Intersections Between Gambling, Substance Use, and Mental Health Challenges Among Veterans and Promising Treatment Approaches

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1 Intersections Between Gambling, Substance Use, and Mental Health Challenges Among Veterans and Promising Treatment Approaches Troy Robison, PhD VA Puget Sound, American Lake Division Tracy Simpson, PhD VA Puget Sound, Center of Excellence in Substance Abuse Treatment and Education University of Washington, Dept. of Psychiatry & Behavioral Sciences Focus on the Future, Evergreen Council on Gambling Vancouver, WA May 2, 2018

2 Introductions Who we are Getting to know you What you are hoping to get from today s presentation on Veterans How you hope this workshop can help you in the work that you are doing to treat gambling

3 By the end of today s presentation you will... Know the rates and epidemiology of gambling among Veterans Understand co-occurring concerns and challenges for Veterans Identify effective ways of treating gambling problems with Veterans

4 What is the draw? Brainstorm gambling positives The gambling itself. The trappings.

5 Overview of Gambling Disorder Changes from DSM-IV to DSM-5 Moved from compulsive disorder to addiction Lowered threshold Removed illegal acts criteria Gambling Disorder in DSM-5 Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by at least 4 of the following in a 12month period:

6 Overview of Gambling Disorder Needs increasing amounts of money in order to achieve the desired excitement. Restless or irritable when attempting to cut down or stop gambling. Repeated unsuccessful efforts to control, cut back, or stop gambling. Preoccupation with gambling (e.g., reliving past gambling experiences, planning next time, thinking of ways to get money). Gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed) After losing money gambling returns another day to get even ( chasing losses). Lies to conceal the extent of involvement with gambling. Jeopardized or lost a relationship, job, educational or career opportunity because of gambling. Relies on others to provide money to relieve financial situations caused by gambling.

7 Overview of Gambling Disorder Severity Mild: 4 5 criteria Moderate: 6 7 criteria Severe: 8 9 criteria Other common classifications: Recreational Problem Pathological

8 Overview of Gambling Disorder Addiction or Compulsion?

9 Gambling in the PNW Washington 2.1% (107,606) #19 ($2.71b) 28,007 EGM / 26 casinos Oregon 2.2% (66,655) #29 ($1.52b) 19,536 EGM / 9 casinos Does availability of gambling lead to problem gambling?

10 Rates Among Veterans Rates of gambling for Veteran s higher than general population % of service members endorse gambling problems 2% lifetime for any VA facility (Whiting et al. 2016) % for Vietnam Era Veterans (Eisen et al. 2004) Highest estimate is 20% in U.S. military Veterans (Hierholzer, 2010) 35% assessed as recreational gamblers Spending average of $79/mo; range $ ; median $25/mo 1. Lottery, 2. Slots, 3. Pull tabs 2.2% assessed as at risk problem gamblers Spending average of $472/mo; range $2-10,000; median $200/mo 1. Slots, 2. Cards, 3. Animal betting

11 Rates Among Veterans Receiving VA Care Treatment Seeking Populations Higher rates of gambling 16.5% Inpatient Psychiatric 28% problem 12% pathological Mental Health 0.2% (indicating lack of assessment) Protective: OEF/OIF, PTSD, dementia Predictive: Homelessness, mental health diagnosis, income more than $25k

12 We Want You to Gamble

13 Veteran Demographics Younger Veteran s slightly higher risk Relation of age to stability, service connection, disability status. Male Native American, Black, Hispanic Served in Navy VA primary source of medical care More likely to be retired 30% unemployed, 20% Social Security Disability, 13% Service Connected Divorced, separated, or single (88%) Genetics account for 35-54% of gambling liability. Children of gambling parents were 3x-12x more likely.

14 Veteran Co-occurring Concerns Substance Use Disorder 22-33% Depression 76% 40% Past suicide attempt 66% among those in residential treatment PTSD 30% Gambling Veterans have higher rates of PTSD (Whiting, 2016; Whyte, 2014) PTSD does not predict gambling (Levy & Tracy, 2018) Cumulative trauma burden, Witnessing death/injury, NOT combat (Scherrer et al, 2007)

15 Veteran Co-occurring Concerns Homelessness Strongest correlates of Veteran homelessness 1. Illicit Substance Use 2. Problem gambling 3. Alcohol Use 4. Personality Disorder PTSD, Anxiety, Depression, Dementia all protective Service Connection (>50%) decreased risk by 66%

16 Gambling on Active Duty Gambling allowed on U.S. military bases Introduced in 1930s Removed in 1970s Reintroduced in the 1980s 2016 = 3148 EGM / $108m annually Rationale? Recreation & Morale, Wellness, and Recreation programs

17 Gambling on Active Duty Impact? Increased payout of Electronic Gambling Machines (EGMs) on bases 90-94% (Vegas = 75%) Argued to have no significant impact 2015 NDAA required study Low findings Not enough screening for it Dept of Defense (1998, 2000, 2002) 5-9% problems; 2% pathological Between there was a 66% increase in addicted gambling according to US Dept of Commerce (Kindt, 2007) Estimated that 36,000-48,000 military personnel may have gambling problems (Whyte, 2011).

