Pathological Gambling: Treatments Based on Those For Substance Abuse

Harvard Health Letters

Gambling has been around for thousands of years. The earliest known six-sided pair of dice, for example, dates back to about 3,000 B.C. Today, rolling the dice is only one of many gambling activities available to people.

Currently all states except for Hawaii and Utah have legalized some type of gambling, including lottery games, slot parlors, and casinos. National surveys in 1975 and 1998 found that 61 percent to 63 percent of Americans gambled at least once a year. Most people are able to enjoy this activity without harming their health or livelihood.

Problem gambling behavior was first mentioned in the medical literature in the early 1800s, but the American Psychiatric Association did not classify pathological gambling as a psychiatric disorder until 1980, in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). An ongoing discussion in the mental health community is whether gambling is an impulse control disorder -- as it's currently classified in the DSM-IV -- or whether it's better understood as an addiction, as the DSM-V proposes.

Epidemiological studies have found that pathological gambling often occurs in conjunction with dependence on a chemical substance. While roughly 1 percent to 3 percent of people in the general population develop a pathological gambling disorder at some point in their lives, as many as 5 percent to 33 percent of people with substance use disorders will do so. One national survey found that pathological gamblers were five times as likely as those in the general population to be dependent on alcohol, and nearly seven times as likely to be dependent on nicotine.

The DSM-V work group cited other evidence to support its proposal that pathological gambling be considered an addiction. Genetic studies suggest that people who develop pathological gambling or a substance use disorder are more likely than those in the general population to have particular gene types (alleles) associated with impulsive behavior. Brain imaging studies have reported that both substance use disorders and pathological gambling create similar types of dysfunctions in a neural circuit involved in reward processing and decision making.

Regardless of how pathological gambling is eventually classified, however, many of the strategies for treating it are based on those used for substance use disorders. Although there's no consensus yet about which therapies are best, several have emerged as the most promising:

-- Although currently considered an impulse control disorder, pathological gambling may be reclassified as an addiction.

-- Pathological gambling is more prevalent in people with substance use disorders, and its treatment is similar to that used for addiction.

-- Although various psychotherapies have been evaluated, most evidence supports cognitive behavioral therapy.

-- Medication is of limited use, but may be helpful as an adjunct to psychotherapy.

SELF-HELP AND PSYCHOTHERAPY

Gamblers Anonymous, a 12-step program modeled on Alcoholics Anonymous, is probably the most common intervention for pathological gambling. This self-help program is available through more than 1,000 chapters across the United States. Participants acknowledge they are powerless over their gambling behavior and try to recover with the help of other members and through reliance on a spiritual higher power. The small amount of published research on this topic suggests that Gamblers Anonymous may help patients abstain from gambling, especially when they attend meetings regularly or combine attendance with psychotherapy or other treatment.

Although various types of psychotherapy have been investigated for treating pathological gambling, most evidence has been collected on cognitive behavioral therapy (CBT). Patients can either meet with a therapist or rely upon a manual of instruction to learn how to recognize distorted thinking or rationalizations about gambling, change the way they think about gambling (cognitive restructuring), learn to identify and avoid gambling triggers, and develop other rewarding activities.

The largest randomized controlled trial of CBT for gambling involved 231 participants. All received referrals to Gamblers Anonymous. Participants were then randomly assigned to eight weeks of participation in one of three interventions: weekly one-hour individual CBT sessions with a therapist, a CBT manual to use on their own at home, or to no additional treatment beyond attendance at Gamblers Anonymous.

By the end of the study, participants in all three groups reduced levels of gambling, but those assigned to individual CBT were significantly more likely than those in the other two interventions to decrease gambling days and dollars wagered per month. At a 12-month follow-up assessment, however, there was no significant difference between the interventions. Roughly the same percentage of participants in all three arms -- 60 percent to 66 percent -- were classified as abstinent or substantially improved.

Another psychotherapy option that has been studied is motivational interviewing, which aims both to promote readiness to change and commitment to treatment. The therapist helps a patient to explore and resolve mixed feelings about giving up gambling, and to develop an individualized set of goals.

