Summary by Jon E. Grant, MD, JD, MPH, and Brian L. Odlaug, MPH
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Based on “Principles of Addiction Medicine” Chapter by Jon E. Grant, MD, JD, MPH, Brian L. Odlaug, MPH, and Liana R.N. Schreiber, BA
Gambling disorder, also known as pathologic gambling, is a psychiatric disorder characterized by persistent and recurrent maladaptive patterns of gambling behavior, which is associated with impaired functioning, reduced quality of life, and high rates of bankruptcy, divorce, and incarceration. Gambling disorder is classified in DSM-5 as a “non–substance-related disorder” in the “substance-related and addictive disorders” category. The diagnosis requires that a person meet four of the possible nine criteria listed for the disorder. The term problem gambling has been used to describe forms of disordered gambling. Problem gambling, like problem drinking, is not an officially recognized disorder by the American Psychiatric Association.
There remains controversy about whether gambling disorder is better understood as a compulsive disorder or an addictive disorder. This is probably so because gambling disorder is often resistant to treatment. It remains unclear whether the treatment approaches of traditional addiction treatment (group, Twelve-Step, relapse prevention, etc.) are superior, inferior, or equivalent or need to be combined with those of psychiatric treatments (medication, cognitive–behavioral therapy [CBT], psychotherapy). Evidence, however, supports significant phenomenologic, clinical, epidemiologic, and biologic links with substance use disorders.
EPIDEMIOLOGY
A range of prevalence estimates have been reported for gambling disorder depending upon the time frame of the study and the instruments used to diagnose the disorder. A meta-analysis of 120 prevalence estimate surveys completed in North America from the late 1970s to the late 1990s found that the lifetime estimate of gambling disorder was 1.6% and of problem gambling was 3.85%, for a combined rate of 5.45% for some form of disordered gambling.
There has been an accelerated proliferation of gambling venues during the past decade, particularly with Native American casinos and riverboat gambling. With increased opportunities to gamble, it is likely that we can expect greater rates of gambling disorder in the future.
CLINICAL CHARACTERISTICS
Although prospective studies are largely lacking, gambling disorder appears to follow a trajectory similar to that of substance dependence, with high rates in adolescent and young adult groups, lower rates in older adults, and periods of abstinence and relapse. Significant clinical differences have been observed in men and women with gambling disorder. Men are more likely to be single and living alone as compared to women with the disorder. Male gamblers are also more likely to have sought treatment for substance abuse, have higher rates of antisocial personality traits, and have marital consequences related to their gambling. Women, who constitute approximately 32% of disordered gamblers in the United States, seem to progress more quickly to a pathologic state than do men, a phenomenon known as telescoping.
The types of gambling preferred by men tend to be different from those preferred by women. Men with gambling disorder have higher rates of “strategic” forms of gambling, including sports betting, video poker, and blackjack. Women have higher rates of “nonstrategic” gambling, such as slot machines or bingo. Both men and women report that advertisements trigger their urges to gamble, but women report that gambling acts as an escape from stress or depression.
Functional Impairment, Quality of Life, and Legal Difficulties
Individuals with gambling disorder suffer significant impairment in their ability to function socially and occupationally. Work-related problems such as absenteeism, poor performance, and job loss are common. It is also frequently associated with marital problems and diminished intimacy and trust within the family. Financial difficulties often exacerbate personal and family problems.
Not surprisingly, individuals with gambling disorder report poor quality of life. Gambling disorder is also associated with greater health problems and increased use of medical services. Possible reasons for these issues include the sedentary nature of gambling, reduced leisure and exercise time, reduced sleep, increased stress, and increased nicotine and alcohol consumption.
Many individuals with gambling disorder have faced legal difficulties related to their gambling, including activities such as embezzlement, stealing, and writing bad checks.
