ral
ssBioMed Cent
BMC Family Practice
Open Acce
Research article
Primary care patients reporting concerns about their gambling
frequently have other co-occurring lifestyle and mental health
issues
Felicity Goodyear-Smith*
1
, Bruce Arroll
1
, Ngaire Kerse
1
, Sean Sullivan
3
,
Nicole Coupe
1
, Samson Tse
2
, Robin Shepherd
2
, Fiona Rossen
2
and
Lana Perese
2
Address:
1
Department of General Practice and Primary Health Care, School of Population Health, The University of Auckland, Auckland, New
Zealand,
2
Department of Social & Community Health, School of Population Health, The University of Auckland, Auckland, New Zealand and
3
Abacus Counselling & Training Services Ltd, Auckland, New Zealand
Email: Felicity Goodyear-Smith* - f.goodyear-smith@auckland.ac.nz; Bruce Arroll - b.arroll@auckland.ac.nz;
Ngaire Kerse - n.kerse@auckland.ac.nz; Sean Sullivan - sean@acts.co.nz; Nicole Coupe - n.coupe@auckland.ac.nz;
Samson Tse - s.tse@auckland.ac.nz; Robin Shepherd - rm.shepherd@auckland.ac.nz; Fiona Rossen - f.rossen@auckland.ac.nz;
Lana Perese - l.perese@auckland.ac.nz
* Corresponding author
Abstract
Background: Problem gambling often goes undetected by family physicians but may be associated
with stress-related medical problems as well as mental disorders and substance abuse. Family
physicians are often first in line to identify these problems and to provide a proper referral. The
aim of this study was to compare a group of primary care patients who identified concerns with
their gambling behavior with the total population of screened patients in relation to co-morbidity
of other lifestyle risk factors or mental health issues.
Methods: This is a cross sectional study comparing patients identified as worrying about their
gambling behavior with the total screened patient population for co morbidity. The setting was 51
urban and rural New Zealand practices. Participants were consecutive adult patients per practice
(N = 2,536) who completed a brief multi-item tool screening primary care patients for lifestyle risk
factors and mental health problems (smoking, alcohol and drug misuse, problem gambling,
depression, anxiety, abuse, anger). Data analysis used descriptive statistics and non-parametric
binomial tests with adjusting for clustering by practitioner using STATA survey analysis.
Results: Approximately 3/100 (3%) answered yes to the gambling question. Those worried about
gambling more likely to be male OR 1.85 (95% CI 1.1 to 3.1). Increasing age reduced likelihood of
gambling concerns – logistic regression for complex survey data OR = 0.99 (CI 95% 0.97 to 0.99)
p = 0.04 for each year older. Patients concerned about gambling were significantly more likely (all
p < 0.0001) to have concerns about their smoking, use of recreational drugs, and alcohol. Similarly
there were more likely to indicate problems with depression, anxiety and anger control. No
significant relationship with gambling worries was found for abuse, physical inactivity or weight
Published: 10 April 2006
BMC Family Practice2006, 7:25 doi:10.1186/1471-2296-7-25
Received: 11 October 2005
Accepted: 10 April 2006
This article is available from: http://www.biomedcentral.com/1471-2296/7/25
© 2006Goodyear-Smith et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 6
(page number not for citation purposes)
concerns. Patients expressing concerns about gambling were significantly more likely to want help
with smoking, other drug use, depression and anxiety.

BMC Family Practice 2006, 7:25 http://www.biomedcentral.com/1471-2296/7/25
Conclusion: Our questionnaire identifies patients who express a need for help with gambling and
other lifestyle and mental health issues. Screening for gambling in primary care has the potential to
identify individuals with multiple co-occurring disorders.
Background
As available opportunities for gambling increase, it
appears that problem gambling is increasing in prevalence
[1]. Gambling disorders have been shown to have high
comorbidity with the use of tobacco [1], problem drink-
ing [2,3], other substance misuse [4], and mood disorder
[5]. As well as impacting on an individual's health and
well-being, problematic gambling may have serious
harmful effects on the patient's family, financial security
and career. Family physicians are often the first in the line
to identify these problems and to provide a proper referral
but problem gambling may go undetected during a stand-
ard consultation.
