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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Minding Your Mind Minding Your Mind
 

Treatments for Gambling Disorder


November 14, 2013

By Michael Craig Miller M.D.

Harvard Medical School



Gambling has been around for thousands of years. The earliest known six-sided pair of dice, for example, dates back 5,000 years. Today rolling the dice is only one of many gambling activities available to people.

Most people are able to gamble without compromising their health or jobs. Sometimes, however — and probably more often than we'd like to see — gambling can cause terrible problems at home and at work. This is when it deserves treatment.

Many of the strategies for treating problem gambling are based on those used for substance use disorders. Although there is no consensus yet about which therapies are best, several have emerged as the most promising.

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Problem Gambling as a Disorder

All states except Hawaii and Utah have some type of legalized gambling — lottery games, slot parlors and casinos. National surveys in 1975 and 1998 found that 61% to 63% of Americans gambled at least once a year.

In recent years, gambling has become a huge business on the Internet. Thousands of websites make it easy for gamblers to part with their money. Such easy access may make a gambling problem worse for certain people.

Problem gambling behavior was first mentioned in the medical literature in the early 1800s. The American Psychiatric Association first recognized it as a psychiatric disorder in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). It was called "pathological gambling."

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), calls it simply "Gambling Disorder" and classifies it as a type of addiction. To be diagnosed with this disorder, a person has to have at least 4 of the following 9 symptoms. (This does not apply to a person having a manic episode.)

  • Gambling with increasing amounts of money
  • Feeling restless or irritable when trying to cut back on gambling
  • Trying to control, decrease or stop gambling repeatedly without success
  • A preoccupation with gambling
  • Gambling when distressed, for example, while feeling anxious, depressed, helpless or guilty
  • Chasing losses, that is, going back to gambling after losing money in order to recover the losses
  • Lying about extent of gambling and concealing behavior from family, friends, therapist and others
  • Having jeopardized or lost a significant relationship, job or opportunity because of gambling
  • Asking others for money to solve financial problems caused by gambling

Gambling disorder used to be considered an impulse control disorder. It has been moved into the addiction category. Here's why:

  • Gambling disorder and problems with drugs or alcohol often go together. While roughly 1% to 3% of people in the general population develops a gambling disorder at some point in their life, as many as 5% to 33% of people with substance use disorders will do so. One national survey found that problem gamblers were 5 times as likely as people in the general population to be dependent on alcohol, and nearly 7 times as likely to be dependent on nicotine.
  • Genetic studies suggest that people who develop gambling disorder or a substance use disorder are more likely than those in the general population to have similar gene types (alleles) that are associated with their behavior.
  • Brain imaging studies have reported that both substance use disorders and gambling disorder create similar types of abnormal functioning in a nerve circuit involved in reward processing and decision making.

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Self-Help and Psychological Approaches

These are the most used treatments for gambling disorder.

  • Gamblers Anonymous – This 12-step program is modeled on Alcoholics Anonymous. It is probably the most common intervention for problem gambling.

    There are more than 1,000 chapters of Gamblers Anonymous 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.

  • Cognitive Behavioral Therapy (CBT) – This is the most studied form of therapy for gambling disorder. The research supports its effectiveness. Patients learn how to recognize distorted thinking about gambling, change the way they think about gambling (cognitive restructuring), learn to identify and avoid gambling triggers, and develop other rewarding activities.
  • Motivational Interviewing – This therapy focuses on getting the gambler ready to change and to commit to treatment. The therapist helps a patient to explore and resolve mixed feelings about giving up gambling, and to develop goals.
  • Brief Interventions – Preliminary research suggests that even brief interventions may help people reduce gambling behavior.

    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 amount of money bet by the end of the six-week study.

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Medication Options

The U. S. Food and Drug Administration has not approved any drugs specifically for treating gambling disorder. Unfortunately, the research suggests that medications are of limited help for gambling itself. But they can be useful to treat other illnesses, such as depression or anxiety, that may be at the root of gambling behavior or that result from gambling.

  • Opioid antagonists – This class of drugs includes medications such as naltrexone (ReVia) and nalmefene (Revex). These are most often used to treat alcohol dependence. They block opioid receptors in the brain that fine-tune the brain's reward circuits, especially those involved in compulsive behavior and addiction. The idea for using these drugs is that they will help subdue the desire or craving that contributes to gambling behaviors. Several randomized controlled studies suggest such drugs are more effective than placebo.
  • Selective serotonin reuptake inhibitors (SSRIs) – Researchers once thought that selective serotonin reuptake inhibitors (SSRIs) — the most commonly prescribed class of antidepressants — might treat  gambling disorder by reducing impulsive behavior. Although preliminary studies were promising, larger and better-controlled studies have found that they offer no benefit over placebo in reducing gambling behaviors and urges. These drugs may be helpful as an addition to other therapies — especially in improving depression or anxiety.

Several randomized controlled trials of mood stabilizers for gambling disorder have had 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 it has not proven effective in gambling disorder. Researchers are investigating drugs that are not yet in the mainstream. So far, nothing can be recommended.

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The Bottom Line

Uncontrolled gambling shares some biological features with addictions. But, like other complicated behaviors, gambling doesn't fit neatly into a particular category. The hope is that by seeing gambling disorder as an addiction (as it now is, in DSM-5), clinicians will be able to offer more helpful treatments.

More research may help us figure out what therapies are most effective, how long treatment should be, how long benefits last, and how to treat gambling disorder when it occurs with other psychiatric disorders.

If your gambling is creating problems in your life, you should probably see a mental health clinician. This person can help identify the problem and determine what other problems may need attention. This is especially important since — as the research has taught us — anyone suffering with gambling disorder is highly likely to have problems with depression, anxiety or another addiction.

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Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.

 

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