Dan I Lubman
Gambling is a mainstream activity across Australia, with increasing accessibility. It is also a significant public health issue, with around 395 000 Australians experiencing harm from problem gambling.
This article reviews current evidence relating to the classification and prevalence of problem gambling in Australia, why problems develop, and how to assess and manage gambling presentations within primary care.
People affected by problem gambling are not a homogenous group in terms of course or onset. Screening is important, especially where financial problems are present or when there are other conditions that commonly co-occur (such as depression, anxiety, substance use disorders and nicotine dependence). Effective management involves a nonjudgemental and empathic approach, which may include referral to telephone or online services, face-to-face problem gambling programs, financial counselling, psychological and pharmacological interventions.
Australia has a longstanding fascination with gambling. Over the past 200 years, unregulated gambling on coin, dice and card games has developed into a large and powerful gambling industry, with regulations on horse race betting commencing in the late 19th century (the first associated public holiday was observed in 1877) and further growth in casino gambling from the 1970s.1 The subsequent introduction of the modern electronic gaming machine in the early 1990s resulted in a considerable increase in community spending on gambling, amounting to $19 billion in 2008–09.2
While over 70% of Australians buy a lottery ticket or place a bet every year,2 problems related to electronic gaming machines are typically the most common issue for those presenting for treatment. However, the recent explosion in online wagering providers and sports betting overcome many potential barriers to gambling such as stigma and geography and there are growing concerns that the cost of gambling to the community is likely to continue to rise.3 The term ‘problem gambling’ is used in the Australian context to describe harms associated with difficulties in limiting time and/ or money spent on gambling (Neal, Delfabbro, & O’Neil, 2005), and is intended to encompass a continuum of severity that includes pathological gambling.
This article discusses the prevalence of problem gambling in Australia, why problems develop, and how to assess and manage gambling presentations within primary care.
Classification of problem gambling
In 1980, for the first time, pathological gambling was classified as a disorder of impulse control within the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).4 Criteria focused on the damage caused by a failure to resist the impulse to gamble. At this time, there was very little research on gambling, highlighted by the fact that the first gambling-specific academic journal only appeared in 1985. Subsequent reviews argued that problem gambling shared many characteristics with substance use disorders,5 which led to the remodelling of pathological gambling’s DSM-III-R criteria to include items on preoccupation, tolerance, withdrawal and repeated efforts to quit or cut down (Table 1).5,6
Despite DSM-III-R criteria being grounded in a familiar framework, researchers and treatment providers were dissatisfied. There were concerns that some items were ambiguous or repetitive, that crucial criteria from DSM-III had been omitted7 and that withdrawal, arguably a cornerstone of addiction, was not a common response to ceasing gambling.8 Rosenthal also argued that diagnostic criteria should identify differences between pathological gambling and nonpathological gambling and account for its progressive nature.8
In response to these concerns, a survey was developed to inform the development of DSM-IV and distributed to 275 gamblers seeking treatment in the United States.7 The final DSM-IV criteria retained DSM-III-R items on withdrawal, tolerance and preoccupation and reintroduced legal problems from DSM-III (albeit with softened wording – arrests for illegal acts changed to committed illegal acts).9 Additionally, researchers recognised increased access, female participation and problems associated with gaming machines, and included a new item – gambling as a means of escape (Table 2).7
Given this history, it is not surprising that there is a current debate about whether to relocate pathological gambling from the impulse control disorders to behavioural addiction in DSM-V. As with concerns around the notion of addiction raised 25 years ago, researchers are still exploring the phenomenon of withdrawal and tolerance. Recent research suggests that 25% of people with pathological gambling experience restlessness or irritability, while 40% cite other withdrawal-like symptoms, such as disappointment and guilt, when trying to change their gambling behaviour.10 Those with more severe problem gambling are more likely to report withdrawal and tolerance experiences than those with less severe problems;11 some researchers argue that reports of tolerance actually reflect increasing spending in an attempt to recoup losses rather than increasing bets to maintain levels of affect (which is different to substance use disorders).12 In a similar fashion, ‘withdrawal’ could be conceptualised as a loss of specific stress reduction or coping strategies rather than an actual physiological state.12
