The major mood disorders include major depression and mania, plus milder versions of each. They are not the usual “ups-and-downs” or occasional “blues” that we all experience as part of life. They are forms of a “chemical imbalance” that result for various biological and/or environmental reasons.

According to the DSM-IV (American Psychiatric Association, 1994), major depression refers to a condition that has persistently occurred, for most of the day, nearly every day, for at least two weeks or more, in which one has clearly changed from one’s previous functioning level. Some of the common features to look for are

• persistently depressed mood and markedly diminished interest in activities that used to bring pleasure
• constant feelings of emptiness, feelings of worthlessness or excessive and inappropriate guilt based on unsubstantial evidence
• unusually reactive emotions
• significant weight change (e.g., more than 5% of original body weight) in a month
• problems falling asleep, or waking up too early, or marked oversleeping
• unusual fatigue, reduced libido, slowness in movements and thinking
• inability to concentrate or follow simple television programs, or restlessness that is uncharacteristic, observable by others
• recurrent thoughts of death, plans for suicide, or fantasies of easing the pain by “escaping this world”

The other major mood disorder is mania, the opposite of depression, a serious chemical imbalance. According to the DSM-IV (American Psychiatric Association, 1994), mania is characterized by an abnormally expansive, euphoric or irritable state that lasts over a distinct period of a week or more. Some common features during this period would include

• inflated self-esteem or grandiosity, believing one is invincible or “on top of the world”
• decreased or no need for sleep
• unusually talkative, often in a loud voice and at a fast rate, on topics that change without apparent connection to the listener
• slowness to recognize problem (i.e., client usually has very little insight into his or her condition, often feels others are unable to keep up with his or her speed and are jealous of his or her abilities)
• becoming “paranoid,” thinking that others are “out to get them” because they possess unusual talents or wealth
• being easily distracted, tending to focus energy on expansive goals, with fervent intensity
• irrational and reckless behaviour with painful consequences (e.g., unrestrained buying sprees, sexual indiscretions, dangerous driving, or foolish business investment, etc.)

While the research done on this subject is not strongly conclusive due to small sample sizes and poor designs, a few pieces of information suggest that there is a link:

• Roughly one-third of pathological gamblers have a biological parent or sibling with a major mood disorder (Roy et al., 1988; Linden et al., 1986)
• Close to 20% of formerly diagnosed pathological gamblers were still depressed in follow-up after stopping gambling and improving their other functions (Taber et al., 1987)
• Pathological gamblers in inpatient treatment setting have depression rates as high as 50%-75% (far above the population average of 10-25%) (McCormick et al., 1984; Linden et al., 1986).
• Pathological gamblers have higher rates of dysthymia (a milder, but chronic form of depression) than controls (Bland et al., 1993).
• Gamblers’ own reports show that they gamble to forget troubles, to avoid feelings of loneliness, depression, and stress — evidence that gambling serves as a way for gamblers to modify their internal state (Corless & Dickerson, 1989).
• Pathological gamblers have increased suicide rate, suicide ideation, number of negative life events (e.g., trauma, a risk factor for depression and suicide), and severity of self-reported depression symptoms (Dell et al., 1981; Morovec & Munley, 1983; Roy et al., 1988; Blaszczynski & McConaghy, 1989).

As part of the bipolar (or manic-depressive) illness, some notable evidence about mania:

• There is a substantial increase (i.e., 24%) of bipolar disorders in first degree relatives of pathological gamblers (vs. 1% in general population) (Linden et al., 1986).
• By self-report, many problem gamblers were found to have had a history of mania or hypomania (a milder version of mania).

Overall, the relationship between mood disorders and problem gambling is complicated but remarkable. Some sub-populations are likely affected more than others. Many gamblers may have mild to moderate mood problems (e.g., dysthymia) to start with, and seek the appeal of thrills and excitement as advertised and occasionally experienced in gambling, possibly to relieve the depressive feelings. Some problem gamblers may progress to the more severe form of a major depression. Once in that state, it is unlikely that they will enjoy the actions of gambling; however, many still go on gambling without being able to retract themselves. This should alarm the counsellor of serious mood disorders. In general, these clients are likely to fall into pathway 2.

There are several treatment issues, including how to recognize and screen mood disorders, when to refer to other mental health professionals and how to collaborate with a psychiatrist once the referral is made.

Screening for Mood Disorders
The client may or may not report mood problems, as he or she may think he or she is in treatment only for problem gambling. The counsellor should actively look for signs of a mood disorder regardless of the chief complaint. Other than clinical acumen, the dsm can be used as a rough guide for symptoms of a mood disorder. As well, some questionnaires are helpful (e.g., the Hamilton Rating Scale for Depression refer for assessment if more than a third of items are 2 or more. See Assessment and Screening Tools.

When to refer for a psychiatric assessment:

• when the client self-reports a concern for mood disorder, particularly if there is a family history
• when the clinician suspects mood disorder, with several dsm symptoms met and/or other questionnaires point to a problem
• when counsellors feel the need for consultation regarding difficult clients — others may have valuable experience or can learn from yours and share the burden
• medical evaluation: if the client has an unresolved medical illness, he or she should be referred — there are many medical conditions (e.g., thyroid conditions, hormonal imbalance, blood abnormalities, nutritional deficiencies, medication interactions, etc.) that can induce or mimic mood disorders
• unclear clinical picture: referring to psychiatric services can clarify differential diagnoses — some forms of dementia, psychotic disorders and anxiety disorders mimic mood disorders
• when client is responding inadequately over time to available treatment
• when client is presenting with significant and acute suicide risk
• when client is developing hallucinations or delusions (i.e., psychotic depression, a very serious form of depression)
• when client has significant disability from mood disorder, low social support, and other medical or substance abuses issues.

