Subin Park Æ Maeng Je Cho Æ Hong Jin Jeon Æ Hae Woo Lee Æ Jae Nam Bae Æ Jong Ik Park Æ Jee Hoon Sohn Æ You Ra Lee Æ Jun Young Lee Æ Jin Pyo Hong

Transcription

1 Soc Psychiat Epidemiol (2010) 45: DOI /s ORIGINAL PAPER Prevalence, clinical correlations, comorbidities, and suicidal tendencies in pathological Korean : results from the Korean Epidemiologic Catchment Area Study Subin Park Æ Maeng Je Cho Æ Hong Jin Jeon Æ Hae Woo Lee Æ Jae Nam Bae Æ Jong Ik Park Æ Jee Hoon Sohn Æ You Ra Lee Æ Jun Young Lee Æ Jin Pyo Hong Received: 11 May 2009 / Accepted: 7 July 2009 / Published online: 28 July 2009 Ó Springer-Verlag 2009 Abstract Objective Based on the National Epidemiological Survey of Psychiatric Disorders in South Korea conducted in 2006, we examined the prevalence, clinical correlations, comorbidities, and suicidal tendencies of pathological in the community. S. Park J. P. Hong (&) Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Pungnap-2dong, Songpa-gu, Seoul , South Korea jphong@amc.seoul.kr M. J. Cho H. W. Lee J. H. Sohn Department of Psychiatry and Behavioral Science, Seoul National University College of Medicine, Seoul, South Korea H. J. Jeon Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea J. N. Bae Department of Psychiatry, College of Medicine, Inha University, Incheon, South Korea J. I. Park Department of Psychiatry, Kangwon National University School of Medicine, Chuncheon, South Korea Y. R. Lee Department of Psychiatry, Seoul Bukbu Geriatric Hospital, Seoul, South Korea J. Y. Lee Department of Psychiatry, Seoul National University Boramae Hospital, Seoul, South Korea Method Of the 6,510 participants who completed the Korean version of the Composite International Diagnostic Interview (K-CIDI) administered by trained lay interviewers, 5,333 subjects fully completed the Diagnostic Interview Schedule (DIS) exploring pathological gambling. The DIS has 13 items mapping to 10 criteria. Endorsement of five DSM-IV criteria was considered to reflect pathological gambling, and we considered endorsement of one to four criteria to indicate problem gambling. The frequencies of psychiatric disorders and suicidal tendency were analyzed among pathological/problem in comparison with controls; both odds ratios and significance levels were calculated. Results The lifetime prevalence rates of pathological gambling and problem gambling were 0.8% and 3.0%, respectively. Of pathological, 79.1% had at least one psychiatric illness in comparison to the control level of 28.1%, and 62.0% of problem also had psychiatric conditions. Associations between pathological/problem gambling and alcohol use disorder, nicotine dependence, mood disorder, anxiety disorder, and suicidality were overwhelmingly positive and significant (p \ 0.05), even after controlling for age and gender. Male gender, divorced/separated/widowed marital status, and urban living were all associated with increased risks of pathological and problem gambling (p \ 0.05). Conclusion Pathological/problem gambling is highly associated with substance abuse, mood and anxiety disorders, and suicidality, suggesting that clinicians should carefully evaluate and treat such psychiatric disorders in. Keywords Epidemiology Pathological gambling Comorbidity Psychiatric disorders Suicidality

2 622 Soc Psychiat Epidemiol (2010) 45: Introduction Pathological gambling is classified as an impulse control disorder and is characterized by persistent and recurrent maladaptive gambling behavior patterns [1]. Pathological gambling correlate with many adverse health measures including suicidal ideation and attempts, divorce, job loss, debt, bankruptcy, and incarceration [6, 28, 31, 37]. Most do not develop the pathological condition. However, subsyndromal gambling levels also correlate with the adverse health measures described above, although associations are weaker than seen in pathological [11, 31, 37]. Several studies investigating clinical pathological gambler populations have documented high psychiatric comorbidity rates, such as substance use disorders, affective disorders, personality disorders, and suicidal ideation and attempt [7, 10, 14, 22], but estimates based on treatment-seeking samples cannot be extended to the general population. Only about 8% of problem actually seek help [27]. In addition, seeking treatment may be motivated by