Timothy W. Fong, MD

Patients increasingly ask about cannabis and whether it can be useful for sleep, PTSD, pain, and even dementia. In this video, Timothy W. Fong, MD gives a brief overview on emerging issues in cannabis. On Monday, May 3, Dr Fong and colleagues will speak at this year’s APA meeting in a presentation titled “

Facing the Challenge of Cannabis Legalization: Psychiatry’s Role

Dr Fong is Professor of Psychiatry & Director, UCLA, and Co-Director of UCLA’s Gambling Studies. The presentation is in collaboration with Laurence Westreich, MD; Kevin Allen Sevarino, MD; and Frances Rudnick Levin, MD.

Videos

Timothy W. Fong, MD, touches on our current understanding about cannabis use for psychiatric disorders.

Addressing Myths and Facts About Cannabis Use

Slideshows

A patient is brought to the emergency department by her daughter for bizarre behavior and symptoms of mania after gambling  from the casino for 48 continuous hours. 

A Case of Gambling Disorder

Nearly 4% of the population has gambling-related problems, and 6% will experience harm from gambling during their lifetime-including financial, legal, relational, and health problems.

 In addition, individuals with gambling problems have exponentially higher rates of suicide attempts and completions. One study found that 81% of pathological gamblers in treatment showed some suicidal ideation, and 30% reported one or more suicide attempts in the preceding 12 months.

DSM-5 criteria for gambling disorder represent the most common symptoms experienced by those with gambling problems. These symptoms characterize 3 heterogeneous dimensions related to gambling disorder: damage or disruption, loss of control, and dependence. The loss of control over urges and behaviors may be the central component of gambling disorders, and the inability to control gambling may be a component of a progressively worsening process in the life span of some gamblers.

Individuals who encounter gambling-related problems but who do not reach the diagnostic threshold (subthreshold gambling disorder meets only 1 to 3 criteria) are referred to as problem gamblers. For the most part, those with subthreshold gambling disorder continue to experience social, psychological, and health repercussions but to a lesser degree. They are also at increased risk for progression to gambling disorder compared with non-gamblers.

Gambling disorder is referred to as a hidden addiction because of the minimal signs and symptoms associated with this condition.

 The level of severity can also be concealed and involve multiple components. For example, a gambler who “hits rock bottom” (or one who has lost everything, including financial assets and social relationships) may have stopped gambling because of the lack of finances, but he or she may be severely depressed and suicidal because of the ongoing repercussion. Other components of severity include gambling behavior (frequency, duration, amount gambled), extent of gambling desires (cravings, urges), repercussions (eg, employment, legal, relationships), level of control, and comorbid symptoms (eg, suicidality, impulsivity, depression). These factors help predict treatment outcome and determine the appropriate treatment (ie, brief intervention, intensive outpatient, hospitalization). In research, severity is usually assessed using the total number of criteria endorsed, which can also be a quick and straightforward method in the clinical setting.

Gambling disorders are strongly associated with comorbid psychopathology. A meta-analysis of 11 population surveys found high mean prevalence for nicotine dependence (60.1%), a substance use disorder (57.5%), mood disorders (37.9%), and anxiety disorders (37.4%).

 A longitudinal 3-year study also found that any mood, anxiety, or substance use–related disorder was more likely to develop in individuals with either subthreshold gambling disorder or gambling disorder than in those who did not gamble.

Clinically, it may be helpful to assess sleep. Those with gambling problems have an increased risk of difficulty in initiating sleep, maintaining sleep, and more and early awakenings.

 Sleep disturbances can impair self-control and decision making, increase impulsivity, degrade cognition in executive functioning tasks, attenuate responses to losses, and increase expectations of gains that can affect gambling behavior.

There are no FDA-approved pharmacological treatments for gambling disorder, but several studies have evaluated the effects of medications on gambling behavior and comorbid symptoms. Grant and colleagues

 reviewed 18 double-blind placebo-controlled studies that included antidepressants, antipsychotics, mood stabilizers, glutamatergic agents, and opioid antagonists. Although the results were mixed and conclusions were limited because of the small sample sizes, opioid antagonists and glutamatergic agents (

-acetylcysteine) seemed to have the most promising results, especially for those with intense gambling urges.

A number of psychosocial strategies have shown promise in controlling aberrant gambling behavior, including self-help manuals, brief one-session interventions (motivational therapy), psychodynamic therapy, cognitive-behavioral therapy (CBT), and referrals to 12-step support groups.

