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| Journal of the New Zealand Medical Association,
29-June-2007, Vol 120 No 1257
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Problem gambling: patients affected by their own or
another’s gambling may approve of help from general
practitioners
Sean Sullivan, Ross McCormick, Michael Lamont, Alison
Penfold
Gambling problems have been associated with many health
conditions including depression, anxiety, alcohol abuse, and suicidal
ideation—and a problem gambler is more likely to be a cigarette
smoker.1–5
The 2002/3 NZ Health Survey identified that problem gambling
is ‘significantly associated with worse self-rated health in several
health domains’ and 1.2% of the population were ‘worried or
depressed after gambling’.6 This accorded
with a recent large overseas study (n=43,093) that concluded that problem
gambling was associated with tachycardia, angina, cirrhosis, and other liver
disease—and was associated with higher medical utilisation and treatment
in hospital emergency departments.1
In addition to health problems, many social and financial
problems develop which may impact upon the health of both the gambler and their
family. For instance, in 2005 in New Zealand, 2875 new clients accessed a
specialist gambling helpline and 2714 new clients accessed counselling
services.7 Less than one in three clients were
family members of problem gamblers, despite an estimate that there may be at
least seven others affected by each problem
gambler.8
It has been estimated that between 3% and 11% of those
suffering problem gambling will seek help from specialist services, but that the
majority of those affected will not seek help from any service specifically for
gambling issues.8–9
The Ministry of Health has now, since the passing of the
Gambling Act 2003, assumed responsibility for the minimisation of harm arising
from gambling. In its 3-year strategic plan, it has identified that ‘a key
focus will continue to be on using training to increase the capability of
primary health and social services to carry out problem gambling
screening’ p16.10
General practitioners (GPs) believe it a legitimate role for
them to address the effects of gambling problems upon their
patients.11–12 Practitioners
participating in the Practice Review Activity part of this
study13 gave positive feedback as to the
importance of identifying health problems arising from problem gambling. There
was some concern, however, that they may not have the time to screen for
gambling and to deal with any previously unknown morbidity.
The aims of this study were to ascertain whether patients
would self-identify as being adversely affected by their own gambling, or by the
gambling of others, whether these patients would be more likely to be depressed,
and whether patients perceive GPs as suitable to provide help for gambling
problems.
MethodsFour Primary Health Organisations (PHOs) in Auckland
(2), Taranaki, and Rotorua continuously invited their patients over a 1- to
4-week period to complete a questionnaire incorporating a brief problem gambling
screen developed for General Practice (the Eight Screen; Sullivan
1999),14–16 a screen to identify those
affected by others’ gambling (the COGS Screen; Sullivan
2002),17 and a two-question depression screen
(Whoolley et al 199718).
The PHOs were approached with the assistance of the
Department of General Practice and Primary Health Care, The University of
Auckland, and 16 practices agreed to participate. Upon presenting to their
GP’s practice, the practice receptionist referred all patients aged 16
years or older to information sheets and posters about the study—and
invited the patient to complete the questionnaire anonymously, and return it
folded to the receptionist for later collection. Patients were invited to
discuss their responses with their GP if they had concerns after completing the
questionnaire.
Patients were asked whether they considered their
doctor could help address gambling problems, and responded by selecting one of
three responses (no, maybe/uncertain, or yes).
Demographic information was also sought.
Gambling screen results were compared with depression
screen findings and with patients’ perceptions of their GP as
help-providers for gambling problems.
Ethics approval for the project was obtained from the
University of Auckland Human Subjects Ethics Committee (reference
2003/384).
Results1580 patients participated—comprising 1075 in
Auckland, 286 in Rotorua, and 219 in Taranaki. Receptionists at the practices
reported that few, if any, refused to participate in the study because of its
content, with the only refusals due to poor health, not having brought
spectacles, or insufficient time to complete the questionnaire between arriving
and their GP being available.
The majority of participants were female (58%; n=914), with
males comprising 36% (n=563), and a further 7% (n=103) not disclosing their
gender.
There was a widespread ethnic range of participants.
Ethnicity of patients approximately reflected that of the
general New Zealand (NZ) population, with Māori comprising 12.5% of
participants, NZ European 51.5%, Pacific 9.5%, Chinese 9.5%, Indian 3.5%, and
‘other ethnicities’ 3.5%; 10% did not disclose their
ethnicity.
