The Dual Burden of Emerging Adulthood: Assessing Gambling Severity, Gambling-Related Harm, and Mental Health Challenges

Abstract

Growing concerns over gambling problems across age groups have sparked research in public health and psychology. During emerging adulthood, individuals are more susceptible to mental health problems and more likely to develop gambling problems than in other age groups. This study explored the potential differences between emerging adults and adults aged 30+ in terms of problem gambling severity (PGS), gambling-related harm (GRH), depression and anxiety, and the mediating role of depression and anxiety in the association between age, PGS, and GRH. A representative online sample of 3244 Israelis aged 18 and over was divided into two groups: 740 emerging adults aged 18–29 and 2504 adults aged 30+. Gambling behaviors, the Problem Gambling Severity Index, the Short Gambling Harm Screen, and the Patient Health Questionnaire-4 assessing depression and anxiety were administered. Emerging adults had significantly higher levels of GRH, PGS, and depression-anxiety than their older counterparts, above and beyond gender and education. Depression-anxiety fully mediated the associations between age and gambling-related outcomes. These findings underscore the importance of considering psychological well-being in efforts to address problem gambling and gambling-related harms, especially in emerging adults.

Full text

Citation: Gavriel-Fried, B.; Malka, I.;
Levin, Y. The Dual Burden of
Emerging Adulthood: Assessing
Gambling Severity, Gambling-Related
Harm, and Mental Health Challenges.
Int. J. Environ. Res. Public Health 2024,
21, 702. https://doi.org/10.3390/
ijerph21060702
Academic Editor: Jiun-Hau Huang
Received: 1 April 2024
Revised: 26 May 2024
Accepted: 28 May 2024
Published: 30 May 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
International Journal of
Environmental Research
and Public Health
Article
The Dual Burden of Emerging Adulthood: Assessing Gambling
Severity, Gambling-Related Harm, and Mental
Health Challenges
Belle Gavriel-Fried 1, * , Inbar Malka 1and Yafit Levin 2
1The Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv-Yafo 6997801, Israel;
inbarmalka@gmail.com
2Department of Social Work, Ariel University, Ariel 40700, Israel; yafitl@ariel.ac.il
*Correspondence: bellegav@tauex.tau.ac.il
Abstract: Growing concerns over gambling problems across age groups have sparked research in
public health and psychology. During emerging adulthood, individuals are more susceptible to
mental health problems and more likely to develop gambling problems than in other age groups.
This study explored the potential differences between emerging adults and adults aged 30+ in
terms of problem gambling severity (PGS), gambling-related harm (GRH), depression and anxiety,
and the mediating role of depression and anxiety in the association between age, PGS, and GRH.
A representative online sample of 3244 Israelis aged 18 and over was divided into two groups:
740 emerging adults aged 18–29 and 2504 adults aged 30+. Gambling behaviors, the Problem
Gambling Severity Index, the Short Gambling Harm Screen, and the Patient Health Questionnaire-4
assessing depression and anxiety were administered. Emerging adults had significantly higher levels
of GRH, PGS, and depression-anxiety than their older counterparts, above and beyond gender and
education. Depression-anxiety fully mediated the associations between age and gambling-related
outcomes. These findings underscore the importance of considering psychological well-being in
efforts to address problem gambling and gambling-related harms, especially in emerging adults.
Keywords: emerging adults; problem gambling severity; gambling-related harm; depression; anxiety;
representative sample; Israel
1. Introduction
The increasing prevalence of gambling behaviors and gambling problems across age
groups, particularly among emerging adults, is a significant public health and psychological
concern [
1
–
3
]. Emerging adulthood is a distinct developmental stage of life between the
ages 18 and 29 characterized by possibility and identity explorations, instability, self-focus,
feeling ‘in between’, and changes in various life domains [
4
,
5
]. While these developmental
characteristics can lead to personal growth and other positive outcomes, such as heightened
self-awareness and self-knowledge, freedom, and optimism [
6
,
7
], they may also account for
the high involvement of emerging adults in risk behaviors [
8
–
10
] and high levels of mental
health problems, such as depression and anxiety, compared to other age groups [11].
Previous studies have linked gambling behaviors in young adults to later problem
gambling severity [
12
,
13
] and showed that newer forms of gambling (e.g., online betting)
posed greater risks [
14
]. This trend suggests a developmental trajectory where gambling
behaviors peak during emerging adulthood, thus underscoring the need for age-specific
interventions [15].
