|HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.
Age, education level, and ethnicity were not big predictors of pathological gambling risk. “The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money,” Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were “homebodies” (typically unemployed men who were married to women with jobs).
Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). “The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect,” said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.
“Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population.” Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. “Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ ”
The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.
Another aim was to identify co-morbid symptoms “so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling,” Dr. Westermeyer said.
The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. “In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems,” Dr. Westermeyer said.
Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.
“All these findings tend to be a tad atypical,” Dr. Westermeyer said.
The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).
The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.
The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. “It’s worrisome with the veterans. The ratio is … like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers … which does not bode well for the future.”
“Veterans in VA care have a high rate” of pathological gambling, he added.
All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as “chasing one’s losses”) were the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.
Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. “Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding,” said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.
Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.
This was a clinical epidemiologic study and not community-based research, a potential limitation.
Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?
The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.
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