Demographic variable effect on problem gambling was analysed
using a generalised linear mixed model, with GP practice included as a random
effect to allow for clustering caused by practice. A similar model was used to
determine the association between depression, problem gambling and the effects
of another’s gambling.
118 patients were positive on the gambling screen (7.5%; 108
did not complete the gambling screen and the percentage is based upon the
assumption that these were negative for problem gambling). Gender of problem
gambling positives were similar (male 7.6%, female 7.9%) and gender was not
found to influence problem gambling (p=0.75).
Those with gambling problems were less likely to be over 54
years of age than younger (15 to 34 years p=0.05 OR 2.4, 35 to 54 years p=0.02
OR 2.6). Fifty percent of those scoring as positive on the problem gambling
screen were Community Services Card (CSC) holders, compared with 38% of all
patients in the survey—although this difference was not statistically
significant (p=0.09). The ethnicity of problem gambling positives is shown in
Table 1.
Table 1. Ethnicity of gambling screen positives
(n=118)
*Gambling problems were statistically more likely for
Māori (p=0.02, OR 2.5), Pacific (p<0.0001, OR 8.8), Chinese
(p<0.0001, OR 5.3), and other ethnicities (p=0.0003, OR 4.0) when compared
with NZ European.
Problem gambling was found to affect the presence of
depression (p=0.0008, OR 2.4). Of those positive on the gambling screen, 63.5%
scored as positive on the depression screen (yes to at least one of the
two depression questions), and 40% answered yes to both depression
questions. This compares with 31.2% of those scoring as negative on the problem
gambling screen that scored positive on the depression screen. Of these problem
gambling negatives, 17.6% answered yes to both depression
questions.
Patients were asked to describe their reason for presenting
that day to the clinic. Of the 118 problem gambling screen positives, 5
presented for medical certificates, 6 for depression (compared with 31 overall
presenting for depression), 2 for ‘addiction’, and 2 for migraines.
Forty-three (36%) of problem gambling positives did not disclose their reasons
for presenting that day to the clinic.
When compared with patients in general, there were no
obvious indicators that would suggest the need to immediately question a patient
about problem gambling.
Patients were asked to respond in the COGS family screen if
they had ever been negatively affected by another’s gambling (Table
2).
Table 2. Affected by another’s gambling?
Responses to COGS gambling screen (n=1561)
Of those possibly affected by another’s gambling, 278
provided a range of current effects of that gambling. Twenty-nine percent
responded that it didn’t affect them any longer, while others worried
(26%), were nervous (5.5%), believed it affected their health (4.5%), found it
difficult to talk about (6%), were concerned about their family’s safety
(8%), or were uncertain about its current effect on them (21%). Most (68.5%)
required no help at this stage, however 16.5% wanted appropriate information,
5.5% wanted to talk in confidence, and 9.5% wanted support or help.
Those affected by another’s gambling were found to be
more likely to be affected by depression (p=0.0001, OR 2.2).
Patients were asked to respond to whether they thought their
doctor could help with gambling problems (caused by their own gambling or the
gambling of another). See Table 3.
Table 3: Perception of GPs being help-providers
for effects of problem gambling
*Positive association
Problem gamblers were more likely than others to consider
their GP to be an appropriate help provider for problem gambling (p=0.007, OR
1.9), but those affected by another’s gambling did not appear to share
this view (p=0.53).
ConclusionThis is the first study to determine the effects of gambling
in a GP patient population upon both those who gamble and their families.
Patients readily participated in screening for gambling problems and were
willing to disclose gambling problems in the GP setting, albeit anonymously.
Those who were problem gamblers comprised 7.5% of the participating patients,
with two-thirds being positive on a depression screen. This depression
prevalence rate was twice that found in those screening negative for problem
gambling. Those affected by another’s gambling were also more likely to be
depressed than non-affected patients.
Eighteen percent of patients appeared to be affected by
another’s gambling, with many being unclear about exactly how they were
affected. This is unsurprising as problem gambling is often difficult to detect
in family members, especially in determining whether it is in the past or has
recurred. Over two-thirds of these family members of problem gamblers appeared
to be currently affected with a range of concerns (many health-related).