As a developmental stage of inherent instability, emerging adulthood represents a
period of heightened susceptibility to mental disorders [
16
]. Studies have consistently
shown high levels of depression and anxiety in emerging adults [
17
]. In a national sample
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Int. J. Environ. Res. Public Health 2024,21, 702 2 of 12
of American 18- to 60-year-olds, one study showed that feelings of anxiety and depression
were reported significantly more often by emerging adults [11].
Depression and anxiety are consistently associated with problem gambling [
14
,
18
].
However, the interplay between mental health and gambling is complex. Some studies
have posited that this association stems from the ineffective nature of gambling to alleviate
feelings of depression and anxiety [
19
,
20
]. Alternatively, individuals with problem gam-
bling may experience heightened anxiety and depressive symptoms due to the negative
consequences of their gambling behavior [
20
]. Hence, this association could function as
both a precursor [
21
] and a result of problem gambling [
22
]. This reciprocal relationship
has been confirmed in samples of emerging adults [
12
,
23
]. For example, Edgerton et al. [
24
]
defined five different classes combining varying levels of depression and gambling. The
most frequent class, accounting for 81% of the respondents (n= 679), consisted of indi-
viduals who experienced a gradual decline in gambling and a simultaneous increase in
depression [
24
]. This underscores the potential of mental health symptoms to mediate the
link between age and gambling behaviors.
Another account of the association between depression and anxiety symptoms and
PG views these symptoms as a mediator between age-related aspects and PG. A study
conducted in UK reported that in 595 individuals aged 65 and above, age-related vul-
nerabilities encompassing physical and psychological factors, such as clinical frailty and
geriatric pain, contributed to the manifestation of PG in late-life, with depression and
anxiety serving as mediators [
25
]. In addition, it was found that loneliness and sense of
mastery as age-related factors [
26
,
27
] were associated indirectly with excessive gambling
via psychological distress in four different country samples of teenagers and emerging
adults [28], thus highlighting the complex effects of age and mental health on gambling.
The most widely used scale to measure problem gambling in population surveys is
the Problem Gambling Severity Index (PGSI) [
29
]. This scale has been used in numerous
epidemiological studies worldwide, e.g., [
30
–
33
], and on emerging adults, e.g., [
34
,
35
].
Recent calls have been made to measure gambling-related harms in addition to PGSI to
achieve a more comprehensive picture of public health in the field of gambling [36].
Both public health theory and empirical findings indicate that individuals can experi-
ence harm from gambling without meeting the clinical criteria for gambling addiction [
37
].
For instance, studies have consistently shown that even gamblers classified as non-problem
or at-risk gamblers on the PGSI still report harm that necessitates some form of interven-
tion, whereas individuals classified as problem-gamblers may not report any harm [
36
].
Consequently, relying solely on the PGSI may not be sufficient and may overlook individ-
uals who suffer negative consequences as a result of gambling [
36
]. This suggests that a
dual index would be of value [
38
]. To the best of our knowledge, no study has explored
gambling-related harm in emerging adults as a separate group.
Based on the literature review, the current study examined the differential impact of
gambling behaviors in a sample of emerging adults compared to older adults by focusing
on gambling harm, problem gambling severity, and depression-anxiety levels. It was
hypothesized that emerging adults would exhibit higher levels of these gambling outcomes,
with depression-anxiety potentially mediating the relationship between age and gambling-
related consequences.
2. Materials and Methods
2.1. Sample and Procedure
This study is part of a broader research project on gambling behaviors in Israeli
adults [
31
]. The participants were recruited through a web-based survey institution that
provided a representative random sample of the Israeli population. The panel was con-
stituted by BI and the Lucille Cohen Institute for Public Opinion Research at Tel Aviv
University according to methodological standards for web-based studies defined by the
National Opinion Research Center at the University of Chicago and the PEW Research
Institute for studies on Israeli society [
39
]. The panel included a stratum for the Jewish

Int. J. Environ. Res. Public Health 2024,21, 702 3 of 12
population and a stratum for the Arab population, thus reflecting Israel’s ethnonational
stratification. More details about the sample are described elsewhere [31].
Overall, the data were collected between July and September 2022, and comprised
3244 individuals: 3080 Israeli Jews and 164 Israeli Arabs. For this study, the sample was
divided into two age groups consisting of individuals aged 18–29, and 30 and above.
2.2. Instruments
2.2.1. Gambling Behaviors
This scale was developed to encompass the 11 most prevalent forms of gambling in
Israel, along with an “other” category to account for any unspecified gambling activities.
Respondents rated their frequency of gambling for each type on a five-point Likert scale
ranging from 1 (‘Not at all’) to 5 (‘Once a week or more’). In this study we used this scale
to determine whether the individual was involved in gambling behaviors in the previous
year or not.
