Jgi10812 721.732

GamblingAn Addictive Behavior with Health and Primary Care ImplicationsMarc N. Potenza, MD, PhD, David A. Fiellin, MD, George R. Heninger, MD, Bruce J. Rounsaville, MD, Carolyn M. Mazure, PhD Over the past several decades, and particularly during the last mendations for generalist physicians for identification of 10 to 15 years, there has been a rapid increase in the individuals with problem or pathological gambling, and accessibility of legalized gambling in the United States and also suggest interventions that can be used to assist these other parts of the world. Few studies have systematically individuals and their families. We conclude that more explored the relationships between patterns of gambling and research is needed to determine the extent to which and health status. Existing data support the notion that some manners in which routine questioning of gambling behav- gambling behaviors, particularly problem and pathologicalgambling, are associated with nongambling health problems.
iors in general medical settings may be warranted.
The purpose of this article is to provide a perspective on therelationship between gambling behaviors and substance usedisorders, review the data regarding health associations and screening and treatment options for problem and pathological gambling, and suggest a role for generalist physicians inassessing problem and pathological gambling. A rationale for Gambling can be defined as placing something of conceptualization of pathological gambling as an addictive value at risk in the hopes of gaining something of greater disorder and a model proposing stress as a possible mediating value. Traditional forms of gambling include wagering in factor in the relationship between gambling and health status casinos and on lotteries, horse and dog racing, card are presented. More research is needed to investigate directly games, and sporting events. Gambling is a widespread the biological and health correlates associated with specific activity, with 86% of the general adult population types of gambling behaviors and to define the role for general- endorsing lifetime participation in traditional forms of ist physicians in the prevention and treatment of problem andpathological gambling.
gambling and 52% of adults reporting participation inpast-year lottery gambling.3 KEY WORDS: addiction; pathological gambling; treatment; While the majority of people gamble, a minority meet the criteria for a gambling disorder. Pathological gambling (Table 1) represents the most severe pattern of excessive ordestructive gambling behavior and is the only gambling- related disorder for which there exist formal diagnostic growing role exists for the evaluation within primary criteria in the current formulation of the Diagnostic and care settings of patients for addictive disorders.1,2 Statistical Manual of the American Psychiatric Association Gambling is a very prevalent legalized activity that can be (DSM-IV-TR).4 Another term, problem gambling, is often considered a non±drug-related behavior with addictive used to describe less-severe but interfering patterns of potential. The relative importance of evaluating patients' excessive or destructive gambling, at times inclusive and at gambling behaviors in a general medical setting is in part others exclusive of pathological gambling (in this article, we dependent on the associated health risks and benefits. In this article, we discuss the rationale for viewing patho-logical gambling as an addiction and review the data on therelationship between gambling behaviors and health, including screening for and treatment of problem and Rates of gambling participation and problem and pathological gambling. We suggest basic current recom- pathological gambling have been increasing with the recentincrease in availability of legalized gambling options.3,6±8 Ameta-analysis of prevalence studies performed over the last Received from Yale University School of Medicine, New Haven, several decades found past-year and lifetime prevalence rates in adults of 1.1% and 1.6%, respectively, for Address correspondence and requests for reprints to Dr.
Potenza: Yale University School of Medicine, CMHC Room pathological gambling and an additional 2.8% and 3.8%, S-104, 34 Park St., New Haven, CT 06519 (e-mail: marc.
