Clinical Assessment and Management of Pathological Gambling

March 1, 2007

Pathological gambling (PG) is characterized by persistent and recurrent maladaptive patterns of gambling behavior (eg, a preoccupation with gambling, the inability to control gambling behavior, lying to loved ones, illegal acts, and impaired social and occupational functioning).1 With past-year prevalence rates similar to those of schizophrenia and bipolar disorder,2 it is apparent that PG has become a significant public health issue. The aim of this article, therefore, is to introduce clinicians to the assessment and treatment of PG with the hope that early interventions will reduce the considerable personal and social costs associated with the disorder.

Pathological gambling (PG) is characterized by persistent and recurrent maladaptive patterns of gambling behavior (eg, a preoccupation with gambling, the inability to control gambling behavior, lying to loved ones, illegal acts, and impaired social and occupational functioning).1 With past-year prevalence rates similar to those of schizophrenia and bipolar disorder,2 it is apparent that PG has become a significant public health issue. The aim of this article, therefore, is to introduce clinicians to the assessment and treatment of PG with the hope that early interventions will reduce the considerable personal and social costs associated with the disorder.

PG usually begins in adolescence or early adulthood; males tend to exhibit symptoms associated with the disorder at an earlier age.3 Although there is some debate about the course of PG, when it is left untreated it appears to be a chronic, relapsing condition for many individuals.4,5

As in substance use disorders, PG appears to develop more quickly in females than in males after they begin to gamble-a phenomenon originally observed in alcohol dependence termed "telescoping."6 Women who are pathological gamblers tend to have problems with nonstrategic forms of gambling, such as slot machines and bingo; men tend to have problems with strategic forms, such as sports and card gambling.7 Both females and males who are pathological gamblers report that advertisements are common triggers of their gambling urges, and females are more likely to report that feeling bored or lonely may trigger an urge.8

Studies have consistently found that co-occurring conditions, such as depression, substance use disorders, and anxiety disorders, are common in individuals who are pathological gamblers (Figure 1).9-13 These co-occurring disorders may provide clues about the most effective treatment options for PG and should be treated simultaneously.

PG often goes unrecognized because patients are hesitant to disclose information about their behavior unless specifically asked.14 Given the personal and social impact of untreated PG, clinicians need to routinely screen for the disorder, perform a thorough assessment of the behavior and co-occurring conditions, and treat the disorder.

DIAGNOSIS
The first and most important step to treating a disorder is to diagnose it properly. Studies have found that most individuals who are pathological gamblers do not voluntarily discuss the issue with clinicians.14 Many are ashamed of the problematic behaviors associated with PG and therefore may not self-report. When asked about gambling, however, most patients are willing to talk about the disorder. The diagnosis of PG is usually straightforward and can be done by asking patients if they feel they cannot control their gambling or if they are preoccupied with gambling.Sample questions clinicians can use to begin a discussion about gambling can be found in Table 1.

    
   
 Does your gambling feel out of control to you? 

An affirmative answer can be followed with questions to determine the degree of impairment (social, financial, familial, or occupational) and distress that this behavior is causing. It must also be ascertained whether the gambling behavior can be attributed to bipolar disorder. Simple self-reports and clinician-administered screenings, as well as diagnostic measures, are available (eg, South Oaks Gambling Screen, Early Intervention Gambling Health Test).15

TREATMENT
Because of the limitations of current research, it is unclear which treatment approach may be most beneficial for a particular pathological gambler. What is known, however, is that no single treatment has been shown to be clear- ly more effective than others. Until greater knowledge of the pathophysiology is available, there is not enough evidence to make definitive treatment recommendations.

An assessment of clinical presentation, comorbidity, and family history, however, may provide useful clues to treatment interventions. Subtyping of PG based on clinical similarities to other disorders (eg, substance use disorders) or existence of co-occurring conditions (eg, bipolar disorder), or due to core features of the behavior (eg, cravings) may be useful when deciding on treatment interventions. A suggested clinical approach is presented in Figure 2.

Although both pharmacological and psychosocial interventions have shown early promise for PG, no comparative studies have been performed. Should an individual with PG begin with medication, therapy, or both? In addition, are there differences in individuals who are pathological gamblers that may indicate a preferential response to a particular intervention? Research addressing these issues is lacking.

