Online sports betting legalization was associated with increased use of antidepressant and antianxiety medications and outpatient visits for depression and anxiety among adults with employer-sponsored health insurance. The associations were more robust among men, while no statistically significant changes were detected in emergency department visits or hospitalizations for behavioral health conditions.
Researchers conducted a quasi-experimental, staggered difference-in-differences analysis using MarketScan commercial insurance claims from January 2016 through December 2023. The analysis included 61,951,305 enrollee-years among adults aged 18 to 64 years across 22 states that legalized online sports betting between 2018 and 2022 and 13 states that had not legalized it by the end of 2023. Women accounted for 52% of enrollee-years, and the mean age was 41.9 years. Researchers compared changes in behavioral health care use between states with and without legalized online sports betting, accounting for differences in legalization timing.
The primary outcomes were the proportions of enrollees with at least 1 prescription fill for antidepressants, antianxiety medications, or medications for substance use disorders (SUDs), as well as outpatient, emergency department, or inpatient visits involving diagnoses of depression, anxiety, or SUDs. Secondary outcomes included prescription fills and medical visits per enrollee, gambling disorder diagnoses, and naltrexone prescriptions. Researchers also assessed differences by sex, age group, and time since legalization.
Following legalization, the probability of filling an antidepressant prescription increased by 0.57 percentage points among men and 1.08 percentage points among women, corresponding to relative increases of approximately 5% in both groups. Antianxiety medication use increased by 0.32 percentage points among men and 0.64 percentage points among women, also representing relative increases of approximately 5%.
Outpatient mental health care use showed similar increases. The probability of an outpatient depression diagnosis rose by 0.34 percentage points among men and 0.57 percentage points among women, corresponding to relative increases of 7% and 5%, respectively. For outpatient anxiety diagnoses, the increases were 0.67 percentage points among men and 1.15 percentage points among women, representing relative increases of approximately 7% in both groups.
Event-study analyses indicated that differences in mental health care use between states with and without legalized online sports betting generally widened over time. Associations were relatively small during the first 2 years following legalization but increased thereafter, particularly 4 to 5 years after legalization. However, legalization was not associated with statistically significant changes in emergency department or inpatient visits involving depression, anxiety, or SUD diagnoses.
Findings for substance use treatment were more limited. Legalization was not associated with statistically significant changes in the probability of filling an SUD medication prescription or receiving an outpatient SUD diagnosis. Secondary analyses, however, identified a 33% relative increase in the number of visits involving gambling disorder diagnoses and an 11% increase in naltrexone prescription fills among men. Neither outcome showed a statistically significant change in the probability of having at least 1 such visit or prescription fill, and corresponding increases were not detected among women.
Age-stratified analyses showed generally consistent associations across adults aged 18 to 34, 35 to 49, and 50 to 64 years, although relative increases in medication use were larger among younger adults. Antidepressant use increased by approximately 6.5% among men aged 18 to 34 years vs 5.2% among those aged 50 to 64 years. Among women, the corresponding increases were 7% and 4%. For antianxiety medications, relative increases were 6% vs 4% among younger and older men and 8% vs 4% among younger and older women.
Although estimated increases were often numerically larger among women, associations were more precise and robust among men. In sensitivity analyses restricted to states with at least 3, 4, or 5 years of postlegalization follow-up, associations involving antidepressant prescriptions, antianxiety prescriptions, and outpatient anxiety diagnoses remained statistically significant among men. The association with outpatient depression diagnoses was less robust, and none of the primary associations that were statistically significant among women remained robust in these analyses.
The analysis included only adults with employer-sponsored health insurance, limiting generalizability to uninsured patients, Medicaid beneficiaries, and populations with less stable employment. Claims data did not capture gambling participation, preventing the authors from distinguishing the effects of direct sports betting involvement from exposure to gambling among family members. Patients who lost employer-sponsored coverage were also not observed following insurance loss, potentially excluding those experiencing more severe gambling-related consequences. Additionally, some outpatient mental health outcomes showed upward trends before legalization, complicating interpretation of the observed associations.
Online sports betting legalization was associated with increased use of outpatient and prescription mental health services, although the underlying mechanisms remain uncertain. The authors noted that increased treatment use could reflect worsening mental health or greater access to care among patients with previously unmet needs.
“Future work is needed to understand the mechanisms underlying these associations,” wrote lead study author Benjamin Westermeyer, BA, of the Johns Hopkins Bloomberg School of Public Health, and colleagues.
Matthew D. Eisenberg, PhD, reported receiving grants from the National Institute on Drug Abuse, National Institute of Nursing Research, National Institute of Mental Health, Commonwealth Fund, Arnold Ventures, and Foundation for Opioid Response Efforts outside the submitted work. No other disclosures were reported.
Source: JAMA Psychiatry
