Behavioural addictions. Problem gambling in general practice: How can we help?

“It is the child of avarice, the brother of inequity and father of mischief … it has been the ruin of many worthy families the loss of many a man’s honour and the cause of suicide.”

– George Washington, 1783

Gambling is defined as betting something of value on an event of uncertain outcome with the intent of winning something of value¹ (eg lotteries, poker machines, casino games, scratch cards, betting on sports/races, keno). Gambling is popular in Australia, with 53% of adults in New South Wales (NSW) gambling at least annually² and 39% of Australians gambling monthly.³ Gambling costs Australia $4.7 billion per year.⁴ Australians spend more money per person gambling than any other country and around twice as much as other Western countries.⁵

Classified as a behavioural addiction in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)⁶ and a disorder due to addictive behaviours in the International Classification of Diseases 11th Revision,⁷ a ‘gambling disorder’ is the result of specific behaviours that are rewarded and reinforced by repetition. Gambling disorders occur in roughly 0.5% of adults⁸ and are comparable to substance-use disorders.⁹ The term ‘problem gambling’ is more commonly used in Australia, and refers to a spectrum of mild, moderate to severe problems² and harms to oneself or others due to gambling.¹⁰ It does not require a clinical diagnosis and is based on self-report generally through validated screening tools. Approximately 1% of adults in Australia experience severe problem gambling,³ and 7.2% are at risk of developing problem gambling.¹¹ Problem gambling is characterised by continuous or periodic loss of control over gambling, increased gambling frequency and amounts wagered, preoccupation with and obtaining funds to gamble and continued gambling despite adverse consequences for the individual and/or those around them. Common harms include psychological distress, poor physical health, lack of sleep, stress, financial distress and relationship breakdown.¹⁰ Suicide rates among people experiencing problem gambling are 15-fold higher than in the general population.¹² More than 96% of those with a gambling disorder have at least one comorbid mental health issue, including depression, anxiety and personality disorders, and are more likely to use nicotine, alcohol and other drugs.¹³ For each person with problem gambling another six people (eg family, friends) will be adversely affected.¹⁴

People can cycle in and out of problem gambling^15,16 (Figure 1). On average, nine years elapse between experiencing problem gambling and seeking treatment. Problem gambling can also develop suddenly and quickly spiral out of control.¹⁶

Online/mobile technologies have made gambling constantly and immediately available, allowing it to become private, easily hidden and impulsive. Digital payments increase spending compared with cash.¹⁷ Internet gambling is threefold more likely to cause problems than venue-based gambling.¹⁸ COVID-19 accelerated the uptake of online gambling, and individuals already at-risk of problem gambling tended to intensify their online gambling and develop problems despite closed venues.^19,20

Aim

The aim of this paper is to enhance general practitioner (GP) awareness of problem gambling, its impact, general practice presentations, screening, effective treatment and referral options.

How problem gambling presents in general practice

Problem gambling may present as physical/mental health difficulties and may not be identified until significant harm has occurred. It may present in the following ways:¹⁰

• relationship difficulties
• stress and related health problems (eg insomnia, poor nutrition or overeating, cardiovascular issues, hypertension, headache/migraine, gastrointestinal symptoms)
• poor self-care
• emotional or psychological distress, including depression and anxiety
• suicidal ideation
• financial and legal problems
• problems with work or study, including lower productivity or job loss
• reduced engagement in activities previously enjoyed
• criminal activity, including fraud, theft or money borrowed from
  family/friends.

Dopamine agonist medication has a rare adverse effect of increasing the risk of problem gambling.

• women experiencing loneliness, grief or interpersonal trauma
• younger men reporting stress, anxiety and financial problems
• middle-aged men with substance use issues
• the unemployed and employees of gambling venues
• Aboriginal and Torres Strait Islander people
• people living in poverty
• culturally and linguistically diverse groups
• individuals with comorbid mental health and drug and alcohol problems.³

Why people do not seek help

Less than 10% of people with problem gambling seek specific professional support,^21,22 and most only at crisis point. This may be due to shame and stigma, lack of awareness or denial of the problem, limited knowledge of treatment options or feeling hopeless about changing their gambling. People may not see problem gambling as a health issue and not connect the physical and mental health symptoms they are experiencing with gambling. Nonetheless, GPs are the most preferred source for help with problem gambling.²³

Sometimes people, like Joan in the case study, are not ready to change their gambling. Ambivalence is normal. This may be the first time problem gambling has been considered or discussed with another person. As GPs, we can express concern and flag that effective treatment is available, we can assist and will follow up. Motivational interviewing techniques can promote understanding and resolve ambivalence, facilitating change.²⁴

How to ask about problem gambling

We can normalise asking about gambling by raising it as part of a lifestyle assessment, when taking a medical history or as part of a mental health assessment (Box 1).

