https://orcid.org/0000-0003-2004-2366
Abstract
The comorbidity between problem gambling and substance use/abuse is high in many populations previously studied. However, the occurrence of problem gambling among individuals with substance abuse has not been thoroughly studied, which is especially true for individuals in inpatient or compulsory care. The present early-stage study explored the presence of gambling and problem gambling among inpatients in compulsory care in Sweden who has been court-ordered to treatment for their substance abuse (alcohol and/or drugs). The study furthermore investigates the use of preventive measures and treatment seeking. The most effective strategy to recruit participants (no incentive, incentive and incentive and face-to-face recruitment) was also explored. Twenty-one participants were recruited and seven of them had at-risk or problem gambling and none of them had accessed treatment. The best way of recruiting was to offer a gift certificate and inform about the study face-to-face. The implications are that individuals in compulsory care for substance abuse need to be screened for problem gambling, that recruitment for studies in this population is best carried out by offering incentives and educational efforts and that it might be beneficial for the clients in compulsory care to be offered gambling treatment.
REVIEWING EDITORS:
1. Introduction
High rates of comorbidities such as alcohol problems, anxiety and depression have been found among individuals with problem gambling as the primary cause of concern (Håkansson et al., Citation2018; Lorains et al., Citation2011). Also, comorbid gambling disorder for different types of substance abuse disorder has been investigated in several studies. The studies available have found high rates of problem gambling among individuals with substance abuse as the main diagnosis (Anpaa et al., Citation2011; Di Nicola et al., Citation2015; Fernández-Montalvo et al., Citation2012; Punzi & Fahlke, Citation2015; Thomas Sherba & Martt, Citation2015; Toneatto & Brennan, Citation2002). Only one study found low rates of problem gambling among individuals with substance abuse (Leino et al., Citation2021). However, there is still a lack of studies investigating gambling, at-risk gambling and problem gambling among inpatients treated for substance abuse.
Unique for the Swedish setting, is that an individual can be court-ordered to attend compulsory inpatient care for substance abuse and approximately nine hundred individuals attend this type of treatment per annum. High rates of problem gambling have been found among patients in voluntary residential care (Leavens et al., Citation2014). To our knowledge, there are no studies available that investigate the presence of problem gambling among individuals in compulsory care for substance abuse.
Substance abuse compulsory care clients have been studied in Sweden regarding mortality (Hall et al., Citation2015; Ledberg & Reitan, Citation2022), but not in relation to gambling. At intake, the individuals are asked if they have increased their online gambling and the number that endorses this question has increased during the past years. Having more information about the level of at-risk and problem gambling at treatment centres that offers compulsory care could help tailor adequate treatment and perhaps diminish the risk of developing or further progressing into a severe gambling addiction. The risk of relapse is also higher when there are other addictions present for an individual in treatment and decreasing at-risk or problem gambling during their treatment stay could help diminish that risk {Werb, 2016 #550}.
Due to the lack of research and general knowledge about the Swedish compulsory care population, it is important to explore gambling related issues in this population. Based on previous findings of high rates of problem gambling in vulnerable populations, such as individuals with mental illness (Forsström et al., Citation2022) or inpatient care (Anpaa et al., 2011; Di Nicola et al., Citation2015; Fernández-Montalvo et al., Citation2012; Punzi & Fahlke, Citation2015; Thomas Sherba & Martt, Citation2015; Toneatto & Brennan, Citation2002) one can assume that this current study will reach similar results. The rationale for this study is to explore if there is a high rate of problem gambling in a population in compulsory care. Since the individuals that are studied have been court-ordered treatment and probably have not sought treatment for their alcohol and/or drug abuse, it is also important to investigate the use of preventive measures and treatment for problem gambling in this population to understand if there is a pattern of non-treatment seeking. Furthermore, since this is a population that has not been extensively studied it is relevant to understand which recruitment procedure is the most successful.
1.1. Aim and research questions
The aim of the study is to explore the occurrence of gambling, at-risk and problem gambling among clients in compulsory care in a Swedish setting. Also, the study aims to explore the level of treatment seeking and use of preventive measures and finally which recruitment procedure is the most effective when recruiting participants.