It is well known in the literature that comorbidity is linked
with problem gambling and this link is bidirectional [6].
This connection between problem gambling and comor-
bidity has been widely supported worldwide mainly from
treatment populations of problem gamblers, substance
abusers, or psychiatric cohorts [7]. Within the general
population, a link is reported between problem gambling
and 'hazardous use of alcohol' as well as weaker associa-
tions between problem gambling and minor mental dis-
orders and with substance abuse and psychiatric illness
amongst young people [8]. Overall studies support the
supposition that there is a link albeit a weaker one in the
general population compared to treatment settings.
Comorbid conditions and problem gambling should not
be viewed as discrete disorders, particularly when these
individuals engage in treatment. Some problem gamblers
will binge on alcohol if they do not have the resources to
gamble [9]. Those with dual disorders may engage in
other addictive behaviors such as alcohol or drug abuse
when recovering from gambling, or relapse with gambling
if they are also abusing substances [10].
Individuals with gambling and related comorbidity, tend
to move in and out of these disorders. Many do not com-
pletely recover from these problem behaviors. For exam-
ple, women casino employees were able to decrease the
problem drinking symptoms over a three year time space
frame, but they continued to gamble problematically
[11]. Furthermore, many problem gamblers suffer from
medical problems such as insomnia, irritable bowel syn-
drome, peptic ulcer, hypertension, migraines, and other
stress-related problems which may be presented to the
The aim of this study was to compare the group of New
Zealand (NZ) screened primary health care patients who
identified concerns with their gambling behavior with the
total population of screened patients in relation to co-
morbidity of other lifestyle risk factors and mental health
issues.
Methods
The assessment of the multi-item screening tool has been
reported previously [13]. This is an instrument that con-
tains screening questions for 10 potential issues: smoking,
alcohol, substance abuse, gambling, depression, anxiety,
stress, violence, eating disorders, physical activity. It also
has the addition of a help question asking if the individ-
ual wants help no, yes, yes but not today. The gambling
question 'Sometimes I've felt depressed or anxious after a ses-
sion of gambling' has been found to have a sensitivity of
0.857 and a specificity of 0.935 to a positive score in the
EIGHT test for problematic gambling [14], which in turn
has been validated against the South Oaks Gambling
Screen (SOGS) [15]. Validity of the multi-item screening
tool against a composite gold standard is currently under-
way.
The tool was assessed by 51 primary health care providers
(family physicians or practice nurses) in one urban, one
mixed urban and rural and one rural center in New Zea-
land. Practitioners were randomly selected using a com-
puter-generated random number table. Multi-center
ethical approval was obtained from the Auckland, Otago
and Hawkes Bay ethics committees. Participant Informa-
tion Sheets were provided both for practitioners and for
patients, and written consent forms were signed from all
participants.
Fifty consecutive adult patients were recruited per practi-
tioner. All consecutive patients aged 16 years and over
attending the practice (including those attending as car-
egiver of another patient) were invited to complete the
lifestyle assessment screening tool and evaluation sheet.
Exclusion criteria were patients who were unable to
understand English or mental impairment that precluded
meaningful participation. Demographic data included
gender, age and ethnicity.
Data analysis, using descriptive statistics and non-para-
metric binomial (chi-squared tests and Fishers Exact 2-Page 2 of 6
(page number not for citation purposes)
medical physicians rather than a gambling problem [12]. tailed) was conducted using SPSS-10.0 statistical package.
Data included demographic information; positive

BMC Family Practice 2006, 7:25 http://www.biomedcentral.com/1471-2296/7/25
responses to each screening question and number of
patients requesting assistance from their doctor or nurse
concerning risk factors.
The 79 who screened positive for concerns about gam-
bling (answered yes to 'Do you sometimes feel unhappy or
worried after a session of gambling?') were compared with
the total patient population (2536) with respect to their
responses to other screening factors. To examine the
effects of age, gender, other behaviors on gambling status,
a Pearson chi-squared statistic was corrected for the survey
design using the second-order correction of Rao and Scott
[16] and converted into an F-statistic. Adjusting for clus-
tering by practitioner used STATA survey analysis, χ
2
and
logistic regression (51 clusters). All analyses were done
with the group of 79 as cases.