2.2.2. The Problem Gambling Severity Index (PGSI)
This is a nine-item scale designed to gauge problem gambling severity in general
population surveys [
29
]. It utilizes a 4-point scoring system, where 0 signifies ‘never’ and
3 indicates ‘almost always’. Based on their scores, participants are categorized into four
levels of gambling severity: 0 indicates ‘Non-problem gamblers’, scores between 1 and 2
denote ‘Low-risk gamblers’, scores ranging from 3 to 7 identify ‘Moderate-risk gamblers’,
and scores of 8 or higher indicate ‘Problem gamblers’. In the current study, the PGSI
demonstrated satisfactory reliability, with a Cronbach’s alpha coefficient of 0.86 and a
McDonald’s omega score of 0.88.
2.2.3. The Short Gambling Harm Screen (SGHS)
This 10-item scale measures the negative consequences of excessive gambling over the
previous 12 months in six domains including health, emotions, relationships, work/study,
financial, and social dysfunction [
37
]. The SGHS was developed as a population level
measure to monitor the impact of gambling on the community. Individuals respond
Yes/No to each item describing a specific harm. The total score is obtained by summing
the number of Yes responses. In the current study, the SGHS demonstrated satisfactory
reliability, with a Cronbach’s alpha coefficient of 0.81 and a McDonald’s omega score of
0.86, indicating its effectiveness in measuring gambling-related harm within the context of
this study.
2.2.4. Patient Health Questionnaire-4 (PHQ-4)
An ultra-brief 4-item scale derived from the Patient Health Questionnaire-4 (PHQ-4)
was administered in the current study to assess the severity of depression and anxiety
symptoms. This scale has two components: the first two items, known as the Generalized
Anxiety Disorder-2 (GAD-2), assess levels of generalized anxiety, and the latter two, referred
to as the Patient Health Questionnaire-2 (PHQ-2), assess depression symptoms. Each item
is scored on a four-point Likert scale ranging from 0 (‘Not at all’) to 3 (‘Nearly every day’).
The cumulative scale score thus ranges from 0 to 12. This scoring approach facilitates
analysis of the measure as a continuous variable by providing a more fine-grained view of
anxiety and depression severity.
The PHQ-4 served as a mediator variable in this study based on the combined con-
tinuous score of all four items, representing depression-anxiety levels. A previous study
utilized this 4-item measure to effectively gauge the psychological well-being of diverse
populations, with an internal consistency of 0.85. It is considered to provide insights
into the intensity of anxiety-depression symptoms [
40
]. In the current study, the scale
demonstrated satisfactory reliability, with a Cronbach’s alpha coefficient of 0.81 and a
McDonald’s omega score of 0.83, thus demonstrating the utility of the PHQ-4 as a unified
depression-anxiety measure.

Int. J. Environ. Res. Public Health 2024,21, 702 4 of 12
2.3. Analytic Strategy
We conducted a series of one-way ANOVAs and mediation analyses using the SPSS
PROCESS macro. Three separate one-way ANOVAs were conducted to evaluate the impact
of age categories (emerging adults vs. adults aged 30+) on the three dependent variables:
the Short Gambling Harm Screen, the Problem Gambling Severity Index, and depression-
anxiety levels. Two mediation analyses were conducted using the PROCESS macro in
SPSS [
41
] to test the hypothesis that depression-anxiety would mediate the relationship
between age (categorized as emerging adults and adults aged 30+) on the one hand, and
gambling harm and gambling severity on the other. It is important to note that the original
dataset, which was weighted by level of ethnonational affiliation (Israeli Jewish/Arab)
and level of education to ensure representativeness, included individuals from diverse age
groups. However, the current study included a specific subset of young individuals. Finally,
we conducted additional analyses to examine whether the associations between age and
gambling-related outcomes were significant, while controlling for gender and education,
and to specifically test the associations between gender and education and gambling-related
outcomes. We conducted two analyses of variance with covariates (ANCOVAs) to test the
association between age groups on the one hand, and gambling-related harm and problem
gambling severity on the other, while controlling for education and gender.
3. Results
The socio-demographic characteristics of the sample in the two age groups are listed
in Table 1.
Table 1. Sociodemographic characteristics according to age group.