respectively, for problem gambling.7 Similar or slightly higher rates have been reported in primary care settings Potenza et al., Gambling, Health, and Primary Care Implications Table 1. Diagnostic Criteria for Pathological Gambling A. Persistent and recurrent maladaptive gambling behavior as indicated by 5 (or more) of the following: (1) Is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble) (2) Needs to gamble with increasing amounts of money in order to achieve the desired excitement (3) Has repeated unsuccessful efforts to control, cut back, or stop gambling (4) Is restless or irritable when attempting to cut down or stop gambling (5) Gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, (6) After losing money gambling, often returns another day to get even (``chasing'' after one's losses) (7) Lies to family members, therapist, or others to conceal the extent of involvement with gambling (8) Has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling (9) Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling (10) Relies on others to provide money to relieve a desperate financial situation caused by gambling B. The gambling behavior is not better accounted for by a manic episode Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000American Psychiatric Association.4 (6.2% in one study),9 and consistently higher rates have consequences.5,20 This feature is generally accompanied been observed in other specific populations, including by a diminished control over the behavior and an adolescents, individuals in correctional facilities, and anticipatory urge or craving state prior to the engagement people with mental health problems.6,10±12 in the behavior.20,22 Using these criteria, pathologicalgambling can be considered an addiction without exoge- Pathological Gambling: Addiction or Compulsion? Two prominent, non±mutually exclusive conceptuali- zations of pathological gambling classify the disorder as an impulse control disorder lying along an obsessive- As with substance use behaviors, there exists a compulsive spectrum or like an addiction to a drug.5,13,14 spectrum of gambling-related behaviors ranging from Although data exist to support each categorization,5,14,15 abstinence to recreational gambling to problem gambling large studies of probands with obsessive-compulsive dis- (similar to substance abuse) to pathological gambling order have generally not observed increased rates of (similar to substance dependence).5,23±25 Both commonal- pathological gambling16,17 nor have high rates of obsessive- ities and differences in the natural histories of gambling compulsive disorder been found in large samples of and substance use disorders have been reported.26±29 For problem or pathological gamblers.11 For example, the example, data from the few existing studies performed to St. Louis Epidemiologic Catchment Area (ECA) Study date describe a proportion of individuals with problematic found an odds ratio of 0.6 for obsessive-compulsive gambling or substance use behaviors believing they do not disorder in problem or pathological gamblers as com- have a gambling- or substance use±related problem and pared with nongamblers.11 Nonetheless, compulsive fea- reporting decreased participation in the destructive behav- tures have long been described as a core component of ior over time without formal intervention.26±29 Another addiction.18,19 In order to determine more precisely the proposed similarity is that of telescoping, a process used to relationship between ``behavioral'' addictions, such as describe the gender-specific nature of temporal progression pathological gambling, and drug addictions, current of substance use problems in men and women. Originally investigations into the underlying neurobiologies are described for alcohol dependence30 and more recently for cocaine and other forms of drug dependence,31,32 telescop- Addiction: Gambling and Substance Use Disorders ing refers to the phenomenon that women in general beginusing substances later in life, but once beginning, progress Beginning with DSM-III-R, there has been a shift in the to dependence more rapidly. Studies of callers to a definition of essential features of substance use disorders, gambling helpline33 and individuals in treatment for with a greater emphasis on lack of control and a lesser gambling problems34 both find results consistent with the emphasis on tolerance or physical dependence.19,21 Con- applicability of the telescoping phenomenon to individuals currently, there has been debate regarding the definition with gambling disorders. Analogously, typologies used to of addiction, and the extent to which disorders and describe individuals with alcohol dependence (e.g., Clonin- behaviors lacking habitual excessive or self-destructive ger's Types I and II) have been proposed to have appli- substance use (e.g., pathological gambling) should be cability to individuals with gambling problems.35,36 The classified as addictive.20 A core feature of addiction is the distinguishing characteristics of Type II alcoholics (e.g., continued engagement in a behavior despite adverse early-onset, male predominance) have been reported to have prognostic implications with regard to treatment legal complications related to drinking or gambling than outcome (e.g., treatment with ondansetron).37 Given the the groups with only gambling problems (2.1%) or sub- potential for these typologies in assisting with selection of stance use problems (16.4%).45 The extent to which other optimal treatments, more research is needed to substan- comorbid disorders such as antisocial personality disorder tiate their applicability to problem and pathological gamb- or the pathological gambling behaviors per se contribute to ling and directly investigate within these patient the adverse measures warrants additional investigation,35 populations the clinical implications.
and toward this goal the National Gambling Impact StudyCommission report recommended the inclusion of gam- bling components to the annual National Household High rates of comorbidity have been described between substance use and gambling disorders.11,12,38 Pathological gambling has been reported up to 2- to 10-fold more Common genetic factors have been reported to contrib- frequently in individuals with drug or alcohol use problems ute to pathological gambling and alcohol dependence in than in the general adult population.39±41 Conversely, high men, with 12% to 20% of the variance accounted for by rates of substance use disorders have been described in shared genetic factors.25,46 These estimates are similar to individuals with gambling problems.42,43 For example, a those reported for the shared genetic contributions for recent survey study of 2,638 adults in the United States marijuana and alcohol use disorders, and less than those found an odds ratio of 23.1 for current alcohol dependence for the shared genetic contributions for nicotine and with current gambling pathology.8 An even stronger alcohol use disorders.25 An even stronger genetic link in association between alcohol use and gambling disorders men between pathological gambling and antisocial person- was observed in the higher socioeconomic status group in ality and conduct disorders has been reported, with which having alcohol abuse or dependence increased the between 61% and 86% of the variance for these behaviors odds of being a problem or pathological gambler by a factor determined by shared genetic factors.46,47 of 66.8 While these odds ratios are of quite significant In addition to genetic commonalities, similar neural magnitude, the relatively small number of individuals with systems have been identified as contributing to drug- and pathological gambling in the study (36 subjects with gambling-related behaviors.20,22,48 One of the central path- current pathological gambling) lessens the stability of the ways implicated in substance dependence and rewarding estimates. Data from a survey of 2,016 adults in Ontario44 and reinforcing behaviors in general is the dopaminergic and the St. Louis ECA Study11 also demonstrate a strong mesocortical limbic system, with core neural connections association between alcohol use and gambling. For between the dopamine neurons in the ventral tegmental example, in the ECA study, problem gamblers, as com- area and their projection site in the nucleus accumbens.
