Addictions

June 2014

FocusAddictions

Problem gambling

Volume 43, No.6, June 2014 Pages 362-364

Shane Thomas

Background

Problem gambling is an increasingly common problem in Australia. General practitioners (GPs) have an important role in ensuring that problem gambling is detected and treated.

Objective/s

We review the clinical issues associated with the detection and treatment of problem gambling.

Discussion

At any one time 1% of the adult Australian population satisfy the clinical criteria for problem gambling; a further 4% are at a significant risk. Problem gambling frequently presents with other serious mental health conditions. There are several guidelines from the National Health and Medical Research Council and Australian Medical Association that recommend GP involvement in screening for problem gambling. Simple one-item tools are available for that purpose. GP screening and referral for problem gambling addresses the currently very low rates of treatment. Effective and durable psychological treatments are available for the treatment of problem gambling including cognitive behaviour therapy and motivational interviewing.

The epidemiology of problem gambling

Problem gambling in Australia has been studied extensively over the past two decades. Two comprehensive Australian Productivity Commission inquiries have been conducted on the Australian gambling industry and its effects on the Australian community.1,2

In Australia, the most recent statewide gambling surveys suggest that 69–75% of adults have participated in some form of gambling activity in the past 12 months.3 In 2008–2009, gambling losses for the Australian community were $19 billion and average losses for each gambling adult were $1500.2 However, problem gamblers typically lose many times that amount and experience high levels of debt and disruption. The point prevalence estimates of problem gambling rates vary considerably from study to study in Australia but a reasonable estimate is that 1% of the adult population satisfies clinical criteria for a problem gambling diagnosis and that a further 4% are at a significant risk.4

The problem gambling prevalence estimates are, of course, influenced by the particular clinical criteria used. The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) defines gambling disorder as ‘persistent and recurrent gambling behavior leading to clinically significant impairment or distress’ with associated criteria required to be attained in order to merit the diagnosis.5 These criteria include:

  • has made repeated unsuccessful efforts to control, cut back or stop gambling
  • lies to conceal the extent of involvement with gambling
  • has jeopardised or lost a significant relationship, job or educational or career opportunity because of gambling.5

There are three levels of severity of this disorder specified in the DSM-V (mild, moderate and severe). Many epidemiological studies have used self-report tools, such as the Canadian Problem Gambling Index,6 rather than clinician assessment, so the studies should be interpreted in this context.

What populations are of particular concern?

Problem gambling is widely distributed in the Australian community. Australia has a high number of gambling venues and gambling opportunities.7 Australia has one electronic gaming machine (EGM) per 118 people, whereas Switzerland has one per 1796 people and the United Kingdom has one per 404 people. Younger men are over-represented as problem gamblers, as are people from Aboriginal and Torres Strait Islander backgrounds and those from lower income settings. The Victorian Gambling Study has shown in one study that the risk for problem gambling among adult females was 0.47% versus 0.95% for Victorian adult males.8 Older age is associated with lower rates of problem gambling but age and gender are no barrier to being a problem gambler despite the moderately differential relative risks for different subgroups.

Australia is unusual in this regard perhaps because of the very wide distribution of opportunities to gamble. In some countries female rates of gambling are much lower because their access is restricted through social conventions and venue access. However, with the advent of online gaming, access is virtually universal globally.

It is certainly the case that problem gambling is markedly over-represented with other comorbid psychological problems. A recent systematic review and meta-analysis of large community mental health prevalence studies has shown that people with problem gambling have much higher rates of psychological disorders than in the general community.9 For example, 57.5% of problem gamblers in these studies were shown to have substance use disorders.

Comorbidity poses significant issues for the identification and treatment of problem gambling because of the high case complexity. Most people with problem gambling have one or more additional disorders that require intervention in their own right. For this reason it has been proposed that people with problem gambling should be screened for other psychological disorders and vice versa.10 Many people with problem gambling are ‘missed’ because their symptoms are masked by other disorders and often hidden from practitioners because of shame considerations.

There is no good epidemiological evidence as yet but there is a developing literature concerning suicide risk and problem gambling. The work that is available suggests that suicide risk is strongly elevated for problem gamblers.11 The Victorian coroner’s report analysed 128 gambling-related suicides in Victoria.

What are current public health measures, their effectiveness, and controversies surrounding them?

There has been considerable controversy concerning the stance of government in regulating the gambling industry. Licence fees and taxes for the gambling industry represent a significant proportion of the income for some Australian states. Problem gambling support groups and advocates have strongly criticised the Australian state and Commonwealth governments for their approaches to this issue and the intrinsic conflicts of interest in receiving gambling-related income while regulating the industry, operating treatment services and running public health interventions.

The states and the Commonwealth run gambling education campaigns and fund various telephone and face-to-face counselling services. However, the investment in the services represents a small fraction of the revenue received from gambling activities. There is limited evidence that public education actually measurably influences problem gambling rates or uptake of problem gambling services.

While governments assert they are using the public health tools of prevention, harm minimisation and treatment in their problem gambling strategies, frequently these activities are not integrated with the mainstream health system and in fact have somewhat tokenistic resourcing. South Australia has excellent integration of these activities in the clinical mainstream as is discussed later.

What are current evidence-based treatment options for problem gamblers?

The National Health and Medical Research Council (NHMRC) guideline for the screening assessment and treatment of problem gambling is based on several linked Cochrane systematic reviews of options for problem gamblers. These reviews are somewhat limited by the availability of high-quality evidence but there were nevertheless sufficient studies to make some clear recommendations.