Variable Emerging Adults Adults Aged 30+
Women 447 (60.4%) 1388 (55.4%)
Men 293 (39.6%) 1116 (44.6%)
In a Relationship 287 (38.8%) 1953 (78.0%)
Not in a Relationship 453 (61.2%) 551 (22.0%)
High School Diploma 316 (42.7%) 544 (21.7%)
No Formal Education 37 (5.0%) 167 (6.7%)
Partial Academic Degree 113 (15.3%) 177 (7.1%)
Full Bachelor’s Degree 179 (24.2%) 727 (29.0%)
Master’s Degree or Higher 45 (6.1%) 692 (27.6%)
Non-Academic Technical Diploma 50 (6.8%) 197 (7.9%)
Descriptive statistics were calculated for the 740 emerging adult participants and 2504
older adults. Out of the total sample, 46.7% (n= 346) of the emerging adults (aged 18–29)
gambled in the previous year. Of these, 67.6% were classified as non-problem gamblers,
20.2% as low-risk gamblers, 9.2% as medium-risk gamblers, and 2.9% as problem gamblers.
Roughly 51.1% (n= 1280) of the adults aged 30 and over had gambled in the previous year.
Of these, 73% were classified as non-problem gamblers, 17.4% as low-risk gamblers, 8% as
medium-risk gamblers, and 1.5% as problem gamblers.
3.1. Group Differences
The group differences between the emerging adult group and the 30+ adult group
are presented in Table 2. An ANOVA indicated a statistically significant age-related dif-
ference for the Short Gambling Harm Screen scores (F(1, 1624) = 4.72, p= 0.03, partial
η² = 0.003
). Specifically, emerging adults (mean = 0.47, SD = 0.78) reported experiencing
greater gambling harm than the older adult group (mean = 0.38, SD = 0.7).

Int. J. Environ. Res. Public Health 2024,21, 702 5 of 12
Table 2. Means and standard deviations for problem gambling severity, gambling-related harm, and
depression and anxiety by age group.
Emerging Adults
(n= 740)
Adults Aged 30+
(n= 2504)
M SD M SD
Problem gambling severity 0.4740 0.78068 0.3797 0.69707
Gambling-related harms 0.8092 1.69005 0.6297 1.39822
Depression and anxiety 3.8446 2.68790 3.2025 2.61578
Another ANOVA examining the Problem Gambling Severity Index showed a statisti-
cally significant difference between the two age groups (F(1, 1624) = 4.09, p= 0.043, partial
η
² = 0.003). Emerging adults reported higher levels of gambling severity (mean = 0.81,
SD = 1.69) than the older adult group (mean = 0.63, SD = 1.4).
The third ANOVA focused on depression-anxiety levels and revealed a significant
age group difference (F(1, 3242) = 33.99, p< 0.0001, partial
η
² = 0.01). Emerging adults
had higher levels of depression and anxiety (mean = 3.84, SD = 2.69) than the older adult
group (mean = 3.20, SD = 2.615). Thus, the emerging adults were more adversely affected
by gambling-related harms and problems, and exhibited higher levels of depression and
anxiety than the older adult group.
3.2. Mediation Analysis
3.2.1. The Mediating Role of Depression-Anxiety in the Association between Age Group
and Gambling-Related Harm
The model is presented in Figure 1. The analysis revealed a statistically significant
positive association between age (emerging adulthood) and depression-anxiety (
β
= 0.36,
t= 2.24
,p= 0.025). Depression-anxiety significantly predicted gambling-related harm
(β= 0.1, t= 0.01, p< 0.0001).
Int. J. Environ. Res. Public Health 2024, 21, x 5 of 12
difference for the Short Gambling Harm Screen scores (F(1, 1624) = 4.72, p = 0.03, partial
η² = 0.003). Specifically, emerging adults (mean = 0.47, SD = 0.78) reported experiencing
greater gambling harm than the older adult group (mean = 0.38, SD = 0.7).
Tab le 2 . Means and standard deviations for problem gambling severity, gambling-related harm,
and depression and anxiety by age group.
Emerging Adults
(n = 740)
Adults Aged 30+
(n = 2504)
M SD M SD
Problem gambling severity 0.4740 0.78068 0.3797 0.69707
Gambling-related harms 0.8092 1.69005 0.6297 1.39822
Depression and anxiety 3.8446 2.68790 3.2025 2.61578
Another ANOVA examining the Problem Gambling Severity Index showed a statis-
tically significant difference between the two age groups (F(1, 1624) = 4.09, p = 0.043, partial
η² = 0.003). Emerging adults reported higher levels of gambling severity (mean = 0.81, SD
= 1.69) than the older adult group (mean = 0.63, SD = 1.4).
The third ANOVA focused on depression-anxiety levels and revealed a significant
age group difference (F(1, 3242) = 33.99, p < 0.0001, partial η² = 0.01). Emerging adults had
higher levels of depression and anxiety (mean = 3.84, SD = 2.69) than the older adult group
(mean = 3.20, SD = 2.615). Thus, the emerging adults were more adversely affected by
gambling-related harms and problems, and exhibited higher levels of depression and anx-
iety than the older adult group.
