Intersections Between Gambling, Substance Use, and Mental Health Challenges

Among Veterans and Promising Treatment Approaches

Troy Robison, PhDVA Puget Sound, American Lake Division

Tracy Simpson, PhDVA Puget Sound, Center of Excellence in Substance Abuse Treatment and Education

University of Washington, Dept. of Psychiatry & Behavioral Sciences

Focus on the Future, Evergreen Council on GamblingVancouver, WA May 2, 2018

Introductions • Who we are• Getting to know you• What you are hoping to get from today’s presentation on Veterans • How you hope this workshop can help you in the work that you are

doing to treat gambling

By the end of today’s presentation you will...

• Know the rates and epidemiology of gambling among Veterans• Understand co-occurring concerns and challenges for Veterans • Identify effective ways of treating gambling problems with Veterans

What is the draw?

Brainstorm gambling positives• The gambling itself….• The trappings….

Overview of Gambling Disorder

Changes from DSM-IV to DSM-5• Moved from compulsive disorder to addiction• Lowered threshold• Removed “illegal acts” criteria

Gambling Disorder in DSM-5• Persistent and recurrent problematic gambling behavior leading

to clinically significant impairment or distress, as indicated by at least 4 of the following in a 12month period:

Overview of Gambling Disorder Needs increasing amounts of money in order to achieve the desired excitement.

Restless or irritable when attempting to cut down or stop gambling.

Repeated unsuccessful efforts to control, cut back, or stop gambling.

Preoccupation with gambling (e.g., reliving past gambling experiences, planning next time, thinking of ways to get money).

Gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed)

After losing money gambling returns another day to get even (“chasing” losses).

Lies to conceal the extent of involvement with gambling.

Jeopardized or lost a relationship, job, educational or career opportunity because of gambling.

Relies on others to provide money to relieve financial situations caused by gambling.

Overview of Gambling DisorderSeverity

• Mild: 4–5 criteria• Moderate: 6–7 criteria• Severe: 8–9 criteria

Other common classifications:• Recreational • Problem• Pathological

Overview of Gambling Disorder

Addiction or Compulsion?

Gambling in the PNW

Washington2.1% (107,606)

#19 ($2.71b)28,007 EGM / 26 casinos

Oregon2.2% (66,655) #29 ($1.52b)

19,536 EGM / 9 casinos

• Does availability of gambling lead to problem gambling?

Rates Among VeteransRates of gambling for Veteran’s higher than general population

• 6.3-8.1% of service members endorse gambling problems• 2% lifetime for any VA facility (Whiting et al. 2016)

• 2.3-9.9% for Vietnam Era Veterans (Eisen et al. 2004)

• Highest estimate is 20% in U.S. military Veterans (Hierholzer, 2010)

• 35% assessed as “recreational” gamblers • Spending average of $79/mo; range $1-5000 ; median $25/mo• 1. Lottery, 2. Slots, 3. Pull tabs

• 2.2% assessed as “at risk problem gamblers” • Spending average of $472/mo; range $2-10,000; median $200/mo• 1. Slots, 2. Cards, 3. Animal betting

Rates Among Veterans Receiving VA Care

Treatment Seeking Populations• Higher rates of gambling – 16.5%• Inpatient Psychiatric

• 28% problem• 12% pathological

• Mental Health – 0.2% • (indicating lack of assessment)

• Protective: OEF/OIF, PTSD, dementia• Predictive: Homelessness, mental health diagnosis, income more than $25k

“We Want You” to Gamble

Veteran Demographics • Younger Veteran’s slightly higher risk

• Relation of age to stability, service connection, disability status. • Male• Native American, Black, Hispanic • Served in Navy • VA primary source of medical care• More likely to be retired

• 30% unemployed, 20% Social Security Disability, 13% Service Connected• Divorced, separated, or single (88%) • Genetics account for 35-54% of gambling liability.

• Children of gambling parents were 3x-12x more likely.

Veteran Co-occurring Concerns

• Substance Use Disorder – 22-33%• Depression – 76%

• 40% Past suicide attempt• 66% among those in residential treatment

• PTSD – 30% • Gambling Veterans have higher rates of PTSD (Whiting, 2016; Whyte, 2014)

• PTSD does not predict gambling (Levy & Tracy, 2018)

• Cumulative trauma burden, Witnessing death/injury, NOT combat (Scherrer et al, 2007)

Veteran Co-occurring Concerns

• Homelessness • Strongest correlates of Veteran homelessness

1. Illicit Substance Use 2. Problem gambling3. Alcohol Use4. Personality Disorder

• PTSD, Anxiety, Depression, Dementia all protective • Service Connection (>50%) decreased risk by 66%

Gambling on Active Duty

Gambling allowed on U.S. military bases• Introduced in 1930s• Removed in 1970s• Reintroduced in the 1980s

• 2016 = 3148 EGM / $108m annually

• Rationale? Recreation & Morale, Wellness, and Recreation programs

Gambling on Active Duty Impact?