Comorbidity
Psychiatric comorbidity is common in individuals with gambling disorder. Substance use disorders (especially tobacco and alcohol use disorders) are the most commonly seen comorbid conditions with gambling disorder. There are also high estimates of co-occurring mood and anxiety disorders (mainly generalized anxiety disorder). The rates of co-occurring disorders often have wide ranges, and this may be owing to the lack of structured clinical interviews used, the small sample sizes of gamblers assessed, and the possible heterogeneity of gambling disorder. Estimates of any personality disorder in disordered gamblers range from 25% to 93%. Borderline, narcissistic, avoidant, and obsessive-compulsive personality disorders are most commonly reported.
Suicidal ideation and suicide attempt/completion are also commonly reported in gambling disorder. Large numbers of gamblers report having suicidal ideation related to their gambling losses, and between 17% and 24% of Gamblers Anonymous participants have attempted suicide owing to gambling.
Family History
High frequencies of psychiatric disorders are seen in the first-degree relatives of those with gambling disorder (mood, anxiety, substance use, and antisocial personality disorders). Studies have also found that 20% of the first-degree relatives of disordered gamblers also have gambling disorder.
TREATMENT
Psychotherapy
There are no randomized controlled trials supporting the effectiveness of psychodynamic psychotherapy, Gamblers Anonymous, or self-exclusion contracts in the treatment of gambling disorder. Psychosocial treatments such as cognitive therapy, behavioral therapy, CBT, and brief interventions and motivational interviewing have been examined in controlled studies, and some of their findings are outlined below.
In one study, subjects involved in individual cognitive therapy combined with relapse prevention strategies appear to experience reductions in both gambling frequency and the subjects’ perceived self-control over their gambling behavior at 12 months. Similar results were noted in a study employing group cognitive therapy (using a wait-list control). These studies do not include data from a significant number of subjects who completed the 12- or 24-month follow-up.
Behavioral approaches have been examined in controlled studies. One study reported significant reductions in gambling behaviors in a comparison of imaginal desensitization to traditional aversion therapy. At 1-year follow-up, 70% of the group assigned to imaginal desensitization was still maintaining reductions in gambling, compared to 30% of those assigned to aversion therapy. In a second study, benefits to behavioral therapy were initially observed but not maintained at a 12-month follow-up. In the third study, long-term outcomes to several behavioral approaches were assessed and there was some evidence that subjects assigned to imaginal desensitization had decreased or ceased gambling, but no difference was reported in the rates of abstinence.
Several studies assessing CBT have demonstrated promise for the treatment of gambling disorder. CBT combined with interventions designed to improve treatment compliance and CBT with mapping-enhanced treatment appear more successful than CBT alone.
A study that looked at subjects assigned to either workbook (CBT and motivational enhancement techniques) or to workbook plus a single in-depth interview reported significant reductions in gambling at 6 months. Another study showed a lower frequency of gambling and money lost in a workbook plus motivational intervention group, compared to a workbook alone or wait-list group.
Assessment of Psychotherapies
Some version of CBT should be considered a first-line psychosocial treatment for gambling disorder, but the optimal frequency and duration of psychotherapy remains unclear.
Pharmacotherapy
There are currently no medications approved by the U.S. Food and Drug Administration for the treatment of gambling disorder. Several placebo-controlled trials of pharmacotherapy treatment have been conducted and suggest that medications may be beneficial in treating gambling disorder.
Opioid Antagonists
Given their ability to modulate dopaminergic transmission in the mesolimbic pathway and to block μ-opioid receptors, opioid receptor antagonists have been investigated in the treatment of gambling disorder. In an 11-week, double-blind, placebo-controlled study, significant improvement was seen in 75% of naltrexone subjects, compared to 24% of placebo subjects. A second, larger study replicated these findings with significantly greater reductions in gambling urges and gambling behavior in the naltrexone group as well as greater improvement in psychosocial functioning. Another opioid antagonist (with partial agonist qualities), nalmefene, has also shown promise in the treatment of gambling disorder in two large double-blind studies.
“Antidepressants”: Serotonin Reuptake Inhibitors and Bupropion
Based on the proposed neurobiology of gambling disorder, antidepressant medications have been examined as treatment. Low levels of the serotonin metabolite, 5-hydroxyindole acetic acid (5-HIAA), and blunted serotonergic response within the ventromedial prefrontal cortex (vmPFC) have been associated with impulsive behaviors. Compared to controls, individuals with gambling disorder demonstrate diminished activation of the vmPFC during gambling-related activities.
