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ORIGINAL PAPER
Comorbid Problem Gambling and Major Depression
in a Community Sample
Leanne Quigley
•
Igor Yakovenko
•
David C. Hodgins
•
Keith S. Dobson
•
Nady el-Guebaly
•
David M. Casey
•
Shawn R. Currie
•
Garry J. Smith
•
Robert J. Williams
•
Don P. Schopflocher
Published online: 12 August 2014
Ó Springer Science+Business Media New York 2014
Abstract Major depression is among the most common comorbid conditions in problem
gambling. However, little is known about the effects of comorbid depression on problem
gambling. The present study examined the prevalence of current major depression among
problem gamblers (N = 105) identified from a community sample of men and women in
Alberta, and examined group differences in gambling severity, escape motivation for
gambling, family functioning, childhood trauma, and personality traits across problem
gamblers with and without comorbid depression. The prevalence of major depression
among the sample of problem gamblers was 32.4 %. Compared to problem gamblers
without depression (n = 71), problem gamblers with comorbid depression (n = 34)
reported more severe gambling problems, greater history of childhood abuse and neglect,
poorer family functioning, higher levels of neuroticism, and lower levels of extraversion,
agreeableness, and conscientiousness. Furthermore, the problem gamblers with comorbid
depression had greater levels of childhood abuse and neglect, worse family functioning,
higher neuroticism, and lower agreeableness and conscientiousness than a comparison
sample of recreational gamblers with depression (n = 160). These findings underscore the
need to address comorbid depression in assessment and treatment of problem gambling and
for continued research on how problem gambling is related to frequently co-occurring
disorders such as depression.
Keywords Problem gambling Gambling disorder Depression Comorbidity
L. Quigley (&) I. Yakovenko D. C. Hodgins K. S. Dobson D. M. Casey S. R. Currie
Department of Psychology, University of Calgary, Calgary, AB T2N 1N4, Canada
e-mail: lquigley@ucalgary.ca
N. el-Guebaly
Department of Psychiatry, University of Calgary, Calgary, AB T2N 1N4, Canada
G. J. Smith D. P. Schopflocher
University of Alberta, Edmonton, AB, Canada
R. J. Williams
University of Lethbridge, Lethbridge, AB, Canada
123
J Gambl Stud (2015) 31:1135–1152
DOI 10.1007/s10899-014-9488-8
Introduction
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) recog-
nizes gambling disorder in the diagnostic category of substance-related and addictive
disorders (APA 2013). Gambling disorder is defined by persistent and uncontrolled
gambling, despite serious personal and social consequences (APA 2013). Prior to DSM-5,
the behavior characteristic of gambling disorder was referred to as pathological gambling
(APA 2000), and thus much research has been conducted on the phenomenon of patho-
logical gambling. In the gambling literature, problem gambling is a more general term used
to describe gambling activity that leads to harm to the individual, his or her family, and/or
others in his or her social network or community (Ferris et al. 1999). Problem gambling
includes pathological gambling/gambling disorder as well as harmful gambling behavior
that does not necessarily meet DSM diagnostic criteria for pathological gambling (Raylu
and Oei 2002).
Gambling problems tend to co-occur with other mental disorders. Data from the pop-
ulation-based United States National Comorbidity Survey Replication (NCS-R) indicated
that 96 % of respondents with lifetime pathological gambling also met diagnostic criteria
for at least one other psychiatric disorder (Kessler et al. 2008). Major depression is one of
the most common disorders that co-occur with problem gambling. The rate of comorbidity
between lifetime pathological gambling and depression in the NCS-R was 39 % (Kessler
et al. 2008). Data from another large population-based sample from the United States
indicated a similar comorbidity rate between lifetime pathological gambling and major
depression of 37 % (Petry et al. 2005). A recent meta-analysis reported an average
prevalence rate of 23 % for comorbid major depression among problem and pathological
gamblers from general population samples, combining current and lifetime estimates of the
disorders (Lorains et al. 2011).
While a substantial proportion of problem gamblers also suffer from depression, the
impact of comorbid depression on problem gambling is not yet well understood. It is
increasingly recognized that problem gambling is a heterogeneous condition that may
consist of multiple subgroups with distinct clinical characteristics and etiologies (Blas-
zczynski and Nower 2002; Ledgerwood and Petry 2010; Gupta et al. 2013). From this
perspective, problem gamblers with comorbid depression represent an important subgroup
for study. As of yet, few studies have investigated how comorbid depressive symptom-
atology influences problem gambling severity, gambling behavior, and associated clinical
characteristics. Investigation of how problem gamblers with comorbid depression differ
from those without comorbid depression may suggest important information about etiology
as well as lead to more individualized and effective treatments for individuals with
comorbid depression and problem gambling.
There is some preliminary evidence that the presence of significant depressive symp-
toms may exacerbate the severity and worsen the prognosis of problem gambling.
Thomsen et al. (2009) found that pathological gamblers with higher levels of depressive
symptoms exhibited more severe gambling behavior compared to those low in depressive
symptoms, in the form of increased urges to gamble and greater duration of gambling
during in-laboratory slot machine play. In a study of pathological gamblers who recently
quit gambling, comorbid lifetime depression predicted a longer time to achieve stable
abstinence from gambling (Hodgins et al. 2005) and negative affect was a commonly cited
precipitant to relapse (Hodgins and el-Guebaly 2004). Thus, these studies suggest that
depression may be associated with more severe gambling symptomatology among problem
gamblers.