pared with nongamblers, were found to have elevated odds Studies using a spinner wheel with various outcomes were ratios for alcohol use (7.2; 95% confidence interval [95% used to examine neural activities underlying the expect- CI], 2.3 to 23.0) and alcohol abuse/dependence (3.3; 95% ancy and experiencing of monetary rewards in humans, CI, 1.9 to 5.6). In addition, elevated rates of nicotine use and activations were observed in the ventral tegmental area (2.6; 95% CI, 1.6 to 4.4), and nicotine dependence (2.1; and its projection sites (including the nucleus accum- 95% CI, 1.1 to 3.8) were observed,11 consistent with bens), regions previously identified as being activated in findings from other large surveys.44 Disorders comorbid cocaine-dependent subjects following administration of with pathological gambling (e.g., antisocial personality cocaine.49,50 Early results from investigations of cue- disorder; see gambling and mental health section below) induced gambling urges in pathological gambling subjects are similar to those commonly observed in individuals have identified abnormal functioning of limbic circuitry with substance use disorders.14 Even higher rates of (including the anterior cingulate cortex) and frontal cortex, these comorbid disorders (e.g., nicotine dependence and regions previously found to be differentially activated in antisocial personality disorder) have been observed in cocaine-dependent subjects during exposure to cocaine substance-dependent patients with pathological gambling cues.22,51,52 Given the relatively early nature of research of as compared to those without.40 Individuals with both a biological investigations into the similarities and differences substance use disorder and pathological gambling have between substance use disorders and pathological been reported as being more severely impaired than those gambling,53 more research is needed to define more precisely with a substance use disorder alone. For example, more the shared and unique components of drug addictions and severe adverse measures of well-being (e.g., higher rates of ``behavioral'' addictions like pathological gambling.20 unemployment, illegal behaviors, and incarceration) wereobserved in cocaine-dependent subjects with pathological gambling as compared to those without.40 A survey of6,308 adult Texans found individuals with both gambling The role of the primary care physician in caring for and substance use problems to have higher rates (31.6%) of patients with substance use disorders has expanded due Potenza et al., Gambling, Health, and Primary Care Implications to an increased recognition of the medical basis and biographies, classical articles, dictionaries, directories, deleterious effects of addictive disorders, the development duplicate publications, editorials, festschrifts, historical of effective and efficient methods for screening, the articles, interviews, lectures, legal cases, letters, news, identification of promising new techniques for treatment, periodical indices, published errata, or retracted publica- and the potential of screening and brief intervention to tions were excluded, leaving 712 citations. MeSH and reduce substance use problems.54 Because of their textword searches for ``screening'' (MeSH = ``Mass screen- regular and long-term contact with patients, primary care ing''), ``treatment'' (MeSH = ``Therapeutics''), and ``health'' physicians are in a unique position to recognize patients were used in MEDLINE and combined in a ``Boolean Or'' and with addictive disorders, and to provide a menu of subsequently combined in a ``Boolean And'' to limit the set treatment options and monitor response to treatment in of MEDLINE citations to 227. All eligible citations were these patients. For instance, recent surveys indicate that appraised by 2 co-authors (MNP and DAF) to identify those roughly 40 million Americans drink in excess of recom- related to health status, screening, and treatment, and 127 mended amounts and approximately 70% of adults visit a publications were selected for further review.
physician once every 2 years.55 As currently exists forscreening and treatment of substance use disorders, the potential exists for primary care physicians to have animportant role in the assessment of adverse patterns of Increased rates of mental health disorders have been reported in problem and pathological gamblers.11 In the St.
