Introduction
The terms “concurrent disorders” and “co-occurring disorders” refer to a diagnosis that includes more than one disorder, such as having both a mental health disorder and an addictive disorder (Health Canada, 2002). 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 receive the most effective treatment (Lorains, 2011).
The term “concurrent disorders” refers to the presence of multiple disorders, for example a mental illness and an addiction (Health Canada, 2002). People with mental illnesses have higher rates of gambling problems than the general population (Sagoe, 2017).
Similarly, people with gambling problems have higher rates of other mental health problems, such as major depression, anxiety disorders and other addictive problems. In addition, people with gambling problems have a higher risk of suicide ideation and self-harm attempts (Brooker, 2009; Sagoe, 2017).
Screening your clients with gambling problems for concurrent disorders is a best practice that allows you to create an integrated treatment plan (BC Ministry of Health, 2012; Lorains, 2011).
This page provides an overview of the interactions between mental illnesses (such as mood, anxiety and psychotic disorders) and problem gambling. 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 (Black & Moyer, 1998). It is estimated that approximately 75 per cent of people who seek treatment for gambling problems have at least one other psychiatric diagnosis (Dowling, 2015).
A complex mix of biological and environmental factors can increase the risk of concurrent disorders in people with gambling problems (Moore, 2002).
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 (CAMH, 2021).
What does the evidence say?
Substance use disorders are the most common types of problems seen in clients with problem gambling (Lorrains et al., 2011).
The interaction between problem gambling and both depression and anxiety has been well documented (Dowling, 2015; Lorains, 2011; Momper, 2010; Parhami, 2014; Toneatto & Pillai, 2016). There is also a higher prevalence of impulsivity (e.g.,
attention-deficit/hyperactivity disorder [ADHD], bipolar disorder, personality disorders and psychotic disorders) documented for people with problem gambling (Brown, 2016; Dowling, 2015; Haydock et al., 2015; Lorains, 2011; Waluk, 2016). In addition, research shows that people with schizophrenia and schizoaffective disorders have higher risks of problem gambling (Desai & Potenza, 2009).
Several studies suggest that in some people with mood or anxiety disorders and problem gambling, the mental illness may have preceded their gambling (Martin, 2004). 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 (Martin, 2004).
There is a strong link between excessive gambling and suicide (Hodgins et al., 2006; Maccallum & Blaszczynski, 2003; Petry & Kiluk, 2002). This link is especially strong in people with concurrent disorders (Hodgins et al., 2006). 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 also 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.
How do I put the evidence into practice?
Research on concurrent disorders highlights the importance of integrating primary care with addiction and mental health treatment and supports (Health Canada, 2002). Such integrated care helps ensure that the unique needs of the individual are met and that the services and supports they receive are optimal (BC Ministry of Health, 2012). 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.
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 (BC Ministry of Health, 2012; Lorains, 2011). Screening, through psychiatric consultation or referral, can help identify the person’s eligibility to receive other mental health services.
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 (Lorains, 2011). 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 (American Psychiatric Association, 2006; Silverman et al., 2016).
Research indicates that suicide risk assessment tools yield low predictive reliability and greater possibility of false positive or false negative results (Carter et al., 2017; National Collaborating Centre for Mental Health, 2012; Perlman et al., 2011; Quinlivan et al., 2017). The limitations of these tools can be mitigated by combining them with a clinical interview and by building a strong therapeutic relationship (Fowler, 2012). 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 evidence to support using modified dialectical behaviour therapy as well as a combination of cognitive behavioural therapy and naltrexone (Dowling et al., 2016).
Additionally, research indicates variability in the effectiveness of disorder-appropriate medication (e.g., lithium for concurrent bipolar disorder) (Dowling, 2015; Dowling et al., 2016). 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 for clients with problem gambling (Dowling, 2015).
List of screening tools
To learn about problem gambling-related screening and assessment tools, read this Evidence-informed Practice.
Numerous screening tools can help you identify and monitor addictions and mental health problems, and determine the need for further psychiatric assessment and consultation. Below is a selection of these tools.
Substance use disorders
Alcohol Use Disorders Identification Test (AUDIT) - World Health Organization. (2001). AUDIT: the Alcohol Use Disorders Identification Test : guidelines for use in primary health care / Thomas F. Babor ... [et al.], 2nd ed. World Health Organization.
Instrument: Fagerstrom Test for Nicotine Dependence (FTND) – Cited with permission from National Institute on Drug Abuse (NIDA).
Mood and anxiety disorders
Hamilton Rating Scale for Depression
Beck Depression Inventory (available for purchase)
Beck Anxiety Inventory (available for purchase)
Suicide
Beck Scale for Suicide Ideation (available for purchase)
Attention-deficit/hyperactivity disorder (ADHD)
Adult ADHD Self-Report Scale-V1.1 (ASRS) - Kessler, R.C. et al., (2005). The World Health Organization Adult ADHD Self-Report Scale (ASRS). Psychological Medicine, 35(2), 245-256.
Adult ADHD Self-Report Scale Symptom Checklist - - Kessler, R.C. et al., (2005). The World Health Organization Adult ADHD Self-Report Scale (ASRS). Psychological Medicine, 35(2), 245-256.
Personality disorders
The Personality Inventory for DSM-5. Brief
Minnesota Multiphasic Personality Inventory-II (MMPI-II) (available for purchase)
Psychotic disorders, general mental health symptoms and overall functioning
Mental Health Screening Form III (MHSF-III)
Global Appraisal of Individual Needs Short Screener (GAIN-SS) – English
Global Appraisal of Individual Needs Short Screener (GAIN-SS) – French
GAIN-SS Interviewer instruction – English
GAIN-SS Interviewer instruction – French
GAIN-SS scoring and interpretation – English
GAIN-SS scoring and interpretation – French
Additional resources
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 a 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.)
References
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