Results
A total of 2,536 consecutive patients (1000 in Auckland;
1000 in Otago and 536 in Hawkes Bay), 20 urban doctors,
20 practice nurses and 11 rural doctors (51 practices) par-
ticipated in the study. In Auckland, where patients were
recruited by a research assistant, 23 patients actively
declined to participate (97.75% response rate). In the
other centers refusal rate was not formally recorded but
research assistants said that it was less than 5%.
Forty-three of the 79 patients expressing concerns about
gambling were female (54%), whereas two-thirds of total
sample were female. Those worried about gambling more
likely to be male with an odds ratio (OR) of 1.85 (95% CI
1.1–3.1).
The age of the 79 patients ranged from 18 to 89 years with
a mean of 43 and SD of 16.3. When age was examined
using logistic regression for complex survey data the OR =
0.99 (CI 95% 0.97–0.99) p = 0.035 for each year older –
in other words, the older the patient, the less likely to
identify as worried about gambling.
Maori (6%, 15/242) were significantly more likely than
NZ European (1.55, 15/1002) to be worried about their
gambling behavior (p = 0.0002) and were also more likely
to want immediate help (p = 0.04) [17].
The group concerned about their gambling were also sig-
nificantly more likely (all p < 0.0001) to have concerns
about their smoking, use of recreational drugs, and alco-
hol (see Table 1). Similarly they were more likely to indi-
cate a problem with depression, anxiety and anger
control. They had no significant relationship for abuse,
physical inactivity or weight concerns.
The multivariable logistic regression with 'worry gam-
bling' as the dependent variable is presented in Table 2.
Because the responses to the two depression questions are
highly correlated (0.47), only the first depression ques-
tion was used in the model. The increased odds ratios for
other factors for those concerned by their gambling show
a risk picture of multiple and independent issues.
Eleven out of the 79 (14%) who identified as having gam-
bling concerns expressed a desire for help, five immedi-
ately and six at a later date. Those worried about their
gambling were significantly more likely to want help with
Table 1: Positive responses to screening questions (this is the odds of person being worried about smoking when also worried about
gambling compared with the odds of all the group being worried about smoking)Total patients screened N = 2536 (from 51 practices);
Patients worried about gambling n = 79 (3%)
Total N (%) Worried about
gambling n (%)
*OR (CI 95%) p
Do you ever feel the need to cut down on your smoking?* 406 (16) 30 (38) 3.9 (2.12 – 5.44) <0.0001
Do you ever feel the need to cut down on your drinking? 258 (10) 18 (23) 2.74 (1.64 – 4.55) <0.0001
Do you ever feel the need to cut down on your other drug use? 68 (3) 9 (11) 5.23 (2.51 – 10.9) <0.0001
During the past month have you often been bothered by feeling down,
depressed or hopeless?
1081 (43) 53 (67) 2.84 (1.7 – 4.75) <0.0001
During the past month have you often been bothered by having little
interest or pleasure in doing things?
805 (32) 42 (53) 2.5 (1.67 – 3.81) <0.0001
Have you been worrying a lot about everyday problems? 997 (39) 46 (58) 2.21 (1.38 – 3.55) <0.001
Is there anyone in your life whom you are afraid of, who hurts you in any
way or prevents you doing what you want?
130 (5) 3 (4) 0.73 (0.24 – 2.24) 0.57
Is controlling your anger sometimes a problem for you? 387 (15) 24 (30) 2.52 (1.44 – 4.43) <0.001
As a rule, do you do at least 30 minutes of moderate or vigorous
exercise (such as walking or a sport) on 5 or more days of the week?
1379 (54) 47 (59) 1.24 (0.78 – 1.99) 0.36
Are you happy with your current weight? 1072 (42) 40 (51) 1.4 (0.88 – 2.25) 0.15
* Odds ratio for logistic regression taking into account clusteringPage 3 of 6
(page number not for citation purposes)
their smoking, other drug use, depression and anxiety

BMC Family Practice 2006, 7:25 http://www.biomedcentral.com/1471-2296/7/25
(Table 3) but the small numbers means these results
should be treated with caution.