It has been proposed that substance use disorders are Louis ECA study, problem and pathological gamblers as chronic medical illnesses and that treatment outcomes are compared with nongamblers were reported to have elevated similar to those in other chronic medical conditions, such odds ratios for major depression (3.3; 95% CI, 1.6 to 6.8), as diabetes, asthma, and hypertension.57 Given the schizophrenia (3.5; 95% CI, 1.3 to 9.7), phobias (2.3; 95% commonalities between pathological gambling and sub- CI, 1.2 to 4.3), somatization syndrome (3.0; 95% CI, 1.6 to stance use disorders reviewed above, we postulate that 5.8), and antisocial personality disorder (6.1; 95% CI, 3.2 pathological gambling may best be considered as a chronic to 11.6).11 In a study of 990 subjects recruited from drug medical condition. To evaluate this viewpoint, we con- treatment settings and the community, problem and ducted a review of the literature describing: 1) the pathological gambling behavior was found to follow tem- relationship between gambling and health; 2) screening porally the onset of antisocial personality disorder (100% of for problem and pathological gambling; and 3) treatment of cases), phobias (86% of cases), and nonstimulant drug dependences (56% to 68% of cases for nicotine, alcohol,and cannabis), and precede temporally cocaine or amphet- amine dependences (70% of cases).58 However, furtherresearch is needed to examine the temporal relationships The MEDLINE (1966 to present) database was searched between problem and pathological and comorbid disorders, using the MeSH (Medical Subject Heading) and textword particularly from studies of longitudinal or prospective ``gambling'' to identify candidate articles for review. Poten- design. In the St. Louis ECA study, recreational gamblers tial articles were examined to determine if they met the as compared with nongamblers were found to have an following eligibility criteria: 1) were published in peer- increased odds of having major depression (1.7; 95% CI, reviewed journals between 1966 and 2001; 2) were written 1.1 to 2.6), dysthymia (1.8; 95% CI, 1.0 to 3.0), somatiza- in English and involved humans, 3) discussed the health tion syndrome'' (1.7; 95% CI, 1.1 to 2.8), antisocial effects of gambling, 4) discussed screening strategies for personality disorder (2.3; 95% CI, 1.6 to 3.4), alcohol use problem or pathological gambling, and 5) discussed treat- (3.9; 95% CI, 2.4 to 6.3), alcohol abuse/dependence (1.9; ments for problem or pathological gambling. In an effort to 95% CI, 1.3 to 2.7), nicotine use (1.9; 95% CI, 1.6 to 2.4), minimize the impact of publication bias, abstracts were and nicotine dependence (1.3; 95% CI, 1.0 to 1.7).11 These reviewed from past-year gambling, psychiatry, and addic- and other data support the notion that gambling behaviors tion scientific conferences (e.g., National Conference on can be conceptualized along a continuous spectrum Problem Gambling, College on Problems of Drug Depen- ranging from nongambling to recreational to problem to dence, American Academy of Addiction Psychiatry, Amer- ican Psychiatric Association, Biological Psychiatry, World Despite the data finding adverse mental health Congress of Biological Psychiatry, and the American College measures in association with gambling, it has been of Neuropsychopharmacology). All eligible citations were suggested that gambling can also have beneficial appraised using a standardized process to identify those effects.60,61 Gambling involves risk evaluation and related to screening, treatment, and health status.
decision-making, and this procedure has relevance to many aspects of daily functioning.62,63 As such, participa-tion by children and adolescents in games of chance may The initial MEDLINE search yielded 781 citations.