18 Overall Rates & Co-occurring Concerns Prevalence Ranging anywhere from % (including problem & pathological ).5 2% meet criteria for Gambling Disorder (Shirk et al 2018) Problem gamblers spend median of $400/mo Pathological gamblers median of $2000/mo Frequent associated concerns Substance use, depression, anxiety, relationship breakdown, unemployment, crime, bankruptcy, & suicide (Hodgins et al. 2011).

19 Gambling Residential Treatment Program Louis Stokes VA Cleveland Ohio (formerly at Brecksville campus) Dr. Heather Chapman, PhD (Director) 6 week residential program

20 Puget Sound Outpatient Gambling Treatment Puget Sound VA American Lake Division (Tacoma, WA) Addiction Treatment Center Weekly group Open enrollment, no session limit

21 Cognitive Therapy Cognitive therapy for gambling frequently focuses on teaching randomness, increasing awareness of inaccurate perceptions and restructuring erroneous gambling beliefs (Smith, Battersby et al 2015) Cognitive Distortions By definition, games of chance have random outcomes, beyond gamblers control Many experience false sense of personal control and distorted beliefs about factors such as randomness, continuing to gamble despite accumulating losses (Wohl et al, 2007) Cognitive dysfunction may be present at low levels of gambling, even before meeting full criteria for disordered gambling (Grant et al 2011).

22 Cognitive Therapy Cognitive distortions relevant to problem gambling (Toneatto, 1999). skill misperceptions illusion of control skewed temporal orientation superstitious beliefs selective memory interpretive biases Research shows distorted beliefs associated with bet size, persistence, severity, predictivity, game preference, and overall mental health (Delfabbro & Winefield, 2000; Joukhador et al, 2003; Continotti et al, 2004; Ledgerwood and Petry, 2005; Chamberlin et al, 2017).

23 Gambling Treatment: Cognitive Therapy Research on cognitive distortions in Veteran populations Cognitive distortions related to gambling diagnosis in Vietnam Era Twin Study (Xian et al., 2008). Even after controlling for genetics and shared environmental factor. Higher cognitive distortion score significantly associated with increased gambling severity. Elevated cognitive distortions also related to non-gambling diagnosis Substance Use, Depression, PTSD, and ASPD. The single best predictor of dysfunction from gambling was not severity of gambling but the severity of the cognitive distortions related to the disorder. (Shirk et al., 2018)

24 Gambling Treatment: Cognitive Therapy Unpacking.. Gamblers Fallacy Near Miss Effect Delay Discounting

25 Gambling Treatment: Cognitive Therapy Example of cognitive group exercise (Puget Sound VA)

26 Gambling Treatment: Motivational Motivational Enhancement Therapy & Motivational Interviewing Emphasis on identifying ambivalence and promoting behavioral change. Often done in conjunction with cognitive behavioral techniques to address distorted beliefs related to gambling. (Tolchard, 2017).

27 Gambling Treatment: Motivational Example of motivational intervention (Puget Sound VA)

28 Gambling Treatment: Mindfulness Meditative (or other) exercises aimed at increasing non-judging or present moment awareness Breathing Body scan Urge Surfing Metta (Loving Kindness) Shown to be somewhat effective for addiction, both substance and gambling (Williams, Russell & Russell, 2008; Chawla, Collin, & Brown, 2010; Alfonso, et al., 2011; McIntosh, Crino, & O Neil, 2016)

29 Gambling Treatment: Behavioral Contingency Management 3 major tenets of CM program (Petry, 2009) Frequent and objective monitoring of target behavior Provide tangible reinforcement for completion of target behavior Remove reinforcement if target behavior does not occur CM program for gambling treatment: Reinforcement (canteen vouchers, clinic privileges), escalating in value, for recovery activities (GA attendance, gym exercise, homework completion, aftercare groups, etc.) Should not use fishbowl draws as this may reinforce gambling. Cognitive therapy + Contingency management provided better outcomes for therapy attendance, homework completion, and GA attendance than CT alone (Weinstock, 2007).

30 Gambling Treatment: Pharmacological No current approved drug for Gambling Disorder Limited number of studies looking at gambling directly (Menchon et al., 2018) 3 classes of approach Antidepressants Opioid antagonists Mood stabilizers Paroxetine & Fluvoxamine found better than placebo (Kim et al., 2002; Hollander et al., 2000). Naltrexone & Nalmefene have shown significant improvement in GD (Piquet-Pessoa & Fontenelle, 2016)

31 Gambling Treatment Special treatment concerns:

32 Conclusion Questions? THANK YOU!