A Hidden Problem: Examining Problem Gambling Among US Military Veterans - PowerPoint Presentation

A Hidden Problem: Examining Problem Gambling Among US Military Veterans Shane W. Kraus., Ph.D. VISN 1 New England MIRECC University of Massachusetts Medical School, Division of Addiction Psychiatry, Worcester, MA

Supported by the VISN 1 New England Mental Illness Research, Education, and Clinical Center which is housed within the Department of Veterans Affairs, Veterans Healthcare Administration. Views expressed are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, United States government, or other funding agencies listed above. 1Disclosures and Funding

Gambling Disorder Prevalence Up to 90% of U.S. adults gambleLifetime problem gambling:2-5% of U.S. adults 10% of military VeteransLifetime gambling disorder:1-2% of US adults3% of military VeteransAbout 1/3 of problem gamblers experience natural remission 2

Gambling Among US Veterans A national survey of U.S. Veterans found that approximately 2.2% screened positive for at-risk/problem gambling (Stefanovics, Potenza, & Pietrzak, 2017)4.2% of Iraq/Afghanistan Veterans exhibit at-risk/problem or pathological gambling (Whiting et al., 2016)SEIGMA study surveyed 9,578 Massachusetts residents (9.6% were Veterans) on gambling. Of the 126 identified as having problem gambling, 26 (20.6%) were Veterans. Massachusetts Veteran problem gamblers were more likely to be male, White, older, retired, born within the US, and have worse physical health than non-Veteran problem gamblers (Freeman, Volberg, & Zorn, 2019)

Seeking Help for Problem Gambling Public funding for substance abuse treatment is 281 times greater than for problem gambling services ($17 billion vs. $60.6 million) (Marotta, 2013)~ 11% of U.S. adults with gambling disorder seek professional help in their lifetime (Alegría et al., 2009, Ledgerwood & Milosevic, 2015) A study of Veterans with gambling disorder found that less than 5% had previously sought treatment (Shirk et al., 2018) 4

Study 1: Veterans Seeking Treatment for Gambling Disorder Shirk and colleagues (2018) examined the clinical characteristics of 61 Veterans seeking treatment for gambling disorder at the Bedford VAMC. 5

6 TABLE 1. Demographic Characteristics and DSM-IV Psychopathology Co-morbidities   N/M/Median %/SD/Range Demographics     Age Sex (male) Ethnicity White, non-Hispanic Black, non-Hispanic Hispanic, White Other Years of Education Relationship Status Divorced Separated Single Widowed Married In a relationship Period of Service WWII/Korean War Post-Korean War Vietnam Conflict Post-Vietnam Conflict Persian Gulf Post-Persian Gulf Median Annual Income 50.8 60   43 10 5 3 12.2   29 13 12 4 2 1   3 2 27 26 4 5 $10,944 9.25 98.4%   70.5% 16.4% 8.2% 4.9% 3.55   47.5% 21.3% 19.7% 6.6% 3.3% 1.6%   4.5% 3.0% 40.3% 38.8% 6.0% 7.5% $334-68,000

7 TABLE 1. Demographic Characteristics and DSM-IV Psychopathology Co-morbidities   N/M/Median %/SD/Range Demographics       Any Substance Use a Alcohol Nicotine Cocaine Opioids Cannabis Stimulants Hallucinogens 47 42 46 26 14 10 3 1 77.0% 68.9% 76.6% 42.6% 23.0% 16.4% 4.9% 1.6%   Any Mood Disorder Major Depressive Disorder Dysthymia 25 23 2 41.0% 37.7% 3.3% Any Anxiety Disorder b Panic Disorder Specific Phobia Social Phobia Generalized Anxiety Disorder Agoraphobia 34 7 7 3 2 1 55.7% 11.5% 11.5% 4.9% 3.3% 1.6% Obsessive Compulsive Disorder 2 3.3% Post-traumatic Stress Disorder 18 29.5% Suicidal Ideation 8 13.6%

8 TABLE 2. Gambling History, Type, and Gambling and Clinical Scores   N/M %/SD Gambling History Family history of gambling Father gambled Mother gambled Siblings gambled Age when first gambled Age when first began to regularly gamble Ever sought treatment for gambling   50 28 25 33 13.95 18.73 4   82.0% 45.9% 41.0% 54.1% 6.14 9.05 6.6% Gambling Behavior/Type Playing the Numbers/Lotteries Playing Slot, Poker, or Other Playing Cards Other Games of Skill Gambling at a Casino Betting on Sports Playing Bingo Betting on Animals Playing Dice Games Playing Pull Tabs or “Paper” Games Commodities Market   53 32 31 26 25 23 23 20 16 16 3   86.9% 52.5% 50.8% 42.6% 41.0% 37.7% 37.7% 32.8% 26.2% 26.2% 4.9%

