Evidence-Based Reviews

How to recognize and treat the pathological gambler

Current Psychiatry. 2002 February;1(2):38-44

References

1. Shaffer HJ, Hall MN, Vander Bilt J. Estimating the prevalence of disordered gambling behavior in the United States and Canada: a research synthesis. Am J Public Health. 1999;89(9):1369-1376.

2. Grant JE, Kim SW. Demographic and clinical features of 131 adult pathological gamblers. J Clin Psychiatry. 2001;62(12):957-962.

3. Black DW, Moyer TM. Clinical features and psychiatric comorbidity of subjects with pathological gambling behavior. Psychiatric Serv. 1998;49(11):1434-1439.

4. Phillips DP, Welty WR, Smith MM. Elevated suicide levels associated with legalized gambling. Suicide Life Threat Behav. 1997;27(4):373-378.

5. American Psychiatric Association Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revision. Washington, DC: American Psychiatric Association, 2000.

6. Petry NM, Roll JM. A behavioral approach to understanding and treating pathological gambling. Semin Clin Neuropsychiatry. 2001;6(3):177-183.

7. Hollander E, Frenkel M, DeCaria C, et al. Treatment of pathological gambling with clomipramine. Am J Psychiatry. 1992;149(5):710-711.

8. Hollander E, DeCaria CM, Mari E, et al. Short-term single-blind fluvoxamine treatment of pathological gambling. Am J Psychiatry. 1998;155(12):1781-1783.

9. Hollander E, DeCaria CM, et al. A randomized double-blind fluvoxamine/placebo crossover trial in pathological gambling. Biol Psychiatry. 2000;47(9):813-817.

10. Blanco-Jerez C. A long-term, double-blind, placebo-controlled study of fluvoxamine for pathological gambling. Presented at the 152nd Annual Meeting of the American Psychiatric Association, Washington, DC, May 16-21, 1999 [abstract].

11. Zimmerman M, Breen R. An open-label study of citalopram in the treatment of pathological gambling. Presented at the 11th International Conference on Gambling and Risk Taking, Las Vegas, Nev, June 17-21, 2000 [abstract].

12. Kim SW, Grant JE, Shin YC, Toth JA, et al. A double-blind, placebo-controlled study of the efficacy and safety of paroxetine in the treatment of pathological gambling disorder. J Clin Psychiatry. 2002 (in press).

13. De la Gandara JJ. Fluoxetine: open-trial in pathological gambling. Presented at the 152 Annual Meeting of the American Psychiatric Association, Washington, DC, May 16-21, 1999 [abstract].

14. Kim SW, Grant JE, et al. Double-blind naltrexone and placebo comparison study in the treatment of pathological gambling. Biol Psychiatry. 2001;49(11):914-921.

15. Crockford DN, el-Guebaly N. Naltrexone in the treatment of pathological gambling and alcohol dependence. Can J Psychiatry. 1998;43(1):86.-

16. Kim SW, Grant JE. An open naltrexone treatment study of pathological gambling disorder. Int Clin Psychopharmacol. 2001;16(5):285-289.

17. Moskowitz JA. Lithium and lady luck: use of lithium carbonate in compulsive gambling. NY State J Med. 1980;80(5):785-788.

18. Haller R, Hinterhuber H. Treatment of pathological gambling with carbamazepine. Pharmacopsychiatry. 1994;27:129.-

19. Rugle L. The use of olanzapine in the treatment of video poker pathological gamblers. Presented at the conference titled, “The Comorbidity of Pathological Gambling: A Current Research Synthesis,” Dec 3 5, 2000, Las Vegas, Nev [abstract].

20. Ladoceur R, Sylvain C, Boutin C, et al. Cognitive treatment of pathological gambling. J Nerv Ment Dis. 2001;189(11):774-780.

21. Sylvain C, Ladouceur R, Boisvert JM. Cognitive and behavioral treatment of pathological gambling: a controlled study. J Consult Clin Psychol. 1997;65(5):727-732.

22. Carroll KM, Ball SA, Nich C, et al. Targeting behavioral therapies to enhance naltrexone treatment of opioid dependence. Arch Gen Psychiatry. 2001;58(8):755-761.

Ways to enhance compliance

Pathological gamblers, like those with bipolar disorder or substance dependence, often fail to comply with treatment.

Patients suffering from mania may not adhere to treatment with mood stabilizers in part because drug treatment may reduce positive or euphoric experiences. Similarly, the “high” associated with drug use often makes patients ambivalent about taking medications to remain abstinent.

In treating opioid dependence with naltrexone, a reward system has been incorporated in a contingency management fashion to substitute for drug-related reward and to enhance compliance with the medication.²² Recruitment of friends or family has also been used to enhance compliance with naltrexone in treating opioid dependence.²²

In the case of pathological gamblers, a self-rewarding system for each day of nongambling can be used (e.g., a favorite meal or a movie).⁶ Family members can help by increasing social or other activities that can take the patient’s mind off gambling, particularly at high-risk times (weekends and payday).⁶

How long should you treat?

No guidelines exist for recommended adequate treatment trials for pathological gambling. Available data, however, suggest that an adequate medication trial may require a relatively long duration (4 months or longer).

Many pathological gamblers have never discussed their difficulties, and this unquantifiable therapeutic response may resemble a medication response. Clinicians must monitor symptoms long enough to assess the difference between response to placebo and to medication.

The optimal duration of treatment and rates of relapse associated with discontinuation are not known. Many patients relapse upon discontinuation of medication, and long-term treatment, perhaps 2 to 3 years, may be warranted.

Treatment-resistant pathological gambling

It is not unusual to encounter patients who have had no response or only a partial response to treatment. Several approaches appear promising (Table 2):

If a patient has had an adequate trial of either an SRI or naltrexone as monotherapy, adding another agent appears to result in additional clinical improvement.
A patient who has failed to respond to either an SRI or naltrexone may be effectively treated with a mood stabilizer, either as monotherapy or as augmentation. Some patients with pathological gambling disorder, although not screening positive for a manic episode, exhibit symptoms consistent with cyclothymia or other subclinical cycling mood disorder. For such patients lithium, valproate, or another drug with putative mood stabilizing properties may represent an appropriate option.
The possibility of adding atypical antipsychotics to SRIs in the SRI-refractory pathological gambler warrants consideration.
Patients who only partially respond or fail to respond to medication alone are more likely to find relief with a combination of drug and cognitive-behavioral therapies, since this is considered the optimal treatment strategy for many psychiatric disorders.

Related resources

Gamblers Anonymous International Service Office. Los Angeles, Calif. http://www.gamblersanonymous.org.
National Research Council. Pathological Gambling: A Critical Review. Washington, DC: National Academy Press, 1990.
James K. National Gambling Impact Study Commission: Final Report to Congress 1999. http://www.ngisc.gov/reports/finrpt.html

Drug brand names

Carbamazepine • Tegretol
Citalopram • Celexa
Clomipramine • Anafranil
Fluoxetine• Prozac, Prozac Weekly
Fluvoxamine • Luvox
Naltrexone • ReVia
Olanzapine • Zyprexa
Paroxetine • Paxil
Valproic acid •Depakote

Disclosure

The authors report no affiliation or financial arrangement with any of the companies whose products are mentioned in this article.