Online Sports Betting Legalization Tracks With Higher Outpatient Mental Health Care Use
Online sports betting legalization was associated with measurable increases in outpatient mental health treatment use among adults with employer-sponsored insurance, adding a population-level signal to a behavior that has spread rapidly across the United States. The analysis followed state policy change from 2016 through 2023 and treated legalization as the exposure, comparing states that opened online sports betting during 2018 to 2022 with states that had not legalized by the end of follow-up. Across a national claims sample, the pattern was consistent: more antidepressant fills, more antianxiety fills, and more outpatient diagnoses for depression and anxiety after legalization.
The numbers were small in absolute terms, but they moved in the same direction across multiple outcomes and across both sexes. Men showed a 0.57 percentage-point increase in antidepressant use and a 0.32 percentage-point increase in antianxiety use after legalization. Women showed larger shifts, with a 1.08 percentage-point increase in antidepressant use and a 0.64 percentage-point increase in antianxiety use. Those differences matter because they point to a rise in treatment contact rather than a subtle statistical artifact isolated to one diagnosis code or one drug class.
Claims Data Capture a Broad Employer-Insured Cohort
The study used a quasi-experimental staggered difference-in-differences design and drew from claims data spanning January 2016 through December 2023. The cohort included men and women aged 18 to 64 years living in states that legalized online sports betting during the study window or states that had not legalized by its end. The analytic sample covered 61,951,305 enrollee-years, including 31,914,852 enrollee-years among women, who made up 52% of the cohort. Mean age was 41.9 years, with an SD of 13.5 years.
That scale gives the findings unusual weight. A policy change affecting access to gambling was examined not through self-report or a narrow clinic sample, but through real-world treatment use captured in insurance data. The endpoint structure also mattered: investigators looked separately at prescription fills and at outpatient, emergency department, and inpatient diagnoses tied to depression, anxiety, and substance use disorders. That design makes it possible to see whether legalized online betting corresponded to increased routine care, crisis care, or both.
Depression and Anxiety Treatment Rose After Legalization
The clearest signal emerged in outpatient behavioral health care. Legalization was associated with a higher probability of an outpatient diagnosis for depression in men, by 0.34 percentage points, and in women, by 0.57 percentage points. Anxiety diagnoses increased even more, by 0.67 percentage points in men and 1.15 percentage points in women. Prescription use moved in parallel. Antidepressant fills rose in both sexes, and antianxiety fills did as well.
One sentence captures the clinical pattern: legalization mapped to more outpatient contact for depression and anxiety, not to more substance use treatment.
Biologically and behaviorally, the direction of effect is plausible. Online sports betting is fast, mobile, and repetitive, which can intensify reinforcement loops, financial stress, sleep disruption, and anticipatory anxiety around wagers and losses. Those pressures are well suited to drive outpatient presentations for mood and anxiety symptoms before they escalate into emergency-level crises. In that sense, the treatment changes are not merely administrative signals in claims files; they are consistent with a pathway from easier access to gambling to greater psychological strain and more office-based care.
No Detectable Change in Substance Use Disorder Care
In contrast, the study found no detectable change in substance use disorder medication use and no detectable change in substance use disorder diagnoses in outpatient, emergency department, or inpatient settings. Emergency department and inpatient behavioral health outcomes did not move with legalization either. The absence of an observed shift in acute care suggests that the early treatment burden may be concentrated in less severe or earlier-stage illness, or that substance-related consequences were not yet large enough in this insured population to register in the claims outcomes used here.
This finding should not be mistaken for reassurance. Behavioral health harms can emerge first as insomnia, irritability, depressed mood, escalating anxiety, or conflict at home and at work, long before a crisis visit or hospitalization appears in administrative data. Online betting also differs from many other forms of gambling because of its constant availability and speed of play. A mobile phone can turn a moment of boredom into a recurring exposure, and that exposure may show up first in primary care, psychiatry, or medication management rather than in emergency care.
Women Showed Larger Increases Across Several Endpoints
Across the main findings, women had larger absolute increases than men in antidepressant use, antianxiety use, and outpatient depression and anxiety diagnoses. The study does not establish why, but the pattern invites careful clinical attention. Differences in help-seeking behavior, symptom recognition, baseline mental health burden, and exposure to gambling-related stressors may all contribute. The administrative data cannot resolve those mechanisms, yet the sex-specific pattern is visible enough to matter for surveillance and counseling.
The policy implication is straightforward. When a state legalizes online sports betting, the effect is not confined to gambling markets or tax revenue. It appears in mental health care use, and it appears quickly enough to be detected in claims data across a multi-state cohort.
Behavioral Health Surveillance Should Follow Gambling Policy
The study’s strongest contribution is its linkage of legalization to changes in treatment use rather than to isolated prevalence estimates or public concern alone. Antidepressant prescribing, antianxiety prescribing, and outpatient diagnoses for depression and anxiety all rose after policy change, while substance use disorder outcomes did not. That pattern narrows the clinical focus toward mood and anxiety burden in insured adults, at least over the observed period.
These results also set boundaries. The analysis included people with employer-sponsored insurance, so the findings may not generalize to uninsured populations, Medicaid beneficiaries, or people with unstable access to care. Claims data also identify treatment use, not symptom severity, gambling frequency, or causality at the individual level. Still, the consistency across multiple outpatient endpoints makes the signal hard to dismiss.
For clinicians and health systems, the practical consequence is early case-finding. As online sports betting spreads across states, outpatient depression and anxiety care may rise alongside it, and behavioral health screening will need to account for gambling exposure as part of routine assessment. The unanswered questions now center on how much of this increase reflects new illness, worsening of existing symptoms, or improved recognition once gambling-related distress becomes more common in the community.