Only a proportion of patients acknowledging a problem
identified that they would like help with this, either
immediately or at a later date. Of those identifying smok-
ing, 44% wanted help, 16% immediately; for alcohol use,
13% with 4.6% immediately; other drug use 28% with
14% immediately, and for gambling, 16% identified that
they would like help with this behavior, 6% immediately.
Discussion
It is not surprising that co-occurring symptoms such as
depression, anxiety, and substance use linked with wor-
ries about gambling. Data do suggest that problem gam-
bling can be associated with non-gambling health
problems [18,19]. Co-occurring conditions were fre-
quently identified amongst a group of patients concerned
with their gambling behavior, particularly young males
[20]. It is estimated that youth and adult problem gam-
blers in community and clinical settings drink alcohol
and consume other legal and illegal substances at several
times the average population rates [21,22]. A United
States national problem gambling survey found 10% of
lifetime pathological gamblers alcohol-dependent com-
pared to 1.1% of non-gamblers [23]. A significant number
of patients concerned about their gambling were more
likely to be apprehensive about their smoking, use of rec-
reational drugs and alcohol. Problem gamblers' rates of
smoking have been shown to increase when they gamble
[24].
Co-occurring rates of pathological gambling and mental
disorders have been examined. Pathological gamblers
have been shown to be significantly more likely than non-
gamblers to suffer from anxiety disorder [25], and pho-
bias [26] In the present study, patients responding yes to
the gambling screen commonly also responded positively
to the questions about depression, anxiety and anger con-
trol. While the depression questions have already been
validated [27], validation of those on anxiety and anger
control is currently underway.
It has been reported that moderate to high percentages of
adults seeking treatment for pathological gambling have
comorbid alcohol and/or substance misuse disorders.
[28-30]. In addition, elevated rates of problem and path-
ological gambling (usually 10% to 20%) are evident
among adults seeking professional help for alcohol and
other substance misuse/dependence disorders [29,31-33].
Patients in this study who expressed concerns about their
gambling, were also significantly more likely to want help
with their smoking, other drug use, depression and anxi-
ety. It has been shown that addition of the help question
increases the specificity of the two depression questions
used in this study from 67% to 89% while maintaining a
sensitivity of 96% [34].
Research suggests that due to issues such as shame and
stigma, gamblers are most likely to first seek assistance for
gambling-related problems from informal sources of help
(their family and friends) and to develop a range of self-
help strategies prior to seeking formal (professional)
assistance [35]. It is possible that the distribution of when
Table 2: Multivariable logistic regression with 'worry/gambling' as
dependent variable
'worry gambling' OR 95%CI
Cut smoking 2.86 1.83 – 4.47
Cut drugs 2.86 1.30 – 6.26
Depression (1st q)* 2.29 1.21 – 4.35
Male 1.85 1.11 – 3.07
*Answering 'yes' to 2 depression questions highly correlated (0.47)
Table 3: Patients wanting help with specific issue
Yes, today Yes but not today Yes, either today or later
a
All N (%)
b
G n (%)
a
All N (%)
b
G n (%)
a
All N (%)
b
G n (%)
c
χ
2
p
Smoking 68 (3) 6 (8) 119 (5) 11 (14) 187 (7) 17 (22) 21.4 <0.001
Alcohol 10 (0.4) 1 (1) 19 (0.7) 0 (0) 29 (1) 1 (1) Fishers exact 0.604
Other drugs 8 (0.3) 1 (1) 9 (0.4) 1 (1) 17 (0.7) 2 (4) Fishers exact 0.110
Gambling 5 (0.2) 5 (6) 6 (0.2) 6 (8) 11 (0.7) 11 (14) 167.3 <0.001
Depression 144 (6) 7 (9) 146 (6) 9 (11) 270 (11) 16 (20) 7.3 0.007
Anxiety 149 (6) 10 (13) 139 (5) 9 (11) 288 (11) 19 (24) 11.9 <0.001
Abuse 23 (1) 1 (1) 22 (1) 2 (3) 46 (2) 3 (3) Fishers exact 0.182
Anger 28 (1) 2 (2) 50 (2) 3 (4) 78 (3) 5 (6) Fishers exact 0.103
Exercise 28 (1) 0 (0) 57 (2) 1 (1) 85 (3) 1 (1) Fishers exact 0.259
Weight 73 (3) 6 (8) 105 (4) 9 (11) 178 (7) 15 (19) 16.1 <0.001
a
All = total number of screened patients, N = 2356Page 4 of 6
(page number not for citation purposes)
b
G = patients expressing concern about their gambling behaviour, n = 79
c
Significance of difference between all screened patients and those expressing concern about gambling wanting help either immediately or later.

