) to develop lower risk limits for six measures of gambling involvement among subscribers to an online gambling operator. We also tested the utility of these six newly developed online limits and three existing land-based limits for the BBGS outcome and proxies for gambling problems including: (a) voluntary self-limiting, (b) voluntary self-exclusion, (c) closing one's account, and (d) being assigned a flag for potential problem gambling by customer service. RESULTS: We identified five optimal limits for lower risk online gambling with adequate sensitivity and specificity for predicting BBGS-positive status, and four of those that also received additional empirical support. These four empirically supported gambling limits were: (a) wagering 167.97 Euros or less each month; (b) spending 6.71% or less of one's annual income on online gambling wagers; (c) losing 26.11 Euros or less on online gambling per month; and (d) demonstrating variability (i.e., standard deviation) in daily amount wagered of 35.14 Euros or less during one's duration active. CONCLUSIONS: Our findings have implications for lower risk gambling limits research and suggest that unique limits might apply to online and land-based gambler populations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Gambling Self-Control Strategies: A Qualitative Analysis.

There is limited research exploring the perceptions of people who gamble on the self-control strategies used to limit their gambling. This qualitative study examines self-control strategies used to limit money spent gambling, frequency of gambling, and time spent gambling. A total of 56 people who gamble (27 males and 29 females) participated in nine focus groups and five individual interviews in Montreal, Calgary, and Toronto (Canada). Self-control strategies used to limit their gambling expenditure were more common than frequency or time limiting strategies. Strategies to limit expenditure included: restricting access to money; keeping track of money allocated to gambling activities; and avoiding certain types of gambling activities. Various contextual factors were identified to influence those strategies, including social influences; winning or losing; using substances. Findings from this study emphasize the importance of communicating clear gambling limits to people who gamble, as well as the value of developing individual self-control strategies to limit frequency, time and money spent gambling.

Stacked Deck: an effective, school-based program for the prevention of problem gambling.

School-based prevention programs are an important component of problem gambling prevention, but empirically effective programs are lacking. Stacked Deck is a set of 5-6 interactive lessons that teach about the history of gambling; the true odds and "house edge"; gambling fallacies; signs, risk factors, and causes of problem gambling; and skills for good decision making and problem solving. An overriding theme of the program is to approach life as a "smart gambler" by determining the odds and weighing the pros versus cons of your actions. A total of 949 grade 9-12 students in 10 schools throughout southern Alberta received the program and completed baseline and follow-up measures. These students were compared to 291 students in 4 control schools. Four months after receiving the program, students in the intervention group had significantly more negative attitudes toward gambling, improved knowledge about gambling and problem gambling, improved resistance to gambling fallacies, improved decision making and problem solving, decreased gambling frequency, and decreased rates of problem gambling. There was no change in involvement in high risk activities or money lost gambling. These results indicate that Stacked Deck is a promising curriculum for the prevention of problem gambling.

A population-based study on ways of dealing with daily stress: comparisons among individuals with mental disorders, with long-term general medical conditions and healthy people.

OBJECTIVE: Stress plays an important role in the etiology of mental and physical disorders. The effect of stress on health may be moderated by how people deal with stress. The objectives of this analysis were to (1) estimate the population proportions using various ways of dealing with stress in healthy people, in people with mental disorders and substance dependence and in individuals with general medical conditions only, and (2) identify factors associated with ways of dealing with stress. METHODS: Data from the Canadian Community Health Survey, Mental Health and Well-being (CCHS-1.2) were used (n = 36,984). This was a national mental health survey which used a probability sample and incorporated a version of the Composite International Diagnostic Interview. RESULTS: Participants with mental disorders differed from healthy people in ways of dealing with stress. Among participants with mental disorders, women were more likely to report that they "talk to others" and "eat more/less" to deal with stress. Men were more likely to use "avoid people" and "drink alcohol" to deal with stress than women. Age differences within groups in ways of dealing with stress were found and having a history of mental disorders was also associated with reported ways of dealing with stress. CONCLUSIONS: Ways of dealing with stress differ by gender and age, but there is no over-arching pattern of maladaptive coping associated with mental disorders that applies across illness, age and gender categories. Healthy behaviors should be promoted as ways to relieve stress, leading to better self-care skills.