1136 J Gambl Stud (2015) 31:1135–1152
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Comorbid depression may also influence motivations for gambling. Studies of problem
gamblers have found that a substantial proportion report gambling to escape from negative
emotions or problems and/or to increase positive affect (Beaudoin and Cox 1999; Blas-
zczynski and McConaghy 1989; Wood and Griffiths 2007). Given the centrality of neg-
ative affect to major depression, problem gamblers who are depressed may be more likely
than those who are not depressed to use gambling to reduce negative feelings. Along this
line, Blaszczynski and Nower (2002) proposed a conceptual pathways model of problem
gambling which delineates three distinct subtypes of problem gamblers, one of which is
emotionally vulnerable gamblers. According to the pathways model, emotionally vulner-
able problem gamblers have comorbid emotional problems such as depression and anxiety
and are motivated to gamble initially to improve their mood or escape from negative
emotions or problems.
The pathways model (Blaszczynski and Nower 2002) provides a framework for con-
ceptualizing other important variables that may distinguish depressed from nondepressed
problem gamblers. Blaszczynski and Nower (2002) suggested that emotionally vulnerable
problem gamblers are more likely to present with problematic family backgrounds, adverse
childhood experiences, and life stress. They hypothesized that these risk factors as well as
certain personality traits produce emotional vulnerability that can lead to problem gam-
bling in conjunction with other biological vulnerabilities and ecological factors. Thus, from
this theoretical perspective, problem gamblers with comorbid depression may differ from
those without depression in terms of their family functioning, history of childhood trauma
and abuse, and personality profile. While no studies have yet examined these factors in
individuals with comorbid problem gambling and depression, there is some research on
these factors in the contexts of problem gambling and depression separately.
A small number of studies have found that treatment-seeking problem gamblers report
greater family dysfunction (Ciarrocchi and Hohmann 1989; Dowling et al. 2009).
According to these studies, treatment-seeking problem gamblers perceive their family
members to be less supportive and committed, less assertive and self-sufficient, less likely
to emphasize achievement or competition, and less likely to have intellectual or cultural
interests, compared to a normative standardization sample (Ciarrocchi and Hohmann 1989;
Dowling et al. 2009). Depression has also been found to impair family functioning
(Cummings et al. 2005; Foster et al. 2008; Moos and Moos 2009). Parental depression is
correlated with higher levels of conflict and use of psychological control (e.g., intrusive-
ness, control through guilt) and lower levels of parental warmth (Cummings et al. 2005).
Given that both problem gambling and depression have shown associations with poorer
family functioning independently, family dysfunction may be particularly associated with
comorbid problem gambling and depression.
Studies have reported elevated rates of childhood abuse and trauma among problem
gamblers seeking treatment, with higher rates for female gamblers (Ciarrocchi and Rich-
ardson 1989; Specker et al. 1996; Taber et al. 1987). Childhood maltreatment has predicted
greater severity and frequency of gambling in both treatment-seeking and community
samples of gamblers (Petry and Steinberg 2005; Hodgins et al. 2010). However, it is
unclear whether relationships observed between childhood trauma and gambling in these
studies may have been influenced by comorbid conditions, including depression. Child-
hood trauma is also a strong risk factor for the development of depression (Heim et al.
2008). Severity of childhood abuse has been linked to earlier age of onset of depression and
greater chronicity of depression (Bernet and Stein 1999). Given these associations,
childhood trauma may be a particularly important factor for the development of comorbid
problem gambling and depression.
J Gambl Stud (2015) 31:1135–1152 1137
123
Personality factors have also been demonstrated to predict both problem gambling and
depression (e.g., King et al. 2010; Miller et al. 2013; Bagby et al. 2008). A recent meta-
analysis suggests that the personality profile of problem gamblers is characterized by high
negative affect, low conscientiousness, and disinhibition (MacLaren et al. 2011). Evidence
indicates that depression is linked to the personality traits of high neuroticism/negative
emotionality, low extraversion/positive emotionality, and low conscientiousness (Klein
et al. 2010; Kotov et al. 2010). Comorbid depression may affect the personality profile of
problem gambling, with implications for theories of the etiology of comorbid problem
gambling and depression.
The present study had three primary aims. The first was to identify the prevalence of major
depression among individuals with problem gambling. A number of previous studies that
examined prevalence rates of depression and other comorbid disorders among problem
gamblers have focused on lifetime prevalence rates (e.g., Kessler et al. 2008; Park et al. 2010;
Petry et al. 2005). Thus, we were interested in current (within the past 12 months) rates of
comorbidity between problem gambling and depression. The second aim was to determine
the effect of comorbid depression on problem gambling severity and escape motivation for
gambling. We hypothesized that problem gamblers with comorbid depression would report
greater severity of gambling problems and be more likely to endorse gambling to reduce
negative affect or escape problems. The third aim was to compare problem gamblers with and
without comorbid depression on family functioning, history of childhood abuse and trauma,
and personality traits. In line with the pathways model (Blaszczynski and Nower 2002) and
research from the problem gambling and depression literatures, we hypothesized that indi-
viduals with comorbid problem gambling and depression would report worse family func-
tioning, greater history of childhood trauma, higher levels of neuroticism, and lower levels of
extraversion and conscientiousness, compared to problem gamblers without comorbid
depression. For the non-gambling-specific outcomes (i.e., family functioning, childhood
trauma, personality factors), significant group differences were followed by comparing the
individuals with comorbid problem gambling and depression to a group of recreational
gamblers with depression on these outcomes. These follow-up analyses were conducted to
test whether any significant group differences between the groups of problem gamblers with
and without comorbid depression on family functioning, childhood trauma, and personality
factors were greater than would be expected due to the presence of depression alone. The data
for this study are from the first assessment wave of the Leisure, Lifestyle, and Lifecycle
Project (LLLP), which is a 5-year longitudinal study of gambling behavior conducted in
Alberta, Canada (el-Guebaly et al. 2008).