• Increased payout of Electronic Gambling Machines (EGMs) on bases• 90-94% (Vegas = 75%)

• Argued to have no significant impact• 2015 NDAA required study

• Low findings Not enough screening for it• Dept of Defense (1998, 2000, 2002) – 5-9% problems; 2% pathological • Between 1991-1998 there was a 66% increase in addicted gambling according to US Dept

of Commerce (Kindt, 2007)

• Estimated that 36,000-48,000 military personnel may have gambling problems (Whyte, 2011).

Overall Rates & Co-occurring ConcernsPrevalence

• Ranging anywhere from 0.3 – 7.6% (including problem & pathological ) • .5 – 2% meet criteria for Gambling Disorder (Shirk et al 2018)

• Problem gamblers spend median of $400/mo• Pathological gamblers median of $2000/mo

Frequent associated concerns• Substance use, depression, anxiety, relationship breakdown, unemployment,

crime, bankruptcy, & suicide (Hodgins et al. 2011).

Gambling Residential Treatment Program

Louis Stokes VA – Cleveland Ohio (formerly at Brecksville campus) • Dr. Heather Chapman, PhD (Director) • 6 week residential program

Puget Sound Outpatient Gambling Treatment

Puget Sound VA – American Lake Division (Tacoma, WA) • Addiction Treatment Center

• Weekly group• Open enrollment, no session limit

Cognitive TherapyCognitive therapy for gambling frequently focuses on teaching randomness, increasing awareness of inaccurate perceptions and restructuring erroneous gambling beliefs (Smith, Battersby et al 2015)

Cognitive Distortions• By definition, games of chance have random outcomes, beyond gamblers control • Many experience false sense of personal control and distorted beliefs about factors such

as randomness, continuing to gamble despite accumulating losses (Wohl et al, 2007)

• Cognitive dysfunction may be present at low levels of gambling, even before meeting full criteria for disordered gambling (Grant et al 2011).

Cognitive TherapyCognitive distortions relevant to problem gambling (Toneatto, 1999).

skill misperceptionsillusion of controlskewed temporal orientationsuperstitious beliefsselective memoryinterpretive biases

Research shows distorted beliefs associated with bet size, persistence, severity, predictivity, game preference, and overall mental health (Delfabbro& Winefield, 2000; Joukhador et al, 2003; Continotti et al, 2004; Ledgerwood and Petry, 2005; Chamberlin et al, 2017).

Gambling Treatment: Cognitive Therapy

Research on cognitive distortions in Veteran populations• Cognitive distortions related to gambling diagnosis in Vietnam Era Twin Study

(Xian et al., 2008).

• Even after controlling for genetics and shared environmental factor. • Higher cognitive distortion score significantly associated with increased gambling severity.• Elevated cognitive distortions also related to non-gambling diagnosis

• Substance Use, Depression, PTSD, and ASPD.

• The single best predictor of dysfunction from gambling was not severity of gambling but the severity of the cognitive distortions related to the disorder. (Shirk et al., 2018)

Gambling Treatment: Cognitive Therapy

Unpacking…..• Gamblers Fallacy• Near Miss Effect• Delay Discounting

Gambling Treatment: Cognitive Therapy

• Example of cognitive group exercise (Puget Sound VA)

Gambling Treatment: Motivational

Motivational Enhancement Therapy & Motivational Interviewing• Emphasis on identifying ambivalence and promoting behavioral change.

• Often done in conjunction with cognitive behavioral techniques to address distorted beliefs related to gambling. (Tolchard, 2017).

Gambling Treatment: Motivational

• Example of motivational intervention (Puget Sound VA)

Gambling Treatment: Mindfulness Meditative (or other) exercises aimed at increasing non-judging or present moment awareness

• Breathing • Body scan• Urge Surfing • Metta (Loving Kindness)

Shown to be somewhat effective for addiction, both substance and gambling (Williams, Russell & Russell, 2008; Chawla, Collin, & Brown, 2010; Alfonso, et al., 2011; McIntosh, Crino, & O’Neil, 2016)

Gambling Treatment: Behavioral Contingency Management

• 3 major tenets of CM program (Petry, 2009)

• Frequent and objective monitoring of target behavior• Provide tangible reinforcement for completion of target behavior• Remove reinforcement if target behavior does not occur

• CM program for gambling treatment: • Reinforcement (canteen vouchers, clinic privileges), escalating in value, for recovery

activities (GA attendance, gym exercise, homework completion, aftercare groups, etc.) • Should not use fishbowl draws as this may reinforce gambling.

• Cognitive therapy + Contingency management provided better outcomes for therapy attendance, homework completion, and GA attendance than CT alone (Weinstock, 2007).

Gambling Treatment: Pharmacological No current approved drug for Gambling Disorder

• Limited number of studies looking at gambling directly (Menchon et al., 2018)

3 classes of approach • Antidepressants• Opioid antagonists• Mood stabilizers

• Paroxetine & Fluvoxamine found better than placebo (Kim et al., 2002; Hollander et al., 2000).

• Naltrexone & Nalmefene have shown significant improvement in GD (Piquet-Pessoa & Fontenelle, 2016)

Gambling Treatment

• Special treatment concerns:

Conclusion

Questions?

THANK YOU!