Gambling Addiction: What Every Mental Health Professional Should Know

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Gambling Addiction What Every Mental Health
Professional Should Know

• Timothy Fong MD
• UCLA Gambling Studies Program
• UCLA Extension
• February 8, 2008

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Financial Disclosures

• Speaker Bureau Research Support
• Reckitt Benckiser NIDA
• Pfizer OPG (California)
• Cephalon Ortho-McNeil
• Forest Somaxon
• Ortho McNeil

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Availability of Gambling, 1975
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Availability of Gambling, 1999
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Gambling Nation

• 600 billion wagered annually
• Revenue Comparisons (2005)
• Gambling (Legal) 83 Billion per year
• DVDs 22 Billion per year
• Cigarettes 19 Billion per year
• NIH Annual Budget 30 Billion per year
• (American Gaming Association, CDC, Hollywood
  Reporter)

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The California Scene

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Types of Gambling In California

• State lottery (1985)
• Card clubs (97)
• 1,500 tables
• Indian casinos (61)
• (San Diego, Palm Springs, Northern California)
• Horseracing
• Proximity of Las Vegas, Reno

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Background

• Exponential growth of legalized gambling
• 2.5 billion (1997) to 13 billion (2003)
• Horse race wagering (4 billion)
• Lottery (3 billion)
• Card rooms (1 billion)
• Tribal casinos (5 billion)
• 60 Californians gambled last year

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Recent Events

• Crackdown on Internet Gambling (2006)
• New Indian Compacts
• 20,000 slot machines!
• Asian Expansion (Macau, Singapore)
• Little noise from federal level
• NIH funds (2007)
• Gambling 36
• Methamphetamine 199

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World Series of Poker 2007

• 6,400 Entrants
• 10,000 Buy-In
• First Prize
• 8.25 Million
• 30-day coverage on ESPN
• Winner - PhD

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The Range of Gambling Behavior

• Social Gambler (85 of the population)
• Problem Gambler (5-6)
• Pathological Gambler (1)
• (or Compulsive Gambling, Gambling Addict)

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Pathological Gambling DSM-IV Criteria

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Consequences ofPathological Gambling
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Similarities to Addictions

• Loss of control
• Preoccupation, urges, pathological wanting
• Negative impact on major areas of life
• Major impacts on mood. Judgment and insight
• Tolerance/ Withdrawal

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Differences from Addictions

• No toxicology test to diagnosis it easier to
  hide
• Behaviors are not due to drug effects (thus,
  makes it more open to shame/guilt)
• Greater uncertainty of outcome (i.e. anything can
  happen)
• Ego Dystonic or Ego Syntonic
• Mix of impulsive and compulsive

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Economic Burden of Pathological Gambling
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Prevalence RatesGeneral Population

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California Prevalence Study (2005)

• n7,121 respondents, 18 years and older
• Problem gambling 2.2
• Pathological gambling 1.5
• 1,000,000 problem/pathological cases
• Highest Risk African-Americans, Disabled,
  Unemployed

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Screening Assessment Diagnosis
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Screening Tools

• South Oaks Gambling Screen
• Lie/Bet Questionnaire
• Have you lied about your gambling?
• Have you ever increased bets to get same sense
  of action?
• No objective tests

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South Oaks Gambling Screen (SOGS)

• Identifies patients with gambling problems
• Self-Scored greater than 5 PG
• 16 items
• 5-10 minutes
• Psychometrically solid
• Lesieur, Blume and Zoppa, 1986

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When to screen

• Intake
• Waiting room
• As homework
• Annually
• Families and friends

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Improving Assessment

• Standardized instruments (SCID-PG)
• Focus on impact, not frequency
• Legal - Family Functioning
• Financial - Productivity
• Social - Mental health
• Physical
• 2 rule

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Assessment Tips

• Note shame, secrecy, stigma
• Collateral information a MUST
• Can take several sessions to get the picture
• Ask for evidence (statements)

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Clinical Questions

• How much time do you spend on gambling?
• What is the meaning of gambling?
• Do you plan trips only to where gambling is
  available?
• Do you gamble alone?
• What kind of problems has gambling caused you?