Psychological therapy is certainly indicated for the treatment of problem gambling. Cognitive behaviour therapy (CBT) and motivational interviewing have some supporting evidence for their effectiveness with the strongest evidence base centred on CBT.

A range of studies12 has examined various pharmacological agents for the treatment of problem gambling but there is insufficient evidence for their effectiveness. Indeed, as reviewed in the NMHRC clinical guideline, evidence is emerging for their ineffectiveness. Thus, while pharmacological interventions may be useful for some of the comorbidities associated with problem gambling, they are not indicated for the primary treatment of problem gambling.

In the systematic reviews,12 peer-based and self-help treatments have been shown not to be effective. Thus, while referral to peer support agencies may be considered useful for people with problem gambling, there is no actual current evidence to suggest that this action will result in effective resolution. This should not be considered a frontline approach when evaluating treatment options.

A major issue for treatment of problem gambling is deciding to access it. The best US study in this area showed that only 7–12% of pathological gamblers have ever sought formal treatment or attended a Gamblers Anonymous or other peer support meeting over the lifetime of their condition.13 We do not have good Australian data, but clinical experience suggests that most people with problem gambling never receive formal treatment because they do not choose to do so. The reasons for these decisions should be an active area of research so that the low levels of access can be remediated.

In summary, psychological treatments delivered by competent practitioners have been shown to be effective and durable in the treatment of problem gambling.

Clinical considerations

Problem gambling is, in many respects, a hidden disorder and many people with the disorder never receive formal treatment for it. Paradoxically, however, psychological treatments have been shown to be effective for problem gamblers with good and durable resolution and good acceptance by patients once engaged with it. Further, many problem gamblers have comorbid psychological disorders. Thus, the pressing issue is effective case finding in order that appropriate referrals and treatment may be implemented.

What then is the best way to detect problem gambling? The state government in South Australia in conjunction with the AMA is incorporating a standard screener into health checks.14,15 Patients will be asked ‘have you or anyone in your family an issue with gambling?’. This simple approach can unblock a reluctance to discuss an important and distressing issue to enable the appropriate referral to take place. This is a commendable initiative and one that could and should be incorporated into Australian general practice more broadly. When there is any evidence of psychological distress or disorder, such screening for problem gambling is strongly recommended and indicated. Problem gambling is an easily missed condition. There are effective and durable psychological treatments, including CBT and motivational interviewing for problem gambling and the GP should screen and refer identified cases for psychological treatment.

Key points

  • Problem gambling is a common and frequently untreated problem.
  • GPs can play an important role in ensuring that problem gambling is detected and treated.
  • There are effective and durable treatments for problem gambling, including CBT and motivational interviewing.

Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.

References

  1. Productivity Commission. Australia’s Gambling Industries, Report No. 10. Canberra: AusInfo, 1999. Available at www.pc.gov.au/__data/ assets/pdf_file/0004/49234/summary.pdf [Accessed 6 May 2014].
  2. Productivity Commission. Gambling, Report no. 50. Canberra, 2010. Available at ov.au/__data/assets/pdf_file/ 0010/95680/gambling-report-volume1.pdf [Accessed 6 May 2014].
  3. Thomas SA, Merkouris SS, Radermacher HL, et al. Australian guideline for treatment of problem gambling: An abridged outline. Med J Aust 2011;195:664–65.
  4. Thomas SA, Browning CJ. Treatment of gambling problems in adults. In: Grossman L, Walfish S, editors. Translating Psychological Research into Practice. New York: Springer Publishing, 2013.
  5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edn. Arlington, VA: American Psychiatric Publishing, 2013.
  6. Ferris J, Wynne H. The Canadian problem gambling index: Final report. Submitted for the Canadian Centre on Substance Abuse, 2001. Available at www.problemgambling.ca/ EN/Documents/ProblemGambling SeverityIndex.pdf [Accessed 1 May 2014].
  7. Gaming Technologies Association. World Count of Gaming Machines 2014. Available at www.gamingta.com/ pdf/World_Count_2014.pdf [Accessed 1 May 2014].
  8. Department of Justice Victoria. Victorian Gambling Study. 2012. Available at www.gamblingstudy.com.au/ baseline-study.html [Accessed 1 May 2014].
  9. Lorains FK, Cowlishaw S, Thomas SA. Prevalence of co-morbid disorders in problem and pathological gambling: systematic review and meta-analysis of population surveys. Addiction 2011;106:490–98.
  10. Thomas SA, Piterman L, Jackson AC. Problem gambling: what do general practitioners need to know and do about it? Med J Aust 2008;189:135–36.
  11. Coroners Court of Victoria. Gambling related suicide (2000–2012). 2013. Available at www.coronerscourt.vic.gov.au [Accessed 1 May 2014].
  12. Monash University Problem Gambling Research and Treatment Centre. NHMRC approved guideline for screening, assessment and treatment in problem and pathological gambling. Clayton: Monash University; 2011. Available at www.nhmrc.gov.au/_files_nhmrc/ publications/attachments/ ext0005_problem_gambling_guideline.pdf [Accessed 20 May 2014].
  13. Slutske WS. Natural recovery and treatment-seeking in pathological gambling: Results of two U.S. national surveys. Am J Psychiatry 2006;163:297–302.
  14. Australian Medical Association. Health Effects of Problem Gambling – 2013. Available at https://ama.com.au/ position-statement/health-effects-problem-gambling [Accessed 20 March 2014].
  15. Ciconte D. South Australian doctors to question patients on problem gambling. December 23, 2013. Available at www.australiangambling.com.au/ gambling-news/south-australian-doctors-to-question-patients- on-problem-gambling/27051/ [Accessed 20 March 2014].

Correspondence afp@racgp.org.au

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