Stigma and shame limit help seeking. Using non-stigmatising person-centred language (eg ‘problem gambling/harms’ rather than ‘problem gambler’ or ‘gambling addict’) can assist disclosure. Labelling the person as a ‘gambler’ or ‘addict’ defines the person by the problem, implying change is impossible.

Displaying posters and pamphlets in your waiting room will signal that it is part of our role as GPs to discuss gambling and that it may be asked about during consultations.

There are a number of validated screening tools to help people talk about their gambling.

• Lie/bet test:²⁵ This consists of two questions based on the DSM-5. One or more ‘yes’ answers suggests that help is needed.
  • Have you ever bet more than you intended to?
  • Have you lied to others to conceal the extent of your gambling?
• Brief Bio-Social Gambling Screen:²⁶ This consists of three questions based on the DSM-5. One or more ‘yes’ answers suggests that help is needed.
  • During the past 12 months, have you become restless, irritable or anxious when trying to stop/cut down on gambling?
  • During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?
  • During the past 12 months, did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends, welfare?
• Problem Gambling Severity Index (https://www.gamblinghelponline.org.au/take-a-step-forward/self-assessment/problem-gambling-severity-index-pgsi#/?_k=uv7n6a): This nine-question screening tool explores behaviour and harms. Responses are classified as no-risk, low-risk, moderate-risk or probable problem gambling.

Managing problem gambling

Psychological treatment has a strong evidence base and is effective for problem gambling.²⁷ Pharmacological options have little evidence of benefit.²⁸ Gambling-specific treatment services are freely available in every Australian state and territory and offer confidential, online and in-person treatment options without referral for people and their family members affected by gambling. There are many resources available for professionals (Box 2).

As GPs we can help our patients:

• understand that gambling-related concerns are common and can happen to anyone
• understand what motivates them to start a gambling session, what leads them to repeat the same cycle and how gambling adversely affects their life
• identify and challenge misinformed beliefs about gambling
• identify behavioural strategies to avoid gambling, reduce gambling and manage urges to gamble
• identify and manage high-risk situations for gambling
• manage the impacts of gambling on their life (eg relationships, daily functioning)
• change habits and patterns in contexts where they are more likely to experience an urge to gamble (eg gambling venues).

Support for people affected by a loved one’s gambling

Support for family members impacted by gambling is important. Gambling services can provide:

• information about gambling and gambling treatment
• guidance on how to start a conversation about gambling with loved ones and encourage them to seek professional help
• ways to support a loved one who is experiencing gambling harms
• information about relationship difficulties (eg trust, communication, boundaries)
• information for people to help them protect themselves against the impacts of their loved one’s gambling (eg financial, legal)
• mental health support (eg stress, anxiety, depression).

Where relevant, a collaborative shared-care approach between GPs and specialist gambling services may be useful for people with problem gambling and their families. People may benefit from referrals to multiple support services, including community mental health, relationship counselling, drug and alcohol services, financial counselling and legal aid.

Conclusion

Problem gambling is an important health issue causing harm to people who gamble, their families and communities. As GPs, we see people impacted by problem gambling in our general practices, but they may need prompting to volunteer this information. We can have real impact by asking about gambling. Although not everyone who gambles has a problem, early intervention can allow people to maintain low-risk gambling. For those who have developed problems, psychological treatment with experienced gambling counsellors is highly effective. As GPs we play an important role by asking and identifying, providing advice and support and helping to motivate change, then referring our patients and their families to address problem gambling. By understanding and recognising the symptoms, impacts and mechanisms of problem gambling, we can effectively assist our patients and increase the use of appropriate interventions, leading to better health and wellbeing outcomes.

Key points

• For every 20 adults in general practice, one person may have problem gambling.
• Gambling is often not the presenting complaint, so screening is essential to identify harms.
• Just ask, or use validated screening tools to help people talk about their gambling.
• Taking a non-judgmental collaborative approach and using resources is helpful.
• Gambling-specific psychological treatments are free, effective and available across Australia.