From the Editor
Can Argentina repeat? Could England end its six-decade drought? Roughly five billion people will watch this year’s World Cup. The tournament can be understood in different ways: a great sporting event, a giant party, and, yes, a huge draw for gamblers. In Ontario – and across North America – recent laws have dramatically expanded gambling options. How have such changes affected problem gambling and the need for help?
In a new CMAJ study, Ryan Forrest (of the University of Toronto) and his co-authors attempt to answer that question. They drew on Ontario data to quantify the increase in help-seeking following the launch of a government-operated online gambling platform in January 2015 and the subsequent expansion of private online gambling. They analyzed almost 750 000 contacts to a helpline over 13 years, finding that the mean monthly rate of gambling-related contacts nearly doubled. “The rapid expansion and privatization of online gambling, including single-event sports betting, in Ontario were respectively associated with marked increases in gambling-related helpline contacts, specifically among adolescent boys and young men.” We consider the paper and its implications.
In the second selection, from JAMA Psychiatry, Laura M. Rowland (of the University of Maryland) and Dr. Ellen E. Lee (of the University of California San Diego) write about schizophrenia and women. “The lack of focused health research on women in general is well recognized, and mental health research remains no exception. Surprisingly, there is also a lack of mental health research on older people with schizophrenia with less than 5% of scientific publications on schizophrenia dedicated to this older group.”
Finally, in the third selection, Dr. John V. Campo (of Johns Hopkins University) discusses faith and psychiatry. In a personal essay for The Washington Post, he notes his own religious experience and declining health. “Taking our patients seriously requires physicians to explore issues of ultimate concern, suggesting that a spiritual history should be an expected component of any comprehensive clinical evaluation.”
DG
Selection 1: “Help-seeking for gambling problems following expansion of Ontario’s online gambling market and legalization of single-event sports betting”
Ryan Forrest, Robert Talarico, Anosha Waqar, Daniel T. Myran
CMAJ, March 02, 2026
Over the past decade, gambling regulation in North America has shifted toward increasing liberalization. In 2018, the US Supreme Court removed federal restrictions on sports betting, leading to rapid expansion across multiple states. In Canada, federal legislation amending the criminal code passed in 2021 legalized single-event sports betting, allowing provinces and territories to choose how to regulate sports betting within their jurisdictions…
Gambling can be addictive and is associated with adverse outcomes, including depression, anxiety, financial hardship, relationship disruption, and suicidality. In 2018, an estimated 64.5% of Canadians reported past-year gambling (most participated in lotteries or raffles), and 1.6% of past-year gamblers were at moderate or severe risk of a gambling disorder… Several policy changes in Ontario, Canada’s most populous province, present an opportunity to evaluate gambling liberalization. In January 2015, the Government of Ontario began offering online gambling through a government-run online platform, PlayOLG, with online lottery, casino, and instant games. In April 2022, Ontario expanded online gambling, allowing private companies to offer legal online gambling services, including sports betting…
So begins a paper by Forrest et al.
Here’s what they did:
- They conducted “an interrupted time-series analysis of contacts with Ontario’s free 24-hour mental health and addictions helpline (ConnexOntario)…” to examine gambling-related contacts before and after major online gambling policy changes in Ontario.
- Monthly data were obtained from ConnexOntario from January 2012 through September 2025; analyses included individuals aged 15 years and older.
- Four policy periods were examined: pre-PlayOLG, post-PlayOLG launch, COVID-19 period, and post-privatization of online gambling.
- Primary outcome: any ConnexOntario contact (telephone, text, email, or live chat) identified as primarily gambling related.
- Different statistical analyses were done, including segmented linear regression to estimate immediate (level) and gradual (trend) changes to “compare immediate, gradual, and overall changes in monthly rates of gambling-related contacts after gambling expansion”
Here’s what they found:
- ConnexOntario received 745 716 contacts with 5.0% for gambling.
- Demographics. The mean age was 39 years and 68.2% were men.
- Monthly contacts. “The mean monthly rate of gambling-related contacts per 1 000 000 individuals aged 15 years and older was stable over time before the launch of PlayOLG (13.4); the rate increased after PlayOLG’s launch (17.0) and further increased following privatization (26.2).” (!)
