Comorbidity of mental disorders and substance use: a brief guide for the primary care clinician
Problem gambling affects a large proportion of the population(426-429). Pathological gambling is listed in the DSM-IV as an impulse control disorder. These disorders are initially driven by pleasure, arousal and gratification.
Recurrent gambling behaviour causes significant disruptions in personal, family, social and vocational pursuits(426-429). People preoccupied with gambling may report that they are seeking action or an aroused, euphoric state, more so than the money itself(426, 428).
The features of pathological gambling are persistent. Over time, patients develop unpleasant feelings, physiological activation and dysphoria which are relieved when the compulsive behaviour is undertaken.
In a manner similar to substance use disorders, as the opportunities for gambling increase (e.g. easily accessible internet gambling can be likened to an increase in the 'supply' of a substance of misuse), so does the proportion of the population that develops gambling associated problems. Hence, gambling disorders and problem gambling continue to rise(426, 428-430).
Gambling addictions typically begin in early adolescence in males and later in life for females(428, 431). Males are significantly more likely to experience gambling-related problems than females(431-436).
Gambling is a complex phenomenon and may also be viewed as:
- An addiction:
- Tolerance can develop as people feel the need to spend increasing amounts of time and money in order to achieve the same level of excitement(426, 428).
- Withdrawal symptoms can occur on cessation of gambling and can resolve on recommencement of gambling(426, 428).
- Self medication theories of other mental disorders are also applied to gambling as they can be to chemical substances of addiction(426, 428).
- An affective disorder.
- A specific type of obsessive compulsive disorder.
The clinical course of gambling can be separated into three phases(428).
- Winning: Wins are greatly dramatised and losses are often forgotten about and even denied.
- Losing: The individual begins to gamble less cautiously in an attempt to win back lost finances and impending losses mount.
- Desperation: Gambling is frequently associated with criminality and legal problems in an attempt to gain more money to gamble(428, 439, 440). Debts grow, individuals may be prosecuted and guilt and depression set in leading to suicide.
- Treatment of problem gambling is often delayed due to cognitive distortions and denial(428).
- Few clinicians are skilled in the area of treatment of problem gambling(430).
- CBT, in particular, exposure therapy is effective at reducing problem gambling****(441-443).
- Motivational approaches are also effective when used in the treatment of problem gambling***(444).
- Pharmacological treatments for gambling are more effective than no treatment or placebo****(445).
- There are three broad classes of pharmacological agents used in an attempt to treat and manage problem gambling. These are antidepressants, opioid antagonists and mood stabilisers(438, 445, 446).
- There appears to be no significant difference in outcome between the three main classes of pharmacological interventions used****. However, it may be that some people with problem gambling with specific comorbidities may benefit more from certain drug interventions than others(445).
- SSRIs have been used when problem gambling is viewed as an OCD or an affective disorder(427).
- If there is any benefit, doses of SSRIs used in the treatment of gambling may need to be higher and require administration for longer periods of time before a response is observed(428, 447).
- The effect of SSRIs appear to be independent of underlying depressive symptoms***(447-450).
- Fluvoxamine***(448, 451) and citalopram*(450) have been shown to significantly improve overall gambling severity [reduced urge to gamble, reduced number of days gambled, reduced amount of money lost]. Results for paroxetine are mixed(449, 452).
- SSRIs are well tolerated when used for these indications(448, 453).
- Bupropion is also effective in reducing gambling scale scores as well as global functioning scale scores and is as effective as naltrexone in producing full responders to gambling treatment***(454).
- Note: Bupropion is not currently indicated for problem gambling in Australia.
Opioid antagonistsThe mechanism by which naltrexone may be effective in reducing problem gambling is by reducing the
urge to gamble****(454-456).
Mood stabilisers and anticonvulsants
- A study of small numbers of people using mood stabilisers for the treatment of gambling alone (valproate and lithium) has shown promise in reducing gambling. However, few conclusions are able to be drawn from this single study**(457).
- Topiramate is as effective in reducing gambling as fluvoxamine with even more individuals in full remission following topirimate than fluoxetine, as well as higher treatment compliance following topiramate***(458).
- Note: Topiramate is not currently indicated for problem gambling in Australia.