 Research findings indicate that the treatment for gambling disorder not only reduces gambling behavior but can also help reduce comorbid psychiatric symptoms, such as anxiety and depression; improve quality of life; decrease psychological stress; and decrease the likelihood of comorbid psychopathology.

Jack, a 16-year-old 10th grader, is brought by his mother for evaluation of his “excessive online gaming.” Jack’s mother is concerned that her son plays casino-based “freemium” games 5 hours every day. (Freemium games are free to download but require tokens that are purchased with real money and gambled among players.) He buys approximately $30 worth of tokens every day and has spent more than $5000 on tokens in the past 6 months. He constantly argues with his parents regarding his playing time, his school work has deteriorated, and he no longer has any social interactions.

Jack admits that he lies to his parents about the extent of his playing-he sometimes plays more than 10 hours a day. He has a hard time stopping and usually plays until he loses all his tokens. He uses his mother’s credit card to buy tokens without permission. He is proud of his online accomplishments and enjoys the winning and competition with real adults. Although he now has no desire to interact with peers outside of school, he had enjoyed participating in a recreational sports league in the past.

Jack does not appear to suffer from any other disorder. He has never had problems with alcohol or drugs, and he has never seen a mental health professional or received psychotropics. His childhood and development have been without incident. Last year, his mother returned to work and Jack started taking care of his 7-year-old sister after school (during which he games the most).

During the initial session, gaming patterns and repercussions are discussed (financial, educational, and developmental). Recommendations are made that include changing passwords to the app store and limiting Internet access to supervised sessions, and Jack’s access to his mother’s credit card is cut off. After-school activities for both children are also highly encouraged, possibly restarting recreational sports competitions for Jack. Potential positive reinforcement methods for complying with clean Internet play are also discussed. The family is referred to a family therapist to continue working on family dynamics.

A 19-year-old college sophomore is referred by student health for evaluation of his gambling problems. Michael’s gambling has become pathological in the past year: he either bets on sports online or spends about 6 hours at a local casino daily. Although he does not work, he lost $50,000 in the past year, using money from his sports scholarship and financial aid. His mother has bailed him out multiple times by paying his credit card bills. He still has a credit card debt and owes money to his friends, which totals $25,000. He usually chases his losses, has strong cravings to gamble during the day, and experiences anxiety trying to find money to use for gambling. The time he spends on academics and team practices has become significantly reduced.

His primary care physician (PCP) prescribed stimulants after a diagnosis of ADHD in middle school, which Michael took until 12th grade. He has never seen a mental health professional or taken any psychotropic medication. He started binge drinking at college parties (probably twice a month, enough to black out); in addition, he smokes one blunt of marijuana every week.

Michael started gambling recreationally with friends in middle school, but he acknowledges that his problem controlling gambling started last year. Although he is disheartened by his gambling problem (and its repercussions), he is not depressed, still enjoys hobbies (which he indicates is gambling), and has fun with his girlfriend. He seems intelli-gent and brags about knowing the poker odds. He is seeking treatment because he wants to control his gambling (make only smart bets or play the good hands). His biggest problem is “losing a few bets in a row and going on tilt!”

During the first session, gambling patterns and repercussions are discussed, which he had initially minimized (ie, the possibility of losing his scholarship and being kicked off the team). He agrees to restart treatment with a stimulant, to include his mother in the next session via phone, and to go to Gamblers Anonymous. He agrees to continue CBT at the student health center to work on his aberrant alcohol use.

During the second session (3 weeks later), he reports that he has restarted the stimulant, which helps his impulsivity and studying habits. He has completed 8 sessions of CBT at the student center. He went to a Gamblers Anonymous meeting but did not agree with their tenet for abstinence. His mother agrees to stop bailing him out, control his credit cards and scholarship checks, and provide a limited allowance.

For the next few months, his gambling decreases (both in duration and frequency), but he places larger bets and loses more. Since his mother stopped bailing him out, he borrows money from a loan shark. He is kicked off the team and his scholarship is terminated. He decides to contact a state-funded mental health professional for more regular therapy sessions. He also agrees to ask the loan shark for a repayment plan.

By the fifth session (4 months after his initial presentation), he has stopped gambling and has a part-time job. He is making regular payments to his loan shark, studying more, drinking less alcohol, and playing more sports recreationally. He still enjoys gambling but now is aware of the repercussions. He is more focused on raising his grade point average and returning to the sports team.

