Sports betting laws tied to more anxiety and depression care in US states

Since 2018, legal online sports betting has spread from one state to 31, and in most states a bet on tonight’s game is now a few taps away. What that has done to the mental health of people in those states is only starting to be measured.

A team at Johns Hopkins has now measured one part of it, using the insurance records of working-age adults. After a state legalized online sports betting, slightly more of its insured residents filled prescriptions for antidepressants and anti-anxiety drugs, and slightly more were diagnosed with depression or anxiety in outpatient care. Treatment for drug and alcohol problems did not change. Benjamin Westermeyer, Matthew Eisenberg and Mark Meiselbach, of the Johns Hopkins Bloomberg School of Public Health, published the study on October 14 in JAMA Psychiatry.

How online sports betting spread from one state to 31

Until 2018, Nevada was in effect the only state with legal sports betting. That year the US Supreme Court, in Murphy v National Collegiate Athletic Association, allowed states beyond Nevada to legalize sports betting, and they did so quickly. A study of the aftermath in JAMA Internal Medicine found that total sports wagers increased from $4.9 billion in 2017 to $121.1 billion in 2023, and that 94% of wagers during 2023 were placed online.

The same study tracked Google searches and found 23% more searches nationally for gambling addiction help after the court’s decision, and online sportsbooks corresponded with a larger increase in searches than betting shops did.

Gambling problems rarely travel alone. A review of population surveys found that people with gambling problems often have other conditions too: about 38% had any type of mood disorder, such as depression, and a similar share an anxiety disorder.

What was missing was evidence about everyone else. Unlike earlier studies, which counted signals of gambling trouble itself such as searches for addiction help, the new study looks at depression and anxiety care across whole state populations. Despite the known burdens of gambling, the Johns Hopkins authors write, little is understood about what legalization has done to the use of mental health and substance use treatment.

How do you test a law’s effect on mental health?

A state cannot be assigned at random to legalize betting, but the staggered rollout gave the researchers the next best thing. They compared states that legalized online sports betting during 2018-2022 with states that had not done so by the end of 2023, and asked how each state’s mental health care changed after its own law took effect, against the change over the same years in states without one. The method is called a difference-in-differences design. If the two groups of states were on similar paths beforehand, a gap that opens up afterward points to the law.

The records came from a large, national convenience sample, one built from available insurance data instead of drawn at random, of people aged 18 to 64 with coverage through an employer, from January 2016 to December 2023. Because people move in and out of insurance, the sample is counted in enrollee-years, one person insured for one year, and it came to nearly 62 million of them, a little over half from women.

The researchers did not ask anyone how they felt. They counted what the insurance claims recorded. One set of measures asked whether a person filled at least one prescription in a year for an antidepressant, an anti-anxiety drug or a medicine for drug or alcohol addiction. The other asked whether they had a visit with a diagnosis of depression, anxiety or a substance use disorder, split by outpatient clinics, emergency departments and hospital stays.

What changed in depression and anxiety care after legalization

The changes in depression and anxiety care were small, and all of them pointed the same way. Legalization went with a rise in the probability of antidepressant use of 0.57 percentage points in men and 1.08 points in women. A percentage point is one person in 100, so those figures amount to roughly six more men and 11 more women in every 1,000 filling an antidepressant prescription in a year.

Anti-anxiety prescriptions rose by roughly half as much as antidepressants, in both sexes. Diagnoses made in outpatient clinics followed the same pattern. Depression diagnoses rose by a third of a point in men and by a little over half a point in women, and anxiety diagnoses showed the largest shift of any measure: two thirds of a point in men, and slightly more than one full point in women.

Two outcomes did not move. There was no detectable change in the use of medicines for substance use disorders, or in substance use diagnoses. Nor did legalization go with any change in behavioral health diagnoses in the emergency department or during hospital stays, which is where the most severe crises end up. What rose, in the authors’ words, was outpatient and prescription mental health care, the kind delivered in a doctor’s office or at a pharmacy counter.

The women’s figures stand out. Each change was larger in women than in men in absolute terms, though the ranges around the women’s estimates are wider. Two 2026 studies from Ontario, Canada, in the Canadian Medical Association Journal and the American Journal of Preventive Medicine, show how unusual that is for gambling harms. When online gambling and single-event sports betting expanded there, the rise in calls to a gambling helpline came almost entirely from adolescent boys and men aged 15 to 44, and emergency visits for gambling disorder roughly doubled, with increases occurring only in young men. Insurance claims cannot show why women’s care rose.

What other studies of sports betting and mental health found

The new results sit among a handful of studies that use the same staggered rollout, and they do not all agree.

On alcohol, a study in Health Economics used national survey data and found that legalizing online sports betting increased binge drinking frequency among young men who already binged, by approximately 10 percent, with no effect on smoking. The Johns Hopkins study found no change in substance use treatment, which is a different question: heavier drinking can rise for years before anyone is treated for it.

On mental health itself, an analysis of 4,660,948 respondents to a national health survey found that legalization had no discernible effect on poor mental health days or on reported depression diagnoses, and no change in suicide or alcohol deaths, in up to three years of follow-up. That analysis was posted as a preprint in May and has not yet been peer reviewed. Survey questions about the past month and insurance claims for treatment measure different things, and the two studies cover different people, so they can both be right. But the preprint is a reminder that a population-wide rise in distress has not been shown.

The direction of the link between gambling and depression also runs both ways. In a study of 265 young Australian men, problem gambling severity was explained in part by higher levels of depression and by more frequent sports and fantasy sports gambling. Someone who is already low may bet more, as well as the reverse.

What insurance records on sports betting leave unanswered

The study tracked care, not illness. A rise in prescriptions could mean more people became depressed or anxious, or that the same number sought help, or both, and claims data cannot tell those apart. The authors describe their finding as treatment use.

The outcomes were measured at the state-year level, as the share of each state’s insured adults in each year, so the study describes populations and does not follow any one person from before a law to after it. Exposure, likewise, was a state law. Nobody in the data was known to be a bettor, so the study cannot say whether the extra prescriptions went to people who gambled, to their partners and families, or to neither.

Everyone in the data had insurance through an employer and was 18 to 64, so people without insurance, people on Medicaid and people over 64 are not represented, and those groups may differ in both betting and access to care. The design also rests on an assumption that cannot be fully tested: that legalizing and non-legalizing states would have followed similar paths without the law. The study years also cover the COVID-19 pandemic, when mental health care changed everywhere, and the comparison absorbs that only if both groups of states were affected alike. And the headline figures are percentage-point changes, which say how many more people per 100 received care, not how large each rise was relative to its starting level.

What the sports betting results mean

For an individual, the shifts are small: on the largest measure, about one extra woman in 100 a year with an anxiety diagnosis. Across the tens of millions of adults now living where betting is a phone app away, small shifts add up to many more people receiving care for depression or anxiety.

The authors write that their results show “the importance of prevention and treatment of potential adverse health consequences of legalized online sports betting.” The study does not test any prevention measure, and it does not show that betting caused depression.

Do not stop or change a prescribed medicine without talking to your doctor. Whether low mood or anxiety in a particular person needs treatment is assessed by their doctor.

The Johns Hopkins study adds evidence from health records that legal online betting went with a small rise in depression and anxiety care across US states, in women as well as men, while leaving open who was betting and why the care rose.