J Gambl Stud (2015) 31:1245–1255

DOI 10.1007/s10899-014-9518-6

ORIGINAL PAPER

A Longitudinal Examination of Depression Among

Gambling Inpatients

Jacquelene F. Moghaddam • Michael D. Campos • Cynthia Myo •

Rory C. Reid • Timothy W. Fong

Published online: 27 December 2014

Ó Springer Science+Business Media New York 2014

Abstract Problem and pathological gamblers demonstrate high levels of depression,

which may be related to coping styles, reactive emotional states, and/or genetics (Potenza
et al., Arch Gen Psychiat 62(9):1015–1021, 2005; Getty et al., J Gambl Stud
16(4):377–391, 2000). Although depression impacts treatment outcomes (Morefield et al.,
Int J Men Healt Addict 12(3):367–379, 2013), research regarding depression among
gamblers in residential treatment is particularly limited. This study attempts to address this
deficit by examining the course of depressive symptoms among clients at a residential
gambling program in the Western United States. Forty-four adults were administered a
weekly measure of depression (Beck Depression Inventory-II, BDI-II) for eight consecu-
tive weeks. Levels of depression were classified into three groups based on standard
scoring criteria for the BDI-II: no/minimal, mild/moderate, and severe depression. Results
from a mixed-model analysis indicated a main effect for group and time, as well as an
interaction between group and time. Examination of the slopes for the rate of change for
the three depression groups indicated no change in the non-depressed group and a decrease
in depression scores over time for both the mild/moderate and severely depressed groups.
The slopes for the two symptomatic depression groups were not significantly different,
indicating a similar rate of change. We speculate that reductions in depression symptoms
may be related to feelings of self-efficacy, environmental containment/stabilization, and
therapeutic effects of treatment. These results help to illuminate the role of significant
processes in residential treatment, including initial stabilization, insight, self-efficacy, and
termination.

Keywords Pathological gambling
Problem gambling
Residential gambling treatment

Depression
Beck Depression Inventory-II

J. F. Moghaddam (&)
M. D. Campos
C. Myo
R. C. Reid
T. W. Fong

University of California Los Angeles (UCLA) Gambling Studies Program, UCLA Department of
Psychiatry and Biobehavioral Sciences, 760 Westwood Plaza, Suite 38-181, Los Angeles,
CA 90095-1759, USA
e-mail: Jacquelene@post.harvard.edu

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Introduction

Problem and pathological gamblers have high rates of depression in comparison to the
general population (Rizeanu 2013; Kim et al. 2006), with as many as 75 % of compulsive
gamblers endorsing major depressive symptoms (Rizeanu 2013). In population studies,
pathological gamblers are more than three times at risk for developing a major depressive
episode during their lifetime compared to non-pathological gamblers (Petry et al. 2005).
Reasons for high rates of depressive symptoms among those with gambling disorders may
include a shared genetic predisposition for both a gambling disorder and major depression
(e.g., Potenza et al. 2005), dysfunctional coping styles involving avoidance/escapism,
impulsiveness, and reactive negative emotional states which are depleting (Getty et al.
2000) and the associated impact of negative consequences commonly linked to problem
gambling. Clinically, the co-occurrence of major depression is relevant in that it negatively
impacts treatment outcomes including higher rates of attrition and diminished response to
therapeutic interventions (Morefield et al. 2013).
Previous research has suggested several possible relationships between gambling
problems and depressive symptoms. For example, mood symptoms may be a precipitating
risk factor for gambling disorders predating gambling behaviors which are subsequently
used to alleviate depressive mood states. A second theory postulates that gambling
behavior and its consequences result in depressive symptoms (e.g., Hills et al. 2001). For
example, in a cohort of patients admitted to a hospital-based gambling treatment program,
gambling was found to be pre-existing in over 80 % of patients with co-occurring
depression and gambling (McCormick et al. 1984). Thus, depressive symptoms may stem
from issues including difficulties at work, problems with social and family relationships,
and financial stress due to gambling losses. Moreover, the shame and guilt the gambler
may feel as a result of his/her behavior can contribute to depressive symptoms. Conversely,
some have suggested there is no relationship between problem gambling and depression,
particularly among non-treatment seeking community samples (Thorson et al. 1994).
The relevance of examining relationships between problem gambling and depression
cannot be underestimated. Indeed, given some evidence that gambling disorders co-
occurring with depression have the potential to impact trajectories in treatment, it is
important to further elucidate this relationship (Morefield et al. 2013). Specifically,
depression severity has been associated with the persistence of gambling symptoms both
during and post residential treatment (Morefield et al. 2013). Prior studies have emphasized
the assessment of depression for prevalence and descriptive data to demonstrate depression
rates in a respective gambling sample (often at baseline) as well as the severity of
depression symptoms related to gambling behaviors. However, few studies of gambling
treatment have included depression measures as a systematic index of change over time,
and if included, are instituted sometime during the following time points: baseline, end of
treatment and the post-treatment follow up period (Morefield et al. 2013; Smith et al. 2010;
Hodgins et al. 2005).
Consequently, changes in depressive symptoms which may occur during the in-treat-
ment period have not been documented in these cases. In their review of published studies
on mood disorders and pathological gambling, Kim et al. (2006) indicated that of the 15
studies included in the review, all utilized a cross sectional design, meaning that when
depression rates were cited, they did not capture clinical change over time. Studies which
longitudinally assess depression in treatment are important because they help to inform of
the nature of the relationship between gambling symptoms and depression. These patterns
may be able to tell us how depression can impact the clinical, social, and interpersonal

