Beyond the Bet: Exploring Gambling Disorder and Its Comorbidities: Case Series

Gambling was first considered a sin and then a vice throughout history. ¹ Gambling has a long history in India, stemming from the epic Mahabharata and the traditional practice of gambling on Diwali. Card games like teen patti, poker, rummy, sports betting, bingo, lottery, and casino games like roulette are all common forms of gambling. ¹ Even though practically all gambling is prohibited in India, some card games, including online rummy, are exempt from most anti-gambling legislation since they are classified as “games of skill.” ² Gambling disorder has been defined as a “behavioral addiction” in the International Classification of Diseases (ICD-11) ³ and as a psychiatric disease of a non-substance-related category in the Diagnostic and Statistical Manual of Mental Disorders-5. ⁴ Gambling is the act of wagering or staking something of worth while being conscious of the risk, in the hope of winning something of greater value. It is marked by an intense urge and loss of control over gambling behavior, which is persistent and maladaptive and results in a person gambling repeatedly and frequently despite serious adverse effects. ⁵ Some may perceive gambling as merely a stress reliever or a form of entertainment; for others, it develops into a chronic condition that leads to gambling disorder, which is defined by a lack of self-control, constant craving, the “chasing of losses,” financial debt, mental stress, and involvement in illegal activities. ⁶ A recent systematic review reported the prevalence of gambling disorder to be 1.29% in the adult population. ⁷ While laws around the world restrict gambling, modern technology, which includes online gaming applications and internet gambling platforms, has significantly increased vulnerability to the risks of gambling disorders. ⁸ According to a quick internet search, 30 gambling applications are available in India. India’s online gambling market is predicted to expand at an annual rate of 8.5%, with an estimated 12.17 million users. India’s illegal gaming sector is worth about 60 billion dollars. ⁹ Psychiatric disorders such as depression, substance abuse, and suicide often co-occur with gambling disorders.

There is a paucity of case series from India highlighting clinical presentations, comorbidities, and treatment outcomes in gambling disorders. Understanding these presentations is vital for early identification, intervention, and development of targeted public health strategies. Given this, we present three case reports of gambling disorder and its comorbidities to explain the distinct manifestations of gambling and the clinical implications for practice.

We followed the CARE reporting guidelines, ¹⁰ to describe three individuals with gambling disorder who attended the outpatient department. The ICD-11 was used to diagnose the disorder. Instruments used included the Alcohol Use Disorders Identification Test (AUDIT) for screening alcohol use (scores ≥8 indicate hazardous use), ¹¹ the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar), to assess the severity of alcohol withdrawal, ¹² the Beck Depression Inventory (BDI) for measuring depressive symptoms (higher scores indicate greater severity), ¹³ the Beck Scale for Suicidal Ideation (BSSI) for assessing the severity of suicidal ideation, ¹⁴ and the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) to measure obsessive–compulsive symptom severity. ¹⁵ Written informed consent was obtained from all the patients for publication of this case series.

Case 1

A 28-year-old married male from a middle socioeconomic class presented to the psychiatry outpatient department with complaints of alcohol use for the past 5 years, which had increased over the past 3 months. This escalation coincided with financial debt due to involvement in online gambling over the past 4 years. The patient, a painter supporting his wife and two daughters, began using alcohol in 2018 at social gatherings, consuming approximately six units of alcohol weekly. His alcohol use increased to four times a week over the past 18 months. He was introduced to online rummy through peers and initially wagered ₹500–₹1,000 per game, playing 1–2 h daily. He gained approximately 7 lakhs in the first 6 months, which motivated him to continue playing. Subsequent losses led him to increase his bets to ₹5,000–₹8,000 per game, culminating in a loss of around 16 lakhs, which depleted his family’s savings.