be adaptive in allowing for practice of risk assessment and Citations that were listed as addresses, bibliographies, decision making, processes relevant to many adult experiences, particularly those involving competitive risk- For example, rates of past-year job loss were higher in both taking.64 Gambling in older age groups has been described problem and pathological gamblers (10.8% and 13.8%, as a form of adult play behavior, not only providing fun, respectively) than in low-risk or nongamblers (5.8% and excitement, and entertainment, but also possibly enhancing 5.5%, respectively).3 Rates of divorce were 39.5% and memory, problem solving ability, mathematical proficiency, 53.5% in problem and pathological gamblers, respectively, concentration, and coordination.60 Engaging in certain as compared with 29.8% in low-risk gamblers and 18.2% in forms of gambling activities may have desirable interper- nongamblers.3 Rates of having filed for bankruptcy were sonal social benefits; e.g., fraternization during bus trips to 10.3% and 19.2% in problem and pathological gamblers, casinos, particularly in older adult populations. However, respectively, and 5.5% and 4.2% in low-risk gamblers and the risks and benefits associated with gambling ventures nongamblers, respectively.3 Rates of arrest and incarcer- such as older adult casino trips have not been fully ation, respectively, were 32.3% and 21.4% in pathological investigated. Research to date has not assessed carefully gamblers, 36.3% and 10.4% in problem gamblers, 11.1% the risks of specific populations (such as older adults) with and 3.7% in low-risk gamblers, and 4.5% and 0.4% in regard to frequency of participation in specific gambling nongamblers.3 The cost of problem and pathological behaviors. In general, there exists a need for further gambling to the United States was $5 billion annually, research into the health consequences associated with with approximately one third of the costs attributable to frequencies of participation in specific forms of gambling, criminal justice costs.3 Individual lifetime impact costs particularly those forms in which large proportions of the were estimated at $10,550 for pathological gamblers and $5,130 for problem gamblers, respectively.3 These costs tosociety likely underestimate the true costs. For example, the costs attributed to the increased divorce rates werecalculated as the associated legal fee estimates and did not High rates of suicidal tendencies have been reported in take into account impact on spouse, children, and others clinical populations of pathological gamblers, with esti- affected through the divorce. Despite the widespread mates of attempted suicide in the range of 17% to 24%.65 prevalence of gambling, systematic studies have not yet Few structured investigations have directly investigated an investigated directly over time the beneficial and det- association between gambling and suicide. One study rimental effects associated with different levels of gambling reported that cities with established casinos have 2-fold behaviors.60 More research is needed to specify the nature (Atlantic City) or 4-fold (Las Vegas) the expected rates of of the relationships (e.g., cause and effect, timecourse) completed suicide for cities of similar demographic between different levels of gambling and measures of social composition.66 Available data were consistent with an increase from the expected rates following the introductionof casinos (data only available for Atlantic City).66 However,the interpretation of the data has been challenged, particularly given complexities of making population-based estimates in cities with high rates of noninhabitant Casino gambling is a widespread activity. It is estimated visitation. The St. Louis ECA study found no association that 29% of the general adult U.S. population has gambled between problem/pathological gambling and suicidal ten- at a casino within the last year, and this rate represents an dencies in the general population,11 and a controlled pilot approximately 3-fold increase from that of 10% in 1975.3 study of Marines found a negative correlation between a Despite the high rate, few investigations have systematically history of gambling participation and attempted or com- studied potential morbidity and mortality associated with pleted suicide.12,67 Taking the data together, the relation- casino gambling. One investigation found high rates of ship between different levels and types of gambling and second-hand smoke exposure in nonsmoking casino suicidal thoughts and behaviors is at present incompletely employees.68 Given the high rates of tobacco smoking in understood and warrants further investigation.
casino employees68 and nicotine dependence in recreational and problem and pathological gamblers,11 further invest-igation is warranted into the potential for tobacco-related Research has been performed to investigate the health risks in casinos and other gambling venues. A review relationship between problem and pathological gambling by the Chief Medical Examiner of 398 casino-related deaths and general measures of social well-being. Recently, the in Atlantic City from 1982 to 1986 found 83% to be sudden National Opinion Research Center surveyed 2,417 adults cardiac deaths. Although the authors concluded that and an additional 530 adult gambling venue patrons to ` gambling-related activities can be hazardous to one's determine the gambling-related attitudes and behaviors of health, especially among elderly cardiac patients,''69,70 the U.S. citizens.3 In addition to high rates of mental health extent to which the finding represents an elevation in risk for problems and poor general health, high rates of job loss, cardiac arrest remains to be investigated directly. However, divorce, bankruptcy, arrest, and incarceration were found given that the use of on-site automated external defibrilla- to be associated with problem and pathological gambling.
tors in casinos was found to enhance survival rates following Potenza et al., Gambling, Health, and Primary Care Implications cardiac arrest,71 the data suggest routine use of these Interventions for Problem and Pathological devices at casinos should be considered.