Pharmacological treatment
Several drugs have been investigated as treatments for PG, and the range of medication classes (opioid antagonists, SSRIs, mood stabilizers) reflects the heterogeneity of individuals who are pathological gamblers. Because no medication is currently FDA-approved to treat PG, patients should be informed of off-label use of medications for the disorder, as well as the empirical basis for considering pharmacological treatment (Table 2).

             
 Table 2 Double-blind pharmacotherapy trials for pathological gambling
 Medication  Subjects (number completed)  Mean dosage  Outcome  
 Opioid antagonists           
 Naltrexone  45  188 mg/d  Naltrexone group significantly improved compared with placebo group  
 Nalmefene  73  25, 50, or 100 mg/d  Nalmefene group significantly improved compared with placebo group  
 Antidepressants           
 Clomipramine  1  125 mg/d  90% improvement in gambling symptoms  
 Fluvoxamine  10  195 mg/d  Fluvoxamine superior to placebo  
 Fluvoxamine  13  200 mg/d  Results with fluvoxamine not significantly different from those with placebo  
 Paroxetine  41  51.7 mg/d  Paroxetine group significantly improved compared with placebo group  
 Paroxetine36  45  50 mg/d  Similar improvement in both groups  
 Sertraline  44  95 mg/d  Similar improvement in both groups  
 Mood stabilizers           
 Lithium carbonate (sustained-release)  29 bipolar- spectrum subjects  1170 mg/d  Lithium group significantly improved compared with placebo group  

Opioid antagonists. The dopaminergic system, which influences the rewarding and reinforcing behaviors in substance use disorders, has also been implicated in PG. It has been proposed that alterations in dopaminergic pathways underlie the reward-seeking behaviors (eg, in gambling and drug use) that trigger the release of dopamine and produce feelings of pleasure.7 Opioid antagonists are thought to decrease dopamine neurotransmission in the nucleus accumbens, thereby affecting the motivational neurocircuitry and dampening gambling-related excitement and cravings.16

Initially, open-label treatment suggested the efficacy of high dosages of naltrexone (mean dosages of 157 mg/d)-an FDA-approved treatment for alcohol and opioid dependence-in reducing the intensity of gambling urges, thoughts, and behaviors.17 A 12-week double-blind placebo-controlled trial of naltrexone demonstrated superiority to placebo in 45 subjects who were pathological gamblers.18 The drug was effective in reducing the frequency and intensity of gambling urges and behaviors (mean dosage of 188 mg/d). Naltrexone's clinical use, however, is limited by its significant side effects and its tendency to elevate enzyme levels in the liver, especially in patients taking NSAIDs.19

A recently completed multicenter study demonstrated the efficacy of another opioid antagonist, nalmefene, in the treatment of PG. In a sample of 207 subjects, nalmefene dosages of 25 and 50 mg/d demonstrated statistically significant improvements (P = .007, P = .016, respectively) in gambling symptoms (reduced gambling urges, thoughts, and behaviors) compared with placebo in a 16-week double-blind trial.20 Although nalmefene, like naltrexone, causes nausea in some individuals, it was not associated with hepatotoxicity in this large study.

Antidepressants. Pathological gamblers demonstrated diminished activation of the ventral medial prefrontal cortex (vmPFC) when they viewed gambling-related videotapes or during a simulated gambling task.21,22 These findings suggest that decreased serotonin function within the vmPFC may engender disinhibition and contribute to PG. Thus, drugs targeting serotonin neurotransmission have been examined in PG treatment.

Data from double-blind randomized pharmacotherapy trials of SSRIs in the treatment of PG, although promising, have been inconclusive, with only some trials showing superior efficacy when compared with placebo (see Table 2).

Some important findings, however, emerge from these studies. First, antidepressants-particularly those that influence serotonergic systems, like the SSRIs-may be effective in reducing the symptoms of PG. Second, the effects of antidepressants appear to be independent of underlying depressive or anxiety symptoms.