Despite guilt and shame, he could not resist gambling. He engaged in binge drinking, consuming up to 18 units daily, 3–4 times a week. This impacted his work and family relationships. Due to withdrawal symptoms, including tremors, nausea, vomiting, and decreased sleep, he was brought to the psychiatry department. The patient initially refused treatment but consented to following appropriate counseling. On admission, Mental State Examination (MSE) revealed a moderately kempt individual with heightened psychomotor activity, guilt, and difficulty resisting gambling urges. Hematological and biochemical profiles were within normal limits. Assessments indicated an Alcohol Use Disorders Identification Test (AUDIT) score of 31 (alcohol dependence), CIWA-Ar score of 8 (moderate withdrawal), BDI-II score of 6 (no depression), and Y-BOCS score of 6 (subclinical symptoms). He was diagnosed with gambling disorder, predominantly online (6C50.1), and alcohol dependence, current use, continuous (6C40.20), according to ICD-11. Treatment included Tab. Naltrexone 50 mg/day, Tab. Bupropion 150 mg/day, Tab. Thiamine 200 mg/day, and Tab. Lorazepam, started at 12 mg/day (gradually tapered and stopped). Non-pharmacological interventions involved Cognitive Behavioral Therapy (CBT) and Motivational Enhancement Therapy. He completed 5 weeks of inpatient treatment and maintained abstinence during follow-ups.

Case 2

A 35-year-old married male with no past psychiatric or substance use history presented with low mood, decreased energy, sleep disturbances, and a financial debt of ₹15 lakhs due to online rummy participation over 7 years. He learned the game from his father and began playing during vacations. After his marriage, he shifted to online rummy, betting ₹500–₹1,000 per game. His wife supported him initially but later distanced herself as his gambling escalated. Over 2 years, he spent most of his time gambling, neglecting family responsibilities. His losses reached ₹15 lakhs, leading to summons and the estrangement of his family. On admission, MSE revealed dull affect, depressive cognition, and partial insight. Psychometric assessments indicated a BDI-II score of 25 (severe depression) and a BSSI score of 5. He was diagnosed with gambling disorder, predominantly online (6C50.1), and single episode depressive disorder, moderate, without psychotic symptoms (6A70.1), according to ICD-11. Treatment included Tab. Bupropion 150 mg/day, Tab. Naltrexone 50 mg/day, Tab. Clonazepam 0.5 mg/day, problem-solving therapy, and improving coping skills. He showed significant improvement over 4 weeks. Depressive symptoms improved notably, with the BDI-II score decreasing from 25 at baseline to 19 at discharge and further to 14 during follow-up.

Case 3

A 34-year-old unmarried male with no comorbidities or substance use history presented with sleep disturbances, crying spells, headaches, and suicidal thoughts due to financial loss from online gambling over 1 year. He was introduced to online rummy through advertisements, initially betting ₹1,000–₹2,000 per game. His losses escalated, resulting in a debt of ₹9 lakhs. Despite attempts to abstain, he relapsed, borrowing more money and experiencing severe depressive symptoms. His father intervened, but he continued gambling, culminating in a suicide attempt. On admission, MSE revealed depressive cognition, guilt, and suicidal ideas. Psychometric assessments indicated a BDI-II score of 34 (severe depression), a Y-BOCS score of 13, and a BSSI score of 15. He was diagnosed with gambling disorder, predominantly online (6C50.1), single episode depressive disorder, moderate, without psychotic symptoms (6A70.1), and suicidal ideation according to ICD-11. Treatment included Tab. Bupropion 150 mg/day –300 mg/day, Tab. Naltrexone 50 mg/day, Tab. Clonazepam 0.5 mg/day, and psychotherapy involving CBT. He showed significant improvement over 4 weeks. Depressive symptoms improved notably, with the BDI-II score decreasing from 34 at baseline to 18 at discharge and further to 15 during follow-up. The summary of three cases and the scales used are described in Tables 1 and 2 respectively.

Table 1.

Summary of Cases of Gambling Disorder and Its Comorbidities.