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Differential Diagnosis

• Mood Disorders, esp. Bipolar
• Manic episodes
• Anxiety Disorders
• ADHD
• Substance Use Disorders
• Timelines and history are the essential

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Etiology
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Biological Causes

• Genetic contributions
• Medical Conditions
• Medications / Toxic Exposures
• Neurochemicals
• Neuroanatomy
• Neurofunctioning

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Neurochemicals

• Serotonin
• Dopamine
• Norepinephrine

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Neurotransmitters in Pathological Gambling
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Neuroanatomy

• Prefrontal Cortex (OFC, DLPFC, VMPFC)
• Assessment of reward value, central evaluator,
  brakes
• Somatic-marker hypothesis
• Similar performances as those with drug abuse,
  ADHD,
• impaired on Gambling Task, Delay Discounting
  Tasks, Go-No-Go Tasks,

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Neurobiology of PG(Neuroanatomy)

• Potenzas Imaging Studies (PG vs Normals)
• Decreased activity in
• Left ventromedial PFC (Decision-making)
• Orbitofrontal cortex (processing of rewards,
  dealing with uncertainty, inhibiting responses)
• Anterior Cingulate (Decision-making)
• Ventral striatum (NA, Limbic system)

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Risk Factors Psychological

• Exaggerated illusion of control
• Reason for gambling escape
• High levels of impulsivity
• aggressive or hyperactivity NOT a RF

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Psychological Causes

• Positive Reinforcement
• Negative Reinforcement
• Tension-Reduction / Affective Regulation
• Cognitive Distortions
• Vicarious Learning
• Personality traits
• Impulsivity, reward-seeking, loss aversion

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Social Causes

• Accessibility
• Acceptability
• Peer behaviors
• Availability of treatment and prevention
• Societal portrayal

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Risk Factors Social

• Parents that gamble or have substance abuse
• Gambling peers
• Unstructured time
• Lack of parental control
• Access to money

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Protective Factors

• Almost no research
• Clinically,
• Empathy
• Capacity for honesty
• Social capital
• Problem solving skills
• Mindfulness

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Vulnerable Populations
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Vulnerable Populations

• Incarcerated
• 1 pastime is gambling
• Substance Use Disorders
• 10x risk for PG
• Lower SES
• Problems develop sooner

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Vulnerable Populations

• Adolescents
• 5-6 meet criteria
• Elderly
• Harder to recoup financial losses
• Casino Workers
• Chicken or the egg?

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How much do adolescents gamble?

• 60-90 have gambled
• Similar, internationally
• Strong pop culture influences
• No monitoring system
• Societal, parental acceptance

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Reasons for gambling

• Win money
• Social activity
• Excitement
• Competition
• Fantasy
• Family members

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Asians and Gambling

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History of Gambling in China

• 3,000 B.C.
• Many games invented
• All segments of society
• Officials of government
• Gambling as a profession
• Gambling associated with secret society,
  corruption and drugs

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History of Gambling and Asia

• Different story in each country
• Forbidden, ambivalent, promoted
• Unique definitions of gambling
• Mahjong, lottery, stocks vs. casinos
• Common thread gambling always part of the
  social dialogue

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Cultural factors that promote gambling

• Acceptable way to make money
• Inquire about ones destiny
• Honoring the Gods
• Losses are sacrifice
• Equate gambling with self-worth and ability to
  move up classes

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Cultural factors that promote gambling

• Emphasis on numbers that have power over life
  events
• Heavy peer involvement
• Gambling is family entertainment
• Gambling as a rite of passage
• Superstitions

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Asian Gambling Expansion

• Vietnam Ho Chi Minh (2009)
• Singapore Two casinos (2009)
• Phillipines Manila Bay
• Hong Kong Horse-racing, lottery,
• Taiwan / Thailand / Japan Considering
• China Not on the mainland

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Asians in America
US Census 2000
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Asians in California