Method
Participants and Recruitment
The recruitment procedure for the LLLP involved random digit dialing (RDD) to initiate
telephone surveys (el-Guebaly et al. 2008). Telephone contact was followed up by in-
person interviews and the administration of self-report questionnaires. Additionally, a
media release, posters in gambling venues, advertisements in local newspapers, and emails
were used to supplement initial recruitment. A total of 1,808 individuals were recruited
from the community, 1,372 of whom were adults (age 18?). Participants were oversam-
pled based on age and gender specific cut-offs for the 70th percentile for gambling
expenditure and frequency in order to capture more high-risk gamblers in the sample. The
1138 J Gambl Stud (2015) 31:1135–1152
123
following age cohorts were sampled: 13–15, 18–20, 23–25, 43–45, and 63–65 years old.
Due to budget constraints as a result of the use of RDD, recruitment did not result in equal
representation of each age cohort. The 23–25 and 63–65 year old cohorts were under-
represented and 43–45 year olds were overrepresented. Similarly, geographical sampling
yielded more participants from major urban centers in Alberta, Canada than the rural
communities, despite the original intent being for equal sampling.
The LLLP project to date has consisted of four assessment points collected over 5 years.
The present study used data for adult cohorts only (N = 1,372) from Time 1. Gambling
severity was assessed with the Problem Gambling Severity Index (PGSI; Ferris and Wynne
2001). A total of 86 individuals were categorized as moderate risk gamblers (score of 3–7)
and 19 individuals were categorized as high risk or problem gamblers (score of 8?) according
to PGSI scores (Ferris and Wynne 2001). Due to sample size constraints, for the purposes of
this study moderate and high risk categories were combined to provide a sample of 105
individuals who were collectively referred to as ‘‘problem gamblers’’, as has been done in
other studies of problem gambling (e.g., Crockford et al. 2008; el-Guebaly et al. 2006).
Depression was assessed with the depression subscale of the Composite International
Diagnostic Interview short form (CIDI-SF; Kessler et al. 1998). A score of 3? on the CIDI-SF
depression subscale indicates probable major depression, whereas a score of less than three
indicates probable non-cases of major depression (Nelson et al. 2001). For the between-group
analyses, individuals who obtained a score of three or greater on the CIDI-SF depression
subscale formed the comorbid problem gambling and depression group (PG-D group) and
individuals who obtained a score of less than three formed the problem gambling without
depression group (PG-ND group). The group of recreational gamblers with depression (RG-D
group) was composed of 160 individuals who gambled at least once in the past year, but were
categorized as non-problem (score of 0) or low risk (score of 1–2) gamblers on the PGSI, and
who scored three or greater on the CIDI-SF depression subscale.
Demographic information for the PG-D, PG-ND, and RG-D groups is presented in
Table 1. Chi square tests or one-way analysis of variance (ANOVA), as appropriate, were
used to test for group differences on each of the demographic variables. There were no
significant differences between the participant groups with regard to age, ethnicity, marital
status, employment status, and education level. However, there was a significant group
difference on gender that was accounted for by there being a greater proportion of females
in the PG-D group than the PG-ND group, v
2
(1) = 4.08, p = .043. Thus, gender was
included as a covariate in all comparisons between the PG-D and PG-ND groups. Gender
effects are not reported for any of the analyses as they are not relevant to the present
hypotheses. The interaction between gender and group was not significant in any of the
analyses. There was no significant difference on gender between the PG-D and RG-D
groups, p [ .10; thus, gender was not included as a covariate in the follow-up group
comparisons involving the PG-D and RG-D groups.
Measures
Gambling severity was measured using the 9-item Problem Gambling Severity Index
(PGSI) from the Canadian Problem Gambling Index (CPGI; Ferris and Wynne 2001). The
PGSI consists of questions about negative consequences experienced as a result of gam-
bling, loss of control, financial problems, and illegal acts related to financing gambling
activity, over the past 12 months, which are coded on a 4-point Likert response scale
ranging from ‘‘never’’ to ‘‘almost always’’. The PGSI provides a continuous score with
ranges for non-problem (0), low risk (1–2), moderate risk (3–7), and problem gamblers
J Gambl Stud (2015) 31:1135–1152 1139
123
Table 1 Demographic characteristics across participant groups
Problem gamblers
with comorbid
depression (n = 34)
Problem gamblers
without comorbid
depression (n = 71)
Recreational gamblers
with depression
(n = 160)
F/v
2
p
Mean age 32.03 (SD = 13.60) 35.45 (SD = 16.22) 34.84 (SD = 15.73) .59 ns
Gender
Female 18 (52.9 %) 23 (32.4 %) 105 (65.6 %) 22.02 \.001
Ethnicity
Caucasian 27 (79.4 %) 61 (85.9 %) 146 (91.3 %) 15.45 ns
Asian 3 (8.8 %) 3 (4.2 %) 2 (1.3 %)
South Asian and Southeast Asian 0 1 (1.4 %) 1 (0.6 %)
Arab and West Asian 1 (2.9 %) 0 0
Aboriginal 2 (5.9 %) 4 (5.6 %) 8 (5.0 %)
Black 0 0 0
Mixed race 0 2 (2.8 %) 2 (1.3 %)
Marital status
Single, never married 21 (61.8 %) 35 (49.3 %) 76 (47.5 %) 4.08 ns
Married or common-law 9 (26.5 %) 26 (36.6 %) 58 (36.3 %)
Divorced or separated 4 (11.8 %) 8 (11.3 %) 18 (11.3 %)
Widowed 0 2 (2.8 %) 8 (5.0 %)
Employment status
Not currently employed 11 (32.4 %) 16 (22.5 %) 51 (31.9 %) 2.23 ns
Employed part- or full-time 23 (67.6 %) 55 (77.5 %) 109 (68.1 %)
Education level
Less than high school 7 (20.6 %) 13 (18.3 %) 20 (12.5 %) 10.15 ns
1140 J Gambl Stud (2015) 31:1135–1152
123
Table 1 continued
Problem gamblers
with comorbid
depression (n = 34)
Problem gamblers
without comorbid
depression (n = 71)
Recreational gamblers
with depression
(n = 160)
F/
v
2
p
Completed high school 7 (20.6 %) 14 (19.7 %) 36 (22.5 %)
Some technical school/community college 4 (11.8 %) 9 (12.7 %) 27 (16.9 %)
Completed technical school/community college 5 (14.7 %) 10 (14.1 %) 34 (21.3 %)
Some university 6 (17.6 %) 12 (16.9 %) 23 (14.4 %)
Bachelor’s degree 5 (14.7 %) 11 (15.5 %) 16 (10.0 %)
Master’s degree 0 1 (1.4 %) 4 (2.5 %)
Professional degree/doctorate 0 1 (1.4 %) 0
J Gambl Stud (2015) 31:1135–1152 1141
123
(8?). The screening instrument has demonstrated excellent internal consistency with a of
.90 (Orford et al. 2010).
