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Challenges and Opportunities in Gambling Disorder: A Comprehensive Overview

Explore the complexities of gambling disorder, including diagnostic criteria, prevalence rates, co-morbidities, gender differences, and treatment outcomes. Gain insights into the levels of gambling problems and the associated challenges and opportunities in managing this disorder.

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Challenges and Opportunities in Gambling Disorder: A Comprehensive Overview

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  1. Gambling disorder: challenges and opportunities Anders håkansson, MD, PHD. Lund University. Malmö Addiction Center.

  2. Gambling disorder / pathological gambling • DSM-5: Gambling disorder • Substance-related and addictive disorders • ICD-10: Pathological gambling • Habit and impulse disorders (along with pyromania, kleptomania, trichotillomania)

  3. Levels of gambling and gambling problems • Level 0 gambling: never gambled • Level 1 gambling: ”social” gambling, without any problems • majority of the general population • Level 2 gambling: gambling problems (guilt, debts…) • may correspond to ’harmful use’/’abuse’ – no dependence • Level 3 gambling: compulsive gambling, fullfills diagnostic criteria • Petry et al., 2005

  4. Prevalence of pathological gambling and problem gambling • Ever gambled: 60-90% i the Western world • Sweden • pathological gambling currently 0.6%, lifetime 1.2% • pathological gambling + problematic gambling: currently 2%, litetime 3.9% (10% in young males) • Taiwan: currently 2.7-4%, lifetime 4-6% • Petry et al., 2005

  5. Psychiatric and SUD co-morbidity in problematic gambling • Among patients with pathological gambling or problematic gambling: • 28% alcohol abuse/dependence • 17% drug abuse/dependence • 23% depression • 37% anxiety disorders • Petry et al., 2005

  6. Problematic gambling in SUD patients • Lifetime history of pathological gambling in SUD rehab patients in the US: 20% • 1 out of 6 ever sought treatment • Leavens et al., 2014 • Review of studies in SUD patients in Western countries: • 15% level 2 gambling (’problem gambling’) • 14% level 3 gambling (’gambling disorder’)

  7. DSM-5 • 4 out of 9 criteria • 4-5 criteria: mild gambling disorder • 6-7 criteria: moderate gambling disorder • 8-9 criteria: severe gambling disorder

  8. DSM-5 Gambling disorder – diagnostic criteria 1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement. 2. Is restless or irritable when attempting to cut down or stop gambling. 3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling. 4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).

  9. DSM-5 Gambling disorder – diagnostic criteria 5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed). 6. After losing money gambling, often returns another day to get even (“chasing” one’s losses). 7. Lies to conceal the extent of involvement with gambling. 8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling. 9. Relies on others to provide money to relieve desperate financial situations caused by gambling.

  10. DSM-5 vs DSM-IV? • Crime criterion removed from DSM-5 diagnosis • Little impact on total prevalence of the disorder in the general population • Granero et al., 2014 • 5.6% of clinical DSM-5 patients did not meet criteria for DSM-IV • Jiménez-Murcia et al., 2015. In preparation. • Clients endorsing the criminal acts criterion have a more severe gambling problem • Ledgerwood et al., 2007

  11. Swedish prevalence data: Swelogs • 2008/2009: • 72% past-year prevalence of any gambling • 53% more than once a month • Estimate of past-year pathological gambling 0.6%, problem gambling 1.4% • Risk factors of problem gambling: male gender, age<25 yrs, lower education, born abroad, resident in major city • Abbott et al., 2014

  12. Gender differences • Similar rates of gambling prevalence in the population, but more intense gambling patterns in males • Disordered gambling around 3 times more common in males

  13. Gender differences • Higher rates of gambling severity, psychiatric comorbidity, SCL-90 symptom scores, suicidal behaviour in women • Women more likely to have depression or anxiety comorbidity • Women less likely to have SUD comorbidity • Connection alcohol-gambling most pronounced in males

  14. Gender differences • Comparable severity in women and men applying for treatment • Later onset but more rapid progression of gambling problems in women • Ladd & Petry, 2002; Toneatto & Wang, 2009 • Comparable treatment outcome in psychosocial and medical treatment • Some data indicating a more severe prognosis in women and lower treatment satisfaction • Toneatto & Wang, 2009

  15. Gambling disorder in Parkinson’s disease • Impulse control disorders in 9.3% in Parkinson’s disease (vs 1.6% in the general population) • Complication of dopamin-enhancing treatment

  16. CLiP • Har du någonsin haft en period på två veckor eller mer när du har lagt mycket tid på att tänka på ditt spelande om pengar eller på att planera framtida spelinsatser eller vadslagning om pengar? (Preoccupation) • Har du någonsin försökt sluta spela om pengar, skära ner eller kontrollera ditt spel om pengar? (Loss of control) • Har du någonsin ljugit för familjemedlemmar, vänner eller andra om hur mycket du spelar (om pengar) och hur mycket pengar du har förlorat på spel? (Lying) • Sensitivity: 96% (men), 91% (women) • Volberg et al., 2011

  17. Lie-Bet Lie-Bet – twoscreening questions • Har du någonsin känt behov av att satsa mer och mer pengar på spel? ja  nej • Har du någonsin varit tvungen att ljuga för dina närstående om hur mycket du spelar? ja  nej Reported to haveveryhighsensitivity (>0.9) and specificity (>0.9) • Johnson et al., 1998

  18. Treatment evidence Cochrane Review in 2012: 14 studies • CBT vs control (11 studies) • 0-3 months: medium to verylargeeffect on financial loss • 9-12 months: no significanteffect (onestudy) • MI vs control (4 studies) • 0-3 months: significanteffect on financial loss • 9-12 months: significanteffect on gambling frequency (onestudy) • Cowlishaw et al., 2012

  19. Pharmacological treatment? • Naltrexone • Ntx as needed vs placebo as needed – no effect • Kovanen et al., 2016. RCT. N=101 • Reviewpaper: Significantbut small effect (associatedwithearlieryearofpublication and non-adherence to ITT procedures) • Bartley and Block, 2013.

  20. Pharmacological treatment? • Nalmefene • 40 mg but not 20 mg superior to placebo. • Grant et al., 2010. • 25 mg clearlysuperior to placebo (59 vs 34% improved) • Grant et al., 2006.

  21. Pharmacological treatment? • Lack of effect (in few studies) • SSRIs • Antipsychotics • Bupropion • Yip & Potenza, 2014

  22. Current challenges and research gaps • Little clinical data in settings with little structured treatment • Need for further treatment trials in gambling disorder • psychosocial interventions • pharmacological trials • Adapted treatment to different problem levels and comorbidity status? • Primary and secondary prevention – what works? • Clarification of treatment responsibility in Sweden

  23. Thank you for your attention anders_c.hakansson@med.lu.se

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