Some psychiatrists/physicians are reluctant to treat depressive symptoms in a problem gambler, attributing the symptoms to life or gambling crises. Others believe aggressively treating depression can not only improve mood, but also facilitate the effort to curtail impulses and compulsion to gamble. I favour the latter as the more useful approach, particularly with the newer antidepressants (serotonin-specific reuptake inhibitors, (SSRI): Prozac®, Luvox®, Paxil®, and Zoloft®), which appreciably improve mood and some of the core symptoms, without many significant side effects. There are also more recent encouraging developments in the treatment of mania.

Issues to Consider while Counselling

• Active counselling can curtail gambling and reduce depression — it has been shown that continued gambling worsens current mood disorders and predisposes the client to further and protracted mood disorders. Other consultants may not be available to see your client regularly. Thus, with acutely ill clients, it is better to engage clients at least twice a week. Some clients will claim that they are too weak or too busy to attend — discussing with the clients that active engagement with counselling is a critical part of the process to ensure success of treatment may help to motivate the client to make counselling more of a priority.
• Look for and point out mood symptoms that are not “situationally” or “geographically” related to gambling on a day-to-day basis. Help clients to realize how pervasive mood symptoms are so they can be more active in their own treatment.
• Reinforce the non-blaming therapeutic attitude by framing the mood disorders as a “chemical imbalance,” or neurochemical dysregulation of the brain. The illness does not reflect the client’s “weakness” or lack of willpower.
• Reinforce the benefits of treatment by advising that mood disorders will not disappear spontaneously (some may resolve in six to nine months, some go on indefinitely), and they will have significant negative impact if left untreated.
• Assess major cofounders such as substance abuse/dependence — the interrelationship of the three (i.e., gambling, mood disorders and substance) has the power to maximize each other’s negative effects. Refer for substance abuse assessment when indicated.
• Communicate all relevant findings to other professionals involved to maximize treatment efficacy. Obtain consent from client beforehand.
• Evaluate physical and psychological progress on an ongoing basis with feedback to clients to encourage them to be aware of change and impact. This is particularly relevant in the hypomanic/manic clients, whose insight into their illness is usually low.
• Ensure safety. Be alert to risk involved in self-harm ideas or intentions or plans (for depression); risk for violence, risk-taking behaviour, suicide (for mania) — treat any such warning with due caution.

Case study: Depression

Mr. A is a 40-year-old divorced physician who lives alone and works with different clinics on short contracts. Since his divorce two years ago, he has had a few unsuccessful relationships. Over the last few months, he has been distressed by a profound sense of purposelessness in his life. Feeling not quite like his usual self, he has noticed that he was not performing his work as efficiently and confidently as before, and easily bursts into anger over trivial matters. Others have joked about his sloppier appearance; he laughed it off, but could not muster enough energy to bother to change. He has surprised himself with teary eyes at the movies and had to hide his unexpected emotions from his friends. He has become more withdrawn and has noticed his energy and interests in reading, exercising and golfing waning drastically over the same period of time. However, he did develop one strong liking over this time — poker.

Having been known as a poor card player by his university friends, he had no trouble convincing himself that he was only playing for entertainment at the charity casinos. He found the intense atmosphere of the card table, the fantasizing of a perfect hand, the exhilaration of bluffing other players, and the triumphant feeling of an occasional winning hand irresistible. Though he almost always lost at the end of the night, he discounted the large losses as “educational money.” Playing made him forget his malaise and general “slump.” Soon, he was visiting casinos almost every night, constantly thinking about last night’s hands and planning to get to the next game during the day. His work deteriorated further. He became more irritable and aloof, and seemed remote and preoccupied to his colleagues. He sustained this pattern of gambling for almost a year. During the same period, he was dismissed from two jobs, lost all his savings and part of his RRSP, and lost contact with most of his friends.

By the time he went to a Gambling Service for help, he was no longer enjoying the game, but simply went each night because there was “nothing better” to do — he seemed to be “pulled” there. He dreaded the cards during the day. His energy, interests, mood and hopefulness were much worse than before he started gambling. A psychiatrist diagnosed him with major depression, and he started on antidepressants and psychotherapy, plus gambling addictions counselling. Six months after the start of treatment he was gambling only once a week or less.

Applying the Pathways Model
The above case has elements of both pathway 1 (the “Normal Problem Gambler”) and pathway 2 (the “psychologically Vulnerable Problem Gambler”). On the one hand, the client was psychologically vulnerable and his attraction to gambling was predisposed by the effects of his failed marriage and poor relationships. Continued gambling ultimately precipitated the full concurrent disorders. On the other hand, he was relatively high-functioning, with no long history of psychological problems, and had been caught in the web of gambling through early winnings, a taste of thrill, etc., making him a client with likely good prognosis, requiring limited interventions. He did well with some supportive and cognitive-behavioural therapy, along with antidepressant medication.

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