Pathological Gambling: Strategies for Successful Treatment

Professor of Psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA

First published in Psychiatry Weekly, Volume 2, Issue 41, on October 29, 2007

This interview was conducted on September 28, 2007 by Lonnie Stoltzfoos

Dr. Donald Black, who has studied pathological gambling and its treatment, describes the condition as “gambling that has gotten out of control.” Specifically, he says, “there are 10 symptoms of pathological gambling listed in the DSM-IV, and the patient has to demonstrate 5 or more. Typical symptoms include, preoccupation with gambling, needing to gamble increasing amounts of money in order to achieve the desired level of excitement, unsuccessful efforts to stop, or cut back, in gambling behavior, and so on. Also, the gambling behavior is not accounted for by a manic episode.”

The prevalence rate of pathological gambling, based on reliable information, is ~1%, according to Dr. Black. “Pathological gambling is currently classified as a disorder of impulse control in the DSM-IV,” he explains. “It’s controversial as to whether it’s related to obsessive-compulsive disorder; it probably is not. There are other conditions it appears to be related to, such as kleptomania, compulsive shopping, and other so-called compulsive disorders.”

Some of Dr. Black’s past and present research focuses on the familial aspect of pathological gambling. “Quite simply, gambling runs in families,” he explains. “It may be genetic to some extent, and in those families there are excessive numbers of cases of comorbid alcohol and drug dependence and anti-social behavior.” Pathological gambling rarely seems to surface as a solitary behavioral problem, then, according to Dr. Black: “The gambling is only one of many behavioral problems. My own observation is that—and the data shows this, too—if you examine a group of pathological gamblers, many, if not most, have a history of alcohol or drug abuse. Many of them also have a history of anti-social behaviors, criminal acts, etc.”

The Pleasure System and Gambling

“There are studies that point to certain brain regions as being involved with pathological gambling, or perhaps predisposing to gambling,” says Dr. Black. “For example, some investigators have suggested that this disorder may in part arise because of disturbances in dopamine transmission. Dopamine tends to serve the pleasure centers of the brain. These are interesting theories, but they have not proven useful in developing treatments even if they are correct theories. Drugs that disrupt the dopamine pathways have not worked very well in treating pathological gambling.”

Treatment

Treating pathological gambling is complicated by several factors, not least of which being the reluctance, or refusal, of many gamblers to seek treatment. Cognitive behavioral therapy (CBT), which has shown to be highly efficacious for treating this population, requires a commitment from the patient that Dr. Black says is particularly difficult to acquire from many pathological gamblers. Pharmacological treatment is also an option, as Dr. Black explains: “The most effective class of medications for treating pathological gambling is probably the opiate antagonists, namely naltrexone and nalmephene. Nalmephene is not available in the United States, but naltrexone is, and it is indicated for treating alcohol dependence. Many other medications have been studied, but the data are inconsistent. I have also studied bupropion, an antidepressant that works in part by manipulating the dopamine system. It was not shown to be effective for treating pathological gambling in a controlled study I released earlier this year. Now, one of the problems in treatment studies of pathological gambling is the high placebo-response rate. That is, regardless of what drug is prescribed, there will be high rates of improvement. Therefore, to demonstrate that something is actually effective becomes very difficult, because even a sugar pill will produce high rates of response.”

Dr. Black stresses that much more treatment research is needed. CBT, combined with what is termed “motivational interviewing,” is a valuable treatment, but is not yet widely available. “If the patient is willing to comply with these techniques—and many of them won’t—the patient will probably achieve around 70%–80% improvement, maybe higher,” says Dr. Black. “For pharmacologic treatment, the success rate is high as well, around 50%–80% improvement, but those figures are complicated by the high placebo-response rate. So, nearly everyone improves, but very few people actually stop gambling completely. They have improved in their gambling—they don’t gamble away as much money, they have better control of their urges—but they are not abstinent. Many critics look at that data and consider it to be unsuccessful because of the low abstinence rates. My goal as a clinician is to help the patient achieve abstinence, but at the end of treatment, maybe one-quarter to one-third have actually abstained, although many gamble less frequently. Thus, there’s an emerging concept of controlled gambling. That is, we don’t tell the patient what to do, we don’t tell them they must abstain, but we encourage them to reduce their gambling and get it under control.”

One way to improve clinicians’ response to gambling treatment might be to extend the training therapists receive on CBT methods, says Dr. Black. “As far as I can tell, most therapists were not specifically trained in CBT techniques, and most therapists have little to no experience with gamblers. So the number of therapists who have both experience working with gamblers, and good working knowledge of CBT, is quite small. Therapists also need training in motivational interviewing techniques that are proven to help pathological gamblers. Pathological gambling is widespread, so, at this time, how could we possibly begin to help a substantial number of patients with CBT?”

Future Research

“In the future, I believe we’ll have a much better handle on the genetics of pathological gambling, and perhaps we’ll even find some genes that correlate with gambling behavior,” says Dr. Black. “Also, I think we’ll be able to pin down more specific gambling subtypes. Each subtype may respond to a different type of treatment, so I think that’s important.”

“Further research is also needed to understand the course of outcome in pathological gambling. There has been very little research on this matter. We know that it typically develops in the 20s and 30s for most gamblers. We believe that it’s chronic for most, but do not know for sure. There may be some people who remit spontaneously with no treatment. Others go through periods of heavy gambling and get that under control on their own. That puts into question treatment studies, because if gamblers get better on their own without any treatment, how does that mesh with what we know from studies where 50%–60% of gamblers improved?”

“I think in the future we’ll probably have whole varieties of drugs that are effective to treat gambling, and I think that psychologists interested in CBT and other approaches will have a much more refined version of this therapy than we have now, with great potential for CBT and drug combination therapy. But the overriding issue is how we can encourage pathological gamblers to seek treatment, because so few do. If they don’t seek treatment, how can we help them?”

Dr. Black is a consultant to Forest and Jazz; receives grant/research support from Forest and Shire; and is on the speaker’s bureau of Pfizer.