Online Sports Betting Legalization and Behavioral Health Care Use

Importance The number of states with legal online sports betting has grown from 1 to 31 since 2018, expanding access to gambling. Despite the known behavioral health burdens associated with gambling, little is understood about legalization’s impact on mental health and substance use treatment use. Objective To evaluate the association between online sports betting legalization and treatment use for mental health conditions and substance use disorders (SUD). Design, Setting, and Participants This was a quasi-experimental staggered difference-in-differences study using claims data from January 2016 to December 2023. The setting was a large, national convenience sample of people with employer-sponsored health insurance. Included in the analysis were men and women aged 18 to 64 years living in states that legalized online sports betting during 2018-2022 or had not by the end of the study period. Exposure State legalization of online sports betting. Main Outcomes and Measures Outcomes were measured at the state-year level, weighted by number of enrollees as follows: proportions of enrollees with 1 or more prescription fills for antidepressant, antianxiety, or SUD medications and proportions of enrollees with 1 or more outpatient, emergency department, or inpatient visits with a diagnosis for depression, anxiety, or SUD. Results Among 61 951 305 enrollee-years, 31 914 852 (52%) were women, and the mean (SD) age was 41.9 (13.5) years. Online sports betting legalization was associated with increases in the probability of antidepressant use (men: 0.57 percentage points; 95% CI, 0.26-0.89 percentage points; women: 1.08 percentage points; 95% CI, 0.23-1.94 percentage points) and antianxiety use (men: 0.32 percentage points; 95% CI, 0.14-0.50 percentage points; women: 0.64 percentage points; 95% CI, 0.16-1.12 percentage points), but there was no detectable change in SUD medication use. Legalization was also associated with increases in the probability of an outpatient diagnosis for depression (men: 0.34 percentage points; 95% CI, 0.20-0.49 percentage points; women: 0.57 percentage points; 95% CI, 0.25-0.89 percentage points) and anxiety (men: 0.67 percentage points; 95% CI, 0.32-1.01 percentage points; women: 1.15 percentage points; 95% CI, 0.50-1.81 percentage points) but not SUD. Legalization was not associated with behavioral health diagnoses in the emergency department and inpatient settings. Conclusions and Relevance Results of this quasi-experimental difference-in-differences study suggest that online sports betting legalization was associated with an increase in outpatient and prescription mental health care use among people with employer-sponsored health insurance. These findings underscore the importance of prevention and treatment of potential adverse health consequences of legalized online sports betting.