- Estimates. “Compared with the scenario in which PlayOLG never launched, the estimated effect was 9.3… additional monthly contacts per million individuals aged 15 years and older in February 2022 (an approximately 80.7% increase). Compared with the scenario in which neither PlayOLG nor private online gambling was allowed, the estimated effect was 20.8… additional monthly contacts per million individuals aged 15 years and older in September 2025 (an approximately 198.3% increase).”
- Age. “Increases in gambling-related contacts occurred almost exclusively in adolescent boys and men aged 15 to 44 years.” (!!)
A few thoughts:
1. This is a good study, offering an important look at the impact of legal changes around gambling, with data spanning more than a decade.
2. The main finding in a sentence: “The introduction of online gambling and subsequent privatization with single-event sports betting were each associated with substantial increases in gambling-related helpline contacts, specifically in adolescent boys and young men, suggesting increased gambling problems, care-seeking, or both.” More: The authors’ modelling suggests that these trends were not simply part of a long-term background increase.
3. Focusing on youth: Among males aged 15 to 24 years, the monthly rate of gambling-related contacts rose by 317% between the pre-PlayOLG period and the post-privatization period.
4. Ouch.
5. The authors see implications for policy. “Ontario is currently the only province in Canada with privatized online gambling, and the findings caution against both increasing online access to gambling and privatization of such markets in other jurisdictions. Furthermore, the findings may support restrictions on particularly harmful types of online gambling that are associated with greater gambling intensity and risk of addiction and harms. These include online slots and electronic gambling machines, single-event sports betting with live or ‘inplay’ or micro-betting during games, which allow rapid repeat wagers and shorten the delay between bets and outcomes.” Thoughtful.
6. What are the clinical implications? Do we ask adolescents about online gambling? Should we?
7. Like all studies, there are limitations. The authors note several, including: “ConnexOntario responders do not make diagnoses, and gambling-related contacts may be subject to under- or overreporting because of misclassification.”
The full CMAJ paper can be found here:
https://www.cmaj.ca/content/198/8/E281.abstract
Selection 2: “Women With Schizophrenia—Ignored and Aging”
Laura M. Rowland and Ellen E. Lee
JAMA Psychiatry, 13 May 2026 Online First
Sex differences are well established in schizophrenia spectrum disorders, with respect to age at illness onset and symptom profiles. During clinical training, we were taught that male individuals diagnosed with schizophrenia had worse prognoses than females, with earlier age at illness onset, greater symptom severity, poorer functional outcomes, and required higher doses of antipsychotic medications. In contrast, we learned that women were more likely to have a later age at illness onset, more mood symptoms, and better functional outcomes due to the protective factors of estrogen. This zeitgeist appears to hold true for research that assessed longitudinal outcomes of less than 10 years and examined younger individuals. However, this is not the case when studies examine outcomes greater than 10 years and people later in life, specifically after the age of 40 years old.
So begins Rowland and Lee.
“Many clinical and scientific gaps in knowledge pertaining to the course and features of schizophrenia and related disorders in women remain, especially centered around reproductive stages of life, including menarche, menstrual cycle, pregnancy, perimenopause (also referred to as the menopausal transition), and postmenopause. This knowledge gap stems from a long history of research in predominantly male samples coupled with the lack of large-scale, deeply phenotyped, female-specific research on schizophrenia and related disorders examining these critical life periods.”
They focus on psychosis. “A recent large-scale nationwide Finnish cohort study shows women during midlife to late life (age ≥45 years, around the median ages of perimenopause and postmenopause transitions) have worsening of psychiatric symptoms requiring greater hospitalizations and decreased response to antipsychotic medications compared with younger women and men of comparable ages with schizophrenia… Estrogen decline during menopause is likely one causal mechanism, as results generated from the same nationwide cohort study show menopausal hormone therapy to be associated with lower psychosis relapse risk in women aged 40 to 55 years old, coinciding with perimenopause through recent postmenopause stages, that was not observed in women aged 56 to 62 years.”