3.2. Mediation Analysis
3.2.1. The Mediating Role of Depression-Anxiety in the Association between Age Group
and Gambling-Related Harm
The model is presented in Figure 1. The analysis revealed a statistically significant
positive association between age (emerging adulthood) and depression-anxiety (β = 0.36,
t = 2.24, p = 0.025). Depression-anxiety significantly predicted gambling-related harm (β =
0.1, t = 0.01, p < 0.0001).
To evaluate the indirect effect of age on gambling harm via depression-anxiety, boot-
strapping techniques were utilized. Confidence intervals were constructed based on
10,000 bootstrap samples from the original data. The results at the 95% confidence level
indicated that the confidence interval for the indirect effect of age on gambling-related
harm was significant (estimate = 0.04, SE= 0.02, 95%, CI: 0.004, 0.0714), suggesting that
depression and anxiety fully mediated this relationship such that emerging adulthood
(compared to the 30+ group) was associated with greater severity of depression-anxiety,
which was related to more gambling-related harm. The direct effect of age on gambling-
related harm was found to be insignificant (estimate = 0.14, SE = 0.09, t = 1.64, p = 0.1, 95%,
CI: 0.0277, 0.3155). These findings thus highlight the pivotal role of depression-anxiety in
mediating the impact of age on gambling harm.
Figure 1. Unstandardized estimates of the indirect effects between age and gambling-related harm
via depression-anxiety. Notes: *** p< 0.001 * p< 0.05. Full arrows indicate significant associations
and dashed arrows indicate non-significant associations.
To evaluate the indirect effect of age on gambling harm via depression-anxiety, boot-
strapping techniques were utilized. Confidence intervals were constructed based on
10,000 bootstrap samples from the original data. The results at the 95% confidence level
indicated that the confidence interval for the indirect effect of age on gambling-related harm
was significant (estimate = 0.04, SE = 0.02, 95% CI: 0.004, 0.0714), suggesting that depression
and anxiety fully mediated this relationship such that emerging adulthood (compared
to the 30+ group) was associated with greater severity of depression-anxiety, which was
related to more gambling-related harm. The direct effect of age on gambling-related harm
was found to be non-significant (estimate = 0.14, SE = 0.09, t= 1.64, p= 0.1, 95% CI:
−
0.0277,
0.3155). These findings thus highlight the pivotal role of depression-anxiety in mediating
the impact of age on gambling harm.

Int. J. Environ. Res. Public Health 2024,21, 702 6 of 12
3.2.2. The Mediating Role of Depression-Anxiety in the Association between Age Group
and Problem Gambling Severity
The model is presented in Figure 2. Age was significantly associated with depression-
anxiety (
β
= 0.36, t= 2.24, p= 0.025). Depression-anxiety was found to be statistically
significant in predicting problem gambling severity (
β
= 0.03, t= 4.99, p< 0.0001). At a
95% level of confidence, the indirect effect of age on gambling severity via depression-
anxiety was significant (estimate = 0.01, SE = 0.00, 95% CI: 0.0011, 0.0251), suggesting that
depression and anxiety fully mediated this relationship such that emerging adulthood
(compared to the 30+ group) was associated with higher severity of depression-anxiety,
which in turn was related to greater problem gambling severity. These results suggest that
depression fully mediated the association between age and problem gambling severity. The
direct effect was marginally significant (estimate = 0.08, SE = 0.04, t= 1.91, p= 0.06, 95% CI:
−0.0022, 0.1699).
Int. J. Environ. Res. Public Health 2024, 21, x 6 of 12
Figure 1. Unstandardized estimates of the indirect effects between age and gambling-related harm
via depression-anxiety. Notes: *** p< 0.001 * p< 0.05. Full arrows indicate significant associations and
dashed arrows indicate non-significant associations.
3.2.2. The Mediating Role of Depression-Anxiety in the Association between Age Group
and Problem Gambling Severity
The model is presented in Figure 2. Age was significantly associated with depression-
anxiety (β = 0.36, t = 2.24, p = 0.025). Depression-anxiety was found to be statistically sig-
nificant in predicting problem gambling severity (β = 0.03, t = 4.99, p < 0.0001). At a 95%
level of confidence, the indirect effect of age on gambling severity via depression-anxiety
was significant (estimate = 0.01, SE = 0.00, 95%, CI: 0.0011, 0.0251), suggesting that depres-
sion and anxiety fully mediated this relationship such that emerging adulthood (com-
pared to the 30+ group) was associated with higher severity of depression-anxiety, which
in turn was related to greater problem gambling severity. These results suggest that de-
pression fully mediated the association between age and problem gambling severity. The
direct effect was marginally significant (estimate = 0.08, SE = 0.04, t = 1.91, p = 0.06, 95%,
CI: −0.0022, 0.1699).