Gambling involvement variables (i.e., range, frequency, and expenditure) based on the
CPGI were also examined as additional indices of gambling severity. The range variable
was a count of all types of gambling in which the participant said he/she had participated
during the last 12 months (total score 0–12). The frequency variable was based on the
question: ‘‘In the past 12 months, how often did you bet or spend money on [specific
gambling activity]?’’ and was coded on a seven point frequency scale, ranging from
‘‘Daily’’ to ‘‘Between 1 and 5 times per year’’. The maximum frequency endorsed by the
participant for any gambling activity was used as the frequency variable. The expenditure
variable was the total amount of money spent on all types of gambling. It was based on the
question: ‘‘In the past 12 months, how much money did you spend on [specific gambling
activity] in a typical month?’’ The values for all endorsed types of gambling were summed
to produce a total dollar amount. The CPGI has demonstrated excellent internal consis-
tency (a = .84) and good test–retest reliability (r = .78; Ferris and Wynne 2001).
The Composite International Diagnostic Interview Short Form (CIDI-SF) was used to
assess symptoms of depression. The CIDI-SF is the short form of the World Health
Organization’s full structured interview for psychiatric disorders (Kessler et al. 1998). The
instrument evaluates eight mental health disorders over the past 12 months using Likert-
type items ranging from dichotomous yes/no answers to four or five-point answers. The
depression module of the full CIDI (WHO 1990) has shown excellent interrater reliability
(k = .95) and acceptable test–retest reliability (k = .71; Wittchen 1994). For diagnoses of
Major Depressive Disorder, a 93 % concordance rate between the CIDI-SF and the full
CIDI has been documented (Kessler et al. 1998).
Escape from problems or emotional regulation as primary motivation for gambling was
assessed using criterion five of the DSM-IV TR: ‘‘Gambles as a way of escaping from
problems or of relieving a dysphoric mood (e.g. feelings of helplessness, guilt, anxiety,
depression)’’ (APA 2000). Categorical scores were derived based on whether the partici-
pant endorsed the criterion or not. The ten DSM-IV items for pathological gambling have
been evaluated to have acceptable internal reliability (a = .73; Orford et al. 2010). Cri-
terion five was shown to have the highest item-total correlation of any individual DSM
criteria (.62) as well as the largest loading on the first unrotated factor (.80) of a scale
modeled after the DSM-IV criteria.
Abuse and neglect during childhood and adolescence were assessed with the Childhood
Trauma Questionnaire (CTQ; Bernstein et al. 1997; Bernstein and Fink 1998). The 28-item
self-report inventory consists of five subscales (emotional abuse, physical abuse, sexual abuse,
emotional neglect, and physical neglect) which use 5-point Likert responses ranging from
‘‘never true’’ to ‘‘very often true’’. Higher scores indicate greater childhood abuse and neglect.
The test–retest reliability of the overall CTQ score was .86, and the test–retest reliability
estimates for the emotional abuse, physical abuse, sexual abuse, emotional neglect, and
physical neglect subscales were .82, .86, .79, .82, and .77, respectively (Hodgins et al. 2010).
The Family Environment Scale (FES; Moos and Moos 2002, 2009) was used to measure
family functioning and social climate. The FES produces a total score, as well as separate
scores for its ten subscales: cohesion, expressiveness, conflict, independence, achievement
orientation, intellectual/cultural orientation, active/recreational orientation, moral/religious
orientation, organization, and control. The FES consists of 90 statements about families, and
the respondent indicates whether each of the statements is true or false for his/her family. The
FES has demonstrated good test–retest reliability ranging from .68 to .86 depending on the
subscale. The Cronbach’s a for each of the ten subscales varies from .61 to .78.
1142 J Gambl Stud (2015) 31:1135–1152
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The short version of the Revised Neuroticism, Extraversion, Openness Personality
Inventory (NEO PI-R; Costa and McCrae 1992) was used to provide a comprehensive
description of personality traits. The short version (NEO-FFI) is a 60-item version of Form
S of the NEO PI-R, which assesses the same five domains of personality as the full version:
neuroticism, extraversion, openness, agreeableness, and conscientiousness (Costa and
McCrae 1992). Twelve items examine each of the five domains. The items are scored on a
5-point Likert scale ranging from ‘‘strongly disagree’’ to ‘‘strongly agree’’. Internal reli-
ability coefficients for the five domains are excellent, ranging from .86 to .92 (Costa and
McCrae 1992).