Table 1. DSM development for pathological gambling
|DSM-III (6 items)
- The course is chronic and progressive and characterised as a failure to resist the impulse to gamble
- Focus on damage to the individual or family (work, relationships, deception, legal, financial problems and bailouts)
|DSM-III-R (9 items)
- Major revision from harm focused to criteria modelled on substance use disorders
- Two financial items retained from previous edition: chasing lost money and gambling in spite of financial harms
|DSM-IV (10 items)
- Retain substance use criteria from previous revision
- Escape introduced in response to modern gaming machines
- Lying to others to conceal gambling behaviour introduced
- Illegal acts and bailouts reintroduced from DSM-III
|DSM-V (? items – likely to be included as a behavioural addiction)
|DSM = Diagnostic and Statistical Manual of Mental Disorders
Table 2. Typical criteria for pathological gambling
- Is preoccupied with gambling
- Needs to gamble with increasing amounts of money
- Has repeated, unsuccessful efforts to control, cut back or stop
- Is restless or irritable when trying to cut down or stop
- Gambles as a way of escaping from problems or relieving mood
- After losing returns to win it back
- Lies to family members, therapist or others
- Has committed illegal acts
- Has jeopardised relationships or career
- Relies on others to provide bailout
How common are problems associated with gambling?
Problem gambling is a significant public health issue in Australia, costing between $4.7 billion and $8.4 billion per year.2 Estimated prevalence rates are between 0.5% and 1.0%, with a further 1.4–2.1% at risk of problems developing, equating to over 395 000 Australians.2 Gambling is typically a relapsing remitting condition, with relapse rates around 75%.13 Although there is little research on recovery, many do recover with or without professional help; most people accessing government funded treatment agencies report reductions in gambling involvement.2
How problem gambling develops
Across Australia, there are almost 200 000 electronic gaming machines in 6000 venues,2 seven times the number of McDonald’s outlets.14 Gaming venues are overrepresented in lower socioeconomic areas,15 and the geographic accessibility of gaming venues appears to be related to the incidence of problem gambling.16
Access to gambling is an integral component of the Blaszczynski and Nower pathways model, which incorporates a biopsychosocial approach to conceptualising problem gambling.16 The model proposes all gamblers experience a degree of behavioural conditioning, which occurs through a combination of access, conditioning (classical and operant), development of faulty cognitions (eg. overestimating the amount of control over random events) and chasing (trying to recoup lost money).17 Within the model, individual vulnerability is considered an important additional pathway into problem gambling. Vulnerabilities include pre-existing mood and anxiety disorders, trauma or poor coping skills, as well as biological factors, such as impulsivity.17 Accordingly, treatment for gambling should include interventions that also target the underlying condition.
Implications for primary care
Screening and assessment
Problem gambling is associated with high levels of shame and stigma and a nonjudgemental and empathic approach should be adopted when identifying gambling problems. While people who are unemployed or on low incomes are particularly at risk,18 most people maintain employment and an appearance that there is not a problem. This is particularly pertinent to online gambling, such as sports betting, which is attracting young men with higher than average incomes.19 The development of therapeutic engagement and an ongoing relationship can facilitate disclosure. While it is not practical to screen all patients for problem gambling, it is helpful to raise the issue when patients present with the following clinical features:
- indications by patient or others that gambling is being used to improve financial problems
- signs of stress, depression and/or anxiety
- disrupted sleep, changed eating patterns
- history of alcohol or nicotine dependence
- unexplained loss of time or money
- dissatisfaction with quality of life.
Relevant sociodemographic factors include:20,21
- reports of social isolation or poor relationships
- family history of gambling or problem gambling
- legal and financial difficulties
- non-English speaking backgrounds and recent immigrants.
People with problem gambling experience high rates of co-occurring conditions, including depression, anxiety, substance use disorders and nicotine dependence.22 In addition, population health surveys have found high rates of co-occurring depressive symptoms and stress related issues.23 It is therefore important to screen for gambling problems when these conditions are present.