A Canadian population level analysis of the roles of irrational gambling cognitions and risky gambling practices as correlates of gambling intensity and pathological gambling.

Using population data (N = 11,562) drawn from five Canadian gambling prevalence surveys conducted between 2000 and 2005, the current study investigated the relationship between irrational gambling cognitions and risky gambling practices upon (a) gambling intensity, as measured by percent of income spent on gambling and (b) tolerance, a diagnostic indicator of pathological gambling. First, we found irrational gambling cognitions and risky gambling practices to be positively related. Second, irrational gambling cognitions moderated the relationship between risky gambling practices and gambling intensity. Specifically, people engaging in risky practices, spent less of their income on gambling when they had fewer irrational gambling cognitions compared to those with more irrational cognitions. Third, irrational gambling cognitions moderated the relationship between risky gambling practices and tolerance. Of the people engaging in risky practices, those with no irrational cognitions reported lower levels of tolerance than those with at least one irrational cognition. Interactions with gender are reported and discussed. These findings demonstrate the importance of both gambling cognitions and gambling practices upon the intensity of gambling and pathological gambling.

Replication of low-risk gambling limits using canadian provincial gambling prevalence data.

A set of low-risk gambling limits were recently produced using Canadian epidemiological data on the intensity of gambling behavior and related consequences (Currie et al. Addiction 101:570-580, 2006). The empirically derived limits (gambling no more than two to three times per month, spending no more than $501-$100o CAN per year or no more than 1% of gross income spent on gambling) accurately predicted risk of gambling-related harm after controlling for other risk factors. The present study sought to replicate these limits on data collected in three independently conducted Canadian provincial gambling surveys. Dose-response curves and logistic regression analyses were applied to gambling prevalence data collected in surveys conducted in 2001-2002 within the provinces of Alberta, British Columbia, and Ontario (combined sample N = 7,675). A comparable dose-response relationship between gambling intensity and risk of harm was found in each province. The optimal thresholds for defining an upper limit of low-risk gambling were similar across the three provinces despite variations in the availability and organization of legalized gambling opportunities within each region. These results provide additional evidence supporting the validity of the low-risk gambling limits. Quantitative limits could be used to augment existing responsible gambling guidelines.

Does providing extended relapse prevention bibliotherapy to problem gamblers improve outcome?

Relapse rates among pathological gamblers are high with as many as 75% of gamblers returning to gambling shortly after a serious attempt to quit. The present study focused on providing a low cost, easy to access relapse prevention program to such individuals. Based on information collected in our ongoing study of the process of relapse, a series of relapse prevention booklets were developed and evaluated. Individuals who had recently quit gambling (N = 169) were recruited (through media announcements) and randomly assigned to a single mailing condition in which they received one booklet summarizing all of the relapse prevention information or a repeated mailing condition in which they received the summary booklet plus 7 additional booklets mailed to them at regular intervals over the course of a year period. Gambling involvement over the course of the 12-month follow-up period, confirmed by family or friends, was compared between the two groups. Results indicated that participants receiving the repeated mailings were more likely to meet their goal, but they did not differ from participants receiving the single mailing in frequency of gambling or extent of gambling losses. The results of this project suggest that providing extended relapse prevention bibliotherapy to problem gamblers does not improve outcome. However, providing the overview booklet may be a low cost, easy to access alternative for individuals who have quit gambling.

Problem gambling symptomatology and alcohol misuse among adolescents: A parallel-process latent growth curve model.

The objective of the current study was to examine the possible temporal associations between alcohol misuse and problem gambling symptomatology from adolescence through to young adulthood. Parallel-process latent growth curve modeling was used to examine the trajectories of alcohol misuse and symptoms of problem gambling over time. Data were from a sample of adolescents recruited for the Leisure, Lifestyle, and Lifecycle Project in Alberta, Canada (n = 436), which included 4 assessments over 5 years. There was an average decline in problem gambling symptoms followed by an accelerating upward trend as the sample reached the legal age to gamble. There was significant variation in the rate of change in problem gambling symptoms over time; not all respondents followed the same trajectory. There was an average increase in alcohol misuse over time, with significant variability in baseline levels of use and the rate of change over time. The unconditional parallel process model indicated that higher baseline levels of alcohol misuse were associated with higher baseline levels of problem gambling symptoms. In addition, higher baseline levels of alcohol misuse were associated with steeper declines in problem gambling symptoms over time. However, these between-process correlations did not retain significance when covariates were added to the model, indicating that one behavior was not a risk factor for the other. The lack of mutual influence in the problem gambling symptomatology and alcohol misuse processes suggest that there are common risk factors underlying these two behaviors, supporting the notion of a syndrome model of addiction. (PsycINFO Database Record

Deriving low-risk gambling limits from longitudinal data collected in two independent Canadian studies.

