Most pathological gamblers are fairly specific about their choice of gambling activity. Women tend to play slot machines and bingo, whereas men choose sporting events, blackjack, and cards. Both cite advertisements as a common trigger of their urges to gamble, although females are more likely to report that feeling bored or lonely may also trigger these urges.
Despite their preoccupation with gambling, many pathological gamblers function quite well, although often below their capacity. But others are severely debilitated—unable to function socially or occupationally.
In a series of 131 patients with pathological gambling disorder, 44% had lost all their savings, 24% had filed for bankruptcy, 23% had lost their homes or cars, and 15% had significant marital problems because of their gambling.2 Financial concerns may become so distressing that many pathological gamblers engage in illegal behavior, such as stealing, embezzlement, and writing bad checks.2
Table 1
Questions that can help diagnose pathological gambling
| Yes | No | Questions | |
|---|---|---|---|
| ○ | ○ | 1. Are you preoccupied with previous or future gambling experiences? That is, do you think about them a lot and wish you could think about them less? | |
| ○ | ○ | 2. Have you been unable to stop gambling or decrease the amount you gamble? | |
| ○ | ○ | 3. When you tried to stop or cut down, did you feel more irritable or anxious? | |
| ○ | ○ | 4. Has the amount you gamble increased to get the same sort of “high” or excitement? | |
| ○ | ○ | 5. Do you gamble as a way of escaping feelings of depression? | |
| ○ | ○ | 6. After you lose, do you go back in the next couple of days to try and win back the money? | |
| What effect has your gambling had on your life? | |||
| ○ | ○ | 7. Have you lied to others about your gambling? | |
| ○ | ○ | 8. Have you committed illegal acts as a result of gambling or lack of money? | |
| ○ | ○ | 9. Has gambling significantly interfered with school, job, or relationships? | |
| ○ | ○ | 10. Have you needed to borrow money because of gambling? | |
| ○ | ○ | 11. When you aren’t gambling, do you have urges to gamble? | |
| ○ | ○ | 12. If you have urges to gamble, do they preoccupy you or interfere with school, job, or relationships? | |
| adapted from DSM-IV criteria5 | |||
Table 2 Medical options for pathological gambling
Treatment response findings appear promising
Only a few controlled treatment studies of pathological gambling have been done, but the findings on the response to treatment appear promising. Thus far, the uses of serotonin reuptake inhibitors (SRIs), either clomipramine or selective serotonin reuptake inhibitors (SSRIs), the opioid antagonist naltrexone, mood stabilizers, and atypical neuroleptics have met with varying degrees of success. Additional strategies targeting urge and behavior reduction and mechanisms for coping with urges and behavior (e.g., cognitive behavioral therapies) may represent important adjunctive components.6
Because no medication is currently approved by the Food and Drug Administration (FDA) for treating pathological gambling, it is important to inform your patients of any “off-label” use of medications for this disorder, as well as the empirical basis for considering the medication.
The role of SRIs Response to SRIs usually means decreased thoughts about gambling, decreased gambling behavior, and improved social and occupational functioning. Patients may initially report feeling both less preoccupied with gambling and less anxious about having thoughts of gambling. For people who gamble because they are depressed and trying to escape loneliness or depressed feelings, SRIs are a reasonable first-line medication (Table 2).
As in the treatment of obsessive-compulsive disorder (OCD), dosages of SRIs required to treat pathological gambling symptoms appear to be higher than the average dosages required to treat depressive disorders. Some studies suggest that a significant initial response may be largely placebo. This means that improvement should be monitored for several months and that patients and clinicians need to be cautious about early improvement. An SRI should not be considered ineffective unless it has been tried for at least 10 to 12 weeks and the highest dose tolerated or recommended by the manufacturer has been reached.
The following SRIs have been used with varying degrees of success:
- Clomipramine has been shown effective in reducing gambling behavior with dosages between 125mg/d to 175mg/d.7
- Fluvoxamine has demonstrated mixed results in 3 studies of pathological gambling. Two studies supported its efficacy at an average dosage of 195mg/d to 207mg/d,8-9 but a third found that time spent gambling did not decrease when subjects took 200mg/d.10
- Citalopram has also shown some benefit as a possible treatment option in a single study.11
- Paroxetine, at dosages between 20mg/d and 60mg/d, was found to decrease thoughts of gambling and gambling behavior after approximately 6 to 8 weeks of treatment.12
- Fluoxetine (20mg/d) plus monthly supportive psychotherapy was found to improve gambling symptoms more than did supportive therapy alone.13