Use of a screening tool can be helpful in eliciting a history of gambling and associated harms, and the following are particularly suitable within a primary care setting:
- the 1-item problem gambling screening (ie. ‘have you ever had an issue with gambling?’)24
- the 3-item Brief Bio-Social Gambling Screen25 assesses withdrawal, lying and financial difficulties and the three-item NODS-CliP26 assesses lying, preoccupation and attempts to control or cut down gambling – these tools can be administered in a couple of minutes
- the 9-item Problem Gambling Severity Index (PGSI) of the Canadian Problem Gambling Index27 closely resembles DSM-IV criteria and is the most common tool used in Australia to screen for problem gambling (Table 3).
Table 3. The Problem Gambling Severity Index (PGSI)27
|The following questions relate to gambling behaviour in the past 12 months.
Thinking about the past 12 months …
- Have you bet more than you could really afford to lose?
- Have you needed to gamble with larger amounts of money to get the same feeling of excitement?
- When you gambled, did you go back another day to try to win back the money you lost?
- Have you borrowed money or sold anything to get money to gamble?
- Have you felt that you might have a problem with gambling?
- Has gambling caused you any health problems, including stress or anxiety?
- Have people criticised your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true?
- Has your gambling caused any financial problems for you or your household?
- Have you felt guilty about the way you gamble or what happens when you gamble?
|Never = 0; sometimes = 1; most of the time = 2; almost always = 3
A score greater than 8 indicates probable problem gambling
People experiencing problem gambling often feel ashamed about their gambling and will conceal the behaviour and associated consequences. Therefore, a nonjudgemental and gentle approach that addresses both the gambling and potential harms is required. Motivational interviewing techniques improve the likelihood of change. Employing reflective listening can assist patients to set their own goals, which can be enhanced by employing a readiness ruler: ‘on a scale of one to 10, how important is it for you to change your gambling?’ If the score is low, it is helpful to explore the benefits and costs of gambling, with questions like ‘what are the good things about gambling?’ and ‘what are the less good things?’ Typically clients talk about excitement and escape versus loss, guilt, regret and remorse.
If the score is high, indicating a readiness to change, it is helpful to ask a follow up question related to confidence levels – ‘on a scale of 1 to 10 how confident are you in resisting the urge to gamble?’ If confidence is high, ask how they plan to go about changing their gambling behaviour. Many people with gambling problems experience low confidence in resisting the urge to gamble. It is helpful to build confidence by normalising lapse and relapse and identifying opportunities to learn about gambling triggers. Relapse is typically triggered by a combination of internal (eg. negative affect, stress) and external (eg. pay cheque, bills in post, venue inducements) factors that build towards an overwhelming urge to act that is supported by erroneous cognitions (eg. selective recall of previous wins).28
For some people it is helpful to ask whether they have considered talking to someone about their gambling. This can be an opportunity to refer to a specialist gambling treatment agency (available via phone, online or face-to-face). A summary of referral options is outlined in Table 4. Some people may be experiencing harms from gambling, but are not ready to change. It is helpful to discuss harm minimisation measures, such as reducing access to cash in a venue, protecting their assets (eg. second signature on their mortgage) or minimising alcohol use while gambling. This approach keeps the door open for when the person is ready to take the next step.
In addition to motivational interviewing, cognitive behavioural therapy, cognitive therapy, behaviour therapy and brief interventions are recommended for problem gambling.29 Cognitive behaviour therapy may also be helpful where gambling and co-occurring conditions co-exist, however, research is scant on how best to address concurrent issues. While each of these therapeutic techniques has been found to be effective in reducing time and money spent on gambling, briefer interventions may also be useful. For example, a Canadian study comparing motivational interviewing, behaviour therapy and cognitive therapy with a minimal intervention found the 90 minute minimal intervention (feedback on assessment and practical strategies) produced reductions in DSM-IV symptoms comparable with longer term interventions.30
A larger trial determining the effectiveness of different psychological approaches is currently being undertaken in Victoria. Pharmacological treatments for problem gambling are in their infancy, with some evidence that treatment with naltrexone may reduce cravings or positive feelings associated with gambling.31 Antidepressants may be prescribed where there is a concurrent diagnosis of depression and/ or anxiety, however there is a lack of evidence to support their use in the absence of these conditions.