• 12 of Californians are AAPIs
• 4 million
• Highest rate of growth
• 1.2 million Los Angeles County
• State population 35 million
• (2000 Census)

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Asians in California

• Largest Asian Groups
• Filipino
• Chinese
• Vietnamese
• Korean
• Asian Indian
• Japanese
• Fastest growing
• Asian Indian, Vietnamese, Hmong

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Asian Communities

• Monterey Park (64)
• Cerritos (61)
• Rowland Heights (52)
• San Gabriel (51)
• San Marino (50)
• Alhambra (48)

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Background Data

• NICOS (SF)
• 70 identified gambling as number one social
  concern (1999)
• 15 problem gamblers
• 21 pathological gamblers

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Asians and Gambling(Los Angeles)

• 30-40 of casino clientele are AAPIs
• Casinos market toward AAPIs
• Significant percentage of casino revenue comes
  from local AAPI residents
• Social activity of choice

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Consequences of PG on APIs

• 20 of child neglect cases
• (Santa Clara)
• 30 of API DV cases (SF Chinatown)
• Numerous bankruptcy reports from Monterey Park
• Recent cases of family violence
• (April 2006)

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Case Examples Bong Joo Lee (April 2006)

• Fontana, California
• Unemployed
• 200,000 in gambling debt.
• Recent separation
• Family discord over gambling
• Past history of assaulting wife
• End Result Murder-Suicide

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Case Example David Lam (2007)

• Casino Employee
• Wife seen, not heard
• Gambling debt (gt50,000) bankruptcy
• Marital discord
• Lam heads to Singapore 9/18/2005
• Body found 9/23/2005
• Caught in 11/2007, w/family in Indonesia

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Impact of Gambling on Los Angeles Asian
Communities

• To understand the impact of problem gambling on
  AAPIs.
• To understand cultural influences which will
  inform prevention and treatment
• (Funded by UCLA in LA)

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Surveys
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Prevalence Survey

• 180 surveys collected over 3 days at Commerce
  Casino (March 2006)
• SOGS
• NODS
• UCLA Gambling Survey
• Convenience Sampling
• 5 Starbucks reimbursement

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Prevalence Survey

• Objectives
• What is the rate of PG among casino patrons?
• What is the rate of PG of AAPIs vs. Non-AAPIs?

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Results
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Results
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Results
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Conclusions

• High rates of PG inside a casino
• How many require treatment?
• No obvious ethnic differences BUT APIs will have
  more PGs
• Replication needed
• Secondary analysis underway (gender, time, health
  status)

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Treatment Strategies
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Treatment Approaches to Pathological Gambling

• Medications
• Psychotherapy
• Gamblers Anonymous
• Family Therapy
• Brief Interventions
• Prevention

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How effective is gambling treatment?

• 30-60 abstinence at 6-12 months after completion
  of treatment
• Similar rates as compared to heart disease,
  addictions, diabetes
• (Stinchfield 2001)

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Principles of Pharmacotherapy

• Target urges/impulses
• Treat co-occurring disorder
• Medications lay the groundwork for psychosocial
  therapies.
• No magic bullets
• No FDA-approved meds

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Pharmacotherapy

• Antidepressants
• SSRIs
• OCD-Subtype, co-occurring anxiety
• Reduce preoccupation?
• Bupropion
• Attention enhancer?
• Negative trial
• (Hollander, Grant, Black)

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Pharmacotherapy

• Mood Stabilizers
• Valproic Acid, Lithium, Carbamazepine
• Co-occurring bipolar disorder
• Target impulsivity, mood lability
• (Hollander, Pallanti)

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Pharmacotherapy

• Opiate Antagonists
• Naltrexone (PO) and Nalmefene
• Block urges, cravings
• Reduce euphoria
• SE dysphoria, LFTs
• No research on IM naltrexone

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Case Reports
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Open Label
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Single Blind
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Double-blind, Placebo-Controlled
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Latest Trials
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Pharmacotherapy Future Directions