The following research questions are addressed:
What is the level of gambling, at-risk and problem gambling in a population in compulsory care for substance abuse?
What was the level of use regarding preventive measures and treatment seeking?
What is the feasibility of recruiting individuals for an online survey from this population?
2. Methods
2.1. Procedure
About ten facilities provides compulsory care in Sweden. Contact was initiated with all the facilities in Sweden via a coordinator working at The Swedish National Board of Institutional Care, which manages the facilities. All the facilities agreed to partake in the study.
A 26-question survey was prepared using Limesurvey.org and included four background questions, one question asking the participants if they had gambled during the past 12 months, and questions regarding problem gambling using the Problem Gambling Severity Index (PGSI) (Ferris & Wynne, Citation2001) and The National Opinion Research Center DSM Screen for Gambling Problems-CLiP (NODS-Clip) (Volberg et al., Citation2011), two questions about the use of preventive interventions and one question about treatment seeking. If a participant had not gambled in the previous 12 months, the survey ended after seven questions. Otherwise, all questions were mandatory.
The participants were asked to participate two weeks after their intake. Personnel at the facilities asked the clients if they wanted to participate and handed out information material. The survey was made available to the target population in three different ways, namely, 1. without any incentive, 2. a gift card worth 50 Swedish kronor (approximately 4.5 Euro) was offered to the clients when asked to participate by the personnel and 3. the first author held a brief lecture about gambling in a care facility for the clients and offered a gift card worth 50 Swedish kronor. The three stages of recruitment were carried out sequentially. The first was no incentive, the second was with incentive and the third stage was incentive plus lecture. Individuals who had been previously asked were not asked a second time in the latter stages of the data collection. This was due to ethical considerations since the included group were deemed as vulnerable and asking them several times could infringe on their integrity. The data collection period was four months between February to June 2022. During the data collection period 313 individuals started treatment and, thus, were potential participants. The survey page containing the answered questionnaires was monitored by the first author. Thus, the number of replies gathered from the different stages was noted.
All the data was collected anonymously and after completing the survey the participants received the gift card. The data was collected using tablets provided by the facilities.
2.2. Diagnosis and severity of symptoms
The basis for the compulsory care is an investigation carried out by social services at a municipality level in Sweden. The investigation contains assessments of the extent to which the individual endangers his or her health, and typically includes questions on alcohol and drug use, health, family and social situation e.g. the Addiction Severity Index (Nyström et al., Citation2010; Padyab et al., Citation2018).
2.3. Setting
The participants were recruited from nine inpatient care facilities where they received court-ordered care. This treatment can last for six months and be renewed if a court rules that it is necessary. During 2022, 890 clients (575 men and 315) were admitted to mandatory treatment (SiS, Citation2022). The facilities aim to provide different types of evidence-based treatments.
2.4. Participants
Of the 313 patients admitted during the collection period, 24 started answering and 21 completed the survey. No data was available for three participants because they did not complete the consent form. See . for demographic data.
Table 1. Gender distribution, mean age, and reasons for compulsory care.
The main gambling activities for the individuals with at-risk and problem gambling were casino gambling, poker, sports betting, and scratch cards tickets.
2.5. Measures
2.5.1. Problem Gambling Severity Index (PGSI)
PGSI, which consists of nine items, was used to assess problem gambling (Ferris & Wynne, Citation2001). The items (e.g. Have you bet more than you could really afford to lose?) are scored from 0 (never) to 3 (almost always), resulting in a score ranging between 0and 27. The internal consistency (Cronbach’s alpha) for the sample was .94. Having over three points was classified as being an at-risk gambler and eight and above was seen as having problem gambling.
2.5.2. The National Opinion Research Center diagnostic Screen for gambling problems-CLiP (NODS-clip)
The NODS-CLiP was used to examine lifetime prevalence (Volberg et al., Citation2011). The instrument was developed from the 10-item NODS (Hodgins, Citation2002, Citation2004; Wickwire et al., Citation2008). The NODS-CLiP contains three questions, and the response is dichotomous (yes or no). The instrument has high sensitivity for identifying people with problem gambling (Toce-Gerstein et al., Citation2009; Volberg et al., Citation2011).
2.6. Ethical declaration
The study was approved by the ethical review authority in Sweden (Dnr. 2021-06302-01 & 2022-02829-02) and the participants gave electronic informed consent.
