Assessing for problem gambling pays off.

If you treat adults, you've provided care to someone who has a gambling disorder--whether you knew it or not.

You won't find your clients volunteering information about their gambling behavior, although between 25 and 63 percent of pathological gamblers meet criteria for a lifetime substance abuse disorder (Crockford, 1998). Surveys of substance abusers in treatment reveal that from 9 to 30 percent meet criteria for gambling problems (Lesieur, 1986).

Data from multiple sources suggest that problem gambling poses a threat to health. Increased awareness and early intervention are the keys to reducing the personal, family and social costs of problem gambling. Counselors can play an integral role in this process by screening clients for gambling problems and readily providing useful referral resources such as the National Problem Gambling Helpline (800-522-4700).

Gambling is a widespread activity, with 70 percent of adults gambling at least once in the past year, and 85 percent sometime during their lifetime. While most people gamble, a small minority develops gambling problems. General-population studies have consistently found that the average national past-year prevalence rate in adults is 1 percent for pathological gambling and an additional 2 to 3 percent for problem gambling.

Pathological gambling represents the most severe pattern of excessive or destructive gambling behavior and is the only gambling-related disorder for which there are formal diagnostic criteria (see box). Problem gambling is a term that has different meanings depending on the context. Used colloquially, it describes any form of gambling that results in functional consequences. This article uses that meaning, except where noted otherwise.

Relationship to client health

Problem gambling affects not only gamblers' finances, but also their mental and physical well-being. Similar to other addictive behaviors, gambling is often considered a precipitating factor in a variety of health problems. The three broad categories of co-occurring conditions include mental health problems, chemical dependency problems and stress-related problems.

Problem gamblers have been identified as being at increased risk of dysthymia, major depression, antisocial personality disorder, phobias and chemical dependency. Studies identify problem gamblers as being at increased risk for cardiac arrest due to sustained stress and hypertension.

Treatment

Research concerning the treatment of problem gambling is early in its development, but has benefited from the body of evidence on other addictive and impulse disorders. Multiple pharmacological approaches to reduce problem gambling behaviors or craving have been evaluated in small pilot studies, but there are no federally approved medications yet.

Gamblers Anonymous (GA) is a self-help fellowship based on 12-Step principles. Dropout rates are very high among GA utilizers. Regular GA participation can be greatly facilitated by directive and supportive counselors, especially those familiar with 12-Step principles.

A number of psychosocial approaches have been used to treat gambling disorders: behavioral, cognitive-behavioral, psychodynamic, and addiction-based. While no best practice exists, most problem gambling treatment programs employ cognitive-behavioral and addiction-based change techniques.

As with other psychiatric disorders, a combination of treatment methods is often most useful, such as GA with professional psychosocial treatment. Comorbid chemical dependency, affective disorders, or anxiety disorders need to be treated and stabilized by health care professionals in conjunction with specialized behavioral treatment for the gambling disorder.

The screening question

Screening for gambling-related history and symptoms is justified because of the prevalence and potential severity of problem gambling, the potential to improve patient outcomes, and the low costs and low risk associated with asking about problem gambling. Simple asking and advising have been proven to be effective interventions in the allied field of alcohol abuse (WHO, 1996). Early intervention of problem gambling through screening and motivating help-seeking may reduce the harm of problem gambling on individuals and their families.

Given that problem gambling has a high rate of co-occurrence with substance abuse and mental health problems, counselors dealing with these clients are strongly advised to screen for gambling problems. If patients present with symptoms that could be related to sustained stress, you should include questions on gambling when you assess for behavioral conditions.

If gambling is a frequent activity, then consider utilizing a simple screening tool, such as the Lie-Bet Questionnaire (Johnson et al., 1988). This questionnaire is valid and reliable for ruling out pathological gambling behaviors. These are the Lie-Bet questions:

1) Have you ever felt the need to bet more and more money?

2) Have you ever had to lie to people important to you about how much you gambled?

If a patient answers yes to one or both of the questions on the Lie-Bet Questionnaire, further assessment is indicated. Either make an assessment, based on the clinical interview, using the DSM-IV criteria provided in the box, or provide self-assessments such as the SOGS or NODS (both instruments can be found by logging on to www.npgaw.org).

Patients suspected of manifesting a gambling problem should be encouraged to seek specialized treatment and be provided with a referral for such services. There is emerging evidence that providing problem gambling services reduces relapse among dually addicted clients.

Resources for clinicians

In addition to resources available on www.npgaw.org, the National Council on Problem Gambling operates a 24-hour confidential helpline (800-522-4700). Operators can assist callers in locating certified gambling treatment providers.

Free resources for health care providers are offered as part of National Problem Gambling Awareness Week (NPGAW), an annual event that takes place in March. NPGAW is a grassroots effort to educate health care professionals about problem gambling, as well as to raise public awareness that hope and help are available for people with gambling problems.

10 Questions About Gambling Behavior

 1. You have often gambled longer than you had planned.
 2. You have often gambled until your last dollar was gone.
 3. Thoughts of gambling have caused you to lose sleep.
 4. You have used your income or savings to gamble while letting bills
    go unpaid.
 5. You have made repeated, unsuccessful attempts to stop gambling.
 6. You have broken the law or considered breaking the law to finance
    your gambling.
 7. You have borrowed money to finance your gambling.
 8. You have felt depressed or suicidal because of your gambling losses.
 9. You have been remorseful after gambling.
10. You have gambled to get money to meet your financial obligations.

Those who answer "yes" to five or more of these are classified as probable pathological gamblers, while those who answer "yes" to one to four of these are considered probable problem gamblers.

Those who answer "yes" to any of these questions or know someone who does are urged to consider seeking assistance from a professional regarding this gambling behavior by calling the confidential National Problem Gambling Helpline Network (800-522-4700).

References

Crockford, D., el-Guebaly, N. (1998). Psychiatric comorbidity in pathological gambling: A critical review. Canadian Journal of Psychiatry, 43: 43-50

Lesieur, H., Blume, S., Zoppa, R. (1986). Alcoholism, drug abuse and gambling. Alcoholism: Clinical and Experimental Research, 10: 33-38

Johnson, E.E., Hamer, R., Nora, R.M., Tan, B., Eistenstein, N., & Englehart, C. (1988). The lie/bet questionnaire for screening pathological gamblers. Psychological Reports, 80, 83-88

WHO Brief Intervention Study Group. (1996). A cross-national trial of brief interventions with heavy drinkers. American Journal of Public Health, 86, 948-955

KeithWhyte is executive director of the National Council on Problem Gambling.