• Topiramate Impulsivity
• Modafanil Neurocognitive enhancer
• Amphetamines Co-occurring ADHD
• N-Acetyl CysteineImproved impulse control

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Psychotherapy

• Cognitive Behavioral
• Motivational
• Psychodynamic
• Psychoeducational
• Family Therapy
• Behavioral

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Cognitive Behavioral Therapy

• Rework erroneous expectations (e.g. gambling
  will solve everything)
• Identify triggers to gambling
• (e.g. payday PAYDAY!)
• Work on cognitive distortions of control
• (e.g. Im due to win)

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Psychodynamic Approaches

• Understand conscious and unconscious motivations
  to gambling
• Competition, success, freedom
• Escape
• Independence,
• Rebel against authority

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Psychodynamic Approaches

• Break denial
• Confront maladaptive defenses
• Interrupt chasing behavior
• Increase motivation
• Decrease shame/guilt/stigma
• No formalized studies

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Efficacy of a Self-Help Workbook for Problem
Gamblers
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Background Workbook

• Many kinds few empirically tested
• Promote self-change
• Easy to distribute wide range of audiences
• No need for training
• Cost effective
• Easy to update

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Objectives Workbook

• Create a self-help workbook for PG
• Test efficacy of workbook for PG
• Publish workbook
• Distribute workbook

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Study Participants

• Recruited from the community
• Newspapers, helpline, word-of-mouth, web
  advertising
• Inclusion SOGS gt 2
• English-speaking
• Exclusion Significant psychiatric d/o
• Active substance abuse

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Study Design

• Participants randomized to
• Workbook (alone)
• Workbook (guided)
• Study visits
• Wk 0 Screening
• Wk 1,2,4,8,12 Workbook
• Wk 20, 52 Follow-up

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Measurements

• Primary Outcomes
• Gambling behaviors
• Gambling urges / cravings
• Quality of life measures
• Secondary outcomes
• Mood / Anxiety symptoms
• Patient feedback

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Results so far . .

• Enrollment began in March 2007
• First version of workbook created, revised,
  edited and printed.

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Results

• 73 participants screened
• 56 eligible
• 26 Workbook Alone
• 28 Workbook Guided
• 2 dropped out (choice)

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Results
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Follow-up data

• Most show reductions within second or third
  visits.
• Need data to analyze post treatment effects.
• Enrollment to end in Spring 2008

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Client Feedback

• No significant complaints
• Mostly positive
• Interactive quality of book is most appealing
• Good for future reference

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Next Steps

• Target Enrollment 60 / 60
• Expand recruitment
• Increase visibility of program
• Complete Enrollment Spring 2008
• Continue to revise Workbook
• Primary and Secondary analyses

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Effectiveness of a Brief Telephone Intervention
for PGCall to Change
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Objectives Helpline

• Evaluate effectiveness of Call to Change
• Expand helpline services to those likely to
  respond

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Participants

• Problem Gamblers calling the California Helpline
• Offered to enroll in Call to Change
  administered by BDA
• Inclusion NODS gt2
• English Speaking
• Data collected by BDA

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Study Design

• Week 0 Intake and Enrollment
• Week 1 Counseling
• Week 2 Counseling
• Week 4 Counseling
• Week 8 Counseling
• Week 12 Counseling
• Week 24 Follow-up
• Week 52 Follow-up

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Measurements

• Primary Outcomes
• Gambling behaviors
• Gambling urges / cravings
• GA Attendance
• Transition to formal treatment
• Secondary outcomes
• Mood / Anxiety symptoms
• Patient feedback

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Results

• Enrollment began March June 2007
• Target 40
• Currently enrolled 40
• Program Retention 33/40
• Follow-up and effectiveness data to be sent by
  BDA very soon

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Next Steps

• Preliminary analyses
• Comparison groups with California
• How to get CA program funded?
• For whom does it work for?

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Gamblers Anonymous

• www.gamblersanonymous.org
• Founded in Los Angeles (1957)
• Based on 12-step model 1500 chapters
  nationally
• Needs more research
• Gam-Anon for families

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Points about GA

• Know what the content of the meetings are like
  and what the make-up of is.
• Know where the meetings are
• No known alternative groups
• What about language and social barriers?