Statistical Analyses
Prior to analysis, the dependent variables were examined for accuracy, missing values, and
normality. The variables were examined separately for each of the participant groups. One
case in the PG-D group and one case in the RG-D group had missing values on ethnicity.
Since the ethnicity variable was used only for sample description and was not included in
subsequent analyses, the cases were retained for analysis. No other variables contained any
missing data. Logarithmic transformation was applied to variables that had non-normal
distributions or contained univariate outliers; however, results were similar with trans-
formed and untransformed variables. For multivariate analysis of variance (MANOVA),
Mahalanobis distance values indicated that there were no multivariate outliers with
p \ .001.
All a priori hypotheses were evaluated at a significance level of p \ .05. Separate 2
(Group: PG-D vs. PG-ND) 9 2 (Gender) ANOVAs were conducted on PGSI severity
scores, CPGI range, frequency, and expenditure scores, FES total scores, and CTQ total
scores. Significant and marginally significant differences on the FES and CTQ total scores
were followed up by ANOVAs on the subscale scores. As significant group differences on
the total scores were observed, follow-up analyses to evaluate differences on the subscale
scores that comprise the total scores were protected against multiple comparisons (Ro-
senthal and Rosnow 1991). A Chi square test was used to test for group differences on
endorsement of DSM-IV criterion five (i.e., gambling to escape from problems or improve
mood). A 2 (Group) 9 2 (Gender) MANOVA was conducted on the NEO subscales to
help protect against inflating the Type I error rate in the follow-up ANOVAs (Cramer and
Bock 1966). The significant Group effect in the omnibus MANOVA was followed by
separate 2 (Group) 9 2 (Gender) ANOVAs on each of the NEO subscales.
Significant differences between the PG-D and PG-ND groups on the FES, CTQ, and
NEO subscales were followed by independent t tests contrasting the PG-D and RG-D
groups on these variables.
Results
The prevalence of major depression was 32.4 % (n = 34) in the overall sample of 105
problem gamblers. Thus, 34 individuals were included in the PG-D group and 71 indi-
viduals were included in the PG-ND group. Means and standard deviations for the PG-D
and PG-ND groups on each of the untransformed dependent variables are presented in
Table 2, as are the values of F (v
2
for the variable escape motivation for gambling),
p values, and g
p
2
values for significant Group effects in the separate ANOVAs on the
dependent variables, controlling for gender effects.
J Gambl Stud (2015) 31:1135–1152 1143
123
The hypothesis that PG-D individuals would report greater severity of gambling
problems than PG-ND individuals was partly supported. PG-D individuals reported greater
severity of gambling on the PGSI than PG-ND individuals. However, analyses indicated
that there were no significant differences between PG-D and PG-ND groups on gambling
range, frequency, or expenditure. In contrast to our hypothesis, PG-D individuals were not
significantly more likely than PG-ND individuals to report gambling to escape from
problems or improve mood.
As hypothesized, the PG-D group reported marginally worse family functioning on the
FES total scale than the PG-ND group. Follow-up analyses on the separate subscales
Table 2 Means and standard deviations (in parentheses) of untransformed dependent variables across
problem gamblers with and without comorbid depression, and between-group comparisons controlling for
gender
Problem gamblers
with comorbid
depression (n = 34)
Problem gamblers
without comorbid
depression (n = 71)
F/v
2
p g
p
2
PGSI gambling severity 8.00 (6.24) 5.30 (3.91) 6.57 .012 .06
Gambling range 4.18 (2.04) 4.31 (1.97) .06 ns
Gambling frequency 4.68 (1.68) 4.44 (1.86) .68 ns
Gambling expenditure 610.76 (786.91) 1149.70 (2746.22) .42 ns
Escape motivation for
gambling (% yes)
44 % 31 % 1.74 ns
CTQ childhood trauma/abuse
(total score)
50.76 (20.13) 38.38 (11.18) 12.59 .001 .11
Emotional abuse 12.85 (5.66) 8.04 (3.12) 26.51 \.001 .21
Physical abuse 9.24 (4.74) 7.10 (3.11) 7.24 .008 .07
Sexual abuse 8.56 (4.74) 6.35 (2.71) 6.99 .010 .07
Emotional neglect 11.41 (5.16) 9.85 (3.56) 2.43 ns
Physical neglect 8.71 (4.14) 7.04 (2.39) 4.88 .030 .05
FES family functioning (total score) 49.85 (10.45) 52.93 (8.59) 3.50 .064 .03
Cohesion 5.59 (2.56) 6.72 (2.09) 5.73 .019 .05
Expressiveness 5.82 (2.43) 6.00 (1.99) .22 ns
Conflict 3.97 (2.37) 2.37 (2.42) 8.41 .005 .08
Independence 6.68 (1.74) 7.37 (1.39) 3.47 ns
Achievement orientation 5.38 (2.00) 5.92 (1.78) 2.01 ns
Intellectual/cultural orientation 4.88 (2.33) 5.42 (2.21) 2.35 ns
Active/recreational orientation 4.65 (2.40) 5.30 (1.98) 2.45 ns
Moral/religious orientation 3.79 (1.95) 4.46 (1.91) 4.71 .032 .05
Organization 4.47 (2.14) 5.37 (1.86) 3.62 ns
Control 4.62 (2.07) 4.01 (2.18) .88 ns
NEO personality
Neuroticism 29.15 (7.53) 18.30 (7.15) 44.05 \.001 .30
Extraversion 26.06 (7.31) 30.15 (7.03) 6.95 .010 .06
Openness 30.09 (6.55) 29.21 (6.14) 1.11 ns
Agreeableness 28.94 (6.70) 31.04 (5.81) 4.31 .041 .04
Conscientiousness 28.18 (6.83) 31.20 (6.44) 3.87 .052 .04
PGSI Problem Gambling Severity Index, CTQ Childhood Trauma Questionnaire, FES Family Environment
Scale, NEO Revised Neuroticism, Extraversion, Openness Personality Inventory—Short Form
1144 J Gambl Stud (2015) 31:1135–1152
123
indicated that PG-D individuals reported significantly less cohesion, greater conflict, and
reduced emphasis on morals and religion relative to PG-ND individuals. The other FES
subscales did not show statistically significant group differences.
