An overview of gambling disorder: from treatment approaches to risk factors

Introduction

Gambling disorder (GD) is a psychiatric condition featuring recurrent, maladaptive gambling behavior that leads to clinically significant distress. GD was reclassified recently into the “Substance-Related and Addictive Disorders” group of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)¹, a first for a behavioral addiction. The recategorization of GD was essentially due to the similarities between this clinical condition and substance use disorders. Numerous studies find analogous characteristics between the two in reference to diagnostic criteria, symptomatology, genetic vulnerabilities, high rates of comorbidity, and their association with biological markers and cognitive deficits^2,3. Furthermore, considering GD a behavioral addiction raises issues regarding the perceived dangerousness of the disorder as well as attitudes toward the chances of recovery and responsibility for creating and solving gambling-related problems⁴.

Although gambling represents a harmless activity for most people who gamble, patients with GD are often characterized by cognitive distortions, such as illusions of control, impulsive behavior, and dysfunctional personality traits (for example, high harm avoidance or high novelty seeking)⁵. Cognitive behavioral therapy (CBT) has become the most common psychological intervention for treating GD and has been demonstrated to be effective in reducing problem gambling behavior^6–9. Pharmacological treatments have also been employed in the treatment of GD, although the number of randomized controlled trials assessing the effectiveness of these interventions is limited^10–12. Several risk factors for developing GD have been identified, and prevention/harm-reduction efforts have provided mixed results^13,14. In this brief review, we will aim to provide a report on the state of the art of pharmacological and psychological treatments for GD. Risk factors for GD will also be covered, and potential future lines of research will be addressed.

Psychological treatment approaches

Despite pharmacological options to palliate GD symptomatology, several reviews of the literature point to psychological treatments as the most effective option for this disorder, and these are associated with significant improvements in both the short and the long term^15,16.

Recent findings on different therapeutic approaches for GD will be presented in this review. However, it should be noted that, despite the relevant research advances in psychiatric disorder management, the understanding of treatment options for GD remains limited¹⁷.

Pharmacological treatment

Currently, there is no drug approved for GD, although clinical practice guidelines usually have a section on the use of psychopharmacology in the disorder. For instance, the guideline for GD published in 2011 in Australia⁶⁶ accepted that naltrexone could be employed to reduce gambling severity in people with gambling problems.

The efficacy and utility of a number of medications have been studied in GD. However, many studies are open trials or reports on single or several cases, and the number of randomized, double-blind, placebo-controlled trials has been scarcer. Nonetheless, several excellent reviews^67–69 and meta-analyses^12,70 on the use of psychopharmacological drugs in GD have been published.

Three main classes of pharmacological approaches have been used on the grounds of clinical characteristics and neuropharmacological action: antidepressants, opioid antagonists, and mood stabilizers. The use of these drugs has been supported by the relationships that may be considered with some groups of mental disorders, mainly (a) compulsive-impulsive disorders; (b) substance use disorders given that GD may be considered a behavioral addiction, which is the view assumed by DSM-5; or (c) bipolar disorder, which has clinical features similar to those of GD. From a neuropharmacological perspective, the drugs that have been studied have a pharmacological action on opioid, serotonergic, dopaminergic, or glutamatergic neurotransmitter pathways.

Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), have been examined. However, only five randomized, double-blind, placebo-controlled trials with SSRIs (two with paroxetine^71,72, two with fluvoxamine^73,74, and one with sertraline⁷⁵) have been carried out, and only two SSRIs—paroxetine⁷¹ and fluvoxamine⁷³—were shown to be significantly superior to placebo. Another study with bupropion, a dopamine and noradrenaline reuptake inhibitor, did not show significant differences with placebo⁷⁶.

Risk factors

Adolescent gambling, despite being an illegal activity for minors to partake in, is relatively common⁷⁷. Studies have found that individuals under the age of 18 years often report taking part in a wide range of gambling activities, and young age is often reported as a common risk factor for developing GD^78,79. A recent meta-analysis quantified the effect size of risk factors in GD. These include 13 individual risk factors (alcohol use frequency, antisocial behaviors, depression, male gender, cannabis use, illicit drug use, impulsivity, number of gambling activities, problem gambling severity, sensation seeking, tobacco use, violence, and under-controlled temperament), one relationship risk factor (peer antisocial behaviors), one community risk factor (poor academic performance), one individual protective factor (socio-economic status), and two relationship protective factors (parent supervision and social problems)⁸⁰.

Although the prevalence of GD is higher in younger age groups, it is also a considerable problem for many older adults. A recent meta-analysis found that older individuals with GD were more likely to be single or divorced/separated⁸¹. In terms of reasons for engaging in gambling activities, their findings indicated that older adults gambled more in an effort to ameliorate negative emotional states because they may have limited access to other exciting activities or because they are unable to participate in activities that they were previously able to do and therefore they attempt to fill this gap with gambling. These factors, along with having a fixed income and limited prospects of future earnings, make them an extremely vulnerable group⁸².

It should be noted that, in terms of other psychological risk factors, impulsivity is a common feature in nearly all addictions, including GD^5,83–85. Personality traits are associated with GD, yet no single profile can encompass all gamblers. However, there is a degree of consensus that harm avoidance, low self-directedness, and difficulties with decision making and planning are, alongside impulsivity and sensation seeking, closely associated with the risk of developing a gambling problem⁶.

In comparison with the general population, individuals with GD have an increased risk for suicide. One study of treatment-seeking patients with GD reported that 32% of individuals had experienced suicidal ideation and that 17% had attempted suicide at least once⁸⁶, whereas another study found that 30.2% of patients reported one or more suicide attempts in the 12 months preceding GD treatment⁸⁷. Increased medical and psychiatric comorbidity leads to a significantly decreased quality of life because of GD, yet still only 10% of individuals with GD ever seek treatment for GD⁸⁸. However, some reports indicate that treatment-seeking rates are higher for patients with greater disorder severity⁸⁹.

Conclusions

The present review provides an understanding of current attempts at developing more inclusive GD treatment approaches. Psychological and, more specifically, cognitive behavioral approaches have provided satisfactory results, at least in the short to medium term^15,90. However, the combination of these programs with other therapeutic strategies, such as brief motivational interventions, mindfulness, or the use of new technologies, seems to be a promising approach in terms of cost-effectiveness. Likewise, innovation in the therapy of this disorder is important. Treatment studies suggest that a percentage of patients fail with the most traditional treatments; therefore, it is compulsory as clinicians and researchers to continue advancing in this field, informing patients of the potential risks and improving the results of the usual psychological therapies. On the other hand, from a pharmacological perspective, opiate antagonists have shown the most promising evidence as being effective medications for GD. Finally, in terms of outcome predictors, numerous individual and social risk factors have been identified in the scientific literature, and prevention efforts should be targeted to those most at risk⁸⁰.

Further studies are required that take differences in GD presentation into account in order to facilitate greater clinical applicability. Likewise, as suggested by some authors, psychiatric comorbidities, for example, are not usually included in studies, hindering the subsequent application of these therapeutic options to the clinical population⁹. In addition, owing especially to the emergence of new platforms that facilitate gambling access, GD is characterized by high heterogeneity and their features are constantly changing. Having updated prevention and treatment plans which take these factors into account and fit the clinical characteristics of each patient is a challenge that should be considered in greater depth in future research.