James, a depressed 40-year-old poker player, is referred by his wife. He was laid off from work 8 months earlier. Since then he plays poker for 8 hours a day at a nearby casino. He gambles “out of boredom” and enjoys the social atmosphere. Although he is well-off financially, he has lost more than $200,000 in the past year. He now plays at higher-limit tables and chases his bets. He lies to his wife regarding his gambling and is on the brink of getting a divorce. He started playing poker as a teenager and had weekly poker games with his colleagues at work.

He lacks motivation, has stopped taking care of himself, and has gained 30 pounds in the past year. He has a hard time falling asleep and at times is restless in the mornings. James has had 3 episodes of depression in the past; he has been taking aripiprazole, citalopram, and bupropion (prescribed by his PCP) for the past 6 months. There is no his-tory suggestive of mania, hypomania, suicidality, or aberrant substance use.

During the first session with James and his wife, his recent gambling winnings/losses are reviewed, including bank statements that his wife brings in. He is surprised at the total amount of losses. He loves poker, but he does not want a divorce. He agrees to give all his bank cards to his wife, ban himself from local casinos, and work on saving his marriage. The couple are given a self-help workbook and listings for Gamblers Anonymous and Gam-Anon, and proper sleep hygiene is emphasized. The couple are also referred to the state-funded gambling provider network to receive therapy to work on their relationship.

Mirtazapine is started to help with depression, and aripiprazole is tapered. (Case report findings suggest a potential correlation between aripiprazole and excessive gambling, which is similar to the association between dopamine replacement therapy for Parkinson disease and gambling.9)

By the next session, James has stopped gambling because he no longer has easy access to money. He has also started attending Gamblers Anonymous several times a week and enjoys their camaraderie. He appreciates how attending Gamblers Anonymous has helped diminish his strong urges to play poker.

By the fourth session (third month), he has completed his rÃ©sumÃ© and started exercising again. His sleep is improved, he regularly attends meetings of Gamblers Anonymous, and he has a sponsor in addition to making a commitment to the group. He is also in the process of completing 12 sessions with the marriage and family therapist. He misses playing poker, but realizes how abstaining has improved his relation-ship with his wife.

Jackie, a 34-year-old nurse, is referred by her coworker for gambling at work. Compelled by her colleague, Jackie came to the addiction clinic to receive help for her uncontrollable need to gamble at work. She plays online slots on her phone for about 6 hours during her night shifts; after work, she usually tries to win back her losses at the local casino. Although she has lost $50,000 in the past 6 months, with an annual salary of $150,000, she does not have any financial difficulties and is still well regarded at work.

Six months earlier, Jackie called off her wedding after discovering her fiancÃ©’s infidelity. Since that time, gambling has been a great escape for her, specifically helping with ruminations. She is sad, has almost daily crying spells, lacks motivation to care for herself, has problems falling asleep and sustaining sleep, and has some thoughts that she may be better off dead. She is also irritable, easily snapping at colleagues and difficult patients at work. She drinks several glasses of wine every day to “help her nerves.”

Jackie describes some history suggestive of hypomania (not sleeping for a few days, very energetic, happy, impulsively shopping, gambling, and having sex). She carries diagnoses of bipolar disorder, depression, borderline personality disorder, and ADHD. When she was 17, she had a psychiatric hospitalization after breaking up with her boyfriend; she had suicidal ideations and self-injurious behavior (cutting). Jackie saw a therapist for 3 years, went to an accelerated nursing school, and currently works full-time at the hospital. She sees a psychiatrist (about twice a year), who prescribes quetiapine extended-release. Her PCP also prescribes trazodone, fluoxetine, methylphenidate (twice daily), clonazepam (3 times daily), and zolpidem.

During the first session, Jackie is ambivalent about treatment for her gambling, but she does want help for her insomnia, irritability, and anxiety. She agrees to consolidate her prescriptions to one prescriber to optimize medications. She receives psychoeducation regarding the importance of sleep hygiene, especially the effects of smoking, alcohol, stimulants, and shift work. The repercussions of her gambling are also discussed, and she is given a self-help workbook with listings for Gamblers Anonymous meetings. She agrees to taper off most of her medications and to start lamotrigine.