AIMS: To derive low-risk gambling limits using the method developed by Currie et al. (2006) applied to longitudinal data. DESIGN: Secondary analysis of data from the Quinte Longitudinal Study (n = 3054) and Leisure, Lifestyle and Lifecycle Project (n = 809), two independently conducted cohort studies of the natural progression of gambling in Canadian adults. SETTING: Community-dwelling adults in Southeastern Ontario and Alberta, Canada. PARTICIPANTS: A total of 3863 adults (50% male; median age = 44) who reported gambling in the past year. MEASUREMENTS: Gambling behaviours (typical monthly frequency, total expenditure and percentage of income spent on gambling) and harm (experiencing two or more consequences of gambling in the past 12 months) were assessed with the Canadian Problem Gambling Index. FINDINGS: The dose-response relationship was comparable in both studies for frequency of gambling (days per month), total expenditure and percentage of household income spent on gambling (area under the curve values ranged from 0.66 to 0.74). Based on the optimal sensitivity and specificity values, the low-risk gambling cut-offs were eight times per month, $75CAN total per month and 1.7% of income spent on gambling. Gamblers who exceeded any of these limits at time 1 were approximately four times more likely to report harm at time 2 [95% confidence interval (CI) = 2.9-6.6]. CONCLUSIONS: Longitudinal data in Canada suggest low-risk gambling thresholds of eight times per month, $75CAN total per month and 1.7% of income spent on gambling, all of which are higher than previously derived limits from cross-sectional data. Gamblers who exceed any of the three low-risk limits are four times more likely to experience future harm than those who do not.

Risk of harm among gamblers in the general population as a function of level of participation in gambling activities.

AIMS: To examine the relationship between gambling behaviours and risk of gambling-related harm in a nationally representative population sample. DESIGN: Risk curves of gambling frequency and expenditure (total amount and percentage of income) were plotted against harm from gambling. SETTING: Data derived from 19, 012 individuals participating in the Canadian Community Health Survey-Mental Health and Well-being cycle, a comprehensive interview-based survey conducted by Statistics Canada in 2002. MEASUREMENT: Gambling behaviours and related harms were assessed with the Canadian Problem Gambling Index. FINDINGS: Risk curves indicated the chances of experiencing gambling-related harm increased steadily the more often one gambles and the more money one invests in gambling. Receiver operating characteristic analysis identified the optimal limits for low-risk participation as gambling no more than two to three times per month, spending no more than 501-1,000 CAN dollars per year on gambling and investing no more than 1% of gross family income on gambling activities. Logistic regression modelling confirmed a significant increase in the risk of gambling-related harm (odds ratios ranging from 2.0 to 7.7) when these limits were exceeded. CONCLUSIONS: Risk curves are a promising methodology for examining the relationship between gambling participation and risk of harm. The development of low-risk gambling limits based on risk curve analysis appears to be feasible.

Chronic back pain and major depression in the general Canadian population.

Chronic pain and depression are two of the most common health problems that health professionals encounter, yet only a handful of epidemiological studies have investigated the relationship between these conditions in the general population. In the present study we examined the prevalence and correlates of major depression in persons with chronic back pain using data from the first cycle of Canadian Community Health Survey in a sample of 118,533 household residents. The prevalence of chronic back pain was estimated at 9% of persons 12 years and older. Rates of major depression, determined by the short-form of the Composite International Diagnostic Interview, were estimated at 5.9% for pain-free individuals and 19.8% for persons with chronic back pain. The rate of major depression increased in a linear fashion with greater pain severity. In logistic regression models, back pain emerged as the strongest predictor of major depression after adjusting for possible confounding factors such as demographics and medical co-morbidity. The combination of chronic back pain and major depression was associated with greater disability than either condition alone, although pain severity was found to be the strongest overall predictor of disability.