The prevalence of problem gambling for different ethnicities
reported here is similar to other studies, with higher risk found amongst
Māori and Pacific peoples.19 The higher
risk with Chinese patients for problem gambling identified in this study has not
been found in NZ epidemiological studies.19
This may be due to a previous Chinese community reluctance to disclose the
presence of an issue that may reflect negatively on that community. In the
current study many of the participating Chinese patients were attending a
practice that specialised in this ethnic group. This may have helped improve
patient participation and feeling safe around disclosure.
Patients who were problem gambling were equally likely to be
male or female. Specialist treatment services report many female patients
reporting problem use of gambling machines. Although problem gambling and
poverty has been shown to be associated,20 in
this study being the holder of a Community Services Card (CSC) was found not to
be associated with problem gambling. Therefore neither gender nor being the
holder of a CSC card is a good indicator to screen for problem gambling, however
being over 54 years appeared to reduce the risk for problem gambling and to
signal a reduced need for problem gambling screening in that older age group.
With insufficient responses to presenting reasons, and the
apparent lack of trends between positive problem gambling and presenting
reasons, our study found no indication of presenting issues that would increase
the need to screen except of course for patients presenting with depression.
However the high level of possible depression identified (not only with problem
gamblers and their family, but with those not affected by problem gambling),
contrasted with the relative absence of depression or associated issues as a
patient presenting reason to GPs.
GPs have identified that they saw problem gambling as within
their field of work, but have questioned whether they had sufficient time to
address gambling issues, especially amongst those who are identified as affected
by problem gambling when presenting for other issues.
One in four problem gambling patients see their GP as an
appropriate help-provider for problem gambling. The currently undecided half of
those affected by their own or another’s gambling might be encouraged to
support this view with more information. Up to one-third of those affected by
problem gambling hold a definite view against this role for a GP.
Selection of the PHOs and their practices were not
randomised and this study may therefore not be generalisable to the extent that
such a process would have provided. It is possible that our distribution to
three centres may have partly mitigated against some of the effects of
non-randomisation. We note that the prevalence of problem gambling identified in
this study, particularly for Pacific patients, was considerably higher than has
been identified in a second patient study.
The authors of the second study used a briefer screen for
gambling embedded in a multi-item instrument3.
The gambling screen used in our study has been validated for a range of New
Zealand settings,15 while the prevalence of
problem gambling amongst the Pacific population, and others, has been found in a
third study to be within the range identified in our
study.19
Raising awareness amongst patients of a GP’s role in
providing help for both the problem gambler and their family; developing
awareness amongst GPs of the prevalence of these problems amongst patients; and
training in the use of specialist problem gambling screens may overcome the
relative absence of clinical indicators to screen shown by this study.
Composite screens,21 such
as the CHAT (a multi-item general practice tool), may assist to overcome the
identification issues that exist in addressing what is a behavioural addiction
that affects the almost 1 in 12 GP patients who problem gamble and the 1 in 6
patients who may be an affected family member of a problem gambler.
The Ministry of Health views primary health providers as an
important resource for those affected by problem gambling. Our findings support
this view and suggest general practitioners offer a viable helping alternative
for problem gamblers and their affected family members.
In future, and with patient and GP education and support,
problem gamblers and their families may come to see their GP as the most
accessible health professional available to assist them address a behaviour and
its effects that they may be reluctant to address elsewhere.
Competing interests: None.
Author information: Sean Sullivan,
Psychologist, Abacus Counselling Training & Supervision Ltd, Auckland; Ross
McCormick, Director, Goodfellow Unit, The University of Auckland, Auckland;
Michael Lamont, Chair, Mangere Community Health Trust & Mangere Health
Resources Trust, Auckland; Alison Penfold, Director, Abacus Counselling Training
& Supervision Ltd, Auckland
Acknowledgements: Funding for this study
was provided by the Problem Gambling Committee, whose responsibilities for
funding treatment and research to minimise problem gambling harm have now passed
to the Ministry of Health with the passing into law of the Gambling Act. The
authors also thank the many GPs and their staff who participated in this study
as well as the patients who contributed important information that enabled the
findings reported in this paper.
Correspondence: Sean Sullivan, Abacus, PO
Box 90710 Auckland Mail Centre, Auckland. Fax: (09) 360 6357; email: sean@acts.co.nz
References:
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