Structured behavioral therapies for the treatment of pathological gambling are beginning to be examined.82Imaginal desensitization, cognitive behavioral therapy, and A recent study suggests a biological mechanism for motivational enhancement have been shown to be effective cardiac arrests in casinos, one due to physiological in small- to moderate-sized controlled trials.83±86 Several of changes produced by sustained stress during gambling.72 these trials document improvement sustained in the groups Sustained stress and hypertension are generally accepted receiving the therapies for prolonged periods following risk factors for cardiac arrest and sudden cardiac treatment intervention; e.g., pathological gamblers receiv- death.73,74 Significant, persistent (over hours) increases ing cognitive behavioral therapy showing gains 6 and 12 in salivary cortisol and heart rate have been reported months following intervention and those receiving motiva- in habitual male gamblers during casino blackjack tional enhancement gains at 3 and 6 months.84±86 Despite gambling.72 Other investigations have similarly observed these encouraging results, the general applicability of these stress-related alterations related to gambling: 1) autonomic techniques awaits the completion of larger-scale, controlled arousal and immune system changes (alterations in T-cells trials, some of which are currently underway.82 As struc- and natural killer cells) in habitual male pachinko players tured, empirically-validated behavioral treatments emerge during gaming75; 2) higher levels of noradrenergic metabo- and become incorporated into professional mental health lites in males with pathological gambling76,77; and 3) higher care treatment settings, a role for primary care physicians epinephrine and cortisol levels and blood pressure differ- in identifying individuals with gambling problems and ences approaching statistical significance on days in which referring them for treatment will become increasingly gambling behavior was concentrated.78 These data raise important. Presently, information regarding professional the possibility that stress associated with gambling con- treatment options (e.g., for certified gambling counselors) tributes to high rates of poor mental and physical health can be obtained in the United States through the National reported by individuals with problem or pathological Council on Problem Gambling's gambling helpline (1-800- gambling3 and cardiac arrests in casinos. Further studies 522-4700) or website (http://www.ncpgambling.org).
are warranted to investigate directly the relationshipbetween stress and specific physical and mental health Interventions for Problem and Pathological problems in different populations of gamblers.
Interventions for Problem and Pathological There do not exist currently any medications that have been approved by the Food and Drug Administration for thetreatment of pathological gambling. Over the past several Although unstructured studies suggest comparable years, small- to moderate-sized, randomized, short-term, outcomes for gambling and substance use treatment placebo-controlled, and, with the exception of one study, programs,79 few controlled trials have been performed to flexible-dosing clinical trials have been performed to identify safe and effective treatments for pathological investigate the efficacy and tolerability of specific pharma- gambling.5 Gamblers Anonymous (GA), founded in 1957, cotherapies in the treatment of pathological gambling represents historically the most widely-available form of (Table 2).87,88 Of the medications tested, 2 selective help accessible for individuals with gambling problems.
serotonin reuptake inhibitors (SSRIs; fluvoxamine89 and Based on the 12-step philosophy originally used in paroxetine90), a m-opioid antagonist (naltrexone91), and a Alcoholics Anonymous, GA has chapters throughout the mood stabilizer (lithium92) have been demonstrated to be world and can be accessed by telephone (1-800-266-1908) superior to placebo in the short-term treatment of individ- or internet (http://www.gamblersanonymous.org).
uals with pathological gambling. Of these, the SSRIs Although GA has been helpful by report of many and naltrexone trials excluded individuals with significant participants, a structured investigation found that only co-occurring mental health/substance use disorders 8% of individuals entering GA were attending at 1 year, (excluding nicotine dependence) and improvement in with the majority discontinuing after 1 or 2 meetings.80 gambling symptomatology and overall clinical status was These results, which are similar to those from outcome observed in the absence of significant changes in measures studies of 12-step programs for individuals with of mood and anxiety.89±91 A trial of lithium included only substance use disorders, indicate that additional inter- bipolar spectrum subjects with pathological gambling, ventions will likely be needed to optimize outcome.81 In exclusive of psychotic disorders, and improvement was addition to self-help groups for problem and pathological observed in measures of gambling, mania, and general gamblers, similar options are available for friends, family clinical status.92 A placebo-controlled trial of the atypical members, or others affected by people with gambling antipsychotic drug olanzapine in the treatment of video problems through Gamanon (1-718-352-1671 or http:// poker pathological gamblers did not demonstrate improved efficacy over placebo, although differences in imp Placeb G-SAS wit hium imp Placeb PG-YB 9/10 rated o effect me urge Potenza et al., Gambling, Health, and Primary Care Implications between-group measures of gambling severity at the onset desire to have a general practitioner broach with them the of the trial complicate interpretations.93 topic of gambling behaviors, including problem or patho- With regard to pharmacological treatments, several logical gambling.97 General practitioners have generally important observations deserve mention. First, as with reported a willingness to intervene in this area, although other treatment trials with other subject groups, a placebo they also frequently reported not having the expertise to do effect has been observed, highlighting the importance of so.96,98 Referrals to self-help or professional treatment and monitoring for gambling-related thoughts and behaviors following up with patients regarding gambling-related over time following treatment initiation and limiting the behaviors and treatment could be of therapeutic benefit, interpretation of open-label studies.87,89 Second, the doses as well as referrals for family members possibly affected by a of SSRIs found to be effective were higher than those loved one's gambling. However, more research in family and generally used to treat major depression and similar to internal medicine settings is warranted to investigate the those used to treat obsessive-compulsive disorder. Third, direct clinical benefit of such interventions.