emotional distress, impairment, depression, or other addictive behaviors [2, 6], such that their psychiatric comorbidity frequencies may be higher than those of who do not seek treatment. General population surveys are considered the gold standard for assessing the true prevalence of psychiatric disorder comorbidities. Although a number of general population surveys have examined comorbidities in pathological and problem, and explored concurrent substance use disorders [3, 9, 36], only two national surveys, both in the United States, have examined associations between pathological gambling and a wide range of psychiatric disorders [17, 29]. Petry et al. [29] from a large sample in United States, found high rates of psychiatric comorbidities in DSM-IV pathological, involving substance use, mood, anxiety, and personality disorders. Kessler et al. [17] investigated temporal associations between pathological gambling and other DSM-IV disorders in the United States household population. These authors found that the onset of pathological gambling was preceded by anxiety, mood, impulse-control, and substance use disorders, and pathological gambling also predicted the subsequent onset of generalized anxiety disorder, posttraumatic stress disorder, and substance dependence. Suicidality is one of the most serious health problems of pathological. Although several general population surveys have examined the association between pathological gambling and suicidality, only one nationally representative general population survey has been reported to date [25]. In this Canadian study, pathological gambling and attempted suicide in the past year were significantly related [25]. Pathological gambling prevalence may be affected by cultural differences between countries (affecting the social availability of gambling) and distinct legal systems in different nations (controlling the physical availability of gambling). For example, in 2005, there were 14 casinos in Korea, only one of which permitted the entrance of a native, while there were 1,568 casinos in North America, most of which permitted the entrance of a native, although each province had its own casino control act [26]. That is, physical availability of gambling in Korea could be lower than US and Canada. Some studies have suggested that when gambling becomes more easily accessible, the numbers of both problem/pathological and recreational rise because of increased gambling opportunities [23, 39, 40]. However, when rising gambling accessibility was accompanied by preventative social measures and appropriate legislation, gambling prevalence did not increase [4]. In Korea, habitual gambling in gambling houses or casinos is strictly controlled by legislation [20]. However, people often play games, such as flower cards with relatives and friends during holiday seasons, to foster family unity [15, 18]. That is, the physical availability of gambling is low, but social availability is high in Korea. In 2006 and 2007, a nationwide epidemiological study was conducted to estimate the prevalence of, and clinical correlations with, psychiatric disorders in a community sample of Korean adults aged years. This study assessed participants for pathological/problem gambling using the Korean version of the Diagnostic Interview Schedule (K-DIS) [34], and assigned psychiatric disorders with reference to responses to the Korean version of the Composite International Diagnostic Interviews (K-CIDI) [5]. We examined the prevalence of pathological/problem gambling, clinical correlations therewith, suicidality, and associations between pathological/problem gambling and DSM-IV psychiatric diagnoses. Methods The Korean Epidemiologic Catchment Area (KECA) study was conducted from July 2006 to April Subjects were selected using a stratified, multi-stage, cluster sample design, which was based on the population census conducted by community registry offices in One individual per selected household was randomly chosen; this was the individual with the earliest birthday without consideration of month or year. From an initially selected 7,968 subjects, aged between 18 and 64 years, a total of 6,510 face-to-face interviews (response rate 81.7%) were conducted, and all subjects completed the K-CIDI. Of 6,510 participants, 5,333 fully completed the K-DIS for pathological gambling.