Mood stabilizers. Because some pathological gamblers appear to have either co-occurring bipolar disorder or subsyndromal hypomania, the use of mood stabilizers has also been examined (see Table 2). There has been only one randomized placebo-controlled trial of a mood stabilizer in PG. In a double-blind placebo-controlled study of 40 subjects who were pathological gamblers with bipolar spectrum disorders (bipolar type II, bipolar not otherwise specified, or cyclothymia), sustained-release lithium carbonate (mean lithium blood level of 0.87 mEq/L) was shown to be superior to placebo in reducing PG symptoms during a 10-week treatment.23

Psychosocial interventions
Controlled studies support the efficacy of cognitive and behavioral therapies for PG (Table 3). Cognitive therapy focuses on changing the patient's beliefs regarding his or her perceived control over randomly determined events. Randomized trials have demonstrated success with cognitive therapy.24 Individual cognitive therapy has resulted in reduced gambling frequency and increased perceived self-control over gambling when compared with a wait-list control group. Cognitive therapy that includes relapse prevention has also produced improvements in gambling symptoms when compared with a wait- list group.

       
 Table 3 Controlled psychological treatment trials for PG
 Design  Outcome  
 Stimulus control and in vivo exposure with relapse prevention; cognitive restructuring; combined treatment; or wait list25  At 12 months, 69% were abstinent or much reduced in the first group compared with 38% for cognitive restructuring or combined treatment  
 Cognitive therapy plus relapse prevention compared with wait list  36% improved on 5 variables compared with 6% on wait list  
 Cognitive therapy plus relapse prevention compared with wait list  32% improved on 4 variables compared with 7% on wait list  
 Group cognitive therapy plus relapse prevention compared with wait list  65% no longer met PG criteria compared with 20% for wait-list group  
 Manualized CBT in individual counseling; use of CBT workbook; or referral to Gamblers Anonymous  Individual CBT more effective than Gamblers Anonymous and use of workbook; at 12 months, groups did not differ in terms of abstinence rates  
 Use of CBT workbook compared with use of a workbook plus a single in-depth interview  Both groups showed improvement at 6 months  
 Use of CBT workbook; use of workbook plus motivational enhancement intervention via telephone; or wait list  74% with motivational enhancement improved according to Clinical Global Impression compared with 61% with use of workbook and 44% with wait list  
 Aversion therapy compared with imaginal desensitization  Improvement in both groups over 12 months  
 Aversion therapy; imaginal desensitization; in vivo desensitization; or imaginal relaxation  Improvements at 1-month and at 9-year follow-up with imaginal desensitization  
 PG, pathological gambling; CBT, cognitive-behavioral therapy.  
       

Cognitive-behavioral therapy (CBT) has been used to treat PG. One study compared 4 groups: (1) an individual stimulus control and in vivo exposure with response prevention; (2) group cognitive restructuring; (3) a combination of 1 and 2; and (4) a wait-list control.25 At 12 months, the rates of abstinence or minimal gambling were higher with individual treatment (69%) than with both the cognitive restructuring and the combined treatment groups (38% abstinence or minimal gambling rate in each).

Based on CBT used in the treatment of substance use disorders and including relapse prevention strategies, an independent controlled trial of 231 subjects also demonstrated short-term improvement relative to a referral to Gamblers Anonymous (GA); at 12-month follow-up, however, abstinence rates did not differ between the 2 groups.26

Brief interventions have demonstrated significant reductions in gambling at 6-month follow-up for gamblers assigned either to the use of a workbook (that included cognitive-behavioral and motivational enhancement techniques) or to the use of a workbook and an interview with a clinician.27 A separate study assigned patients who were pathological gamblers to the use of a workbook, the use of a workbook and a motivational enhancement intervention over the telephone, or a wait list. Compared with the group who used the workbook alone, the group assigned to use motivational intervention and the workbook showed a reduction in gambling throughout the 2-year fol-low-up period.28 Two studies that examined aversion therapy and imaginal desensitization in randomized designs found that both treatments resulted in improvement.29,30

GA is perhaps the most popular and well-known treatment for PG, but few studies have systematically analyzed the outcomes of participation. Although controlled studies are lacking, most of the studies that examined treatment outcomes for patients who attended GA demonstrated the program's potential effectiveness, particularly when combined with professional therapy.31

CONCLUSION
PG has historically received relatively little attention from clinicians and researchers. Despite having prevalence rates similar to or greater than those of schizophrenia and bipolar disorder, there is much less research on PG that investigates treatment strategies. As a consequence, our understanding of effective and well-tolerated pharmacotherapies for PG lags behind that of other major neuropsychiatric disorders. Emerging data from controlled clinical trials, however, suggest that PG frequently responds to both pharmacological and psychosocial intervention.