the doses of naltrexone were higher than those used to treat Although it appears premature to develop guidelines alcohol or opiate dependence and, in conjunction with regarding the precise role for generalist physicians in nonsteroidal anti-inflammatory drugs, were found to be prevention and treatment efforts related to problem and associated with high rates of liver function test abnormal- pathological gambling, it is likely that generalists will ities.94 Fourth, since many individuals with comorbid encounter individuals with gambling problems in their mental health/substance use disorders were excluded provision of clinical care. As such, efficient screening from the drug treatment trials with the SSRIs, naltrexone, methods for problematic gambling behaviors would help and, to some extent, lithium, the extent to which specific minimize potential burden. Identification efforts could be pharmacotherapies are helpful for patients who present assisted by the availability of valid and reliable brief- with pathological gambling and a co-occurring mental screening instruments such as the CAGE for alcohol use health/substance use disorder remains to be more fully disorders,2 and the need for such an instrument was determined. Although the initial results of the short-term, identified in a resource assessment study.96 Brief screening randomized, placebo-controlled drug treatment trials with instruments for problem and pathological gambling are in SSRIs, naltrexone, and lithium appear promising, more the stages of development and testing.97 One instrument, data, particularly from large-scale, randomized, placebo- the Lie-Bet Questionnaire, is a 2-question screen that was controlled, prospective studies, are needed to determine derived from the 10 inclusionary diagnostic criteria items more precisely the utility of specific drugs in the treatment for pathological gambling and found in 2 studies to have high specificity (85% and 91%) and sensitivity (100% and99%) in groups enriched for pathological gambling.99,100 Gambling Assessment and Referral in a Primary The 2 questions found to distinguish individuals with pathological gambling from those without were: 1) ``Haveyou ever had the need to gamble more and more money,'' Relatively few studies have surveyed primary care and 2) ``Have you ever had to lie to people important to you physicians and other health care affiliates to examine their about how much you gambled.''99 The extent to which the attitudes, behaviors, and perceived needs in the area of Lie-Bet questionnaire might efficiently screen for problem gambling disorders. A survey of 180 health care providers and pathological gamblers in general mental health and (nurses, physicians, social workers, and other allied health primary care settings requires more direct examination.
professionals) found 96% reporting knowledge of problem Another instrument (the EIGHT [Early Intervention Gam- and pathological gambling but only 30% inquiring about bling Health Test]; see also www.cgs.co.nz) (Table 3)97 was gambling problems when a patient presents with stress- specifically designed for use in a primary care setting. The related symptoms.95 A separate structured study collected EIGHT begins with a statement to help define which data from Canadian directors of health ministries, medical behaviors constitute gambling and progresses to inquire if school officials, and experts in the area of substance use patients have felt bad (depressed or guilty) about their and gambling disorders to examine office resource needs.96 gambling, withheld from friends or families information Lack of awareness, knowledge, education, and training in about the extent (monetary or temporal duration) of their the area of pathological gambling was cited as the most gambling, encountered criticism about their gambling, important challenge or barrier confronting physicians, and experienced financial problems due to their gambling, or indicated a need for enhanced physician training in felt that they might have a problem with gambling.97 The substance use and gambling disorders during all levels of EIGHT has been shown in preliminary studies in treatment medical training, including through Continuing Medical and forensic settings to have high rates of sensitivity and specificity with respect to more lengthy, standardized Although relatively few studies have investigated prob- screening instruments for problem and pathological lem and pathological gambling in primary care settings,5 gambling, e.g., the South Oaks Gambling Screen.101,102 those that have done so report relatively high rates (e.g., Specifically, in a study of 798 general practitioner patients, 6.2% in a family medicine setting).9 Patients have reported a the EIGHT was found to have sensitivities of 83% and Table 3. The Early Intervention Gambling Health Test (EIGHT) Most people enjoy gambling, whether it's Lotto, track racing, or at the casino. Sometimes, however, it can affect our health. To help us to check your health, please answer the questions below as truthfully as you are able from your own experience.
1. Sometimes I've felt depressed or anxious after a session of 2. Sometimes I've felt guilty about the way I gamble.
3. When I think about it, gambling has sometimes 4. Sometimes I've found it better not to tell others, especially my family, about the amount of time 5. I often find that when I stop gambling I've run out of money.
6. Often I get the urge to return to gambling to win back 7. Yes, I have received criticism about my gambling in the past.