3 Soc Psychiat Epidemiol (2010) 45: The institutional review board of the Seoul National University College of Medicine approved this study. Each subject was fully informed on study aims and methods before interview completion. Informed consent was obtained prior to participation. Data collection Assessment of psychiatric disorders The K-CIDI was administered to each subject. The CIDI [42] is a fully structured diagnostic interview designed to achieve psychiatric diagnoses using the definitions of DSM-IV [1]. The K-CIDI was validated by Cho et al. [5], according to World Health Organization guidelines [43]. KECA-study assessed most DSM-IV psychiatric disorders, but we included only substance use disorder, mood disorder, and anxiety disorder in this study, because of low prevalence of other psychiatric disorders. Diagnosis of pathological/problem gambling We used the K-DIS-IV for pathological gambling [34], to identify subjects who were pathological/problem. The K-DIS was validated by Suh et al. [34] (kappa value of inter-rater reliability was 0.70 for pathological gambling). The DIS-IV [30] is a fully structured diagnostic interview designed to achieve psychiatric diagnoses using the definitions of DSM-IV, and it contains section for pathological gambling. The DSM-IV provides a widely accepted definition of and diagnostic criteria for pathological gambling, but the term problem gambling is somewhat more difficult to conceptualize and define. In this study, endorsement of five DSM-IV criteria was considered to reflect pathological gambling, and, we considered endorsement of one to four criteria to indicate problem gambling, referring terms used by Committee on the Social and Economic Impact of Pathological Gambling, National Research Council [6]. According to terms used by Committee [6] problem gambling means gambling behavior that results in any harmful effects to the gambler, his or her family, significant others, friends, coworkers, etc., but fall below the threshold of at least 5 of the 10 APA DSM-IV criteria used to define pathological gambling. Assessment of suicidality We used the K-CIDI module on suicide to assess lifetime suicidality. Lifetime suicidal ideation was assessed with the item Have you ever seriously thought of committing suicide?, and a lifetime suicide plan with the item Have you ever planned suicide in the concrete? Lifetime suicide attempts were assessed with the item Have you ever attempted suicide? The number of suicide attempts made was also recorded. Statistical analysis Respondent weight values were calculated and used to adjust data, to approximate the national population in terms of age and gender of each catchment area, as defined by the 2005 census of the Korean National Statistical Office. All statistical analyses were based on weighted respondent data. We created three comparison groups. These were controls (KECA study samples excluding pathological and problem, n = 5,132), problem (n = 154), and pathological (n = 43). Chisquared analyses were used to compare between-group demographic characteristics. Odds ratios (ORs) and 95% confidence intervals were derived from a series of logistic regression analyses using DSM-IV psychiatric diagnoses and suicidality as the main outcome variables and pathological/problem gambling as the principal predictor, with and without controls for age and gender. All statistical analyses were performed using SPSS (version 12.0; SPSS Inc., Chicago, IL), with statistical significance defined at an alpha level \0.05. Results Prevalence of and clinical correlations with pathological/problem gambling The lifetime prevalence rates of pathological and problem gambling were 0.8% (43/5,333 subjects) and 3.0% (158/ 5,333 subjects), respectively. Table 1 showed which types of gambling are played most according to group. In this table, recreational means subject whoever have gambled, but does not meet any DSM-IV criteria for pathological gambling. The most popular type of gambling was flower cards (73.4% among recreational, 76.6% in problem, and 74.4% among pathological ). Lottery gambling, the second most prevalent gambling form, was more popular among recreational (65.7%) than in pathological (34.9%) and problem (36.1%), whereas poker, the third most prevalent type of gambling, was more popular among pathological (60.5%) and problem (58.2%) than in recreational (25.6%). Use of gambling machines, and betting on horse and cycle races, also increased with gambling pathology severity, but neither casino nor internet gambling, nor betting on motorboat races, rose with increasing gambling pathology (Table 1).