Figure 2. Unstandardized estimates of the indirect effects between age and gambling severity via
depression-anxiety. Notes: *** p < 0.001, * p < 0.05, ^ p = 0.06. Full arrows indicate significant associa-
tions and dashed arrows indicate non-significant associations.
3.3. Additional Analyses
We examined the association between age and gambling-related harm while control-
ling for education and gender. There was a significant effect for age group, F(1, 3239) =
3.41, p = 0.05, above and beyond education. The main effect of gender on gambling harm
was not significant, F(1, 3240) = 1.06, p = 0.303. Education was significantly associated with
gambling harm, F(1, 3239) = 4.28, p = 0.039, such that lower levels of education correlated
with greater gambling harm.
We next examined the association between age and problem gambling severity while
controlling for education and gender. There was a significant effect for age group, F(1,
3239) = 3.73, p = 0.05, above and beyond education. The main effect of gender on gambling
severity was significant, F(1, 3240) = 4.93, p = 0.027. Men reported higher levels of problem
gambling severity (M = 0.46, SD = 0.77) than women (M = 0.34, SD = 0.65). The level of
education was significantly associated with problem gambling severity, F(1, 3239) = 9.36,
p = 0.002, such that lower levels of education correlated with greater problem gambling
severity.
4. Discussion
This study investigated potential differences between age groups (emerging adult-
hood versus older adults), problem gambling severity and gambling-related harm, and
mental health (depression-anxiety) in a representative Israeli sample. The findings re-
vealed significant differences in problem gambling severity and gambling-related harm,
as well as in depression-anxiety levels between emerging adults and older adults.
Figure 2. Unstandardized estimates of the indirect effects between age and gambling severity via
depression-anxiety. Notes: *** p< 0.001, * p< 0.05, ˆ p= 0.06. Full arrows indicate significant
associations and dashed arrows indicate non-significant associations.
3.3. Additional Analyses
We examined the association between age and gambling-related harm while control-
ling for education and gender. There was a significant effect for age group,
F(1, 3239) = 3.41
,
p= 0.05, above and beyond education. The main effect of gender on gambling harm was
not significant, F(1, 3240) = 1.06, p= 0.303. Education was significantly associated with
gambling harm, F(1, 3239) = 4.28, p= 0.039, such that lower levels of education correlated
with greater gambling harm.
We next examined the association between age and problem gambling severity while
controlling for education and gender. There was a significant effect for age group, F(1, 3239) =
3.73, p= 0.05, above and beyond education. The main effect of gender on gambling severity
was significant, F(1, 3240) = 4.93, p= 0.027. Men reported higher levels of problem gambling
severity (M = 0.46, SD = 0.77) than women (M = 0.34,
SD = 0.65
). The level of education
was significantly associated with problem gambling severity, F(1, 3239) = 9.36, p= 0.002,
such that lower levels of education correlated with greater problem gambling severity.
4. Discussion
This study investigated potential differences between age groups (emerging adult-
hood versus older adults), problem gambling severity and gambling-related harm, and
mental health (depression-anxiety) in a representative Israeli sample. The findings re-
vealed significant differences in problem gambling severity and gambling-related harm,
as well as in depression-anxiety levels between emerging adults and older adults. Emerg-
ing adults exhibited higher levels of gambling-related harm, problem gambling severity,
and depression-anxiety compared to their older adult counterparts. These findings were
observed above and beyond the effects of gender and education. Furthermore, depression-
anxiety fully mediated the relationship between age and gambling-related outcomes.
The group differences related to problem gambling severity, gambling-related harm,
depression, and anxiety highlight emerging adulthood as a developmental stage charac-

Int. J. Environ. Res. Public Health 2024,21, 702 7 of 12
terized by a greater risk of experiencing gambling-related harm and problem gambling
severity, as well as higher levels of depression and anxiety. These findings resonate with
previous research that has linked gambling behaviors and mental health during emerging
adulthood [9,22,42].
The current study contributes to this body of work by elucidating the mechanisms
through which age influences problem gambling severity and gambling-related harm, and
emphasizing the pivotal role of depression and anxiety. Emerging adulthood is marked
by significant developmental challenges, particularly concerning mental health, which
manifested in this study in the form of elevated levels of depression and anxiety that may
contribute to increased gambling harm and severity [6].