In one controlled trial, investigators randomly assigned 68 pathological gamblers either to attendance at Gamblers Anonymous or to six sessions of an intervention that combined motivational interviewing with desensitization (exposure to gambling cues combined with training in relaxation and -- similar to CBT -- coping skills to subdue gambling urges). At the end of the eight-week study, investigators assessed people in both groups, using a standard clinical instrument to assess gambling urges and behaviors. They found that 21 of 33 people (64 percent) assigned to the motivational interviewing and desensitization arm had abstained from gambling for at least a month at that point, compared to only six of 35 (17 percent) who attended Gamblers Anonymous.

Preliminary research suggests that even brief interventions may help people reduce gambling behavior. For example, in one controlled study, investigators randomly assigned 117 college students to one of four arms: 10 minutes of advice about gambling, a single session of motivational enhancement therapy (a briefer form of motivational interviewing), one session of motivational enhancement therapy in addition to three sessions of CBT, or assessment of symptoms only (which served as the control). When compared with the control arm, all three interventions significantly decreased gambling behaviors and dollars wagered by the end of the six-week study.

MEDICATION OPTIONS

The U.S. Food and Drug Administration has not approved any drugs specifically for use in treating pathological gambling, and the research suggests that medications used "off label" are of limited help.

Opioid antagonists.

This class of drugs includes medications such as naltrexone (ReVia) and nalmefene (Revex) that are most often used to treat alcohol dependence. By blocking opioid receptors, the drugs work by modulating reward circuits in the brain, especially in neural areas involved in compulsive behavior and addiction.

The rationale for using opioid antagonists to treat pathological gambling is that these drugs will help subdue the desire, or "craving," that contributes to gambling behaviors. Several randomized controlled studies suggest such drugs are more effective than placebo.

SSRIs.

Investigators once thought that selective serotonin reuptake inhibitors (SSRIs) might treat pathological gambling by reducing impulsive behavior. Although preliminary studies suggested that SSRIs had promise in this regard, larger and better-controlled studies have concluded they offer no benefit over placebo in reducing gambling behaviors and urges. These drugs may be helpful, however, as adjuncts to other therapies -- especially in improving depression or anxiety.

Other medications.

Several randomized controlled trials have evaluated mood stabilizers for pathological gambling, with mixed results. These drugs may be effective at reducing gambling urges in patients who also have bipolar disorder, mainly by reducing mania.

Bupropion (Wellbutrin)

An antidepressant that affects two neurotransmitters, dopamine and norepinephrine, has helped people to give up smoking but has not proven effective in pathological gambling. Researchers are investigating novel agents, such as those that act on glutamate (an excitatory neurotransmitter), to find new options.

SUMMING UP

Uncontrolled gambling shares some neurobiological features with addictions. But, like its brethren, it is a complex human behavior that defies easy categorization. The hope is, by seeing it in a different diagnostic context (as proposed by the DSM-V), clinicians will be able to offer treatments that are most likely to help.

Much more research is needed to determine the best treatment strategies. In particular, unanswered questions include what therapies are most effective, the optimal duration of treatment, how long benefits persist following an intervention, and how to treat pathological gambling in conjunction with co-occurring psychiatric disorders. - Harvard Mental Health Letter

SYMPTOMS OF PATHOLOGICAL GAMBLING

According to the "Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)", a patient who has at least five of the following 10 symptoms -- and who is not having a manic episode -- meets the criteria for diagnosis of pathological gambling.

(The DSM-V draft revision deletes the final symptoms on the list and reduces the number of criteria necessary for a diagnosis from five symptoms to four. It also proposes that pathological gambling be reclassified from an impulse control disorder to an addiction.)

1. Preoccupation with gambling

2. Gambling with increasing amounts of money

3. Has tried to control, decrease, or stop gambling repeatedly without success

4. Feels restless or irritable when trying to cut back on gambling

5. Gambles to escape problems or relieve anxiety, depression, or other dysphoric moods

6. Returns to gambling after losing money in order to recover the losses

7. Lies about level of gambling and otherwise conceals behavior from family, friends, therapist, and others

8. Has jeopardized or lost a significant relationship, job, or opportunity because of gambling

9. Asks others for money to solve financial problems caused by gambling

10. Has stolen money, committed forgery, or engaged in other illegal acts to finance gambling.*

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