Prevalence, clinical, and sociodemographic correlates of gambling disorder in alcohol use disorder patients: A cross-sectional study

INTRODUCTION

The co-existence of gambling disorder (GD) significantly affects the treatment goals of alcohol use disorder (AUD).^[1-3] Whether through a causal relationship or shared third variables, the untreated presence of pathological gambling (PG) alongside AUD demands comprehensive treatment approaches. Recognition of this interconnectedness is vital for optimizing treatment strategies and improving the overall therapeutic efficacy of AUD.^[4] The coexistence of gambling and alcohol use has been reported across the world.^[5-8] Gambling in India has been a common and socially acceptable leisure activity for ages.^[9] Gambling persisted in different forms and currently lotteries are legal in 12 states and 5 union territories though banned in others.^[10] Other forms that are highly prevalent are rummy, cricket (Indian Premier League) gambling, and gambling during different festivals.^[9] In Western countries, large population-based studies have revealed that more than half of the population is engaging in different forms of gambling though only <5% engage in PG.^[11,12] Evidence on PG is limited in the Indian context.^[13-16] In India, though community-based studies regarding GD are lacking, indirect evidence suggests that the reported magnitude and burden are only the tip of the iceberg.^[14]

PG was initially included under Impulse Control Disorder in the International Classification of Diseases (ICD)-10 and Diagnostic and Statistical Manual (DSM)-IV (ICD-10, 1994) (DSM Fourth Edition, Text Revision, 1987). With the emerging epidemiological and neurobiological research, GD has also been included under addictive behavior in ICD-11 and DSM-5.

The existence of PG among alcohol users is reportedly associated with worse outcomes and significant complications in the form of higher medical and psychiatric disorders (mood disorder, attention-deficit hyperactivity disorder, and suicide) and psychosocial issues in terms of family disruption, violence, and criminal activities.^[7,17] In the COVID-19 era, due to the revenue deficit, many of the states in India are turning toward alcohol to substitute their revenue deficit.^[18] This increases the chance of potential public health importance of AUD and comorbid problem gambling. In this background, the current study tried to estimate the prevalence, sociodemographic, and clinical correlates of problematic gambling behavior/GD in AUD patients in the psychiatry outpatient department (OPD) of a tertiary care hospital in eastern India.

MATERIALS AND METHODS

RESULTS

From the pool of 246 eligible patients from the hospital records, we approached 205 patients based on a random selection process and finally recruited 153 participants in the study. Fifty-two patients (25.4%) were excluded due to various reasons including the death of the participants (n = 2, 1%), unreachable over the telephone (n = 17, 8.3%), refusal to take part in the study (n = 13, 6.3%), and expression of inability to visit the psychiatric OPD physically due to various logistic reasons (n = 20, 9.8%).

The mean age of the participants was 38 years (SD 11.3 years). The majority of the participants were males (n = 150, 98.0%), Hindus (n = 149, 97.4%), unskilled laborers (n = 72, 47.1%), and married (n = 112, 73.2%) [Table 1].

The median AUDIT score of the participants was 18 (IQR 13–21). The majority of them (n = 111, 72.5%) belonged to the harmful use (AUDIT score 15–19) or alcohol-dependent (AUDIT score ≥20) category. The mean age of onset of alcohol use is 21.8 years (SD 6.8 years) and the median duration of AUD is 6 years (IQR 4–10 years) [Table 2]. Gambling is ever practiced by 40 (26.1%, 95% CI: 19.0–33.2%) participants. The types of gambling include lotteries (n = 29, 19.0%), pokers (n = 7, 4.6%), slots (n = 6, 3.9%), cricket matches (n = 4, 2.6%), and cards (n = 1, 0.65%). The prevalence of problematic gambling (satisfying minimum four criteria as per DSM-5) behavior in AUD patients was 14.4% (n = 22; 95% CI: 8.7–20.1%). The rest of the 18 (11.7%) participants satisfied three or less than three criteria.

The median PG-YBOCS score among the patients with problematic gambling behavior was 19 (IQR 16–23). Among them, three (13.6%) were mild, 15 (68.2%) were moderate, and four (18.2%) were in severe grade as per the PG-YBOCS score.