During the second session (10 days later), she reports that her gambling at work has decreased significantly because she was being monitored by her colleagues, but her gambling outside of work has increased. She also started melatonin and diphenhydramine on her own to help with insomnia. Her passive suicidal ideations are stronger, because she thinks that she is not doing anything productive with her life. She does not have a specific plan to hurt herself; she believes that suicide is immoral; and she does not want to voluntarily admit herself to an intensive outpatient program, a residential treatment program, or an inpatient unit.

Jackie continues to be irritable and to have poor self-care and low self-esteem. She enjoys talking during the session and wants to come more often. She has not been to any Gamblers Anonymous meetings because she does not believe that she has a gambling problem. Medications continue to be optimized, and the benefits of sleep hygiene are reinforced. She is also referred to a state-funded therapist to help with her gambling problems.

During her third and fourth sessions (weekly), she reports that the new medication regimen is finally working and she feels less irritable. She has not gambled at work during the past week and feels good, and she has started working more shifts (about 90 hours per week). Consequently, she is usually exhausted af-ter work and does not have the energy to go gambling.

At the seventh session (about 10 weeks after intake), Jackie reports that her work shifts have become more irregular. She works subsequent day and night shifts, and then has a few days off. During her most recent off days, she accepted an invitation for free accommodations and a spa package at a casino/hotel. In those 3 days, she lost $30,000 and gambled for 40 hours. She maxed out her credit cards and emptied her savings account. She finally agrees that she has a gambling problem. She plans to remove herself from the casino’s mailing list, ban herself from the local casinos, close her online casino gambling accounts, schedule an appointment with the state-funded therapist, and ask her brother to start controlling her finances.

During the next 6 months (about 15 sessions), she stops gambling. She completes 10 sessions of gambling treatment with the state therapist and decides to continue the therapy out-of-pocket. Her sleep has improved, and her irritability and anxiety have decreased. Jackie also has started working only regular day shifts and has started exercising and socializing with old friends.

Mrs Kim, a 60-year-old manic gambler, is brought to the emergency department by her daughter for bizarre behavior. For the past month, Mrs Kim 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 other than complaining of boredom and lack of motivation to her PCP last month, who 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.

On evaluation, Mrs Kim is restless but alert and oriented. She is talkative with rapid speech. She reports that she feels “amazing”; 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).

She 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.

These fictional case vignettes represent samples of individuals with gambling problems that any practicing psychiatrist may encounter. Although each patient suffered gambling-related problems, treatments were unique and personalized. It is also not uncommon to include significant others to help control finances, professionals (eg, accountants, lawyers), and health care workers (eg, counselors, therapists) in treatment plans. Specifically, free resources are available and can be used as part of the treatment plan, including self-help manuals and referrals to state-funded provider treatments and 12-step support groups (

Dr Parhami, is a PGY 3 Psychiatry Resident at the Delaware Psychiatry Residency Program, New Castle. He has completed a postdoctoral research fellowship at UCLA and will start a Child and Adolescent Psychiatry Fellowship at Johns Hopkins, Baltimore, in July. Dr Fong is Associate Psychiatry Professor, Co-Director of the UCLA Gambling Studies Program, Director of the UCLA Addiction Medicine Clinic, and Program Director for the UCLA Addiction Psychiatry Fellowship. Dr Parhami reports no conflicts of interest concerning the subject matter of this article; Dr Fong has received funding from the California Office of Problem Gambling.

 Lorains FK, Cowlishaw S, Thomas SA. Prevalence of comorbid disorders in problem and pathological gambling: systematic review and meta-analysis of population surveys. 

 Battersby M, Tolchard B, Scurrah M, Thomas L. Suicide ideation and behaviour in people with pathological gambling attending a treatment service. 

 Ladouceur R. Gambling: the hidden addiction. 

 Parhami I, Mojtabai R, Rosenthal RJ, et al. Gambling and the onset of comorbid mental disorders: a longitudinal study evaluating severity and specific symptoms. 

 Parhami I, Siani A, Rosenthal RJ, Fong TW. Pathological gambling, problem gambling and sleep complaints: an analysis of the National Comorbidity Survey: Replication (NCS-R). 

 Grant JE, Odlaug BL, Schreiber LR. Pharmacological treatments in pathological gambling. 

 Hodgins DC, Stea JN, Grant JE. Gambling disorders. 

 Fink A, Parhami I, Rosenthal RJ, et al. How transparent is behavioral intervention research on pathological gambling and other gambling-related disorders? A systematic literature review. 