Daily diary and ambulatory activity monitoring of sleep in patients with insomnia associated with chronic musculoskeletal pain.

Insomnia is a significant problem for many people with chronic pain. In this study, we used a combination of daily sleep diaries and ambulatory activity monitoring (actigraphy) to: (i) examine the nature and severity of the sleep disturbance in this patient group; (ii) determine the concordance between sleep diary and actigraph measures of different sleep parameters; (iii) assess the reliability of sleep parameters across nights; and (iv) identify the clinical correlates of insomnia severity. Forty subjects with insomnia associated with chronic musculoskeletal pain completed questionnaires addressing clinical issues of pain severity, medication use, sleep quality, and affective distress. For 2 consecutive nights, each subject then completed a sleep diary and wore an actigraph unit on the non-dominant wrist. The results showed that the sleep diaries and the actigraphs provided similar estimates of total sleep time, time awake after sleep onset, and sleep efficiency, but differed in the measurement of sleep onset latency and nocturnal awakenings. Both methods of assessment exhibited low to moderate reliability across nights. Measures of the same sleep parameters across the two methods of assessment showed low concordance. Of the clinical variables, pain severity had the strongest association with disturbed sleep, but only using the diary method of assessment. Subjects who reported high pain severity also reported greater sleep impairment than subjects with low pain severity, but this was not confirmed by actigraphy. In general, both methods of assessment point to the significance of insomnia associated with chronic musculoskeletal pain as a distinct clinical problem, but the activity monitoring and self-report procedures provide different information. These findings suggest that multi-method assessment is an important consideration for studies of insomnia in patients with chronic pain.

Outcome from integrated pain management treatment for recovering substance abusers.

There is little information on the efficacy of pain management for substance abusers with noncancerous chronic pain conditions. The present study describes an outcome evaluation of a pain management group adapted to the needs of patients diagnosed with concurrent chronic pain and substance abuse disorders. A heterogeneous group of 44 patients (66% opioid dependent; 61% musculoskeletal pain) attended a 10-week outpatient group based within a multidisciplinary substance abuse treatment program. Measures of addiction severity, pain, use of self-management techniques, emotional distress, medication use, and functional status were obtained at pretreatment, post-treatment, 3-month, and 12-month follow-ups. Outcome data were analyzed on the group and individual level, the latter using the reliable change index. Intention-to-treat analyses showed significant improvements in pain, emotional distress, medication reduction, and coping style. Half of the patients showed a statistically reliable improvement on at least 1 outcome measure, and half were opioid free at the 12-month follow-up assessment. These results suggest that persons with concurrent chronic pain and substance use disorders are responsive to an integrated treatment model of pain management and relapse prevention.

Randomized controlled trial of brief cognitive-behavioural interventions for insomnia in recovering alcoholics.

AIMS: To test the efficacy of a cognitive-behavioural approach to treating disturbed sleep in abstinent alcoholics. DESIGN: Sixty recovering alcoholics with insomnia were assigned randomly to individual therapy, self-help with telephone support or waiting-list control. SETTING: Participants were volunteers recruited from out-patient treatment programs and through the media. MEASUREMENTS: Outcomes were assessed at post-treatment, 3-month and 6-month follow-ups using sleep diaries, the Pittsburgh Sleep Quality Index, wrist actigraphs and time-line follow-back interviews. INTERVENTION: Five sessions of out-patient cognitive-behavioural therapy for insomnia or a self-help manual with five telephone support calls. Treatment duration was 7 weeks. FINDINGS: Treated participants were significantly more improved than control participants on diary measures of sleep quality, sleep efficiency, awakenings and time to fall asleep. No significant differences between the individual therapy and self-help treatment conditions on measures of insomnia severity were evident at post-treatment. Self-reported improvement in sleep was corroborated by clinician and spousal ratings of insomnia severity, but not by actigraph recordings of nocturnal activity. At 3- and 6-month follow-up assessments treatment gains were reasonably maintained in both treatment groups, although individual therapy was associated with a higher rate of clinically significant improvement. At the 6-month follow-up, 60% participants who were regular users of sedative medication at baseline discontinued the use of their medication. Treatment appeared to have little impact in preventing relapses to alcohol. CONCLUSIONS: Recovering alcoholics with insomnia can achieve better sleep by applying cognitive-behavioural strategies.