Although little evidence exists on matching severity of problem gambling and type of intervention, those with comorbid mental health issues may benefit from referral to specialist providers located in government funded agencies as well as Medicare funded treatment with psychiatrists and psychologists.
Table 4. Management resources for problem gambling
- Free face-to-face counselling is available for problem gambling across Australia by calling 1800 858 858
- A free, confidential, 24/7 helpline (1800 858 858) is available in every state and territory, and provides counselling, information and referral for gamblers and concerned family members. Self help booklets and printed service information are also available from these helplines
- Online services appear attractive to those who experience high levels of shame and stigma. Accessed most often by young men, 70% of people accessing this service have never previously accessed treatment. Compared with other treatment modes, clients state that it is easy to access, easy to talk and convenient. The national online counselling service (www.gamblinghelponline.org.au) is available 24/7 and provides real time chat and email support
- A four to six session semi-structured telephone counselling program (Ready to Change) is available in Victoria, Queensland and Tasmania, and can be accessed by calling 1800 858 858
- www.gamblinghelponline.org.au/helping-others/assistance-for-professionals.aspx has links to state government resources for professionals
- Financial counselling
Family and friends
Family and friends affected by gambling comprise around 20–25% of help seeking populations and there is very limited research as to how and when this group seeks help. It has been noted that family and friends are significant in assisting the gambler seek help and improving gambling outcomes.32 However, they also experience significant harms associated with problem gambling, including poor mental health, family violence and increased financial problems.33 It may be useful to ask whether anyone in the family experiences problem gambling, particularly when there are financial difficulties. Problem gambling treatment services also offer free counselling and financial advice for families and friends (Table 4).
- Problem gambling is a significant public health issue in Australia costing between $4.7 and $8.4 billion per year.
- People with problem gambling experience high rates of co-occurring conditions, including depression, anxiety, substance use disorders and nicotine dependence.
- Screening for problem gambling can be simple, using tools such as the 1-item: ‘have you ever had an issue with your gambling?’
- When problem gambling is identified, motivational interviewing can facilitate change.
- There are a range of free accessible treatment options in Australia, which include face-toface, telephone and online modalities.
- Australian Institute for Gambling Research. Australian gambling: comparative history and analysis. Melbourne: Victorian Casino and Gaming Authority, 1999.
- Productivity Commission. Gambling. Productivity Commission Inquiry Report vol. 1, no. 50. Canberra: Productivity Commission, 2010.
- Neal PN, Delfabbro PH, O’Neil MG. Problem gambling and harm: towards a national definition. Victoria: Department of Justice, 2005.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 3rd edition (DSM-III). Washington, DC: American Psychiatric Association, 1980.
- Lesieur HR. Altering the DSM-III criteria for pathological gambling. Journal of Gambling Behavior 1988;4:38–47.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 3rd edition, revised (DSM-III-R). Washington, DC: American Psychiatric Association, 1987.
- Bradford J, Geller J, Lesieur HR, Rosenthal R, Wise M. Impulse control disorders. In: Widiger TA, Frances AJ, Pincus HA, Ross R, First MB, Wakefield-Davis W, editors. DSM-IV sourcebook. Washington (DC): American Psychiatric Association, 1996:1007–32.
- Rosenthal RJ. Pathological gambling and problem gambling: problems of definition and diagnosis. In: Shaffer, H, et al, editors. Compulsive gambling: theory, research, and practice. Lexington, MA: Lexington Books, 1989:101–25.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edn (DSM-IV). Washington, DC: American Psychiatric Association, 1994.
- Cunningham-Williams RM, Gattis MN, Dore PM, Shi P, Spitznagel EL. Towards DSM-V: considering other withdrawal-like symptoms of pathological gambling disorder. Int J Methods Psychiatr Res 2009;18:13–22.