The PG-D group had significantly greater childhood trauma scores on the CTQ total
scale than the PG-ND group, as hypothesized. Both participant groups had higher
mean total scores on the CTQ than the mean scores of normative data provided by Scher
et al. (2001; M = 31.71, SD = 9.13 for males and M = 31.77, SD = 11.20 for females).
The mean CTQ total score for the PG-D group fell within the 95
th
percentile of scores for
the norming sample, whereas the mean CTQ total score for the PG-ND group fell within
the 75th–90th percentile of scores (Scher et al. 2001). Follow-up analyses found significant
group differences on all of the CTQ subscales except for emotional neglect. PG-D indi-
viduals reported greater childhood emotional abuse, physical abuse, sexual abuse, and
physical neglect than PG-ND individuals.
In line with hypotheses, analysis of NEO personality subscale scores found that the PG-
D group had significantly higher levels of neuroticism, and significantly lower levels of
extraversion and agreeableness, relative to the PG-ND group. PG-D individuals reported
marginally lower levels of conscientiousness than PG-ND individuals. There was no sig-
nificant group difference on the openness subscale.
To follow-up the observed group differences between the PG-D and PG-ND groups on
family functioning (i.e., cohesion, conflict, and emphasis on morals and religion), child-
hood trauma and abuse (i.e., emotional abuse, physical abuse, sexual abuse, and physical
neglect), and personality (i.e., neuroticism, extraversion, agreeableness, and conscien-
tiousness), t tests were conducted to compare PG-D individuals with RG-D individuals on
these variables. The t tests indicated that the PG-D group reported marginally lower
cohesion, t(192) =-1.70, p = .09, and significantly greater conflict, t(192) = 2.54,
p = .012, than the RG-D group (M = 6.38, SD = 2.45 for cohesion and M = 2.83, SD =
2.39 for conflict for RG-D group). There was no significant difference between the PG-D
and the RG-D groups on emphasis on morals and religion, p [ .10 (M = 4.24, SD = 2.27
for RG-D group). The PG-D group reported significantly greater emotional abuse,
t(192) = 2.87, p = .005, marginally greater physical abuse, t(42.03) = 1.98, p = .054,
and significantly greater physical neglect, t(192) = 2.82, p = .005, than the RG-D
group (M = 10.12, SD = 4.60 for emotional abuse, M = 7.52, SD = 3.41 for physical abuse,
and M = 7.01, SD = 2.88 for physical neglect for RG-D group). There was no significant
difference between the PG-D and RG-D individuals on childhood sexual abuse,
p [ .10 (M = 7.66, SD = 4.85 for RG-D group). The PG-D group scored significantly
higher on neuroticism, t(192) = 3.68, p \ .001, and significantly lower on agreeableness,
t(192) =-
2.68, p = .008, and conscientiousness, t(192) =-2.03, p = .044, than the
RG-D group (M = 23.33, SD = 8.54 for neuroticism, M = 32.05, SD = 6.04 for agree-
ableness, and M = 30.95, SD = 7.33 for conscientiousness for RG-D group) . There was no
significant difference between PG-D and RG-D individuals on their levels of extraversion,
p [ .10 (M = 27.21, SD = 7.21 for RG-D group).
Discussion
The present study examined the prevalence and effects of major depression in a community
sample of problem gamblers. Of the 105 problem gamblers in the current sample, 32.4 %
met the criteria for probable major depression, which is in line with estimates of the
prevalence of comorbid depression among problem gamblers found in previous research
J Gambl Stud (2015) 31:1135–1152 1145
123
(23–39 %; Kessler et al. 2008; Lorains et al. 2011; Park et al. 2010; Petry et al. 2005).
Previous studies of comorbidity in problem gambling have typically focused on lifetime
prevalence rates of depression and other mental health disorders. Thus, our present results
are notable in that they suggest that approximately one-third of problem gamblers in a
community sample experience current comorbid major depression. This prevalence rate
may be an underestimate of the rate of comorbid major depression among individuals with
more severe gambling problems. Due to sample size constraints, we combined individuals
categorized as moderate risk (score of 3–7) and high risk or problem gamblers (score of
8?) on the PGSI to form our sample of problem gamblers. Of the 19 individuals who were
categorized as high risk or problem gamblers on the PGSI, 10 (52.6 %) met the criteria for
probable major depression. While the small number of high risk gamblers limits the
reliability of this result, it suggests that comorbid major depression may be even more
prevalent as the severity of problem gambling increases.