BMC Family Practice 2006, 7:25 http://www.biomedcentral.com/1471-2296/7/25
patients would like help with their gambling could be par-
tially explained by the above preferences of help-seeking.
Major reasons suggested for not seeking treatment are the
desire to handle the problem without help, negative atti-
tude related to stigmatization of addiction problems and
embarrassment and pride [36]. For services to be accessi-
ble, they must be sensitive to the target demographics. For
example, despite inflated problem gambling rates, some
ethnicities [35,37] and age groups (adolescents) [38],
often do not access mainstream gambling help agencies.
It should be noted that other reasons for a low rate of
desire for help with gambling might reflect not having a
gambling problem, not identifying a gambling problem
that is present, or having a past gambling problem that
has been resolved. The latter is less likely however, given
that the gambling question is framed in the present tense.
A strength of this study is that it is the first to report co-
morbidity in both lifestyle behaviors and mental health
issues in a general practice setting. A weakness of this
study is that we cannot be specific about the response
rates in some of the centers but believe it to be low and
unlikely to over-estimate any morbidities. Each question
is quite brief however we know from other work that ask-
ing for help for depression is associated with a positive
predictive value of 48% for major depression [39]. A fur-
ther limitation is that a single question was used to assess
gambling behavior with no specific timeframe referenced.
While individual brief questions may have been validated,
the composite tool has not yet been fully validated against
a complied gold standard, although this work in under-
way. Furthermore because the question asks about feeling
worried or unhappy after gambling, the likelihood of co-
occurrence with a generalized anxiety or depressive disor-
der is increased and a positive response to the question
does not necessarily indicate a gambling disorder.
Conclusion
While screening is recommended by some authorities for
depression, alcohol problems and obesity, some thought
needs to be give to considering screening for problem
gambling in primary care [40]. There is a need for more
research, particularly of a detailed nature with more struc-
tured assessments used in conjunction with screening
items, to improve prevention and treatment strategies.
Abbreviations
CI confidence interval
MIST multi-item screening tool
OR odds ratio
Competing interests statement
The authors declare that they have no competing interests.
The complete independence of researchers from funders is
declared.
Authors' contributions
FG conceived of the study, participated in its design, co-
ordination and analysis and drafted the manuscript.
BA participated in the design and analysis of the study and
helped draft the manuscript.
NK participated in the design and analysis of the study
and contributed to manuscript revision.
SS participated in the design of the gambling component
of the study and contributed to manuscript revision.
NC participated in the design and analysis of the study
and contributed to manuscript revision.
ST participated in analysis of the study and contributed to
manuscript revision.
RS participated in analysis of the study and contributed to
manuscript revision.
ST participated in analysis of the study and contributed to
manuscript revision.
FR participated in analysis of the study and contributed to
manuscript revision.
LP participated in analysis of the study and contributed to
manuscript revision.
All authors read and approved the final manuscript.
Acknowledgements
The study involved initial collaboration between primary health care
researchers with specific lifestyle or mental health interests and expertise
in the Department of General Practice and Primary Health Care, the Uni-
versity of Auckland in the development of the tool.
Funding for this study was provided by the Charitable Trust of the Auckland
Faculty of the Royal New Zealand College of General Practitioners; the
Ministry of Health Mental Health Directorate and the Institute of Rural
Health, Hamilton.
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atry 1993, 38:.