9 TABLE 2. Gambling History, Type, and Gambling and Clinical Scores   N/M %/SD Gambling, Function, & Impulsivity Questionnaires SOGS (past year) G-SAS Total PG-YBOCS Total Obsession Compulsion GBQ Total Luck/Perseverance Illusion of Control BIS-11 Total Attentional Motor Non-planning SDS Total   10.51 21.87 15.13 7.75 7.38 89.63 55.03 34.59 72.34 19.47 24.17 28.71 12.44   4.02 8.00 6.92 3.56 3.98 25.60 16.05 11.06 4.89 2.77 3.83 2.62 7.79 Note. SOGS = South Oaks Gambling Screen; G-SAS = Gambling Symptom Assessment Scale; PG-YBOCS = Yale Brown Obsessive Compulsive Scale for Problem Gambling; PG-YBOCS Obsession = Yale Brown Obsessive Compulsive Scale for Problem Gambling Obsession Subscale; PG-YBOCS Compulsion = Yale Brown Obsessive Compulsive Scale for Problem Gambling Compulsion Subscale; GBQ = Gambling Belief Questionnaire; BIS-11 = Barratt Impulsiveness Scale; SDS = Sheehan Disability Scale.

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Study 1: Summary Of Findings Veterans seeking treatments for gambling disorder had high rates of psychiatric and addictive disorders.When investigating how gambling-related characteristics impacted functioning, we found that severity of cognitive distortions was the strongest predictor of functional disability.Veterans with mental health problems, including addiction-related issues, should be screened for problem gambling. 11

Study 2: Gambling Disorder And Pain Among Veterans We examined the relationships between gambling disorder, pain, and suicide attempts among US military Veterans who were using Veterans Health Administration (VHA) pain-related services.This was a retrospective cohort analysis of 221,817 Veterans using pain services. 0.13% of Veterans were diagnosed with gambling disorder. 12

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Study 2: Study Findings and Conclusions Female sex, depression, alcohol, drug, and tobacco use disorders are positively associated with gambling disorders, but severe pain score is negatively associated with gambling disorders. We also found that gambling disorder diagnosis was associated with suicide attempt in Veterans who received a pain-related visit in VHA in the past year.Our findings suggest that gambling disorder in female Veterans and suicide attempts in Veterans with gambling disorder should not be underestimated and they warrant further consideration. Further studies are needed to confirm our finding that Veterans with severe pain may be less likely to have a diagnosis of gambling disorder. 16

Study 3: Assessing Gambling in a National Sample Of US Veterans In Fall 2018, we surveyed 1,019 US military Veterans. This study was funded by US Department of Veterans Affairs.We assessed for gambling behaviors and other mental health issues, including whether they were enrolled in VA health care services or had knowledge of VA health care services. N=551 (54.1%) reported they did not gamble in past 12 months.N=467 (45.9%) had past-year gambling behavior: N=420 (89.9%) were considered recreational gamblers (denied any problems). N=47 (4.6%) reported at least one problem with gambling on the Brief Biosocial Gambling Screener (BBGS) – at-risk/problem gamblers (ARPG). 17

Study 3—Screening Instrument: Brief Biosocial Gambling Screen (BBGS) 18 Have you gambled in the past 12 months? N=467 Yes No 1. During the past 12 months, have you become restless irritable or anxious when trying to stop/cut down on gambling? 29 (6.2%) 438 (93.8%) 2. During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled? 32 (6.3%) 435 (93.1%) 3. During the past 12 months, did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends or welfare? 20 (4.4%) 447 (95.9%) BBGS SUM (0-4). No - items were endorsed (none) 1 problem 2 problems 3 problems N=467 420 (89.9%) 22 (4.7%) 16 (3.4%) 8 (2.0%)

Study 3: Recreational Gamblers vs. At-risk Problem Gamblers   Recreational gambler (N=420) At-risk/problem gamblers (N=47) Gambling Type Card games Horses/dogs Sports betting Slots or poker machines Lotto Bingo Scratch ticket/pull tabs Internet gambling     6.0% 1.3% 9.7% 29.8% 42.4% 1.6% 9.1% 1.9%   9.0% 4.4% 11.3% 35.5% 28.1% 2.1% 5.7% 0% Money spent typical month Under $50 Under $100 $250 or more   65.5% 17.3% 10%   27.5% 12.8% 45% 19