The present study found that comorbid problem gambling and depression were asso-
ciated with greater severity of gambling problems than problem gambling without
depression. This result is consistent with previous studies that have found that comorbid
depression is associated with more severe gambling behavior and prolonged duration of
problem gambling (Thomsen et al. 2009; Hodgins et al. 2005). Although the comorbid
problem gambling and depression group reported more severe gambling problems than the
problem gambling without depression group in the present study, there were no group
differences with regard to the gambling involvement variables of gambling frequency,
expenditure, and range. Thus, it appears that comorbid depression may be associated with
greater consequences of gambling, but not necessarily with increased gambling involve-
ment. One possibility is that the negative consequences of gambling (e.g., financial losses,
relationship problems, feelings of guilt, legal problems, stress) may lead to depressive
symptoms in problem gamblers (Dussault et al. 2011). Alternatively, given that depression
is characterized by negative interpretive and memory biases (Gotlib and Joormann 2010), it
is possible that gamblers who are depressed report more severe problems and consequences
associated with gambling than they actually experience. Future research should employ
assessment methods that could corroborate participant self-report (e.g., collateral report,
legal/financial records) to evaluate whether problem gamblers with comorbid depression
objectively experience more severe gambling problems compared to problem gamblers
who are not depressed.
Contrary to hypothesis, there was no significant difference between the groups of
problem gamblers in their endorsement of escape/mood regulation motivation for gam-
bling. Despite a lack of statistical significance, a greater proportion of problem gamblers
with comorbid depression (44 %; n = 15) reported gambling to improve mood or escape
from problems than problem gamblers without depression (31 %; n = 22). The modest
sample size may have limited the power for this difference to reach statistical significance.
Regardless, a substantial proportion of the overall sample of problem gamblers reported
gambling to improve mood or escape from problems. Previous studies employing treat-
ment-seeking samples have also found that gambling to improve mood is frequently
endorsed by problem gamblers (Beaudoin and Cox 1999; Blaszczynski and McConaghy
1989). A qualitative study revealed that escape from negative mood states and problems
was the primary motivation facilitating the continuation of problem gambling among a
sample consisting of both treatment-seeking and community gamblers (Wood and Griffiths
2007). This work underscores the mood regulation or coping function that gambling serves
for many problem gamblers. Future studies employing larger samples should investigate
1146 J Gambl Stud (2015) 31:1135–1152
123
whether problem gamblers with comorbid depression are particularly motivated by the
mood regulation function of gambling, given that negative affect is central to depression.
As hypothesized, problem gamblers with comorbid depression had significantly poorer
family functioning than problem gamblers without depression. Moreover, this finding does
not appear to be accounted for solely by the effect of depression; problem gamblers with
comorbid depression also had poorer family functioning than depressed individuals
without gambling problems (i.e., recreational gamblers). Specifically, individuals with
comorbid problem gambling and depression reported less cohesion, more conflict, and less
emphasis on morals and religion compared to problem gamblers without depression, and
less cohesion and more conflict compared to recreational gamblers with depression.
Although there were no significant differences between problem gamblers with and
without comorbid depression on the other dimensions of family functioning, the pattern of
differences for all dimensions was in the direction of greater family dysfunction for the
problem gamblers with comorbid depression. Separate lines of research have found that
family dysfunction is associated with both problem gambling (Ciarrocchi and Hohmann
1989; Dowling et al. 2009) and depression (Cummings et al. 2005; Foster et al. 2008; Moos
and Moos 2009). However, family dysfunction appeared to be uniquely characteristic of
comorbid problem gambling and depression in the present study. Comparison with a
normative sample from the FES manual (Moos and Moos 2009) indicates that the problem
gamblers with comorbid depression reported similar levels of family dysfunction to the
norms of distressed families (e.g., families of psychiatric patients, depressed individuals,
and individuals with substance use problems) whereas nondepressed problem gamblers
reported similar family functioning to control families.
The hypothesis that problem gamblers who are depressed would report a greater history
of childhood trauma and abuse than problem gamblers who are not depressed was sup-
ported by the data. Problem gamblers with comorbid depression reported more childhood
emotional, physical, and sexual abuse, and physical neglect, compared to problem gam-
blers without comorbid depression. Individuals with comorbid problem gambling and
depression also had greater childhood emotional neglect than nondepressed problem
gamblers, although this difference was not statistically significant. Childhood trauma has
been linked to both problem gambling (Ciarrocchi and Richardson 1989; Hodgins et al.
2010; Petry and Steinberg 2005 ; Specker et al. 1996; Taber et al. 1987) and depression
(Heim et al. 2008) in previous work. Indeed, the current data show that both comorbid
problem gambling and depression and problem gambling alone are associated with high
levels of childhood trauma and maltreatment, relative to a normative sample (Scher et al.
2001). However, the link to childhood trauma appears to be particularly pronounced for
comorbid problem gambling and depression. The level of childhood trauma experienced by
problem gamblers with depression was at the 95th percentile of the normative data,
whereas the level of childhood trauma experienced by problem gamblers without
depression fell within the 75th–90th percentile of the normative data. Moreover, the
individuals with comorbid problem gambling and depression reported greater emotional
and physical abuse and greater physical neglect than recreational gamblers with depres-
sion. Childhood maltreatment may therefore be a particularly significant risk factor for
comorbid problem gambling and depression.