Sl. No.	History	Findings	Diagnosis and Treatment
1	A 28-year-old married male presented with complaints of: 1. Alcohol use for 5 years, increased use for 1 year, binge drinking for 3 months. 2. Internet-based card game addiction for 4 years. 3. Decreased sleep and tremors for 3 months.	MSE: Conscious, oriented, moderately kempt, increased psychomotor activity, ideas of guilt about gambling and financial loss, impaired judgment, and poor insight. Psychometric assessment showed: • AUDIT: 31 • CIWA-Ar: 8 • BDI score: 6 • Y-BOCS: 6	Diagnosed as: 6C50.1—Gambling disorder, predominantly online, and 6C40.20—Alcohol dependence, current use, continuous. Treated with: • Tab. Bupropion 150 mg/day • Tab. Naltrexone 50 mg/day • Tab. Thiamine 200 mg/day • Tab. Lorazepam (started with 12 mg/day, gradually tapered and stopped) • CBT, MET
2	A 35-year-old married male presented with complaints of: 1. Playing online rummy games for 7 years. 2. Low mood, decreased energy levels, decreased sleep, appetite, and interaction for 1 month.	MSE: Conscious, kempt, decreased psychomotor activity, relevant and coherent speech, depressive cognition, and dull affect with intact judgment and partial insight. Psychometric assessments showed: • BDI score: 25 • BSSI score: 5	Diagnosed as: 6C50.1—Gambling disorder, predominantly online, and 6A70.1 Single episode depressive disorder, moderate, without psychotic symptoms. Treated with: • Tab. Bupropion 150 mg/day • Tab. Naltrexone 50 mg/day • Tab. Clonazepam 0.5 mg/day • Problem-solving therapy, and coping skills improvement
3	A 34-year-old unmarried male presented with complaints of: 1. Online gambling for the past 1 year. 2. Sleep disturbances, decreased interaction, crying spells, headaches, and suicidal thoughts for 3 weeks. 3. Suicide attempt	MSE: Conscious, kempt, eye contact made and not maintained, relevant and coherent speech, depressive cognition, depressed affect, feelings of guilt about financial loss, suicidal ideas, and no remorse for the act. Psychometric assessments showed: • BDI score: 34 • Y-BOCS: 13 • BSSI score: 15	Diagnosed as: 6C50.1—Gambling disorder, predominantly online 6A70.1—Single episode depressive disorder, moderate, without psychotic symptoms, and suicidal ideas. Suicidal risk: Precautions. Family members were explained regarding the risk, and were advised to take proper precautions. Treated with: • Tab. Bupropion 150–300 mg/day • Tab. Naltrexone 50 mg/day • Tab. Clonazepam 0.5 mg/day • CBT

AUDIT: Alcohol Use Disorders Identification Test, BDI: Beck Depression Inventory, BSSI: Beck Scale for Suicidal Ideation, CBT: Cognitive Behavioral Therapy, CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol, Revised, MET: Motivational Enhancement Therapy, MSE: Mental Status Examination, Y-BOCS: Yale–Brown Obsessive–Compulsive Scale.

Table 2.

Summary of Scales Utilized for Assessment of Gambling Disorder Comorbidities.

Scale	Number of Questions	Scoring Range (Per Item)	Total Score Range	Outcome Interpretation	Purpose of the Scale
AUDIT 11	10	0–4	0–40	0–7: Low risk, 8–15: Hazardous drinking 16–19: Harmful drinking 20–40: Alcohol dependence	Measures alcohol risk levels
CIWA-Ar 12	10	0–7	0–67	0–9: Minimal withdrawal 10–19: Mild withdrawal ≥20: Severe withdrawal (needs medical intervention)	Assesses alcohol withdrawal severity
BDI 13	21	0–3	0–63	0–9: Minimal depression 10–18: Mild 19–29: Moderate 30–63: Severe depression	Measures depression severity
BSSI 14	19	0–2	0–38	0–5: Minimal risk 6–9: Mild risk 10–19: Moderate risk 20–38: High risk (immediate intervention needed)	Assesses suicidal thoughts, intent, and risk
Y-BOCS 15	10	0–4	0–40	0–7: Subclinical OCD 8–15: Mild 16–23: Moderate 24–31: Severe 32–40: Extreme OCD	Measures OCD severity (obsessions and compulsions)

AUDIT: Alcohol Use Disorders Identification Test, BDI: Beck Depression Inventory, BSSI: Beck Scale for Suicidal Ideation, CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol, Revised, OCD: Obsessive–compulsive disorder, Y-BOCS: Yale–Brown Obsessive–Compulsive Scale.

