“Mrs Kim” is brought to the emergency department by her daughter for bizarre behavior and symptoms of mania. For the past month, she has been gambling more than usual and today she returned from the casino after gambling for 48 continuous hours. She had maxed out her credit cards and emptied her savings account. A family friend saw her at the casino acting provocatively toward random strangers. Apparently, she has not slept for the past 3 days. Her family has never seen her act this way.
Mrs Kim has no psychiatric history. A month earlier, she complained of boredom and lack of motivation to her PCP last month. She was prescribed an antidepressant. Gambling has been a significant part of her life for years. She has been going to the local casino at least once a week for the past 16 years and playing for 5 to 8 hours each time. Before this past incident, she has never gambled more money than she could afford or chased her bets. She has also never experienced gambling-related repercussions.
The patient is restless but alert and oriented. She is talkative with rapid speech. She reports that she feels “amazing.” Additionally, her affect is labile—she cries when discussing her deceased husband and then suddenly starts making jokes. She is fixated on leaving the hospital and returning to Thailand to see her deceased mother (whom she believes is still alive).
Mrs Kim is admitted to the inpatient unit after a negative medical workup. Medication-induced bipolar and related disorder are suspected. Her antidepressant is discontinued and a low-dose antipsychotic is started.
Fourteen days later, she is discharged: her delusions and manic symptoms have resolved, including her urges to gamble uncontrollably.
This fictional case vignette of a patient with gambling problems represents a scenario that any practicing psychiatrist may encounter. Although the patient suffered gambling-related problems, treatment was unique and personalized. It is not uncommon to include significant others to help control finances, professionals (eg, accountants, lawyers), and health care workers (eg, counselors, therapists) in treatment plans.