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David Baxter PhD

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Treatments for Pathological Gambling
By Michael Craig Miller, M.D., Harvard Medical School
September 21, 2011

Gambling has been around for thousands of years. The earliest known six-sided pair of dice, for example, dates back 5,000 years. Today rolling the dice is only one of many gambling activities available to people.

Most people are able to gamble without compromising their health or jobs. Sometimes, however ? and probably more often than we'd like to see ? gambling can cause terrible problems at home and at work. This is when it deserves treatment.

Many of the strategies for treating problem gambling are based on those used for substance use disorders. Although there is no consensus yet about which therapies are best, several have emerged as the most promising.

Problem Gambling as a Disorder
All states except Hawaii and Utah have some type of legalized gambling ? lottery games, slot parlors and casinos. National surveys in 1975 and 1998 found that 61% to 63% of Americans gambled at least once a year.

In the last decade, gambling has become a huge business on the Internet. Thousands of websites make it easy for gamblers to part with their money. Such easy access may make a gambling problem worse for certain people.

Problem gambling behavior was first mentioned in the medical literature in the early 1800s. The American Psychiatric Association first recognized it as a psychiatric disorder in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). It was called "pathological gambling."

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), a person has to have at least 5 of the following 10 symptoms to be diagnosed with pathological gambling. (This does not apply to a person having a manic episode.)
  • A preoccupation with gambling
  • Gambling with increasing amounts of money
  • Trying to control, decrease or stop gambling repeatedly without success
  • Feeling restless or irritable when trying to cut back on gambling
  • Gambling to escape problems or relieve anxiety, depression, or other dysphoric moods
  • Returning to gambling after losing money in order to recover the losses
  • Lying about extent of gambling and concealing behavior from family, friends, therapist and others
  • Having jeopardized or lost a significant relationship, job or opportunity because of gambling
  • Asking others for money to solve financial problems caused by gambling
  • Having stolen money, committed forgery, or engaged in other illegal acts to finance gambling
A revision to DSM-IV is in the works. The draft of DSM-V deletes the last symptom above. It also reduces the minimum number of symptoms from five to four. It also proposes that pathological gambling be reclassified as an addiction rather than an impulse control disorder. Here's why:
  • Pathological gambling and problems with drugs or alcohol often go together. While roughly 1% to 3% of people in the general population develop a pathological gambling disorder at some point in their lives, as many as 5% to 33% of people with substance use disorders will do so. One national survey found that pathological gamblers were five times as likely as people in the general population to be dependent on alcohol, and nearly seven times as likely to be dependent on nicotine.
  • Genetic studies suggest that people who develop pathological gambling or a substance use disorder are more likely than those in the general population to have particular gene types (alleles) associated with impulsive behavior.
  • Brain imaging studies have reported that both substance use disorders and pathological gambling create similar types of abnormal functioning in a nerve circuit involved in reward processing and decision making.
Self-Help and Psychological Approaches
These are the most used treatments for pathological gambling.
  • Gamblers Anonymous ? This 12-step program is modeled on Alcoholics Anonymous. It is probably the most common intervention for pathological gambling.

    There are more than 1,000 chapters of Gamblers Anonymous across the United States. Participants acknowledge they are powerless over their gambling behavior and try to recover with the help of other members and through reliance on a spiritual higher power.

    The small amount of published research on this topic suggests that Gamblers Anonymous may help patients abstain from gambling, especially when they attend meetings regularly or combine attendance with psychotherapy or other treatment.
  • Cognitive Behavioral Therapy (CBT) ? This is the most studied form of therapy for pathological gambling. The research supports its effectiveness. Patients learn how to recognize distorted thinking about gambling, change the way they think about gambling (cognitive restructuring), learn to identify and avoid gambling triggers, and develop other rewarding activities.
  • Motivational Interviewing ? This therapy focuses on getting the gambler ready to change and to commit to treatment. The therapist helps a patient to explore and resolve mixed feelings about giving up gambling, and to develop goals.
  • Brief Interventions ? Preliminary research suggests that even brief interventions may help people reduce gambling behavior.

    In one controlled study, investigators randomly assigned 117 college students to one of four arms: 10 minutes of advice about gambling, a single session of motivational enhancement therapy (a briefer form of motivational interviewing), one session of motivational enhancement therapy in addition to three sessions of CBT, or assessment of symptoms only (which served as the control).

    When compared with the control arm, all three interventions significantly decreased gambling behaviors and amount of money bet by the end of the six-week study.
Medication Options
The U. S. Food and Drug Administration has not approved any drugs specifically for treating pathological gambling. Unfortunately, the research suggests that medications are of limited help for gambling itself. But they can be useful to treat other illnesses, such as depression or anxiety, that may be at the root of gambling behavior or that result from gambling.
  • Opioid antagonists ? This class of drugs includes medications such as naltrexone (ReVia) and nalmefene (Revex). These are most often used to treat alcohol dependence. They block opioid receptors in the brain that fine-tune the brain's reward circuits, especially those involved in compulsive behavior and addiction. The idea for using these drugs is that they will help subdue the desire or craving that contributes to gambling behaviors. Several randomized controlled studies suggest such drugs are more effective than placebo.
  • Selective serotonin reuptake inhibitors (SSRIs) ? Researchers once thought that selective serotonin reuptake inhibitors (SSRIs) ? the most commonly prescribed class of antidepressants ? might treat pathological gambling by
    reducing impulsive behavior. Although preliminary studies were promising, larger and better-controlled studies have found that they offer no benefit over placebo in reducing gambling behaviors and urges. These drugs may be helpful as an addition to other therapies ? especially in improving depression or anxiety.
Several randomized controlled trials of mood stabilizers for pathological gambling have had mixed results. These drugs may be effective at reducing gambling urges in patients who also have bipolar disorder, mainly by reducing mania. Bupropion (Wellbutrin), an antidepressant that affects two neurotransmitters, dopamine and norepinephrine, has helped people to give up smoking. But it has not proven effective in pathological gambling. Researchers are investigating drugs that are not yet in the mainstream. So far, nothing can be recommended.

The Bottom Line
Uncontrolled gambling shares some biological features with addictions. But, like other complicated behaviors, gambling doesn't fit neatly into a particular category. The hope is that by seeing pathological gambling as an addiction (as proposed by the DSM-V), clinicians will be able to offer more helpful treatments.

More research may help us figure out what therapies are most effective, how long treatment should be, how long benefits last, and how to treat pathological gambling when it occurs with other psychiatric disorders.

If your gambling is creating problems in your life, you should probably see a mental health clinician. This person can help identify the problem and determine what other problems may need attention. This is especially important since ? as the research has taught us ? anyone suffering with pathological gambling is highly likely to have problems with depression, anxiety or another addiction.

Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.
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