The approaches reviewed in this article represent significant advances over the past several years-it is hoped that progress in the treatment of PG will continue to be made at this rate. More definitive treatment recommendations await the completion of additional large-scale controlled treatment studies and comparative investigations of trials of pharmacological agents. Advances in these areas hold the potential for significantly improving the lives of pathological gamblers and those directly or indirectly affected by their behavior.

References:

References1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders-Text Revision. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.
2. Shaffer HJ, Hall MN, Vander Bilt J. Estimating the prevalence of disordered gambling behavior in the United States and Canada: a research synthesis. Am J Public Health. 1999;89:1369-1376.
3. Argo T, Black DW. Clinical characteristics. In: Grant JE, Potenza MN, eds. Pathological Gambling: A Clinical Guide to Treatment. Washington, DC: American Psychiatric Publishing; 2004.
4. Slutske WS. Natural recovery and treatment-seeking in pathological gambling: results of two US national surveys. Am J Psychiatry. 2006;163:297-302.
5. Afifi TO, Cox BJ, Sareen J. Gambling-related problems are chronic and persist for the majority of individuals with a lifetime diagnosis of pathological gambling. Am J Psychiatry. 2006;163:1297.
6. Potenza MN, Kosten TR, Rounsaville BJ. Pathological gambling. JAMA. 2001;286:141-144.
7. Potenza MN, Steinberg MA, McLaughlin SD, et al. Gender-related differences in the characteristics of problem gamblers using a gambling helpline. Am J Psychiatry. 2001;158:1500-1505.
8. Grant JE, Kim SW. Demographic and clinical features of 131 adult pathological gamblers. J Clin Psychiatry. 2001;62:957-962.
9. Black DW, Moyer T. Clinical features and psychiatric comorbidity of subjects with pathological gambling behavior. Psychiatr Serv. 1998;49:1434-1439.
10. Bland RC, Newman SC, Orn H, Stebelsky G. Epidemiology of pathological gambling in Edmonton. Can J Psychiatry. 1993;38:108-112.
11. Linden RD, Pope HG Jr, Jonas JM. Pathological gambling and major affective disorder: preliminary findings. J Clin Psychiatry. 1986;47:201-203.
12. McCormick RA, Russo AM, Ramirez LF, Taber JI. Affective disorders among pathological gamblers seeking treatment. Am J Psychiatry. 1984;141:215-218.
13. Grant JE, Kim SW. Comorbidity of impulse control disorders in pathological gamblers. Acta Psychiatr Scand. 2003;108:203-217.
14. Grant JE, Levine L, Kim D, Potenza MN. Impulse control disorders in adult psychiatric inpatients. Am J Psychiatry. 2005;162:2184-2188.
15. Stinchfield R, Govoni R, Frisch GR. Screening and assessment instruments. In: Grant JE, Potenza MN, eds. Pathological Gambling: A Clinical Guide to Treatment. Washington, DC: American Psychiatric Publishing; 2004.
16. Kim SW. Opioid antagonists in the treatment of impulse-control disorders. J Clin Psychiatry. 1998;59: 159-164.
17. Kim SW, Grant JE. An open naltrexone treatment study in pathological gambling disorder. Int Clin Psychopharmacol. 2001;16:285-289.
18. Kim SW, Grant JE, Adson DE, Shin YC. Double-blind naltrexone and placebo comparison study in the treatment of pathological gambling. Biol Psychiatry. 2001; 49:914-921.
19. Kim SW, Grant JE, Adson DE, Remmel RP. A preliminary report on possible naltrexone and nonsteroidal analgesic interactions. J Clin Psychopharmacol. 2001;21: 632-634.