4 624 Soc Psychiat Epidemiol (2010) 45: Table 1 Lifetime use of gambling forms by all, recreational, problem, and pathological Recreational Problem Pathological (n = 1,904) (n = 158) (n = 43) Flower cards 1,398 (73.4) 121 (76.6) 32 (74.4) Lottery 1,251 (65.7) 57 (36.1) 15 (34.9) Poker 487 (25.6) 92 (58.2) 26 (60.5) Gambling machines 101 (5.3) 26 (16.5) 10 (23.3) Horse racing 84 (4.4) 20 (12.7) 10 (23.3) Internet gambling 82 (4.3) 14 (8.9) 2 (4.7) Casino gambling 74 (3.9) 13 (8.2) 2 (4.7) Cycle racing 38 (2.0) 7 (4.4) 4 (9.3) Motorboat racing 40 (2.1) 5 (3.2) 1 (2.3) Table 2 shows group-specific demographic characteristics. Age, gender, marital status, and urbanicity differed between the three groups (p \ 0.05). Pathological and problem were more likely to be male than were controls. Pathological were more prevalent among subjects aged years and less prevalent in those under 30 years of age, and more frequent in widowed/divorced/separated compared to controls and problem. In addition, pathological more frequently lived in cities compared to controls. Lifetime prevalence of psychiatric disorders among pathological/problem gambling respondents Table 3 displays the results of logistic regression models with psychiatric diagnoses as the main outcome variables and pathologic/problem gambling as the principal predictor, with and without adjustments for age and gender. The overall OR pattern was overwhelmingly positive (OR values [1.0) and statistically significant (p \ 0.05). Of all pathological, 79.1% had at least one psychiatric illness, in comparison to the control frequency of 28.1%. For problem, the proportion was 62.0%. Thus, both pathological and problem were more likely to have at least one psychiatric disorder (crude OR values 9.6 and 4.2; adjusted OR values 7.7 and 3.3, respectively). Both in adjusted and unadjusted analyses, any substance use disorder, alcohol dependence, alcohol abuse, and nicotine dependence were significantly related to pathological gambling, with OR values from 3.1 to 9.4. Any anxiety disorder was also significantly related to pathological gambling, with a crude OR of 2.4 and an adjusted OR of 3.9. Any substance use disorder, alcohol dependence, and nicotine dependence were also significantly related to problem gambling, with OR values ranging from 3.5 to 5.8, before or after controlling for age or gender. Alcohol abuse was significantly related to problem gambling, with an OR value of 2.0, without controlling for age or gender. Any anxiety disorder, any mood disorder, and depressive disorders were also significantly related to problem gambling, with OR values ranging from 1.7 to 2.9. Lifetime prevalence of suicidality among pathological/ problem gambling respondents Table 4 displays the results of logistic regression models with suicidal ideation, plan, and attempt as the main outcome variables and pathological gambling/problem gambling as the principal predictor. In addition to pathological/ problem gambling, age, gender (in adjusted models 1 and 2), and other psychiatric disorders (in adjusted model 2), were considered as independent variables. Suicidal ideation, plan, and attempt were significantly associated with pathological or problem gambling after controlling for age and gender, with OR values ranging from 2.3 to 6.7. These associations became progressively weaker as other psychiatric disorders were added to the model (Table 4). Discussion This is the first study of psychiatric comorbidity and suicidality in Asian pathological/problem. The lifetime prevalence rates of pathological (0.8%) and problem gambling (3.0%) in this study were within the ranges found in Western countries ( %) [17, 29, 33]. Two Asian studies on the prevalence of pathological gambling have appeared [21, 41]. The pathological gambling prevalence of the present report was similar to the rate of 1.0% found in a Korean epidemiologic study conducted in 1984, which used DIS-III criteria [21]. A Hong Kong report, which employed the DSM-IV Gambling- Behavior Index, and defined the problem gambling cutoff

