Gambling Disorder

• According to the ICD-11, pathological gambling is conceptualised as:

  • Hazardous gambling: Escalating behaviour that increases the risk of harm to the individual or others (but harm may not yet have occurred)

  • Gambling disorder: Gambling leads to actual harm for the person or those close to them, and is characterised by:

    1. Impaired control (escalation of time, money, or venues).

    2. Increased priority given to gambling over other life areas.

    3. Persistence despite negative consequences.

Risk Factors

• Early age of onset (adolescence).

• Family history of gambling disorder.

• Mental health conditions: Mood disorders, anxiety, personality disorders, and substance use disorders often co-occur.

• Aboriginal or Torres Strait Islander origin.

• Parkinson disease (possibly due to dopamine agonist use, eg pramipexole).

Clinical Features and Harms

• Markers of escalation: Increasing frequency, higher bets, multiple venues, neglect of other life areas.

• Financial impacts: Mounting debts, inability to pay bills, or engaging in illegal activities (fraud/theft).

• Psychological distress: Comorbid depression, anxiety, substance misuse, and suicidal thoughts.

• Social consequences: Relationship conflict or breakdown, family violence, job loss.

Screening and Assessment

Routine Enquiry

• Given the high prevalence and significant stigma, it is recommended to:

  • Ask routinely about gambling in new patients.

  • Enquire opportunistically in ongoing patients, particularly if risk factors or suspicious presentations (eg financial stress, mood changes).

Simple 2-Item Screening

If a patient admits to gambling, consider:

1. “In the past 12 months, have you been preoccupied with gambling or had a strong urge to gamble?”

2. “In the past 12 months, have you often gambled longer, with more money, or more frequently than intended?”

A “yes” to either suggests potential hazardous or disordered gambling.

Adolescents (12–25 years) – Lie/Bet Questionnaire

1. “Have you ever had to lie to people important to you about how much you gambled?”

2. “Have you ever felt the need to bet more and more money?”

A “yes” to either warrants further assessment.

Further Evaluation

• Detailed history of gambling patterns (time, money, impulsivity).

• Psychosocial assessment (financial stress, relationship strain, mental health).

• Explore coexisting substance use or mental disorders.

• Use validated tools like the 9-item Problem Gambling Severity Index (PGSI) to grade severity.

Management Principles

1. Therapeutic Relationship

   • Non-judgemental, collaborative approach.

   • Provide hope by explaining that recovery is possible, although relapses can occur.

2. Early Referral

   • Encourage patients to use gambling support services (phone, online, or face-to-face).

   • Seek specialist advice (via state-based gambling hotlines or referral systems) in complex cases.

3. Long-Term Care

   • Ongoing follow-up is crucial to address relapse, comorbid mental health, and lifestyle factors.

Specific Management Strategies

Brief Interventions

• Motivational interviewing:

  • Elicit patient’s own concerns about gambling.

  • Explore ambivalence and strengthen motivation for change.

• Small but significant short-term reduction in gambling behaviour is documented.

• Brief interventions can act as a gateway to more intensive therapy.

Gambling Support Services

• Gambling hotlines and websites (e.g. Gambling Help Online, state-based helplines).

• They offer:

  • Assessment of gambling behaviour.

  • Practical support for money management and self-exclusion (“self-barring”) from venues or online gambling platforms.

  • Referrals to financial counselling, peer support groups (e.g. Gambler’s Anonymous), and specialist therapy.

Money Management

• Cancel credit cards or arrange finances to limit access to gambling funds.

• Banks may offer blocking of gambling transactions.

Self-Barring

• Individuals can voluntarily exclude themselves from specific gambling venues or online sites.

• Venues keep a photo register to help enforce exclusion.

Specialist Psychological Therapies

• Cognitive Behavioural Therapy (CBT) has the strongest evidence for reducing gambling frequency and improving outcomes.

  • Addresses distorted beliefs (illusion of control, gambler’s fallacy).

  • Teaches behavioural strategies:

    • Avoidance of triggers vs. graded exposure (recognising triggers, controlling urges).

• Motivational Enhancement Therapy and extended motivational interviewing approaches are also beneficial.

• Group CBT or individual sessions can be used, often through specialist gambling services.

Pharmacological Therapy

• No medication is TGA-approved for gambling disorder in Australia.

• Naltrexone (an opioid antagonist) may be used off-label by specialist services as an adjunct to therapy where other interventions have not succeeded.

• Evidence for pharmacotherapy remains limited.

Comorbidities

• Substance use disorders (particularly alcohol) commonly co-occur; treat concurrently.

• Mood and anxiety disorders (assess and manage, potentially with psychological therapy and/or medication if indicated).

• Parkinson disease: consider careful review of dopaminergic medications if gambling behaviours arise.

Self-Help Resources

1. Online Self-Assessments:

   • Gambling Help Online offers screening tools and immediate advice.

2. Mobile Applications:

   • The “Reset” app, “100 Day Challenge,” and “Gamble Less” help with motivational tracking and coping strategies.

3. Peer Support Groups:

   • Gambler’s Anonymous (in-person or online).

These can be first-step interventions for patients reluctant to engage in formal treatment or those preferring anonymity.

Special Populations

1. Aboriginal and Torres Strait Islander Peoples

   • Higher prevalence of gambling disorder.

   • Tailored, culturally sensitive strategies recommended.

2. Young People

   • May not identify gambling as a problem.

   • Lie/Bet questionnaire is useful for screening.

   • Address gaming vs. gambling overlap (loot boxes, micro-transactions).

3. Older Adults

   • Risks include social isolation, cognitive decline, and certain medications (eg dopamine agonists).

Follow-Up and Relapse Prevention

• Reinforce the therapeutic alliance; schedule regular reviews to monitor gambling behaviour, finances, and mental health.

• Address early warning signs of relapse: strong urges, changes in mood, or access to funds.

• Offer re-referral to support services or specialist therapy if the patient disengages or relapses.