3. Results
3.1. Results from the survey
Nine (42.8%) individuals had not gambled for money in the last 12 months and 12 (57.2%) individuals had gambled for money in the last 12 months. Those who gambled for money consisted of nine men and three women. Three individuals were at-risk and four had problem gambling (see ).
Table 2. Characteristics of the participants that had gambled.
Three participants had used self-exclusion and the other six did not endorse the use of responsible gambling (RG) tools. No one had sought formal treatment. The individuals with problem gambling played casino games, poker and used scratch cards of various kinds. The at-risk gamblers used scratch cards and gambled on sports games.
With 313 individuals admitted during the data collection period, the confirmed cases of at-risk and problem gambling were 2.2 percent.
The results from NODS-Clip show that six participants answered yes on at least one question and two answered yes on all three questions indicating the presence of a lifelong condition.
3.2. Feasibility of recruiting individuals
Three recruitment strategies were evaluated (no incentive, incentive, incentive, and brief lecture). Six participants agreed to complete the survey without incentives, five agreed after being offered a gift card, and 13 agreed after listening to a brief lecture and receiving a gift card. Giving a lecture and an incentive was, thus, the most successful strategy.
4. Discussion
Of the 12 individuals who gambled, seven (57%) were at-risk or had a gambling problem, which is in line with previous research focused on inpatient treatment (Anpaa et al., 2011; Di Nicola et al., Citation2015; Fernández-Montalvo et al., Citation2012; Leavens et al., Citation2014; Punzi & Fahlke, Citation2015; Thomas Sherba & Martt, Citation2015; Toneatto & Brennan, Citation2002). Even though the number of participants is low and keeping in mind that this is a pilot study at an early stage, there seems to be a need for screening for gambling related problems among clients in compulsory substance abuse care. The results from NODS-CLip provide further evidence of problem gambling in the sample and support the need for routine screening. Providing screening and finding cases in this population is important from an ethical perspective. Since this is a vulnerable group, acknowledging problem gambling and providing treatment is important because individuals with at-risk or problem gambling might have the opportunity to continue to gamble while in compulsory care.
Previous studies examining individuals with substance abuse and mental illness (Bergamini et al., Citation2018; Forsström et al., Citation2022; Vita et al., Citation2021) reported much lower prevalence rates of problem gambling than our study, but high rates compared to the general population. One important aspect of our results in combination with previous studies is that vulnerable groups in terms of substance abuse and mental illness are prone to have higher rates of at-risk and problem gambling. Therefore, as mentioned previously, there is a need for screening, preventive efforts, and treatment for these groups.
One important finding is that none of the participants had sought professional help. Overall, individuals with gambling disorder rarely seek treatment (Slutske, Citation2006; Slutske et al., Citation2009) and the rate is usually between 10 and 15 percent. The rate is lower in our study. Groups with substance abuse and problem gambling might require a lot of assistance to seek treatment for problem gambling. Another interesting finding is the low use of prevention measures. However, studies investigating the use of responsible gambling (RG) tools found that the use was low (Forsström et al., Citation2016, Citation2017, Citation2020) and these findings might indicate an overall low use of RG measures and that this in part can explain our results.
The best recruitment strategy was face-to-face interaction. Using an incentive did not seem to affect the outcome. Therefore, when conducting similar studies, resources are needed to travel to the facilities. In hindsight, two aspects of the recruitment strategy are important to highlight. First, recruiting participants at the facilities after intake seems to be an ineffective strategy. Screening this group for gambling should, thus, be a part of a standard practice when clients are admitted. Secondly, one can argue that there is an ethical dilemma when it comes to visiting the facilities since the individuals admitted in most cases do not want to be at the care facility. Therefore, screening for gambling as a part of standard practice is a better option.
4.1. Practical implications
The results show that it is important to screen clients in compulsory care for problem gambling and there is a need for face-to-face interaction to reach the inpatients. Also, activities that are available for the clients in the facilities might have to be restricted in some ways to prevent clients from engaging in gambling activities. Otherwise, there is a risk that clients will engage in gambling activities and develop more gambling related problems. Access to and information about preventive measures (e.g. self-exclusion registers) might also be fruitful in trying to decrease at-risk and problem gambling at the facilities.