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presentation of inpatient gamblers which vary depending on the severity of the depression
as well as how depression symptoms of varying intensities respond to a specific time
period of residential treatment and their association with various interventions. For
example, the trajectory of outcomes for gambling disordered patients with and without
depression has the potential to influence allocation of resources including length of
treatment periods. Thus, the paucity of research in this area in previous studies warrants
further investigation of problem gambling and depression. Our study aims to address this
deficit by assessing the course of depressive symptoms for a group of patients who were
enrolled in a residential treatment program for their gambling.

Methods

Participants and Treatment

We gathered data from 44 adults receiving inpatient treatment for problem gambling at a
residential treatment center in the Western United States. Participants met criteria for
pathological gambling (DSM-IV) and received services through a state-funded treatment
program for gambling disorders. This program offered 8 weeks of residential treatment for
those who qualified. Treatment consists of 16 weekly hours of gambling-specific pro-
gramming and together with their individual counseling and therapy, programming aims to
address financial repair, career advising, wellness, and family education (if desired).
Although programming is primarily cognitive behavioral (and group) oriented, therapeutic
approaches also include 12-step, such as Gamblers Anonymous and Alcoholics Anony-
mous, as well as Dialectical Behavioral Therapy, Mindfulness Based Relapse Prevention,
and Motivational Interviewing. If clients sought further treatment services beyond the
8-week period, alternate financial support was found.

Measures

Beck Depression Inventory-II

The Beck Depression Inventory II (BDI-II) is a 21-item scale which assesses depression
symptoms, including suicidal thoughts or wishes, feelings of guilt, and pessimism. The
BDI-II has been normed and validated on psychiatric inpatients and outpatients, including
adolescents (Steer et al. 1999, 2000; Krefetz et al. 2002) and has yielded high internal
consistency indices for these populations (a = 0.90–0.92). BDI-II items are endorsed on a
scale from 0 to 3 with a ‘‘3’’ indicating the greatest disability for a given item. Total scores
for the instrument range from 0 to 63. The BDI-II utilizes cut offs based on the total score
to determine placement into one of four depression groups: minimal depression: 0–13, mild
depression; 14–19; moderate depression: 20–28, and severe depression: 29–63. Whereas
we employed categorical BDI-II groupings derived from the initial assessment of
depression scores, BDI-II scores were treated as a continuous variable in the depression
analyses throughout the treatment period. The use of BDI-II grouping categories over time
has implications for clinical decision making and may provide data on the course of
symptoms for individuals endorsing severe, mild/moderate, and non-depression, respec-
tively. The application of the BDI-II grouping may also provide clinicians with standard
reference points from which to conceptualize the groups considered in this study in other
clinical contexts. Regarding research, group-based analysis of the BDI-II (as opposed to

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empirically derived) scores were selected because of their generalizability and replicability
properties in possible subsequent analyses as well as a reflection of our sample size.

National Opinion Research Center DSM Screen for Gambling Problems (NODS)

We used an adapted 10-item version of the NODS utilizing the DSM-IV criteria for
pathological gambling. This version of the NODS is based on the original 17-item, semi-
structured interview (Gerstein et al. 1999) used to assess gambling problems and shown to
be clinically valid and reliable in the screening of gambling-related disorders among
treatment seeking gamblers (Hodgins 2004; Wickwire et al. 2008). All NODS items are
scored dichotomously (yes/no). Total scores on the NODS range from 0 to 10 with higher
scores indicating increasing gambling pathology. Participants who answered positively to
five or more items on the NODS were classified as pathological gamblers.