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Financial Counseling

• Know bankruptcy laws
• Limit credit cards and access to ATMs
• Tell families to separate accounts
• Debt consolidation / relief
• No formal studies

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Other interventions

• Helpline Services
• 1-800-GAMBLER (National)
• 1-800-522-4700 (CA)
• Self-Exclusion Programs
• Internet assistance
• Online chat rooms
• Internet treatment manuals

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Working with Families

• Educate
• Reduce enabling behaviors
• Support self-efficacy and therapy
• Minimize negative situations
• Encourage time together
• Protect familys financial interests
• Recommend formal family therapy

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Behavioral Measures

• Limit access to money and transportation
• Cut-up credit cards
• Increase structured time
• Self-exclusion programs
• No monitoring systems available, yet

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Case study 1

• 47 year-old white male
• 250,000 per year income
• 50 of income lost to gambling last year
• Consequences
• Divorce, no retirement savings, depressed,
  doesnt see a way out, drinking and sex control
  issues

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Treatment Plan

• GA 90/90
• Weekly therapy
• No alcohol or gambling
• No meds after intake
• Bring ex-wife in next time
• Plan time out

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Case study 2

• 54 yo Chinese Female
• Lives with husband, 2 kids
• Housewife, 1st-generation, English poor
• Drives or buses to casinos
• gt 45,000 in debt
• Kids bring her to treatment

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Treatment Plan

• GA Chinese GA
• Individual Therapy APCTC
• No meds
• Family meeting for history and decrease enabling
• Alternative socializing plan needed.

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Prevention
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Primary Prevention

• Casinos and advertisers to target underage
  gambling
• Addressing parental education
• Responsible Gaming Programs
• School-based programs

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Secondary Prevention

• Screenings at school, primary care, mental health
  settings, alcohol and drug programs
• Self-Help Workbooks
• Brief Interventions (1,2 sessions)
• Telephone Counseling

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Tertiary Prevention

• Self-Exclusion Programs
• Gateway to Treatment
• Gambling Courts / Forensic Care
• Does Harm Reduction apply?
• Managing co-occurring disorders

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Natural Recovery

• Percentages are unknown but thought to be high
  among those who
• avoid gambling stimuli
• engage in alternate activities
• less precipitating life events
• more positive events during recovery
• less severe PG
• (Hodgins 2000)

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Outcomes and Symptom Monitoring

• Treatment participation
• Collateral history
• Assessment of overall functioning
• Preoccupation, urges
• Time analysis
• Ongoing screening for addl disorders

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Treatment Options in California (2008)

• Inpatient Treatment Programs
• Outpatient Treatment Programs
• UCLA Impulse Control Disorders Clinic
• UCLA Addictions Medicine Clinic
• Gamblers Anonymous
• Private Practitioners
• Helplines

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California Funding and Gambling Treatment

• California Department of Alcohol and Drug
  Programs
• Office of Problem Gambling (2003)
• 3 million per year
• 2/2007 0 State-Funded Treatment
• 7/1/07 150,000 per year
• UPAC San Diego County

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Who is responsible for treatment?

• Alcohol and Drug Programs
• Department of Mental Health
• Criminal Justice
• Casino Industry
• Private programs / concerned citizens?

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Treatment Summarized

• History and collateral information
• GA
• Therapy (go with whats familiar)
• Address co-occurring disorders
• Supervision, if needed
• Motivate, motivate

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Resources

• Gamblers Anonymous and GamAnon
• [phone]
• www.gamblersanonymous.org
• California Department of Drug and Alcohol
• (Office of Problem Gambling)
• www.adp.cahwnet.gov
• California Council on Problem Gambling
• www.calproblemgambling.org
• National Council on Problem Gambling
• www.ncpgambling.org

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Contact Information Timothy Fong MD Richard
Rosenthal MD310-825-4845tfong_at_mednet.ucla.eduuc
lagamblingprogram.org