Furthermore, one way of helping individuals in this population that has a substance abuse problem and at-risk or problem gambling is to provide treatment that addresses both problems during compulsory care. Another alternative could be to provide online treatment for problem gambling during their compulsory care.
4.2. Limitations
There are several major limitations present. The most severe limitation is the small number of participants in the study compared to the over 300 clients that were admitted during the data collection. Thus, it is not possible to generalize our findings to the total population. However, this is early-stage research and needs to be considered from that perspective. Self-report bias is also a limitation. Here, more so than in other cases since the use of substances might have made it harder for the participants to remember and assess past gambling behaviour and negative consequences. Three studies have shown that gamblers underestimate their actual losses (Auer & Griffiths, Citation2017; Braverman et al., Citation2014; Heirene et al., Citation2022), and this might be true in our sample as well. The results found that providing an incentive and a lecture was the most successful recruitment strategy. However, this could have been caused by chance and/or other variables not controlled for. If more participants had been recruited, statistical test would have been carried out to examine potential differences in the groups.
4.3. Future research
Future research should investigate a larger population, which will result in a more accurate prevalence rate. Also, there is a need to investigate the effect of prevention (e.g. educational efforts) and treatment on this population.
4.4. Conclusions
The major conclusion of this early-stage study that can be inferred based on the results is there is a need for more in-depth screening of clients in compulsory care. Providing information about preventive measures to help individuals with at-risk gambling and offer treatment for problem gambling for this population are important steps to take. Also, preliminary results indicate that recruitment should occur onsite or as a part of routine screening.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The data used in this study will not be made available due to the small number of participants included because of the risk of being able to identify individual data. Upon request, additional analyses can be carried out by the first author.
Additional information
Funding
Notes on contributors
David Forsström
David Forsström is a psychologist and has a PhD in clinical psychology. His research focus is on gambling from different perspectives. He has carried out studies investigating the use of responsible gambling tools and also studies focusing on gambling prevention in general. He is also involved in a project investigating the relationship between gambling and crime and he is the principal investigator in a project about betting on e-sport.
Kristina Sundqvist
Kristina Sundqvist has a PhD in psychology and holds a position as a researcher and temporary lecturer at the Department of Psychology at Stockholm University. She is a licensed psychologist. Her main research concerns psychological aspects of problem gambling as well as alcohol prevention in work life.
Eva Samuelsson
Eva Samuelsson (PhD in social work) is a Senior Lecturer and Associate Professor at the Department of Social Work, Stockholm University. She conducts research on help-seeking processes and organization of support and treatment for people with substance use and gambling problems.
Jessika Spångberg
Jessika Spångberg (formerly Svensson), PhD, is a public health scientist who works with problem gambling and other public health issues at the Public Health Agency of Sweden. She also conducts research within the REGAPS (Responding to and Reducing Gambling Problems) research program at Stockholm University.
References
- Anpaa, Nalpas, B., Yguel, J., Fleury, B., Martin, S., Jarraud, D., & Craplet, M. (2011). Pathological gambling in treatment-seeking alcoholics: A national survey in France. Alcohol and Alcoholism (Oxford, Oxfordshire), 46(2), 1–7. https://doi.org/10.1093/alcalc/agq099
- Auer, M., & Griffiths, M. D. (2017). Self-reported losses versus actual losses in online gambling: An empirical study. Journal of Gambling Studies, 33(3), 795–806. https://doi.org/10.1007/s10899-016-9648-0
- Bergamini, A., Turrina, C., Bettini, F., Toccagni, A., Valsecchi, P., Sacchetti, E., & Vita, A. (2018). At-risk gambling in patients with severe mental illness: Prevalence and associated features. Journal of Behavioral Addictions, 7(2), 348–354. https://doi.org/10.1556/2006.7.2018.47
- Braverman, J., Tom, M. A., & Shaffer, H. J. (2014). Accuracy of self-reported versus actual online gambling wins and losses. Psychological Assessment, 26(3), 865–877. https://doi.org/10.1037/a0036428
- Di Nicola, M., Tedeschi, D., De Risio, L., Pettorruso, M., Martinotti, G., Ruggeri, F., Swierkosz-Lenart, K., Guglielmo, R., Callea, A., Ruggeri, G., Pozzi, G., Di Giannantonio, M., & Janiri, L. (2015). Co-occurrence of alcohol use disorder and behavioral addictions: relevance of impulsivity and craving. Drug and Alcohol Dependence, 148, 118–125. https://doi.org/10.1016/j.drugalcdep.2014.12.028
- Fernández-Montalvo, J., López-Goñi, J. J., & Arteaga, A. (2012). Prevalence of pathological gambling in treatment-seeking addicted patients: An exploratory study with the South Oaks Gambling Screen. Anales De Psicología, 28(2), 344–349. https://doi.org/10.6018/analesps.28.2.147611
- Ferris, J. A., & Wynne, H. J. (2001). The Canadianproblem gambling index. Canadian Centre on Substance Abuse.