Procedures

All study materials and procedures were approved by the Institutional Review Board of our
host university and the State of California human subjects review board. BDI-II data were
collected weekly in groups from patients from May 2013 through May 2014. The com-
pletion of the instrument was integrated into regular programming. Those who gave
consent to participate in treatment services were approached and requested to complete a
BDI-II on a weekly basis; however, some participants did not complete a questionnaire for
a given week(s) due to concurrent therapy appointments, employment obligations, etc.
Because the BDI-II was originally designed to assess depressive symptoms over 2 weeks
and data were collected weekly, we instructed the participants to complete the instrument
using a 1-week time frame, rather than the traditional 2-week time frame. Participants were
instructed to write only their initials on the BDI-II, rather than their full names. Once
completed, the questionnaires were collected by the researcher and brought to our offices
for scoring, data entry and analysis.
An intake coordinator at the treatment program administered the NODS on an indi-
vidual basis from early 2013 through May 2014 as part of the intake process. NODS data,
and information collected as part of the intake process, were utilized to help establish
baseline gambling pathology characteristics among participants (Table 1). NODS data and
intake data were entered into an online, secure data management system (DMS) where
participants were identified by a unique patient identifier. The DMS was later accessed by
the researchers to obtain NODS data for analysis (Fig. 1 and Table 2).

Analyses

Because we had repeated measures nested within participants, had missing data points, and
our sample was small, we employed a mixed-effects model with an auto-regressive vari-
ance component and used restricted maximum likelihood for the estimation of variance
components. The auto-regressive variance component accounts for the stronger correla-
tions between time points which are close together and accounts for decay in the corre-
lations for time points which are farther apart. The restricted maximum likelihood
approach to estimating variance components accounts for lost degrees of freedom resulting
from testing fixed effects (Harville 1977). In order to test differences between slopes we
used t tests comparing the obtained slope for each group against a test value of zero.

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Table 1 Sample demographics

Variable N or mean % or SD
and background characteristics
Age 48.2 14.8
Gender
Male 16 66.7
Female 8 33.3
Race
Caucasian 22 91.7
Non-Caucasian 2 8.3
Married 6 25.0
Education
[High school 2 8.3
High school/GED 10 41.7
Some college 6 25.0
College graduate 5 20.8
Professional Degree 1 4.2
Employment
Full/part time 4 16.7
Unemployed 20 83.3
Income
[$9,999 7 29.2
$10,000–$14,999 3 12.5
$15,000–$24,999 3 12.5
$25,000–$34,999 0 0.0
$35,000–$49,999 3 12.5
$50,000–$74,999 4 16.7
$75,000–$99,999 0 0.0
$100,000–$149,999 3 12.5
$150,000 or more 1 4.2
Intake NODS score 9.3 1.1
Gambling activities
Baccarat 1 4.3
Bingo 2 8.7
Black jack 7 30.4
Craps 1 4.3
Dog racing 2 8.7
Horse racing 5 21.7
Lottery 3 13.0
Poker 13 56.5
Roulette 1 4.3
Slots 8 34.8
Sports 7 30.4
Stocks/financial 1 4.3
Video Poker 2 8.7
Other 5 21.7

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Table 1 continued
Variable N or mean % or SD

Mean gambling debt

Casinos 945 4,259
Credit card 13,850 24,118
Family/friend 119,400 352,732
Other debt 7,186 22,081

45

40

35

30

25

20

15

10

0
1 2 3 4 5 6 7 8

-5
Severe Mild/Moderate No/Minimal

Fig. 1 Mean BDI-II scores with 95 % C.I. bars by depression group and week

Finally, we tested for a difference between slopes by level of depression using a t test for
the slopes of the mild/moderate versus the severe-depression groups.