The self-medication hypothesis provides a useful framework for understanding these
findings. It suggests that individuals who are emotionally vulnerable may use gambling as
a coping mechanism to escape negative feelings [
19
,
43
]. This aligns with other studies on
young adults [
44
]. For this particular subgroup, gambling is a way to relieve depressive
symptoms, a refuge from distressing emotions, or a magical opportunity orchestrated by
the hand of fate in games of chance [
43
]. These findings are also in line with previous
studies that have applied the self-medication hypothesis in cases of alcohol and substance
use in emerging adults aged 18 to 25 [45].
Studies have also shown that a depressed mood may contribute to the formation
and/or perpetuation of a gambling disorder through poor emotional regulation and mal-
adaptive coping strategies [
46
]. A recent study on emerging adults indicated that difficulties
in emotion regulation and coping motivations linked to gambling were associated with
problem gambling behavior. The simultaneous presence of poor emotional awareness
and poor emotional clarity, in conjunction with a strong inclination to alleviate or escape
negative mood states (i.e., coping motivations), were shown to contribute to the risk of
engaging in problem gambling [
47
]. Another study on a sample of students (mean age of
20.62), which also found that gambling problems were associated with depressive symp-
toms, suggested that difficulties in identifying emotions may serve as significant factors in
predicting the likelihood and severity of gambling problems. Specifically, the inclination to
overlook one’s mental states and internal emotions, given their lack of coherence or when
they are perceived as unendurable or chaotic, can hamper the recognition of the adverse
long-term consequences of addictive behavior [44].
Anxiety, like depression, plays a significant role in the development of gambling
disorders [
48
], as found in the current study. Studies on the mechanisms underlying
addictive behaviors in the context of alcoholism can provide valuable insights into how
anxiety contributes to gambling, since alcohol briefly alleviates anxiety and seems to
regulate emotions, but in fact aggravates these symptoms [
49
]. This leads to more recurrent
and severe addictive behaviors. Consequently, individuals who experience anxiety may be
more prone to severe gambling disorders [
48
,
49
]. Studies on emerging adults have reported
a positive correlation between the severity of anxiety and gambling, where anxiety appeared
to be associated with clinical factors within the broad range of gambling activity [48].
Another intriguing explanation that goes beyond the more classic view of gambling as
a means of escaping from negative emotions has been put forward for adults. Drawing on
incentive–sensitization theory proposed by Berridge and Robinson [
50
], Rogier et al. [
46
]
suggested that difficulty in enjoying positive experiences may account for the association
between depressive symptomatology and gambling disorder. One of the fundamental
characteristics of depression is diminished responsiveness to positive emotional stimuli [
51
].
Thus, the high hedonic rewards related to gambling may be more satisfying in cases of
depression than natural rewards [46].
This study also tested the use of a Short Gambling Harm Screen to examine gambling-
related harms in emerging adults. The findings showed that the mechanisms influencing
the Problem Gambling Severity Index were similar to the mechanisms detected on the
Short Gambling Harm Screen. This supports the utility of both measures in capturing
gambling-related harms across different age groups [
52
,
53
]. The significant differences

Int. J. Environ. Res. Public Health 2024,21, 702 8 of 12
between age groups are also consistent with a recent systematic review that unequivocally
emphasized the importance of age in the context of gambling-related harm, and advocated
for further investigations to better understand the distribution of harm across various age
cohorts [54].
The current findings also show that while depression and anxiety can be interpreted
as gambling harms [
54
,
55
], they can contribute to various other aspects of harm as well.
Despite the fact that the Short Gambling Harm Screen is designed to examine the detri-
mental effects of excessive gambling rather than behavioral symptoms [
37
,
38
], it can be
inferred that anxiety and depression contribute specifically to harm and not only to the
severity of gambling. Thus, even individuals who do not meet the criteria for problem
gambling [
36
] stand to benefit from addressing their mental health issues to mitigate
gambling-related harm.
This study has several limitations. The cross-sectional design of this study limits our
ability to infer causality between age, mental health, and gambling behaviors. Longitudinal
studies are needed to unravel the temporal dynamics of these relationships. Further, the
reliance on self-report measures introduced the potential for response bias, thus highlight-
ing the need for a multi-method approach in future research. The unbalanced proportions
between the number of emerging adults aged 18–29 (n= 740) and adults over age 30
(
n= 2504
) in our sample constitute another limitation. This imbalance in group sizes could
have impacted the statistical power of the analyses involving age comparisons. Although
a larger sample size in one demographic group may lead to more precise estimates for
that group, it may not provide equally robust findings for the smaller group. Finally, our
participants consisted exclusively of individuals from Israel. Given the more conservative
nature of the gambling market in Israel, future studies could extend this work to more
diverse markets, as well as more diverse populations and cultures.