They argue that these women “constitute a vulnerable group for mental health decompensation that warrants rigorously tailored research…” They also see problems in terms of cognition. “People living with schizophrenia and related disorders have a 2- to 5-fold increase in Alzheimer disease and related dementias, with women with schizophrenia constituting higher rates. One recent population-based cohort study found that women with schizophrenia had increased dementia risk (adjusted odds ratio, 5.6…) compared with men with schizophrenia (adjusted odds ratio, 4.0…). This is especially relevant given that the number of people with schizophrenia and related disorders aged 55 years and older is expected to significantly grow, constituting 50% of all cases by year 2060, with women being the majority. Hence, not only are women with schizophrenia in midlife to late life at a heightened risk rate for clinical worsening and functional deterioration, but they are also at a heightened risk for developing dementia compared with men.”
They argue that more work needs to be done. “Women aging with schizophrenia deserve targeted research.”
A few thoughts:
1. This is a thoughtful paper.
2. They focus on research and clinical care. There are implications to the overall healthcare system, of course. Are nursing homes ready for an aging population of women with schizophrenia?
3. I wonder what Dr. Mary Seeman would have thought about this commentary paper. I suspect she would have liked it. For those interested in knowing more about the remarkable career of our colleague, a past Reading highlighted her obituary. That Reading can be found here:
The full JAMA Psychiatry paper can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2848620
Selection 3: “As a doctor, I’d lost religion. Then came the electric scrubber.”
John V. Campo
The Washington Post, 5 June 2026
As an academic physician, trained first in pediatrics and then psychiatry, a field highly skeptical of religious faith, I was unprepared for a transcendent experience that followed what I will call a housecleaning misadventure last spring. I have since come to view my previous skepticism of religious experience — one that prevails across much of medicine — as something that can impair doctors’ understanding of patients and their needs.
So begins an essay by Campo.
He writes of his experience. “It started on Memorial Day as my wife and I were cleaning our home. There were some resistant hard water stains in the shower that I decided to tackle with an electric scrubber and an industrial-strength cleaner. Soon after, my left hand and the left side of my face went numb, and I had difficulty controlling my movements. I concluded that I had unwittingly poisoned myself by inhaling the cleaner.”
He describes an experience. “Later that week, I awoke in the middle of the night, my wife sleeping quietly beside me. My mind was filled with a message that felt like it came from outside me, in words that were not my own: ‘Someday your body will fail you, and all you will have is me. It will be enough.’”
His health problems returned. “Several months later, after a long walk on the beach during a family vacation, the symptoms I had while cleaning our shower recurred. It was a focal seizure, as I would later learn. An MRI scan showed a mass in the right posterior frontal lobe of my brain, abutting the motor strip. It was a glioblastoma, an aggressive brain tumor with a poor prognosis.”
He notes his religious background. “As medical science clarified the cause of my symptoms, I was left wondering what to make of the voice that had come to me in the night. Nothing like it had happened to me before. True, as a boy I had often experienced a deep feeling of wonder while wandering the small backyard of my family’s home in Scranton, Pennsylvania. The Divine Liturgy of the Eastern Orthodox Church, in which I was raised, also filled me with a sense of awe… But any sense of connection to something larger than myself slipped away as I grew.”
“Physicians are increasingly comfortable exploring previously stigmatized topics such as a patient’s sexual history. At the same time, they tend to show little interest in the religious experience that is central to the lives of many patients.” Yet he notes that religious experiences aren’t uncommon. “Such a moment of sudden revelation or insight is often referred to as an epiphany, derived from the Greek ‘epipháneia,’ meaning appearance or manifestation. Forty-five percent of U.S. adults report having such experiences. Discounting these occurrences as purely subjective has potential to limit practitioners’ connection with patients in medicine and psychiatry.”
He closes by considering his journey. “My story isn’t complete, but the words that came to me in the quiet of the night are true enough: Someday my body will fail. Indeed, that process has already begun. Following a craniotomy and partial surgical resection of the tumor, along with radiation and chemotherapy, I have experienced changes in sensation and strength on the left half of my body. Although the remaining words of the message contain some mystery, I’m hopeful and confident that the love of God surrounding me ‘will be enough.’”
A few thoughts:
1. This is a moving essay.
2. In secular times, are we too quick to ignore the religious backgrounds and experiences of our patients?
3. His diagnosis is serious and we all wish our colleague well. Of course, it’s important to remember that his story isn’t complete.
The full Washington Post essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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