- Toce-Gerstein M, Gerstein DR, Volberg RA. A hierarchy of gambling disorders in the community. Addiction 2003;98:1661–72.
- Blaszczynski A, Walker M, Sharpe L, Nower L. Withdrawal and tolerance phenomenon in problem gambling. International Gambling Studies 2008;8:179–92.
- Hodgins DC, Currie SR, el-Guebaly N, Diskin KM. Does providing extended relapse prevention bibliotherapy to problem gamblers improve outcome? J Gambl Stud 2006;23:41–54.
- Holmes S. McDonald’s to open new stores despite economic doubts. The Australian, 2008:16 August.
- Livingstone C, Woolley R. Risky business: a few provocations on the regulation of electronic gaming machine. International Gambling Studies 2007;7:361–76.
- Harrison Market Research & University of Adelaide. Evaluation of 2004 legislative amendments to reduce EGMs. Adelaide: Independent Gambling Authority, 2006.
- Blaszczynski A, Nower L. A pathways model of problem and pathological gambling. Addiction 2002;97:487–99.
- Brown K, Pickernell D, Keast R, McGovern M. Socio-economic impacts of access to electronic gaming machines in Victoria: effects on demand and communities. Melbourne, Australia: Office of Gaming and Racing, Victorian Government Department of Justice, 2011.
- Gainsbury S, Hing N, Blaszczynski A, Wood R. An investigation of Internet gambling in Australia. Lismore, NSW: Southern Cross University. Centre for Gambling Education & Research, 2011.
- Delfabbro P, Le Couteur A. Australasian gambling review (1992–2008). Adelaide: Independent Gambling Authority, 2009.
- Johansson A, Grant J, Kim S, Odlaug B, Gotestam K. Risk factors for problematic gambling: a critical literature review. Journal of Gambling Studies 2009;25:67–92.
- Lorains FK, Cowlishaw S, Thomas SA. Prevalence of comorbid disorders in problem and pathological gambling: systematic review and meta-analysis of population surveys. Addiction 2011;106:490–8.
- Queensland Treasury. Queensland Household Gambling Survey 2006–07. Brisbane: Queensland Government, 2008.
- Thomas SA, Jackson AC, Browning CJ, Piterman L. A one item screening tool for problem gambling for use in primary care settings. Melbourne: Problem Gambling Research and Treatment Centre, 2009
- Gebauer L, LaBrie R, Shaffer H. Optimizing DSMIV- TR classification accuracy: a brief biosocial screen for detecting current gambling disorders among gamblers in the general household population. Can J Psychiatry 2010;55:82.
- Toce-Gerstein M, Gerstein D, Volberg R. The NODS-CLiP: a rapid screen for adult pathological and problem gambling. J Gambl Stud 2009;25:541–55.
- Ferris J, Wynne H. The Canadian Problem Gambling Index. Ottawa, Ontario: Canadian Centre on Substance Abuse, 2001.
- Battersby M, Pols R, Oakes J, Smith D, McLaughlin K, Baigent M. The definition and predictors of relapse in problem gambling. Adelaide, Australia: Flinders Human Behaviour & Health Research Unit, 2010.
- Problem Gambling Research and Treatment Centre. Guideline for screening, assessment and treatment in problem gambling. Clayton: PGRTC, Monash University, 2011.
- Toneatto T, Gunaratne M. Does the treatment of cognitive distortions improve clinical outcomes for problem gambling? J Contemp Psychother 2009;39:221–9.
- Flinders Human Behaviour & Research Unit. Naltrexone Feasibility, Acceptability and Preliminary Effectiveness Study. South Australia: Independent Gambling Authority, 2010.
- Ingle PJ, Marotta J, McMillan G, Wisdom JP. Significant others and gambling treatment outcomes. J Gambl Stud 2008;24:381–92.
- Kalischuk RG, Nowatzki N, Cardwell K, Klein K, Solowoniuk J. Problem gambling and its impact on families: a literature review. International Gambling Studies 2006;6:31–60.