  Total sample (N= 1,019)   Non-gambler (n=551) Recreational Gambler (n=420) At-Risk Problem Gambling (n=47) Difference between groups  F or χ 2 Partial Eta Square / Cramer’s V   Age 39 years or younger 40 to 59 years old 60+ years old   552 (54.2%) 418 (41.1%) 48 (4.7%)    65 (11.8%) 339 (61.4%) 114 (26.6%)   46 (11.0%) 257 (61.5%) 115 (27.5%)   6 (12.5%) 30 (62.5%) 12 (25.0%)   0.30   0.02 Gender- Male 921 (90.5%) 489 (88.7%) 389 (92.8%) 43 (89.6%) 4.7 0.07 Education High school Some college education Bachelor’s degree Some Graduate degree Graduate degree   115 (11.3%) 389 (38.2%) 238 (23.4%) 68 (6.7%) 207 (20.4%)   63 (11.5%) 206 (37.5%) 133 (24.2%37 (6.7%)111 (20.2%) 46 (11.0%)163 (38.9%)95 (22.7)30 (7.2%)85 (20.3%) 6 (12.5%)20 (41.7%)30 (7.2%)85 (20.3%)11 (22.9%) 2.6 0.04Annual income $49,999 or less $50,00-99,999 $100,000 or more 357 (37.0%)388 (40.2%)221 (22.9%) 220 (41.7%)204 (38.6%)104 (19.7%) 121 (30.9%)165 (42.1%)106 (27%) 16 (34.8%)19 (41.3%)11 (23.9%) 13.2* 0.08Military branch Army Air Force Marine Corps Navy National Guard Coast Guard  424 (41.7%)232 (2.8%)95 (9.3%)226 (22.2%)22 (2.2%)13 (1.3%) 218 (39.6%)130 (23.6%)53 (9.6%)130 (23.6%)10 (1.8%)5 (0.9%) 187 (44.6%)92 (22.0%)36 (8.6%)89 (21.2%)8 (1.9%)7 (1.7%) 19 (39.6%)10 (20.8%)6 (12.5%)7 (14.6%)4 (8.3%)1 (2.1%) 20.1 0.10 20

21   Total sample (N= 1,019)   Non-gambler (n=551) Recreational Gambler (n=420) At-Risk Problem Gambling (n=47) Difference between groups F or χ 2 Partial Eta Square / Cramer’s V   Served In Combat Zone 476 (46.7%) 275 (49.8%) 175 (41.7%) 26 (55.3%) 7.8* 0.09 Discharge Status Honorable/General   968 (95%)   518 (93.8%)   410 (97.6%)   40 (85.1%)   17.3**   0.13 Ever Received VA Healthcare 478 (47.0%) 266 (48.3%) 179 (42.6%) 33 (70.2%) 13.8** 0.12 Lifetime Thoughts Of Suicide 278 (27.3%) 155 (28.1%) 102 (24.3%) 21 (44.7%) 9.3* 0.10 Past 2-week Suicidal Ideation 160 (15.7%) 97 (17.6%) 46 (11.0%) 17 ( 35.4% ) 22.8** 0.15 Past 2-week Thoughts Of Self-harm93 (9.1%) 59 (10.7%)19 (4.5%)15 (31.9%)41.8**0.20Lifetime Suicide Attempt80 (7.9%)46 (8.7%)22 (5.3%)10 (20.8%)15.6**0.12Any Homelessness History99 (13.1%)64 (11.6%)22 (5.2%)13 (27.1%)28.4**0.17Positive Screen Generalized Anxiety Major Depression Posttraumatic Stress Dx 155 (15.2%)151 (14.8%)164 (16.1%) 88 (15.9%)91 (16.5%)88 (15.9%) 47 (11.2%)45 (10.7%)53 (12.6%)   20 (46.2%) 15 (31.9%) 23 (49%)   32.7** 17.7** 41.4**   0.18 0.13 0.20

22   Total sample (N= 1,019)   Non-gambler (n=551) Recreational Gambler (n=420) At-Risk Problem Gambling (n=47) Difference between groups  F or χ 2 Partial Eta Square / Cramer’s V   Receipt Of Social Support Score 2.7 (1.1) 2.6 (1.2) a b 2.9 (1.1) a c 2.3 (1.1) b c 9.51** 0.02 Provision Of Social Support Score 2.8 (1.0) 2.7 (1.0) a 2.9 (1.0) a 2.6 (0.9) 4.61* 0.01 Brief Inventory Of Psychosocial Functioning Score 2.1 (1.6) 2.3 (1.7) a b 1.8 (1.5) a c 2.9 (1.6) b c 11.45** 0.03 Stigma About Mental Healthcare 1.2 (1.9) 1.1 (1.9) a 1.1 (1.8) b 3.4 (2.5) a b 29.3** 0.07 Barriers To Mental Healthcare 1.6 (1.5) 1.6 (1.5) a 1.5 (1.5) b2.3 (1.6) a b6.33**0.02Negative Attitudes About Mental Healthcare0.3 (0.7)0.3 (0.7) a0.3 (0.59) b1.0 (0.9) a b20.4** 0.05

