Online sports betting legalization was associated with an increase in outpatient and prescription mental health care use among people with employer-sponsored health insurance, underscoring the importance of prevention and treatment of potential adverse health consequences.
Key Findings
Results
Online sports betting legalization was associated with increased antidepressant use among both men and women.
Men showed an increase of 0.57 percentage points (95% CI, 0.26-0.89 percentage points) in probability of antidepressant use.
Women showed a larger increase of 1.08 percentage points (95% CI, 0.23-1.94 percentage points) in probability of antidepressant use.
The effect was consistently detectable for both sexes with confidence intervals not crossing zero.
Outcomes were measured at the state-year level, weighted by number of enrollees.
Results
Online sports betting legalization was associated with increased antianxiety medication use among both men and women.
Men showed an increase of 0.32 percentage points (95% CI, 0.14-0.50 percentage points) in probability of antianxiety medication use.
Women showed an increase of 0.64 percentage points (95% CI, 0.16-1.12 percentage points) in probability of antianxiety medication use.
Women's effect size was approximately twice that of men for antianxiety medication use.
Results
Online sports betting legalization was associated with increased outpatient diagnosis rates for depression in both men and women.
Men showed an increase of 0.34 percentage points (95% CI, 0.20-0.49 percentage points) in probability of an outpatient depression diagnosis.
Women showed an increase of 0.57 percentage points (95% CI, 0.25-0.89 percentage points) in probability of an outpatient depression diagnosis.
The association was limited to outpatient settings; no detectable changes were found in emergency department or inpatient settings.
Results
Online sports betting legalization was associated with increased outpatient diagnosis rates for anxiety in both men and women.
Men showed an increase of 0.67 percentage points (95% CI, 0.32-1.01 percentage points) in probability of an outpatient anxiety diagnosis.
Women showed an increase of 1.15 percentage points (95% CI, 0.50-1.81 percentage points) in probability of an outpatient anxiety diagnosis.
The anxiety diagnosis effect sizes were larger than those for depression in both sexes.
As with depression, the effect was limited to outpatient settings.
Results
Online sports betting legalization was not associated with detectable changes in substance use disorder (SUD) medication use or SUD diagnoses.
No statistically detectable change in SUD medication fills was found following legalization for either men or women.
No detectable change in outpatient SUD diagnoses was found following legalization.
No behavioral health diagnoses changes were detected in emergency department or inpatient settings for any condition.
This null finding for SUD contrasts with positive findings for mental health outcomes.
Methods
The study used a quasi-experimental staggered difference-in-differences design applied to a large national sample of employer-sponsored health insurance enrollees.
The sample included 61,951,305 enrollee-years from January 2016 to December 2023.
Among enrollee-years, 31,914,852 (52%) were women, and the mean (SD) age was 41.9 (13.5) years.
The analysis included adults aged 18 to 64 years living in states that legalized online sports betting during 2018-2022 or had not legalized it by end of study period.
The number of states with legal online sports betting grew from 1 to 31 since 2018.
Outcomes were measured at the state-year level, weighted by number of enrollees.
Results
Women consistently showed larger effect sizes than men across all statistically significant mental health outcomes following online sports betting legalization.
The female-to-male ratio of effect sizes was approximately 1.9:1 for antidepressant use (1.08 vs. 0.57 percentage points).
The female-to-male ratio was approximately 2:1 for antianxiety medication use (0.64 vs. 0.32 percentage points).
The female-to-male ratio was approximately 1.7:1 for outpatient depression diagnoses (0.57 vs. 0.34 percentage points).
The female-to-male ratio was approximately 1.7:1 for outpatient anxiety diagnoses (1.15 vs. 0.67 percentage points).
What This Means
This research suggests that when states legalize online sports betting, more people seek mental health treatment. Analyzing insurance claims from nearly 62 million enrollee-years between 2016 and 2023, researchers found that after a state legalized online sports betting, residents were more likely to fill prescriptions for antidepressants and antianxiety medications, and more likely to receive outpatient diagnoses for depression and anxiety. Women appeared more affected than men across all these outcomes, with effect sizes roughly twice as large in women compared to men.
Interestingly, the study found no detectable increase in substance use disorder treatment or diagnoses, and no increases in emergency department or inpatient behavioral health visits — suggesting the effects were concentrated in outpatient mental health care rather than more severe or acute presentations. The number of states allowing online sports betting has expanded rapidly, growing from just 1 state in 2018 to 31 states by the time the study was conducted.
This research suggests that expanding access to online sports betting has real public health consequences, particularly for mental health. As more states consider legalizing online sports betting, policymakers, clinicians, and public health officials may want to anticipate increased demand for mental health services. The findings also raise questions about whether certain populations — particularly women — may be especially vulnerable to gambling-related mental health impacts, though the study design cannot determine whether the increases reflect new mental health problems caused by gambling or increased recognition and treatment-seeking among existing problem gamblers.
B. Westermeyer, Matthew D. Eisenberg, M. Meiselbach. (2026). Online Sports Betting Legalization and Behavioral Health Care Use.. JAMA psychiatry. https://doi.org/10.1001/jamapsychiatry.2026.3175