5 Soc Psychiat Epidemiol (2010) 45: Table 2 Demographic characteristics of controls, problem, and pathological Controls (n = 5,132) Problem (n = 158) Pathological (n = 43) v 2 df p Post-hoc analyses* A B C Age (years) ,371 (26.7) 48 (30.4) 1 (2.4) ,284 (25) 37 (23.4) 13 (31.0) ,299 (25.3) 39 (24.7) 18 (42.9) (16.5) 28 (17.7) 7 (16.7) (6.5) 6 (3.8) 3 (7.1) Gender \0.001 \0.001 \ Male 2,470 (48.1) 138 (87.3) 39 (90.7) Female 2,662 (51.9) 20 (12.7) 4 (9.3) Marital status 23 4 \ \ Married 3,298 (64.4) 87 (55.1) 21 (50.0) Widowed/divorced/separated 394 (7.7) 11 (7.0) 10 (23.8) Never married 1,427 (27.9) 60 (38.0) 11 (26.2) Education Less than high school 968 (18.9) 35 (22.2) 11 (26.2) High school 1,866 (36.4) 48 (30.4) 18 (46.2) Some college or higher 2,998 (44.8) 75 (47.5) 13 (31.0) Occupation Employed 3,625 (70.6) 103 (65.2) 32 (74.4) Unemployed 1,506 (29.4) 55 (34.8) 11 (25.6) Urbanicity Urban 4,244 (82.7) 140 (88.6) 40 (95.2) Rural 888 (17.3) 18 (11.4) 2 (4.8) Income (Korean won) ,000,000 1,898 (44.3) 57 (41.0) 25 (62.5) 2,000,000 3,000,000 1,172 (27.4) 39 (28.1) 9 (22.5) 3,000,000? 1,210 (28.3) 43 (30.9) 6 (15.0) * A, control vs. problem ; B, control vs. pathological ; C, problem vs. pathological as attainment of scores 3 or 4, documented the lifetime prevalence rates of pathological (1.8%) and problem gambling (4.0%) [41]. Although some of the discrepancy across studies may be related to different instruments used to assess pathological gambling, the prevalence of disordered gambling in Korea may be lower than in Hong Kong, probably because gambling laws are stricter in Korea. Flower cards and purchase of lottery tickets, were the most prevalent gambling forms among any Korean, not exclusively associated with pathological gambling. Flower cards is termed Hwa-tu in Korean, and Hana-Fuda in Japanese (Hwa and Hana means flower, Tu and Fuda means Throw ). Flower cards composed of 12 four-card suits, total 48 cards, and is somewhat similar to playing cards. It was introduced in Korea in the 19th century by merchants from Tsushima Island, Japan. So far, several dozen flower cards games have been developed in Korea and Japan. However, nowadays, only few Japanese know that game, while almost every Korean knows it and many of them play it with relatives and friends, especially in holiday seasons. Welte et al. [40] showed that approval of friends and approval of family were strong predictors of any form of gambling, but were unrelated to problem gambling. The high social acceptability of flower cards and lotteries in Korea may help explain our results. Poker, gambling machine use, and betting on horse and cycle races were more popular among pathological and problem than in recreational. This observation confirms an earlier report on pathological gambling risks associated with gambling forms [17]. Kessler et al. [17] reported that cards, sports betting, gambling machines, and betting on horse races were all associated with a high risk of pathological gambling. In the present study, internet gambling prevalence (4.7%) was higher than in previous works ( %) [17,

6 626 Soc Psychiat Epidemiol (2010) 45: Table 3 Prevalence of and odds ratios for DIS/DSM_IV psychiatric disorders among controls, problem, and pathological Controls (n = 5,132) Problem (n = 158) Pathological (n = 43) Odds ratio (95% Confidence interval) Problem vs. controls Pathological vs. controls Unadjusted OR Adjusted OR Unadjusted OR Adjusted OR Any substance use disorder 980 (19.1) 90 (57.0) 30 (69.8) 5.6 ( )** 3.5 ( )** 9.4 ( )** 6.1 ( )** Alcohol abuse 431 (8.4) 24 (15.2) 13 (30.2) 2.0 ( )* 1.2 ( ) 4.7 ( )* 3.1 ( )** Alcohol dependence 323 (6.3) 42 (26.6) 13 (30.2) 5.4 ( )** 4.0 ( )** 6.9 ( )** 5.3 ( )** Nicotine dependence 344 (6.7) 46 (29.1) 15 (34.9) 5.8 ( )** 3.5 ( )** 7.7 ( )** 4.4 ( )** Any mood disorder 313 (6.1) 18 (11.4) 5 (11.6) 2.0 ( )* 2.8 ( )** 1.9 ( ) 2.9 ( ) Depressive disorder 277 (5.4) 16 (10.1) 5 (11.6) 2.0 ( )* 2.9 ( )** 2.0 ( ) 3.0 ( )* Bipolar disorder 16 (0.3) 2 (1.3) ( ) 3.2 ( ) Any anxiety disorder 323 (6.3) 16 (10.1) 6 (14) 1.7 ( )* 2.5 ( )* 2.4 ( )* 3.9 ( )* Any DSM-IV psychiatric disorder 1,442 (28.1) 98 (62.0) 34 (79.1) 4.2 ( )** 3.3 ( )** 9.6 ( )** 7.7 ( )** * p \ 0.05, ** p\0.001, controlling for age and gender 38]. In Korea, the internet is very accessible, with a penetration rate of over 80% of households, and internet gambling is increasing with the recent development of online gaming businesses. However, no relationship between pathological manifestations and internet gambling has been described in Korea. Previous studies have suggested that internet are vulnerable to development of addiction, because of the anonymity, convenience, and accessibility of cyberspace [13, 19]. However, internet gambling seemed less addictive than poker, gambling machines, and horse race betting, in the present study. Consistent with other studies, pathological gambling was higher among males, widowed/divorced/separated individuals, and those residing in urban areas [21, 29, 32, 35, 36]. Compared with pathological, problem were more likely to have never married, and less likely to be widowed/divorced/separated. This may be because problem are younger than pathological. Neither income nor education emerged as significant pathological gambling predictors in the present study, but our data seemed to parallel trends of some previous reports which found associations between lower socioeconomic status and pathological gambling [32, 35, 36, 41]. In the present study, the pathological gambling risk was greater among those aged 30 to 49 years than in subjects 29 years of age or younger. In previous studies, younger age correlated with pathological/problem gambling [4, 12, 32, 35], and middle-age was associated with DSM-IV pathological gambling in the narrow sense [21, 24, 29]. Problem may become pathological as they age. When psychiatric comorbidities were considered, pathological were more likely than controls to meet the criteria for substance use disorders, mood disorders (especially depressive conditions), and anxiety disorders. Problem were also more likely than controls to attain psychiatric diagnostic criteria, although to a lesser extent than shown by pathological. Among substance use disorders, we included only alcohol and nicotine use, because of the very low prevalence of other drug use in Korea, probably because of strict legislative regulation of marijuana and opiate accessibility. Our results confirm and expand upon prior reports showing strong associations between alcohol/nicotine dependence and pathological gambling [3, 8, 9, 17, 24, 29]. The earlier OR values of such associations ranged from 3.9 to 7.4, within the range seen in the present study. We also found associations between mood/anxiety disorders and pathological/problem gambling, consistent with data in several previous reports. Bland et al. [3] found a significant association between affective disorders and pathological gambling, with an OR value of 2.3, but no differences between pathological and controls in major depression incidence. The cited authors also found a significantly higher level of anxiety/somatoform disorders among pathological, with an OR value of 2.9 [3]. In the largest study from United States to date of gambling comorbidity, pathological were 4.6- and 4.1-fold more likely to suffer from mood or anxiety disorders than were controls [29]. Another nationally representative United States household survey involving 9,282 adults also found that pathological were 3.7- and 3.1-fold more likely than controls to report lifetime histories of mood or anxiety disorders [17]. We did not divide anxiety disorders into subcategories, such as panic disorder, generalized anxiety disorder, or phobia, for example, because of the low prevalence of each individual disorder. In previous studies, panic disorder was