Study 3: Study Findings There were few demographic differences by gambling group.Nongamblers had lower income than gamblers or at-risk/problem gamblersAt-risk/problem gamblers reported more issues with suicidal ideation or attempts, thoughts of self-harm, and psychopathology. At-risk/problem gamblers also reported lower levels of social support, perceived that there were more barriers for seeking mental health care, and had more negative attitudes about the mental health system compared to nongamblers or recreational gamblers. 23

Study 3: Study Findings Overall, Veterans with at-risk/problem gambling reflect a small proportion of the general population (4.5%) but have significant mental health needs such as issues with PTSD, depression, anxiety, and suicidal ideation and thoughts of self-harm.It is reported that 14 US Veterans commit suicide each day. It is unclear how many of these Veterans potentially had undiagnosed addiction-related problems such as problem gambling. 24

All Studies: Key Findings Gambling disorder is rarely listed as a diagnosis in Veterans’ VHA electronic medical records. Further studies are needed to determine the precise rates of gambling disorder among US military Veterans (or active duty military personnel). More comprehensive methods are needed for identifying and diagnosing gambling disorder in Veterans. We used brief screening tools which cannot be used to diagnose. Gambling disorder should be assessed among all Veterans seeking mental health treatment in VHA. Suicide risk is elevated among Veterans with gambling problems. 25

All Studies: Future Directions Identifying barriers regarding self-disclosure about problem gambling and help-seeking is needed for Veterans. This is particularly important given the expansion of casinos in Massachusetts and other Massachusetts-sponsored lotteries (also wide expansion of gambling in US and E sports betting). Challenges with self-disclosure and treatment seeking among Veteran problem gamblers also necessitate the need for future research to expand and refine screening approaches for identifying those with problem gambling. Developing standardized screening for problem gambling is needed for Veterans and other vulnerable populations (Pullman, Potenza, & Kraus, 2018).

All Studies: Future Directions More work is needed to identify perceived barriers for mental health treatment seeking among Veterans with and without at-risk/problem gambling.Conducting focus groups with Veterans, family members, and VHA providers could help identify implementation challenges and strategies for engaging Veterans into VA health care services. Developing public health campaigns targeting socialized gambling among Veterans may be helpful for engaging more Veterans with problem gambling into seeking treatment.

Bedford VAMC Behavioral Addictions Clinic Specialty outpatient clinic that focuses on treating gambling, compulsive sexual behaviors, binge eating, and other behavioral addictions in VeteransCurrent treatment options:Individual therapy: ACT, CBT, MI, psycho-ed, integrativeGroup therapy: Psycho-ed, Emotion & Eating, ACT, Mindfulness-Based Relapse PreventionMedication consultation with addictions psychiatrist 28

Bedford VAMC Behavioral Addictions Clinic Primary Referring Problems (N=121) 29

Bedford VAMC Behavioral Addictions Clinic Veterans with Problem Gambling (N=47) Past-year suicidal ideation (22.3%)Mental health co-occurring problems:Alcohol use disorder (8.5%)Bipolar disorder (10.6%) Depression (21.3%) PTSD (29.8%) Schizophrenia (10.6%) None (10.6%) 30

Treatment of Gambling Disorder Gambling disorder responds to similar treatments as substance use disorders:Recovery support services: peer support & 12-step program (Gamblers Anonymous)Motivational enhancement Brief advice giving/psychoeducation Cognitive behavioral therapies (Petry, Rash, & Alessi, 2016) We are piloting mindfulness-based treatment for gambling within VHA. Naltrexone (opioid antagonist) has shown efficacy in controlled trials ( Bartely & Bloch, 2013). 31

Thank you VISN 1 New England MIRECC Yale University Marc Potenza, MD, PhD Jack Tsai, PhD Robert Pietrzak, PhD Suzanne Decker, PhD Silvia Ronzitti, MD VISN 1 MIRECC Steven Shirk, PhD Kendra Pugh, MA Patricia Sweeney, Psy.D. Canandaigua VA Medical Center Lisham Ashrafioun, PhD

Contact Information and questions Shane W. Kraus, Ph.D. Assistant Professor of PsychologyUniversity of Nevada, Las VegasDepartment of Psychology4505 Maryland ParkwayLas Vegas, NV 89154-5030Email: shane.kraus@unlv.edu 33