 Gaboriau L, Victorri-Vigneau C, GÃ©rardin M, et al. Aripiprazole: a new risk factor for pathological gambling? A report of 8 case reports. 

 National Center for Responsible Gaming. Brief Biosocial Gambling Screen. 

http://www.ncrg.org/resources/brief-biosocial-gambling-screen.

http://www.gamblersanonymous.org/ga/locations

 California Department of Public Health. Freedom From Problem Gambling. 

http://problemgambling.securespsites.com/ccpgwebsite/help-available/publications.aspx

Articles

The loss of control over urges and behaviors may be the central component of gambling disorders, but there is so much more to consider. Individuals with these problems have exponentially higher rates of suicide attempts and completions. 

A Brief Review of Gambling Disorder and Five Related Case Vignettes

Pathological gambling is a common psychiatric condition that can present with a variety of symptoms. Here, practical treatment recommendations for pathological gamblers and their families.

TIPSHEET: TREATMENT RECOMMENDATIONS FOR PATHOLOGICAL GAMBLERS

â  Use medications to address co-occurring psychiatric or substance-related disorders

â  Employ random urine drug screens to rule out substance abuse

â  Screen for medically related conditions that can complicate pathological gambling: Dementia, Parkinson disease, malignancies, prescription drug abuse

Consider medications to target preoccupation and gambling urges and to reduce the reinforcement from gambling

sleep hygiene, with a target of 7 hours of sleep per night in recovery

â  Encourage patients to sign up for self-exclusion programs from casinos and to be removed from casino marketing lists

â  Reduce stigma and shame by educating that pathological gambling is a brain disease, much like depression and addictions

â  Use Web sites or advocacy groups for support (see Resources, below)

â  Seek out supervision or support from gambling treatment specialists

â  Encourage active participation in Gamblers Anonymous, including getting a sponsor and making a commitment to meetings

â  Involve family and friends to monitor overall behaviors and functioning

â  Encourage patients to engage in recovery process by increasing structured activities to replace time spent gambling

Pathological Gambling: Update on Assessment and Treatment

," by Timothy W. Fong, MD, from which this Tipsheet was adapted.

Psychiatric Comorbidity Associated With Pathological Gambling

Pathological Gambling: A Behavioral Addiction

Clinical Assessment and Management of Pathological Gambling

Pathological gambling is a common psychiatric condition that can present with a variety of symptoms. Treatment recommendations available for pathological gamblers, as well as resources for patients and their families in this Tipsheet.

Tipsheet: Pathological Gambling

Gender Differences Should Be Considered in Treatment of Addiction

Surveys show that approximately 60% of the general population has gambled within the past 12 months.

 The majority of people who gamble do so socially and do not incur lasting adverse consequences or harm. Beyond this, approximately 1% to 2% of the population currently meets criteria for pathological gambling.

 This prevalence is similar to that of schizophrenia and bipolar disorder, yet pathological gambling often goes unrecognized by most health care providers.

Screening and treatment for pathological gambling-otherwise known as compulsive gambling, gambling addiction, or disordered gambling-is not generally taught in medical school, during psychiatry residency, or during training for mental health or substance abuse counselors. As a result, clinicians may not recognize the signs and symptoms of pathological gambling and may lack the training and experience to provide state-of-the-art treatment.

 lists pathological gambling in the section on impulse control disorders. There is an ongoing debate as to where to include pathological gambling in 

. One viewpoint is to include pathological gambling as an addictive disorder because both conditions share core features-namely, loss of control in the face of adverse consequences.

 Another possibility is to view pathological gambling as an obsessive-compulsive spectrum disorder because of the shared symptoms of preoccupation; tension; and repetitive, almost ritualistic behaviors.

 Finally, pathological gambling may be viewed as a stand-alone impulse control disorder with unique characteristics, disease course, and pathophysiology.

 criteria, pathological gambling is characterized by continued gambling despite harmful consequences. Some of the cardinal symptoms include preoccupation with gambling, tolerance (need to increase the size of bets), loss of control, inability to cut down, and lost opportunities as a result of gambling. Criteria that are specific to pathological gambling include chasing losses, committing illegal acts to finance gambling, and having others pay gambling debts.

Problem gamblers are considered those who meet 1 or more of the diagnostic criteria for pathological gambling but less than 5. This is similar to substance abuse in that the gamblers’ lives are being harmed by gambling, but full criteria are not satisfied.