Results

The demographic composition of our sample is presented in Table 1. The mean (SD)
age for our sample was 48.2 (14.8). Participants were primarily male (66.7 %), Cau-
casian (91.7 %), and about half had some college education or more. About 83 % were
currently unemployed and total annual income in the year prior to treatment was most

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Table 2 Means and standard

Week No/minimal Mild/moderate Severe
errors for BDI-II scores by week
and depression group
1 6.9 (2.3) 21.5 (2.1) 35.2 (3.1)
2 10.5 (3.2) 15.2 (3.5) 31.1 (3.4)
3 10.5 (2.9) 10.1 (4.7) 29.3 (3.2)
4 14.8 (2.9) 16.2 (2.8) 24.3 (3.4)
5 8.4 (3.4) 8.6 (5.6) 22.0 (4.2)
6 7.0 (3.7) 11.8 (4.1) 26.4 (3.4)
7 9.9 (3.7) 12.0 (4.1) 28.2 (4.8)
8 8.1 (3.5) 11.0 (3.3) 19.2 (4.2)

frequently reported as \$10,000 (29.2 %). The next most frequently reported level of
past annual income was $50,000–$75,000 (16.7 %). Approximately 12.5 % of the
sample reported incomes in the following ranges: $10,000–$15,000; $15,000–$25,000;
$35,000–$50,000; $100,000–$150,000. One individual (4.2 %) reported an income of
$150,000 or more. The mean NODS score was 9.3 out of 10; most individuals reported
playing poker, slots, black jack, or wagering on sports. These categories were not
mutually exclusive; participants may have played more than one type of game. The
highest mean debt was to family/friends and the average loss in the last 30 days was
$25,295.
There were a total of 16 individuals in the non-depressed group, 19 in the mild/moderate
depression group, and nine in the severe depression group. We calculated our effective
sample size using the method described in Bickel (2007); based on an average of 55
observations per group, a design effect of-6.34, and a total number of data points of 165,
our effective sample size was 26. Examination of Akaike’s information criteria for models
with unstructured, compound symmetry, and auto-regressive variance components sup-
ported our use of an auto-regressive approach. Because we grouped our subjects by level of
depression, we were not interested in the group effect. Rather we focused on the time
[F(1, 115.7) = 6.56, p = 0.012] and time by group interaction effect [F(2, 115.2) = 4.21,
p = 0.017], both of which were significant. Examination of the slope for the non-depressed
group (0.505) indicated that it was not significantly different from zero [t(115.2) = 0.87,
p = 0.387]. A significant negative slope (-1.473) for the mild/moderate depressed group
[t(110.5) = -2.59, p = 0.011], and a significant negative slope (-1.825) for the severe
depressed group [t(119.1) = -2.51, p = 0.013] indicated reductions in depression over time
for these two groups. The difference in slopes (-0.352) for the mild/moderate versus
severely depressed groups was non-significant [t(115.8) = -0.38, p = 0.704], indicating
that BDI-II scores declined at approximately the same rate across the 8 weeks for which we
had data.

Discussion

The aim of this study was to further investigate the nature of depression throughout the
course of residential gambling treatment. To this end, we examined in-treatment depres-
sion symptoms over 8 weeks in a sample of individuals with gambling disorder in resi-
dential treatment. Upon initial assessment, a notable percentage of our sample endorsed
depressive symptoms. Analysis of change over time via testing the slopes for depression
scores across weeks indicated that the non-depressed group remained so; however, the

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mild/moderate and severely depressed groups showed a significant reduction in depressive

symptoms from baseline to week eight. We hypothesize that the observed change in
depression scores may be related to stabilization in the treatment environment, self-effi-
cacy, cognitions related to gambling consequences, and attachment styles.

Severe and Mild/Moderate Groups

We speculate that the underlying pattern showing a decrease in depression scores across
the 8 weeks of treatment in the severely depressed and mild/moderate groups is likely
multifactorial. This symptom improvement may be related to a stabilization of living
environment, newly developing rapport with clinical personnel via formal and informal
therapeutic interactions and self-efficacy after making an active step in recovery in an
area that has been problematic. Hodgins (2001) referred to ‘‘self-liberation’’ as ‘‘com-
mitting oneself to action and reminding oneself that success is possible’’; self-liberation
is one of the most vital mechanisms for behavior change in recovered gamblers. Fur-
thermore, therapeutic alliances with clinicians, coupled with the delivery of cognitive
behavioral therapy, have been identified as some of the most significant predictors of
clinical change in individuals with depression (Krupnick et al. 1996; Castonguay et al.
1996). Conversely, social isolation has been associated with lower GAF scores in psy-
chiatry inpatients (Zeeck et al. 2009). This is notable as initial immersion in treatment
programming at this residential treatment program entails formal clinical programming
such as 12-step meetings and socially enriching activities including camping trips and
community service projects.
Additional sources for gains may be related to the therapeutic effect of individual or
group psychotherapy (Krupnick et al. 1996; Castonguay et al. 1996), feelings of self-
efficacy due to sustained enrollment in treatment (Hodgins 2001), as well as aforemen-
tioned contextual factors, including a stable and supportive living environment.
In residential addiction populations, impaired attachment styles have been associated
with higher BDI-II scores (De Rick and Vanheule 2007; De Rick et al. 2009). While formal
indices of attempt were not included in this study, it is possible that unresolved attachment
issues may have resulted in more sustained negative affect in individuals with severe
depression. At the end of 8 weeks of treatment this group still had a mean BDI-II score
suggestive of notable depression symptoms.