Mixed results have been found with the drugs paroxetine and fluvoxamine. A double-blind, 6-month, placebo-controlled trial using sertraline demonstrated no statistical advantage over placebo.
In the only controlled study of a non-SSRI antidepressant, bupropion was not significantly more efficacious than placebo for gambling disorder.
The mixed results of antidepressant trials for gambling disorder may be owing to the fact that serotonergic dysfunction is merely a peripheral aspect of gambling disorder, the small sample sizes of the studies, or the heterogeneity of gambling disorder.
Mood Stabilizers
Mood stabilizers have been examined in gambling disorder with the hypothesis that mood stabilizers are beneficial in reducing impulsivity and hypermotoric activation. Lithium reduced the thoughts and urges associated with gambling disorder; however, no significant difference was found in the episodes of gambling per week, time spent per gambling episode, or the amount of money lost.
Glutamatergic Agents
There is some suggestion that N-acetylcysteine (NAC), a glutamate-modulating agent that is available through health food stores without a prescription, may be beneficial in reducing gambling disorder symptoms. This is based on improving glutamatergic tone in the nucleus accumbens which has been implicated in reducing the reward-seeking behavior of animals.
Assessment of Pharmacotherapies
- Naltrexone should be considered a first-line treatment for gambling disorder.
- Patients with a first-degree family history of addiction may respond preferentially to opioid antagonists such as naltrexone or nalmefene.
- No study has examined pharmacologic treatment effects for longer than 6 months.
- Preliminary data suggest that individuals with gambling disorder and bipolar symptoms may respond to lithium.
Treatment Recommendations
Gambling disorder is a common, disabling psychiatric disorder that is associated with high rates of co-occurring disorders, particularly substance use disorders, and high rates of illegal activities. Psychotherapy and pharmacotherapy have shown promise in the treatment of gambling disorder. Based on treatment literature, CBT and the off-label use of naltrexone would appear the most promising options.
Other factors may influence which treatment option is chosen for a particular patient. First, many clinicians are simply unaware of gambling disorder. Having a list of providers who know about gambling disorder and can provide treatment can minimize this problem. Second, there are no clear recommendations of treatment for the clinician to follow. It is unclear exactly how many sessions of CBT are most helpful for gambling disorder. The exact dose of medication or duration of medication trial for optimal treatment is also unknown. Third, individuals with gambling disorder exhibit high rates of placebo response in treatment studies (clinicians should monitor for several months and not assume they will continue to do well). Fourth, impulsive patients often do not follow recommendations or follow-up with treatment (treatment data show that dropout rates are high for gambling disorder). This can be minimized by providing psychoeducation about the illness, detailing the expectations of treatment, and the expressing the need to stay in treatment.
CONFLICTS OF INTEREST/ACKNOWLEDGMENTS
Dr. Grant has research grants from National Center for Responsible Gaming, Forest Pharmaceuticals, and Roche Pharmaceuticals. He receives yearly compensation from Springer Publishing for acting as Editor-in-Chief of the Journal of Gambling Studies and has received royalties from Oxford University Press, American Psychiatric Publishing, Inc., Norton Press, and McGraw Hill. Mr. Odlaug has received a research grant from the Trichotillomania Learning Center, consults for H. Lundbeck A/S, and receives royalties from Oxford University Press.
KEY POINTS
1. Gambling disorder is often associated with poor quality of life, functional impairment, psychiatric comorbidity, and financial or legal problems.
2. Cognitive–behavioral therapy and the off-label use of opioid antagonists, such as naltrexone, appear to be the most promising first-line treatments for gambling disorder.
3. Suicidal ideation and attempts are common in gambling disorder and must be assessed at each clinical session.
REVIEW QUESTIONS
1. What duration of psychotherapy (including behavioral, cognitive, or cognitive– behavioral therapy) has been shown to be the most effective for gambling disorder?
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