As hypothesized, problem gamblers with comorbid depression showed a different
personality profile from problem gamblers without depression. In particular, the problem
gamblers who were depressed had significantly higher levels of neuroticism, and signifi-
cantly lower levels of extraversion and agreeableness, than the problem gamblers who
were not depressed. The problem gamblers with comorbid depression also had marginally
J Gambl Stud (2015) 31:1135–1152 1147
123
lower levels of conscientiousness than the nondepressed problem gamblers. Compared to
depressed recreational gamblers, depressed problem gamblers reported greater levels of
neuroticism and lower levels of agreeableness and conscientiousness. Problem gambling
has demonstrated associations with high neuroticism and low conscientiousness (MacLa-
ren et al. 2011). The current study extends previous work to suggest that comorbid problem
gambling and depression is particularly associated with these personality traits, as well as
lower levels of extraversion and agreeableness. This particular personality profile may
therefore represent an increased risk for comorbid problem gambling and depression.
While this study was not a direct test of the pathways model proposed by Blaszczynski
and Nower (2002), the results do provide support for the notion of subtypes of problem
gambling. Given that approximately one-third of the sample of problem gamblers endorsed
major depression, problem gamblers with comorbid depression appear to be an important
subgroup for study. Overall, the findings that individuals with comorbid problem gambling
and depression have worse family functioning, greater history of childhood abuse and
neglect, higher levels of neuroticism, and lower levels of extraversion, agreeableness, and
conscientiousness are consistent with Blaszczynski and Nower’s (2002) proposal of an
emotionally vulnerable problem gambler subtype. Problem gamblers with comorbid
depression may represent a group of individuals whose adverse developmental experi-
ences, life stress, and personality vulnerabilities contribute to affective dysregulation and
depression, from which they are motivated to escape by gambling.
The findings from the current study have a number of significant theoretical and clinical
implications. The high rate of comorbidity with major depression and other mental health
disorders in problem gambling highlights the need to investigate how problem gambling is
related to these comorbid conditions. Problem gambling in the absence of comorbidity is
an exceptionally rare phenomenon. Indeed, population-based data from the United States
indicates that only 4 % of individuals with lifetime pathological gambling do not meet
diagnostic criteria for at least one other psychiatric disorder (Kessler et al. 2008). These
high rates of comorbidity suggest that there may be functional relationships between (i.e.,
problem gambling contributes to the development of comorbid disorder or vice versa) or
common etiological pathways to problem gambling and comorbid conditions (e.g., Potenza
et al. 2005). Continued research on how comorbid disorders influence the clinical profile of
problem gambling and on how problem gambling and comorbid disorders develop and co-
vary over time is thus necessary to increase understanding of the etiology and conse-
quences of problem gambling.
From a clinical perspective, the finding that nearly one-third of problem gamblers in a
community sample experience comorbid depression emphasizes the need for clinicians to
assess for and address comorbid depression when treating problem gambling. The findings
from this study may also be used to tailor and improve treatments for individuals with
comorbid problem gambling and depression. For instance, treatment of comorbid problem
gambling and depression may include an added focus on improving family functioning,
addressing past trauma and abuse, and enhancing emotion regulation and problem-solving
skills for individuals for whom these factors may be relevant.
A limitation of this study is its reliance on cross-sectional and correlational data, which
limits conclusions about the direction and causality of the observed relationships. For
instance, it is unclear whether the family dysfunction and personality profile of problem
gamblers with comorbid depression contribute to their depression and/or problem gam-
bling, are a consequence of their depression and/or problem gambling, or both. Likewise,
the directionality of the relationship between problem gambling and depression remains
unknown. It has been hypothesized that depression may precede problem gambling and
1148 J Gambl Stud (2015) 31:1135–1152
123
that depressed individuals may gamble in order to relieve negative emotions and escape
from life problems (Blaszczynski and Nower 2002; Dussault et al. 2011). The inverse has
also been proposed; problem gambling may lead to social isolation, financial problems,
legal problems, and guilt, which may in turn result in depressive symptoms (Dussault et al.
2011). Prospective research on the longitudinal links between problem gambling and
depression is scarce and inconclusive (Dussault et al. 2011; Gambling Research Australia
2013), and thus is a priority for future research in this area.
Another limitation of this study is the relatively small number of problem gamblers in
the community sample, which reflects the low base rate of problem gambling in the general
population. Consequently, individuals who scored in the moderate risk (score of 3–7) or
problem gambler (score of 8?) categories on the PGSI were combined to form the problem
gambler sample to increase statistical power to detect group differences between the
problems gamblers with and without comorbid depression. While previous studies of
problem gambling have dealt with limited sample sizes similarly (e.g., Crockford et al.
2008; el-Guebaly et al. 2006), there are also recognized limitations of using a lower cut-off
of three or greater on the PGSI to define problem gamblers, including the possibility of
false positives (Currie et al. 2013). Despite our attempt to increase the power of our
analyses, some of the null or marginally significant results may have been due to insuf-
ficient power. The modest sample size also precluded the ability of the present study to
examine interactions between the variables in distinguishing the groups of problem
gamblers with and without comorbid depression. Future research should examine such
interactive effects.
Strengths of the present study include use of a large, community-based sample and
standardized assessment instruments. The results support previous work that has shown
that problem gambling and depression frequently co-occur. Further, this work indicates
that comorbid depression influences the clinical profile of problem gambling in a number
of theoretically and clinically important ways. Problem gamblers with comorbid depres-
sion reported greater severity of gambling problems, poorer family functioning, greater
history of childhood abuse and neglect, and higher levels of neuroticism, and lower levels
of extraversion, agreeableness, and conscientiousness, than problem gamblers without
depression. Individuals with comorbid problem gambling and depression may therefore
represent an important subtype of problem gamblers with a distinct clinical profile and
etiological pathway. These data suggest factors that may be important to include in etio-
logical models of comorbid problem gambling and depression, as well as address in
prevention and treatment efforts, and provide strong impetus for including depression as a
focus of assessment and treatment of problem gambling.
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