7 Soc Psychiat Epidemiol (2010) 45: Table 4 Prevalence of and Odds ratios for lifetime suicidality among controls, problem, and pathological Prevalence Odds Ratio (95% Confidence interval) Problem vs. controls Pathological vs. controls Adjusted model 2 Adjusted model 1 Unadjusted model Adjusted model 2 Adjusted model 1 Unadjusted model Pathological (n = 43) Problem (n = 158) Controls (n = 5,132) Suicidal ideation 739 (14.4) 39 (24.7) 13 (30.2) 1.9 ( )* 2.3 ( )** 1.7 ( )* 2.8 ( )* 3.4 ( )** 2.4 ( )* Suicide plan 164 (3.2) 8 (5.1) 5 (11.6) 1.6 ( ) 2.4 ( )* 1.6 ( ) 4.3 ( )* 6.7 ( )** 4.4 ( )* Suicide attempt 153 (3.0) 10 (6.3) 3 (7.0) 2.3 ( )* 2.8 ( )* 1.7 ( ) 2.9 ( ) 3.7 ( )* 2.2 ( ) * p \ 0.05, **p \ 0.001, control for age and gender, controlling for age, gender, substance use disorder, mood disorder, and anxiety disorder most strongly related to pathological gambling, whereas relationships with phobias and generalized anxiety disorder were significant, but weaker [8, 17, 29]. We found a correlation between lifetime suicidal ideation, plan, and attempts, on the one hand, and pathological/ problem gambling on the other, both with and without controlling for age and gender. As stated above, pathological and problem frequently suffer from comorbid psychiatric conditions, such as substance use disorders, mood problems, and anxiety disorders. These comorbid psychiatric disorders are in general associated with elevated rates of suicidal ideation and attempts. For example, mood disorder elevated suicide attempts fold and suicidal ideation 10.7-fold [16]. Patients with alcohol and substance use disorders were 6.5- and 4.6-fold, and patients with anxiety disorders 3.2- and 2.8-fold, more likely to exhibit suicide attempts and ideation, respectively [16]. It is thus important to identify to what extent suicidal ideation and attempts are related to gambling, as distinct from underlying comorbid conditions, which are frequent among. To explore this topic, we included substance use disorder, mood disorder, and anxiety disorder as well as age, gender, and pathological/problem gambling, in our multivariate model. In this model, the OR values for associations between pathological/problem gambling and suicidal ideation were 2.4 and 1.7, respectively, with statistical significance. The OR for association between pathological gambling and suicide plan was 4.4, which was also statistically significant. However, the OR for association between problem gambling on the one hand, and suicide plan and attempts, on the other, disappeared after consideration of other psychiatric disorders. These results suggest that problem gambling is not an independent risk factor, but pathological gambling is per se an independent risk factor for suicide, therefore clinicians should seriously evaluate suicide risks in pathological. Turning to prior studies, Newman and Thompson [24] found that an initial correlation between lifetime attempted suicide and lifetime pathological gambling was lost when controls for mental health problems were applied. However, the 1-year prevalence of pathological gambling was strongly associated with suicide attempts in the previous year in a nationally representative Canadian population sample even after controlling for mental health problems [25]. Our study had several limitations. First, the work was cross-sectional in design, making it impossible to identify a causal relationship between pathological/problem gambling and other psychiatric disorders. Future studies with more detailed information on age-of-onset are required to identify such temporal relationships. Second, we investigated associations between pathological/problem gambling and only some psychiatric conditions, because particular

8 628 Soc Psychiat Epidemiol (2010) 45: disorders, such as psychotic disorders, somatoform disorders, and eating disorders were of low prevalence (0.5, 1.2, and 0%, respectively). KECA-study assessed most DSM- IV psychiatric disorders using K-CIDI and additional modules, but, as explained above, our need for statistical power forced us to not divide anxiety disorders into subcategories, such as obsessive compulsive disorder, posttraumatic stress disorder, panic disorder, agoraphobia, social phobia, generalized anxiety disorder, and specific phobia (0.6, 1.2, 0.2, 0.2, 0.5, 0.7, and 3.8%, respectively). Finally, there were too few pathological to permit us to explore current or 1-year prevalence rates, and therefore only lifetime prevalence rates were examined. 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