- Forsström, D., Hesser, H., & Carlbring, P. (2016). Usage of a responsible gambling tool: A descriptive analysis and latent class analysis of user behavior. Journal of Gambling Studies, 32(3), 889–904. https://doi.org/10.1007/s10899-015-9590-6
- Forsström, D., Jansson-Fröjmark, M., Hesser, H., & Carlbring, P. (2017). Experiences of Playscan: Interviews with users of a responsible gambling tool. Internet Interventions, 8, 53–62. https://doi.org/10.1016/j.invent.2017.03.003
- Forsström, D., Lindner, P., Månsson, K. N. T., Ojala, O., Hedman-Lagerlöf, M., El Alaoui, S., Rozental, A., Lundin, J., Jangard, S., Shahnavaz, S., Sörman, K., Lundgren, T., & Jayaram-Lindström, N. (2022). Isolation and worry in relation to gambling and onset of gambling among psychiatry patients during the COVID-19 pandemic: Amediation study. Frontiers in Psychology, 13, 1045709. https://doi.org/10.3389/fpsyg.2022.1045709
- Forsström, D., Rafi, J., & Carlbring, P. (2020). Dropouts’ usage of a responsible gambling tool and subsequent gambling patterns. Cogent Psychology, 7(1), 1715535. https://doi.org/10.1080/23311908.2020.1715535
- Hall, T., Chassler, D., Blom, B., Grahn, R., Blom-Nilsson, M., Sullivan, L., & Lundgren, L. (2015). Mortality among a national population sentenced to compulsory care for substance use disorders in Sweden: Descriptive study. Evaluation and Program Planning, 49, 153–162. https://doi.org/10.1016/j.evalprogplan.2014.12.013
- Heirene, R. M., Wang, A., & Gainsbury, S. M. (2022). Accuracy of self-reported gambling frequency and outcomes: Comparisons with account data. Psychology of Addictive Behaviors: journal of the Society of Psychologists in Addictive Behaviors, 36(4), 333–346. https://doi.org/10.1037/adb0000792
- Hodgins, D. C. (2002). Using the NORC DSM Screen for gambling problems (NODS) as an outcome measure for pathological gambling: Reliability and validity. Gambling Research: Journal of the National Association for Gambling Studies (Australia), 14(1), 5–17.
