Olanzapine was examined in 2 clinical trials in nonpsychotic nonbipolar participants, but no significant treatment effect was reported for pathological gambling.36,37 Recently, there was a case report of beneficial effects of quetiapine in a patient with Parkinson disease and pathological gambling, but there have not been any follow-up studies.38
In the past few years, trials with unique agents, such as N-acetylcysteine and modafinil, have shown interesting preliminary data, but replication and further testing are required.39,40N-acetylcysteine, a glutamatergic modulator, is thought to mediate learning in the reward pathway. The mechanism of action for modafinil remains incompletely understood, but it is thought to involve dopamine regulation by blocking dopamine transporters and thereby attention and executive functioning.41 Ongoing trials of memantine, acamprosate, and topiramate that will provide new insights into the specific targets of medications are being con-ducted in pathological gamblers.
Currently, only 30 states offer publicly funded gambling treatment (despite gambling being legal in every state except Hawaii and Utah). Similar to certifying bodies that administer alcohol and drug treatment certifications, there are certifying bodies that administer gambling counselor certifications. Intensive outpatient programs and residential treatment programs exist specifically for pathological gamblers, but many are prohibitively expensive and/or have little documentation and evaluation of clinical services.
Short- and long-term monitoring
No objective measure of gambling engagement, such as a urine drug screen, exists for pathological gamblers. Self-report is obviously unreliable. Collateral information, review of financial statements, assessment of life domains (work, medical health, emotional health, social capital, financial, legal, and family functioning) and the patient’s therapy adherence/retention are the best treatment indicators.42
As with those with addictive disorders, pathological gamblers require ongoing monitoring. Significant damage and harm can occur instantly when relapse occurs. In general, patients who have been stable for more than a year and who are no longer experiencing any harmful consequences from gambling can be monitored less frequently.
Pathological gambling is a common psychiatric condition that can present with a variety of symptoms. Addressing problem gambling requires full attention to all aspects of the bio-psychosocial perspective. Even though there are no FDA-approved medications or standard treatment guidelines, there are a variety of treatment options available for pathological gamblers and their families (Table 2). As with addictive disorders, engagement and retention of gamblers in treatment will lead to improved outcomes. The next 5 years are also likely to see an emergence of newer technologies and psychotherapeutic techniques that will increase the treatment armamentarium for pathological gambling.
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