5. Conclusions and Implications
The findings point to emerging adulthood as a potentially vulnerable stage for gam-
bling problems and gambling-related harms to emerge, and the pivotal role of depression
and anxiety in driving the problematic aspects of gambling behavior. The findings have
important implications for both policy and practice. They highlight the need for age-specific
gambling harm reduction strategies and mental health services that address the unique
challenges faced by emerging adults. The current study suggests that interventions aimed
at improving mental health in this age group could be effective in reducing gambling
problems and gambling-related harm. Previous research has suggested that in emerging
adults, problem gambling should be seen as part of a broader syndrome necessitating a
holistic approach to intervention [
56
] based on findings showing that the co-occurrence
of both problem gambling and mental health concerns among emerging adults may be
accompanied by a multitude of additional challenges, including alcohol dependence, illegal
drug use [
57
], and suicidality [
58
]. These recommendations are particularly important
since evidence indicates that the prevalence of gambling among emerging adults remains
relatively constant during this transitional period [13].
Previous studies have pointed to the importance of implementing regular screening
protocols for young adults to effectively pinpoint individuals who may be experiencing
escalating gambling-related harms over time [
59
]. It is essential for primary care providers,
as well as other healthcare, social services, and public health settings, to integrate routine
assessments of gambling behaviors into their protocols to facilitate the early identification
of those at risk [
59
,
60
]. The findings also shed light on the imperative need to incorporate
evaluations targeting mental well-being issues as part and parcel of the screening of
young individuals.
Previous research has focused on factors likely to increase susceptibility to problem
gambling but have neglected the importance of protective factors in mitigating this risk [
61
].
It is essential for emerging adults to be able to cultivate protective factors related to
problem gambling. These factors include social and emotional resources, which may be a

Int. J. Environ. Res. Public Health 2024,21, 702 9 of 12
promising strategy when addressing and potentially averting gambling-related problems,
particularly in young men. Efforts should concentrate specifically on increasing awareness
and involvement of family members, as highlighted in recent research [61].
The findings also suggest the value of initiating public campaigns targeting emerging
adults and raising their awareness that they are a vulnerable group for gambling prob-
lems and harms, and for the risks inherent to involvement in gambling behavior itself.
In addition to the importance of age, these interventions and campaigns should be sen-
sitive and adapted to gender and differences in level of education. Young individuals,
in their formative years, have the potential to benefit from preventive measures that are
strategically integrated into their educational journey [
3
]. These measures should not only
focus on addressing and reducing the risks associated with gambling problems, but should
also include the development and application of comprehensive strategies designed to
proactively prevent the emergence of mental health obstacles and complexities.
In terms of policy, an evaluation should be conducted by regulators and policymakers
to determine the suitability of existing strategies for interventions with young adults. The
results here underscore the need to specifically tackle gambling problems linked to the
unique challenges faced during this crucial period of emerging adulthood. For instance,
research on public policy has suggested that instituting policies in institutions of higher
education could potentially mitigate various risky behaviors that are prevalent among
college students [
62
]. These measures could include the establishment of a gambling
policy, conducting campus surveys on gambling behaviors, and providing gambling-
related information on counseling centers and student service websites [
63
]. Other policy
initiatives could involve providing financial assistance to autonomous scientific research
establishments to evaluate issues related to gambling, prevention, and treatment that
particularly impact the emerging adult population. These could also work to enforce the
industry’s minimum standards to guarantee the marketing of safer gambling products for
young adults [64].
Overall, this study contributes to the growing body of literature on gambling behaviors
and mental health across different age groups. It underscores the importance of considering
psychological well-being in efforts to address problem gambling and gambling-related
harms, especially among emerging adults.
Author Contributions: B.G.-F. led the research from the ground up, formulated the research aims,
and conceptualized the research model. She was responsible for the study design and data collection
and was involved in writing the manuscript. I.M. was involved in writing the literature review and
the discussion. Y.L. conducted the data analysis and was involved in writing the manuscript. All
authors have read and agreed to the published version of the manuscript.
Funding: The current study was funded by a grant from the Committee for Independent Studies of
the National Lottery of Israel awarded to B.G.-F. This grant did not influence the current study.
Institutional Review Board Statement: The study was conducted in accordance with the Ethical
standards of the American Psychology Association, and approved by Tel Aviv University Institutional
Review Board (protocol code 0002764-3, 5 July 2022).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in this study are available from the corresponding
author upon reasonable request.
Conflicts of Interest: The authors declare no conflicts of interest.
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