8. Yes, I have tried to win money to pay debts.
75%, specificities of 92% and 95%, and positive predictive values of 38% and 53% for 3-point and 4-point cutoff Additional research is needed to better define the values, respectively (S. Sullivan, PhD, written communica- relationships between patterns of gambling and specific tion, January 23, 2001). Further studies are needed to forms of health and illness and the biological processes examine the generalizability of these initial findings and underlying the relationships. As more information becomes determine the utility of the EIGHT in specific primary care available regarding efficacious, well-tolerated, empirically validated treatments for pathological gambling, the role for Efforts employed by generalist physicians in the generalist physicians in prevention and treatment of prevention and treatment of problem and pathological problematic forms of gambling behaviors is likely to expand gambling could involve the regular assessment of patients'gambling histories, sensitive broaching of thetopic of the possible existence of gambling problems withthose patients suspected of engaging problematically in We would like to thank Dr. Sean Sullivan for permission to gambling, thoughtful motivating of individuals with reproduce the EIGHT, and Drs. Sean Sullivan, Suck Won Kim, gambling problems to seek treatment, and appropriate and Loreen Rugle for personal communications.
referring and monitoring of gambling-related treatment This research was supported in part by: 1) NIDA grants (see Appendix A).97 Clinicians should be aware of the K12-DA00366 (MNP) and K12-DA00167 (DAF); 2) the National high rates of problem and pathological gambling in Alliance for Research on Schizophrenia and Depression (MNP); specific groups; e.g., males, adolescents, and individuals 3) the National Center for Responsible Gaming (MNP); 4) the with histories of incarceration or psychiatric (including Donaghue Women's Health Investigator Program at Yale (MNP, substance use) disorders. Given the high rates of CMM); 5) the Robert Wood Johnson Foundation Generalist comorbidity between gambling and other psychiatric Physician Faculty Scholar Program (DAF); and, 6) the Veteran'sAdministration - New England Mental Illness Research Educa- disorders, screening of individuals with problem or pathological gambling for other psychiatric disorders(and vice versa) could help in improving diagnosis andproviding better treatment recommendations. Addition- ally, although gambling problems are more prevalent in 1. Weaver MF, Jarvis MAE, Schnoll SH. Role of the primary care men than women, clinicians should be cognizant of physician in problems of substance abuse. Arch Intern Med.
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Early Intervention Gambling Health Test (EIGHT) Gambling Screen Developed by Dr. Sean Sullivan for the Compulsive Gambling Society of NZ, Inc., and the Department of General Practice and Primary Health Care at the Auckland School of Medicine Affirmed 4 or more questions: Gambling is likely to be affecting patient's well-being and may even meet criteria for gambling . Indicate the test is not diagnostic, and is just indicative. (Some of the patient's answers may refer to the past and not the present, or may refer to isolated incidents. These would be false positives).
. Intervene (such as using the Motivational Interviewing steps).
. Ascertain level of patient's concern about their gamblingÐif they have concern, offer an assessment (using DSM-IV-TR criteria)Ð nb, it is not only gambling pathology that warrants intervention in this progressive behavior, while some DSM-IV-TR criteria arenot easily acknowledged because of guilt and shame.
. If their concern is low, offer information; offering of information is appropriate also where gambling pathology exists. Request their permission before offering informationÐthis will enhance acceptance.
. Framing the gambling as a health issue will reduce resistance.
. Offer supportÐguilt and shame may prevent their discussing their gambling with others.
. Ongoing monitoringÐproblem gambling is often progressive, with high suicidal ideation, depression, and anxiety in advanced cases (check extent of their answer to question one on the screen).
. `Sowing the seed'as a possible health matter may prevent progression of gambling behavior even if help is refused.
. Consider alcohol misuse, depression, anxiety, suicidal ideation.
. In offering the screen, emphasize that gambling is a common pastime but that sometimes it can cause health problems and problems sociallyÐthis frames the inquiry as health related rather than inquiry into lifestyle.
. The screen is not diagnostic and mistakes can be madeÐmore important is how the patient feels their gambling is affecting their lives; the screen results may assist them to focus on effects that gambling is having on themÐavoid terms like compulsive orpathological gambling, even if a subsequent assessment using DSM meets this criteria.
. Refer instead to the screen, suggesting that `gambling is causing you problems that may be affecting your health or well-being.' This avoids labeling and allows a discussion of an external (health) problemÐbeing the reason patients see their GPsÐandavoids focussing on personal behavior and circumventing emotions (guilt, self esteem) that the patient may often defend against.

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