Most clinicians can recognize signs and symptoms of gambling addiction, but screening is not routine. There are several validated, simple screens for pathological gambling (

) that can be used in different languages, as well as a quick 2-question (Lie-Bet) tool that can be used.

Frequent screening for pathological gambling is recommended. Patients in substance abuse treatment settings have been known to switch addictions during the recovery process.

Most pathological gamblers do not present with a chief complaint of “being addicted to gambling.” Research has shown that only 10% of pathological gamblers present for treatment.

 Presenting symptoms can be vague and might include commonly seen problems, such as insomnia, stress, depression, anxiety, or interpersonal problems. Since pathological gambling is a hidden addiction that cannot be detected by physical examination, the use of screening tools is essential.

The course of pathological gambling can vary from a chronic relapsing condition to one with a short time course.

Vulnerable groups include males; persons with comorbid psychiatric disorders, especially substance abuse, attention-deficit/hyperactivity disorder, and antisocial personality disorder; the elderly; adolescents; the disabled; and those with low socioeconomic status.

 Pathological gambling has been shown to be a condition with high genetic transmission and heritability.

 It is unclear what is being genetically inherited, although the trait for risk-taking preference, absence of loss aversion, or sensitivity to immediate rewards may be responsible.

The consequences of pathological gambling vary with each case and can range from financial loss, divorce, substance abuse, domestic violence, lost time/productivity, and illegal activity. Suicidal ideation is common in pathological gamblers, affecting nearly 25% of this population.

 In addition, the medical consequences of pathological gambling are also being recognized-insomnia, sleep deprivation, lack of exercise, stress-related illnesses, and decreased attention to self-care have all been seen clinically in pathological gamblers.

Recently, attention has been drawn to the association between Parkinson disease, use of dopamine agonists, and pathological gambling. Although definitive scientific causality has not been established, there is compelling evidence to suggest that pathological gambling behaviors that were not previously evident may develop in a subset of individuals with Parkinson disease who are taking dopamine agonists.

 This association implicates a role for the dopamine reward pathway in the development of the disease and informs clinicians of the need to screen for pathological gambling in this population.

No single treatment approach has been shown to be most beneficial for pathological gamblers. Most gambling treatment programs recommend an integrated biopsychosocial perspective that involves as many collateral participants as possible. The current body of research evidence is stronger for psychotherapeutic approaches than for pharmacological approaches.

 Evidence-based psychotherapies for pathological gambling include cognitive-behavioral therapies (CBT), brief interventions, motivational enhancement, and 12-step support groups.

Brief interventions for pathological gambling include either single or limited sessions that target gambling and also include the use of self-help workbooks and telephone counseling.

 indicates that a single 10-minute informational session or a single 1-hour motivational enhancement interview reduces problem gambling behaviors. Brief interventions with self-help workbooks are also emerging as effective ways to reduce problem gambling behaviors.

Individual psychotherapy is most widely used to address pathological gambling. Compared with other psychotherapies, CBT has the most evidence for the management of pathological gambling.

Several recent studies highlight the importance of targeting cognitive distortions and irrational beliefs associated with continued gambling.

 Individual therapy reduces gambling frequency, increases perceived self-control over gambling, and strengthens relapse prevention. For therapists interested in using CBT for pathological gamblers, clinically tested manuals and guides are available.

 A recent meta-analysis of CBT for pathological gambling suggests that the effect size is promising and that the effect of reduced pathological gambling behavior extends to at least 12 months.

There is compelling evidence that pathological gambling behaviors not previously evident may develop in a subset of persons with Parkinson disease who are taking dopamine agonists.

Social support through Gamblers Anonymous is often recommended for pathological gambling. Gamblers Anonymous has been in operation for more than 50 years; meetings are held daily throughout the United States. Gamblers Anonymous offers peer support, fellowship, and a confidential network to support recovery. Variables that predict abstinence include attendance, participation, and higher social status.

Practical techniques to use with pathological gamblers include discussions of how to limit access to casinos, credit, and transportation to gambling venues. Financial counseling is an essential component in working with pathological gamblers-an area that many therapists find challenging, since they lack formal training. Finally, engaging family members early in treatment is critical to foster treatment retention and adherence, and to minimize enabling behaviors.

Common pitfalls in treating pathological gamblers include nonadherence to therapy, ambivalence, and low motivation. Shame and guilt are palpable in pathological gamblers and their families. A nonjudgmental attitude is critical in dealing with the harmful consequences of continued gambling.

