Identifying problem gambling in patients

Problem gamblers have high rates of physical symptoms, which can cause them to be frequent primary care attendees.

Of the British adult population, 68 per cent will have gambled in the past 12 months and nearly 50 per cent in the past week.

Their most popular gambling activities include the National Lottery (57 per cent), scratch cards (20 per cent), horse races (17 per cent) and fruit or slot machines (14 per cent).1

For the majority, gambling is a harmless and pleasurable pastime, but for a minority it progresses to problem gambling or pathological gambling (gambling addiction).

Problem gambling is gambling to a degree that disrupts or damages personal, family or recreational pursuits.

The Diagnostic and Statistical Manual of Mental Disorders uses the term pathological gambling and defines it as persistent and recurrent maladaptive gambling behaviour, characterised by some of the following: preoccupation with gambling; an increasing need to gamble; inability to cut back or stop; 'chasing' losses; lying about gambling; and adverse social and financial consequences.2

The prevalence of problem gambling in the general population is around 0.6 per cent in Britain. It is more common in men but its prevalence among women and young people is on the rise.

Gambling disorders
The prevalence of gambling disorders in primary care attendees has been found to be as high as 6 per cent.

It is also argued that with increasing availability and access (such as internet gambling) the prevalence could increase.

Problem gamblers experience high rates of physical symptoms (cardiovascular, musculoskeletal, gastrointestinal and other non-specific psychosomatic symptoms) and psychiatric comorbidity (such as depression, anxiety and substance misuse, especially alcohol and tobacco).

Such indirect presentations can result in gambling disorders going unrecognised and unaddressed, resulting in numerous adverse consequences to the patient, family and society.

Brief and easy-to-use gambling screening tools are available for use in primary care; and effective treatments for problem gamblers are also available, which GPs could easily signpost patients to.

Screening for problem gambling
It is seldom that patients will present to their GP with gambling problems and we do not recommend that GPs routinely screen all their patients for gambling behaviours.

However, it would be worthwhile screening high-risk patients such as those presenting with psychosomatic symptoms, stress-related symptoms and those with psychiatric morbidity.

Patients suffering from depression, anxiety-spectrum disorders and substance misuse (especially alcohol and tobacco) all tend to have higher rates of co-existing problem gambling.

There are various questionnaires to screen for problem gambling.3 We recommend the Lie/Bet screen which has two questions: have you ever felt the need to bet more and more money and have you ever had to lie to people important to you about how much you gamble?

A positive response to either question identifies a pathological gambler. This screening tool has a sensitivity of 0.99 and a specificity of 0.91. Note that screening is only the initial step in the diagnostic process, and patients who screen positive should be referred on.

When assessing a problem gambler, always look out for psychiatric comorbidity. Depression is the most noted comorbidity, with prevalence figures between 50 and 75 per cent; suicidal attempts and ideation are also common among problem gamblers; and comorbid substance misuse is seen in up to 75 per cent.

Other co-existing psychiatric disorders include personality disorders, impulse control disorders, anxiety disorders and ADHD.

What if a patient screens positive?
Referral

If patients screen positive, we suggest they be referred on or are signposted to specialist services for further assessment and treatment.

Try the local addiction service and if this yields no success, patients could be signposted to GamCare and/or Gamblers Anonymous (see resources).

Patients can self-refer to both.

Treatment
GamCare is a non-governmental organisation and a charity that 'provides support, information and advice to anyone suffering through a gambling problem'.

Services include information, advice, support, telephone and netline support and counselling, face-to-face (one-to-one and in groups) counselling and psychotherapy.

Gamblers Anonymous is a self-help group modelled on Alcoholics Anonymous.

Pharmacological treatments
No drug is licensed for use in the UK for problem gambling. SSRIs (such as citalopram, fluvoxamine and paroxetine), naltrexone, mood stabilisers (such as lithium, carbamazepine and valproate) and atypical antipsychotics have all been found to be beneficial in short-term trials.

Given the very high rates of psychiatric comorbidity among problem gamblers, GPs should adequately treat these disorders.

Psychological treatments
Psychological interventions shown to be beneficial in problem gamblers include behavioural treatments, cognitive treatments and combined cognitive behavioural interventions, the third being the most commonly used.

Some CBT packages that have incorporated cognitive restructuring, problem-solving, social skills training and relapse prevention training have demonstrated good outcomes in the long term.

When treating gamblers note that no single treatment (or modality) has been shown to be superior to another and the best treatment outcomes are when patients are offered multi-modal and comprehensive treatment packages. Early interventions improve outcome.

Summary
Problem gambling is common in primary care settings, and often has indirect presentations.

We recommend that high-risk patients be screened for gambling disorders and given that brief screening tools are available, it seems feasible in general practice settings.

Our suggestion to the busy GP is to refer or signpost all patients who screen positive to specialist services.

  • Dr George is a consultant and senior research fellow in addiction psychiatry, Birmingham and Solihull Mental Health NHS Trust and Dr Jaisoorya is assistant professor of psychiatry, Co-operative Medical College, Kochi, India
Case Study

John is a 42-year-old married father of two. He had recently lost his job as the manager of a betting shop. He consulted his GP with symptoms of insomnia, non-specific back pain and mild depression. His drinking had escalated since he lost his job and he was referred to the local alcohol service, where his gambling problem was coincidentally uncovered.

He had lost his job, his marriage was shaky and he was £20,000 in debt because of his gambling. He was referred to GamCare where he received 12 sessions of cognitive behavioural therapy (CBT). He also self-referred to Gamblers Anonymous but dropped out after two sessions. Six months later, he stopped gambling but continued to seek support from GamCare's netline.

Resources

References

1. British Gambling Prevalence Survey (2007). Gambling Commission, UK.

2. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). Washington, DC: APA.

3. George S, Murali V. Pathological gambling: an overview of assessment and treatment. Advances in Psychiatric Treatment, 2005; 11: 450-6.

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