20. Grant JE, Potenza MN, Hollander E, et al. A multicenter investigation of the opioid antagonist nalmefene in the treatment of pathological gambling. Am J Psychiatry. 2006;163:303-312.
21. Potenza MN, Leung HC, Blumberg HP, et al. An fMRI Stroop task study of ventromedial prefrontal cortical function in pathological gamblers. Am J Psychiatry. 2003;160:1990-1994.
22. Reuter J, Raedler T, Rose M, et al. Pathological gambling is linked to reduced activation of the mesolimbic reward system. Nature Neurosci. 2005;8:147-148.
23. Hollander E, Pallanti S, Allen A, et al. Does sustained-release lithium reduce impulsive gambling and affective instability versus placebo in pathological gamblers with bipolar spectrum disorders? Am J Psychiatry. 2005; 162:137-145.
24. Hodgins DC, Petry NM. Cognitive and behavioral treatments. In: Grant JE, Potenza MN, eds. Pathological Gambling: A Clinical Guide to Treatment. Washington, DC: American Psychiatric Publishing; 2004.
25. Echeburua E, Baez C, Fernandez-Montalvo J. Comparative effectiveness of three therapeutic modalities in psychological treatment of pathological gambling: long term outcome. Behav Cogn Psychother. 1996;24:51-72.
26. Petry NM, Ammerman Y, Bohl J, et al. Cognitive- behavioral therapy for pathological gamblers. J Consult Clin Psychol. 2006;74:555-567.
27. Dickerson M, Hinchy J, Legg England S. Minimal treatments and problem gamblers: a preliminary investigation. J Gambl Stud. 1990;6:87-102.
28. Hodgins DC, Currie SR, el-Guebaly N. Motivational enhancement and self-help treatments for problem gambling. J Consult Clin Psychol. 2001;69:50-57.
29. McConaghy N, Armstrong MS, Blaszczynski A, Allcock C. Controlled comparison of aversive therapy and imaginal desensitization in compulsive gambling. Br J Psychiatry. 1983;142:366-372.
30. McConaghy N, Blaszczynski A, Frankova A. Comparison of imaginal desensitization with other behavioral treatments of pathological gambling. A two- to nine-year follow-up. Br J Psychiatry. 1991;159:390-393.
31. Petry NM. Gamblers Anonymous and cognitive- behavioral therapies for pathological gamblers. J Gambl Stud. 2005,21:27-33.
32. Hollander E, Frenkel M, Decaria C, et al. Treatment of pathological gambling with clomipramine. Am J Psychiatry. 1992;149:710-711.
33. Hollander E, DeCaria CM, Finkell JN, et al. A randomized double-blind fluvoxamine/placebo crossover trial in pathological gambling. Biol Psychiatry. 2000;47: 813-817.
34. Blanco C, Petkova E, Ibanez A, Saiz-Ruiz J. A pilot placebo-controlled study of fluvoxamine for pathological gambling. Ann Clin Psychiatry. 2002;14:9-15.
35. Kim SW, Grant JE, Adson DE, et al. A double-blind placebo-controlled study of the efficacy and safety of paroxetine in the treatment of pathological gambling. J Clin Psychiatry. 2002;63:501-507.
36. Grant JE,Kim SW, Potenza MN, et al. Paroxetine treatment of pathological gambling: a multi-centre randomized controlled trial. Int Clin Psychopharmacol. 2003; 18:243-249.
37. Saiz-Ruiz J, Blanco C, Ibanez A, et al. Sertraline treatment of pathological gambling: a pilot study. J Clin Psychiatry. 2005;66:28-33.
38. Sylvain C, Ladouceur R, Boisvert JM. Cognitive and behavioral treatment of pathological gambling: a controlled study. J Consult Clin Psychol. 1997;65:727-732.
39. Ladouceur R, Sylvain C, Boutin C, et al. Cognitive treatment of pathological gambling. J Nerv Ment Dis. 2001;189:774-780.
40. Ladouceur R, Sylvain C, Boutin C, et al. Group therapy for pathological gamblers: a cognitive approach. Behav Res Ther. 2003;41:587-596.