From multivariate analysis, we found that problematic gambling is associated with a duration of AUD more than 6 years (aOR 4.2; 95% CI: 1.2, 14.5; P = 0.04). The other variables including young age (<30 years) (aOR 1.2; 95% CI: 0.2, 6.9; P = 0.53), married people (aOR: 1.04; 95% CI: 0.2, 4.6; P = 0.67), and associated medical comorbidities (aOR: 2.1; 95% CI: 0.8, 5.7; P = 0.11) were statistically not significant [Table 3]. All the participants with problematic gambling behavior belonged to participants with increasing severity of AUD (AUDIT score ≥15), and none had an AUDIT score <15. A few variables such as individual annual income <2 lakh rupees (odds ratio [OR]: 1.06, 95% CI: 0.4, 2.7; P = 0.9), education up to middle school (OR: 1.5, 95% CI: 0.6, 3.8; P = 0.37), and current tobacco use (OR: 0.6, 95% CI: 0.2, 1.4; P = 0.21) were not included in the final model as P-values were >0.2 in univariate analysis.

DISCUSSION

In this cross-sectional hospital-based study, we have estimated the problematic gambling behavior among patients with AUD and examined the determinants of the co-existence of two conditions. Findings show that one out of seven treatment-seeking AUD patients has gambling behavior. We also found that the duration of AUD is the strongest predictor of GD in this setting.

Earlier evidence from India suggests that the practice of gambling behavior among AUD patients varies between as low as 3.7% and as high as 65.2%.^[13,15,16] The prevalence of 26.1% of gambling behavior is comparatively higher than the global average of 14% among substance use disorder (SUD) patients.^[21] Nevertheless, the prevalence of gambling is almost 4 times higher than the prevalence among general populations in India.^[14]

The discrepant prevalence observed may stem from various factors. It is widely acknowledged that gambling behavior is influenced by the cultural backgrounds of different populations.^[22] In addition, the legal framework for gambling exhibits considerable variability across different Indian states, potentially impacting the obtained results.^[10] Beyond legal provisions, methodological variations in individual studies contribute to the observed differences. For instance, one study conducted in Goa, India, where gambling is socially and legally acceptable, adopted a community-based approach, while others were based in tertiary-level addiction treatment centers. Notably, differences extend to sample recruitment methods and the use of screening/diagnostic tools, as documented in the gambling literature.^[12,23] Furthermore, disparities in the prevalence and patterns of AUD and SUD exist throughout the country, as evidenced by successive epidemiological studies.^[24] The current study also explored the symptomatology of GD and reported 13.6% as mild, 68.2% as moderate, and 18.2% as severe among the problematic gamblers as rated by the PG-YBOCS score.

The majority of our participants reported engaging in various forms of gambling, with playing the lottery being the most prevalent, followed by poker, slots, cricket matches, and cards – patterns that align with findings from existing Indian studies. For instance, a study in North India^[16] identified playing cards and numbers/lottery as the most common forms of gambling, while another study in Goa highlighted lottery and “Matka” gambling.^[13,16] The consistent popularity of diverse gambling activities across different regions of India may be attributed to the legal status of gambling in 12 states, including West Bengal, where it is permitted while being banned in the remaining 17 states (The Lotteries Regulation Act, 1998). Notably, over the past few years, sports betting has emerged as a thriving illegal betting scene in India,^[25] a phenomenon also reported by 2.6% of our participants.

The limitations of our study include the dropout of the registered patients who were called for follow-up but did not turn up. As we were unsure if the patients failed to follow up due to alcohol-related problems or not, the burden of PG is expected to be underestimated in our study. This might have biased the estimation and the lack of generalizability to the entire population as it has been conducted in a tertiary care setting among the treatment seekers of AUD. Furthermore, the estimate of PG is based on those who are under treatment for AUD and does not include AUD patients, who are unrecognized and do not seek treatment, thus increasing the possibility of underestimation of the actual burden.

CONCLUSION

The study aids in understanding the problem of gambling and its association with AUD in eastern India where there is a dearth of existing studies. The GD is common in this setting. Overall gambling behavior is a majorly overlooked issue in the clinical practice as well as a research priority in India. Future studies are recommended to gather credible evidence on gambling encompassing epidemiological, social, moral, and legal perspectives of gambling in Indian context. Simultaneously, clinicians may consider co-existence of PG while treating AUD, as unrecognized PG behavior may hinder the treatment outcome in these patients.