Discussion

Playing games or taking part in risky activities in an attempt to gain money or accomplish an intended outcome is known as gambling. However, internet gambling has gained popularity as cell phones are now widely used in every home. Homelessness, domestic abuse, bankruptcy, family dissolution, despair, and suicide are among the many potential adverse effects of gambling. ¹⁶ More than 90% of individuals with gambling disorder have a psychiatric diagnosis, and more than 60% have at least three comorbid psychiatric disorders, according to research. ¹⁷ Comorbid anxiety, substance use disorders, and depression have all been closely linked to gambling disorders. More recently, gambling disorder has been viewed as a disease influenced by personal choices, environmental conditions, and genetics. In reality, only 10%–20% of those with gambling disorders seek professional assistance. ¹

Gambling Disorder and Substance Use

Substance use disorders and gambling disorders exhibit substantial overlap. About 60.4% of those with gambling disorders also suffer from nicotine dependence, and 73.2% also have an alcohol use disorder. ¹⁸ Based on a systematic review and meta-analysis, 57.5% of those who suffered adverse outcomes from gambling also had concurrent adverse effects from substance use. ¹⁹

Gambling Disorder and Mood Disorders

Mood disorders are among the most common psychiatric conditions co-occurring with gambling disorders. Studies suggest that 50%–75% of those with gambling disorder also experience mood disorders, with major depressive disorder being the most frequent. ²⁰ Gambling may motivate individuals to escape from depressive states, and gambling-related losses can exacerbate depression. Hypotheses suggest that gambling disorder precedes depression in the majority of cases (up to 86%). ²¹

Gambling Disorder and Suicide

Pathological gamblers are at an increased risk of suicide. Between 22% and 81% of pathological gamblers develop suicidal ideation, and about 7%–30% attempt to end their lives. ²² Comorbid depression, financial debt, and interpersonal conflicts are risk factors for suicide. Gambling disorders with suicidal behavior are significantly associated with mood disorders and substance use disorders. ²³

Our case series details three individuals who suffered from gambling disorder, comorbid substance use, depression, and suicide. These patients were treated using both pharmacological methods (Tab. Bupropion 150 mg–300 mg/day along with Tab. Naltrexone 50 mg/day) and non-pharmacological methods (CBT). The patients successfully abstained from gambling, and their biological, occupational, and social functioning returned to normal. These cases reaffirm the importance of early detection and integrated treatment for gambling disorders. Clinicians should actively screen for gambling behaviors among patients presenting with mood symptoms or substance use issues to enable timely intervention and improve patient outcomes.

We used standardized diagnostic and assessment tools, which ensure accurate and consistent evaluation of gambling disorder and its comorbidities. Additionally, a multimodal treatment approach was adopted, combining pharmacological and psychotherapeutic measures, which enhanced treatment efficacy. However, the short-term follow-up period of these cases restricts conclusions about the long-term sustainability of treatment outcomes. These factors contribute to limited generalizability beyond the clinical settings studied.

Conclusion

With the growth of electronic gambling and the increasing deregulation of the gaming industry, gambling disorder is becoming a global public health concern. Approaches must shift the emphasis from “personal responsibility” to population-level economic, environmental, and social actions. Gambling disorder lowers the quality of life and is a public health concern. The widespread availability of online platforms, advertisements, and the digitalization and convenience of financial transactions via these websites have all contributed to the rise in the incidence of gambling disorders. One way to avoid gambling problems is through public health campaigns that increase knowledge of the risks associated with gambling. Gambling disorder is an emerging public health concern exacerbated by the rise of online gambling platforms. Early identification, public health policies limiting exposure, and evidence-based treatments are necessary to mitigate its harmful impacts. Policies should be put in place to limit access to gambling, especially online, restrict the availability of gambling advertising, and ensure warning signs are prominently displayed in gambling establishments. Healthcare professionals, legislators, and researchers must collaborate and deploy a multifaceted public health strategy to mitigate gambling-related harm. Reducing the harmful impacts of gambling problems requires early detection and management. Successful outcomes are likely to increase with a personalized treatment strategy that addresses the behavioral components of gambling as well as the underlying psychological comorbidities.