No/Minimal Group

The slope for change in depression scores for the no/minimal depression group was not
significantly different from zero. The lack of change in depression scores is interesting in
that one might expect increased depressive symptoms to occur with the awareness of one’s
gambling-related consequences. Increased insight may arise from group therapy, individual
processing with a clinician, or self-reflection in a 12-step context. Gamblers are often
motivated to seek treatment because of their ‘‘gambling related harms’’ including financial
problems, compromised personal relationships, and work and legal issues (Suurvali et al.
2010). Cognitive processes related to gambling consequences, including shame and effects
of gambling on others, are also associated with process of change in gamblers and sus-
tained recovery (Hodgins 2001). Therefore, while the gambler may be conscious of their
past actions pre-treatment, and may be motivated to engage with treatment because of their

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past, one might expect that the therapeutic environment may serve as a catalyst for
depressive symptoms for individuals in the minimal depression group.

Limitations

This study is subject to a number of limitations. First, the results presented here cannot
be generalized to all problem or pathological gamblers. As stated in the ‘‘Methods’’
section, our sample reflects a specific population of the US in regards to age, race,
socioeconomic status, geographic location, etc. Furthermore, the design of our study was
naturalistic, and all interventions delivered by the treatment center, including medica-
tions, were not controlled for in our analyses. Additionally, a true control group design,
in which treatment for depression was either withheld completely or offered in a
modified format in order to compare the therapeutic effects of programming at this
residential program is limited by ethical concerns and a duty to provide clinically sound
treatment as soon as it is available. Another limitation of the current study may be a
testing effect for the BDI-II. Previous work (Arrindell 2000; Sharpe and Gilbert 1998)
has identified testing effects for the BDI, with BDI scores decreasing in subsequent
administrations relative to baseline. Among the reasons proposed by the aforementioned
authors for this effect is socially desirable responding. We attempted to reduce socially
desirable responding by ensuring anonymity.
Finally, we were also limited in our ability to detect gender differences in relation to
changes in depression over time. Although comparable to the (annual) sample sizes in
other studies of residential treatment (Morefield et al. 2013), it did not allow for separate
analysis of males and females. Nonetheless, this paper provides valuable and rare infor-
mation on the longitudinal nature of depression in a residential gambling treatment
program.

Conclusion

Our results indicate that in this sample of inpatient gamblers, there was a significant
reduction in depressive symptoms across the 8 weeks of treatment for both the mild/
moderate and severely depressed groups. Furthermore, these two groups showed similar
rates of change over time. The no/minimal depression group showed no significant change
in depressive symptoms over time. These findings suggest the possibility of an impact of
treatment on depressive symptoms for those who enter residential treatment with either
mild/moderate or severe levels of depression. The observed changes in depressive symp-
toms may be related to self-efficacy about engaging in gambling treatment, therapeutic
effects of treatment for gambling, and other factors related to stabilization and contain-
ment. Furthermore, future studies should consider gender in the analysis of depressive
symptoms among gamblers. Nevertheless, these results help to depict the longitudinal
pattern of depression over time in gamblers receiving residential treatment services for
their gambling, including clarifying the role of important milestones in residential treat-
ment including initial inpatient treatment adjustment, rapport with clinicians, insight, self-
efficacy and termination.

Acknowledgments We thank Dr. Richard Rosenthal and Yael Landa, M.A., whom aided in the prepa-
ration of this manuscript. At the time of the study, Jacquelene Moghaddam, Ph.D. was a Scholar with the

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HIV/AIDS, Substance Abuse, and Trauma Training Program (HA-STTP), at the University of California,
Los Angeles; supported through an award from the National Institute on Drug Abuse (R25 DA035692).

Conflict of interest The authors declare that they have no conflict of interest.

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