There are no FDA-approved medications for pathological gambling. Therefore, when prescribing medications to target pathological gambling, clinicians need to inform their patients of the off-label use of the drug and that the use is based on limited research.

The pursuit of effective medications for pathological gambling has been hindered by clinical trials that report a high placebo response rate, a lack of understanding of pathophysiology, the heterogeneous nature of pathological gambling, and the use of a wide variety of outcome measures.

 Evidence for the use of medications in treating pathological gambling has been inconclusive.

The dopaminergic system, which influences reward, motivation, reinforcement of reward, and appetitive urges has been implicated in addic-tive disorders-including pathological gambling.

 In randomized clinical trials, the opiate antagonists, naltrexone and nalmefene, have been shown to reduce gambling urges, thoughts of gambling, and behaviors in primary pathological gamblers but not in pathological gamblers with comorbid alcohol abuse.

Antidepressants, namely SSRIs, have been tested because pathological gamblers have demonstrated serotonergic dysfunction in the laboratory, which has contributed to possible explanations of impaired disinhibition and impulsivity. Data from clinical trials in which SSRIs have been used to treat pathological gamblers have not been conclusive: some trials have found moderate reductions in gambling while others have not been able to find a significant response.

One trial showed bupropion to be as effective as naltrexone in pathological gamblers, but other trials have not been able to show efficacy greater than that with placebo.

Mood stabilizers have also been examined for the management of pathological gambling because of the high co-occurrence of bipolar disorder and dysfunctional impulsivity in pathological gamblers. To date, lithium, divalproex, carbamazepine, and topiramate have been tested.

 In a double-blind placebo-controlled study of 40 pathological gamblers who had bipolar spectrum disorders (bipolar II disorder, bipolar not otherwise specified, or cyclothymia), sustained-release lithium carbonate (mean lithium blood level of 0.87 mEq/L) was superior to placebo in reducing pathological gambling symptoms during 10 weeks of treatment.

Olanzapine was examined in 2 clinical trials in nonpsychotic nonbipolar participants, but no significant treatment effect was reported for pathological gambling.

 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.

In the past few years, trials with unique agents, such as 

-acetylcysteine and modafinil, have shown interesting preliminary data, but replication and further testing are required.

-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.

 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.

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.

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 (

). 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.

 Welte JW, Barnes GM, Wieczorek WF, et al. Gambling participation in the US-results from a national survey. 

 Welte JW, Barnes GM, Tidwell MC, Hoffman JH. The prevalence of problem gambling among US adolescents and young adults: results from a national survey. 

 Potenza MN. Should addictive disorders include non-substance-related conditions? 

 Tavares H, Gentil V. Pathological gambling and obsessive-compulsive disorder: towards a spectrum of disorders of volition. 

 Johnson EE, Hamer RM, Nora RM. The Lie/Bet Questionnaire for screening pathological gamblers: a follow-up study. 

 Slutske WS. Natural recovery and treatment-seeking in pathological gambling: results of two US national surveys. 

 Sartor CE, Scherrer JF, Shah KR, et al. Course of pathological gambling symptoms and reliability of the Lifetime Gambling History measure. 

 Johansson A, Grant JE, Kim SW, et al. Risk factors for problematic gambling: a critical literature review. 

 Dickson-Gillespie L, Rugle L, Rosenthal R, Fong T. Preventing the incidence and harm of gambling problems. 

 Slutske WS, Meier MH, Zhu G, et al. The Australian Twin Study of Gambling (OZ-GAM): rationale, sample description, predictors of participation, and a first look at sources of individual differences in gambling involvement. 

 Wong PW, Chan WS, Conwell Y, et al. A psychological autopsy study of pathological gamblers who died by suicide. 

 Weintraub D, Hoops S, Shea JA, et al. Validation of the questionnaire for impulsive-compulsive disorders in Parkinson’s disease. 

 Steeves TD, Miyasaki J, Zurowski M, et al. Increased striatal dopamine release in Parkinsonian patients with pathological gambling: a [11C] raclopride PET study. 

Surveys show that approximately 60% of the general population has gambled within the past 12 months.1 The majority of people who gamble do so socially and do not incur lasting adverse consequences or harm. Beyond this, approximately 1% to 2% of the population currently meets criteria for pathological gambling.2 This prevalence is similar to that of schizophrenia and bipolar disorder, yet pathological gambling often goes unrecognized by most health care providers.