- Hodgins, D. C. (2004). Using the NORC DSM screen for gambling problems as an outcome measure for pathological gambling: psychometric evaluation. Addictive Behaviors, 29(8), 1685–1690. https://doi.org/10.1016/j.addbeh.2004.03.017
- Håkansson, A., Karlsson, A., & Widinghoff, C. (2018). Primary and secondary diagnoses of gambling disorder and psychiatric comorbidity in the Swedish health care system—A nationwide register study. Frontiers in Psychiatry, 9, 426. https://doi.org/10.3389/fpsyt.2018.00426
- Leavens, E., Marotta, J., & Weinstock, J. (2014). Disordered gambling in residential substance use treatment centers: An unmet need. Journal of Addictive Diseases, 33(2), 163–173. https://doi.org/10.1080/10550887.2014.909697
- Ledberg, A., & Reitan, T. (2022). Increased risk of death immediately after discharge from compulsory care for substance abuse. Drug and Alcohol Dependence, 236, 109492. https://doi.org/10.1016/j.drugalcdep.2022.109492
- Leino, T., Torsheim, T., Griffiths, M. D., & Pallesen, S. (2021). The relationship between substance use disorder and gambling disorder: A nationwide longitudinal health registry study. Scandinavian Journal of Public Health, 51(1), 28–34. https://doi.org/10.1177/14034948211042249
- Lorains, F. K., Cowlishaw, S., & Thomas, S. A. (2011). Prevalence of comorbid disorders in problem and pathological gambling: Systematic review and meta‐analysis of population surveys. Addiction (Abingdon, England), 106(3), 490–498. https://doi.org/10.1111/j.1360-0443.2010.03300.x
- Nyström, S., Andrén, A., Zingmark, D., & Bergman, H. (2010). The reliability of the Swedish version of the Addiction Severity Index (ASI). Journal of Substance Use, 15(5), 330–339. https://doi.org/10.3109/14659890903431629
- Padyab, M., Armelius, B.-Å., Armelius, K., Nyström, S., Blom, B., Grönlund, A.-S., & Lundgren, L. (2018). Is clinical assessment of addiction severity of individuals with substance use disorder, using the Addiction Severity Index, a predictor of future inpatient mental health hospitalization? A nine-year registry study. Journal of Dual Diagnosis, 14(3), 187–191. https://doi.org/10.1080/15504263.2018.1466086
- Punzi, E. H., & Fahlke, C. (2015). Co-occurring self-reported behavioral problems in a substance use disorder treatment population: Treatment perspective. Alcoholism Treatment Quarterly, 33(1), 105–117. https://doi.org/10.1080/07347324.2015.982466
- SiS (Statens institutionsstyrelse). (2022). SiS i KORTHET 2021: En samling statistiska uppgifter om SiS [SiS In Brief 2021: A collection of statistical data about SiS]. Statens institutionsstyrelse.
- Slutske, W. S. (2006). Natural recovery and treatment-seeking in pathological gambling: Results of two US national surveys. The American Journal of Psychiatry, 163(2), 297–302. https://doi.org/10.1176/appi.ajp.163.2.297
- Slutske, W. S., Blaszczynski, A., & Martin, N. G. (2009). Sex differences in the rates of recovery, treatment-seeking, and natural recovery in pathological gambling: results from an Australian community-based twin survey. Twin Research and Human Genetics: The Official Journal of the International Society for Twin Studies, 12(5), 425–432. https://doi.org/10.1375/twin.12.5.425
- Thomas Sherba, R., & Martt, N. J. (2015). Overall gambling behaviors and gambling treatment needs among a statewide sample of drug treatment clients in Ohio. Journal of Gambling Studies, 31(1), 281–293. https://doi.org/10.1007/s10899-013-9406-5
- Toce-Gerstein, M., Gerstein, D. R., & Volberg, R. A. (2009). The NODS–CLiP: A rapid screen for adult pathological and problem gambling. Journal of Gambling Studies, 25(4), 541–555. https://doi.org/10.1007/s10899-009-9135-y
- Toneatto, T., & Brennan, J. (2002). Pathological gambling in treatment-seeking substance abusers11The views expressed in this article are those of the authors and do not reflect those of the Center for Addiction and Mental Health. Addictive Behaviors, 27(3), 465–469. https://doi.org/10.1016/S0306-4603(00)00173-8
- Wickwire, E. M., Jr, Burke, R. S., Brown, S. A., Parker, J. D., & May, R. K. (2008). Psychometric evaluation of the national opinion research center DSM-IV screen for gambling problems (NODS). The American Journal on Addictions, 17(5), 392–395. https://doi.org/10.1080/10550490802268934
- Vita, A., Bastiani, L., Turrina, C., Benedetti, E., Bergamini, A., & Molinaro, S. (2021). At-risk gambling in patients with severe psychiatric illness and in community subjects matched for age and sex. Psychiatry Research, 304, 114142. https://doi.org/10.1016/j.psychres.2021.114142
- Volberg, R. A., Munck, I. M., & Petry, N. M. (2011). A quick and simple screening method for pathological and problem gamblers in addiction programs and practices. The American Journal on Addictions, 20(3), 220–227. https://doi.org/10.1111/j.1521-0391.2011.00118.x