The latest evidence and guidance on gambling-related harm with practical advice on identification, signposting, and referral

CREDIT: This is an edited version of an article that originally appeared on Medscape

GPs and other primary care practitioners are used to seeing patients living with addiction. They routinely refer and signpost people with addictions to drugs, alcohol, or nicotine to local services. Yet, how often do primary care practitioners think about whether their patients may be addicted to gambling, and whether that is affecting their physical and mental health? 

During the COVID-19 pandemic, the number of adults participating in any form of gambling decreased, but levels have since returned to those seen in 2019.1 In 2021, around 59% of the adult population in Great Britain reported having taken part in gambling of some form in the previous 12.

In the same timeframe, a 2022 Gambling Commission survey estimated that 31% of 11–16-year-olds in Great Britain had spent their own money on gambling. This suggests that participation in gambling is more common among 11–16-year-olds than the use of cigarettes, e-cigarettes, alcohol, or illegal drugs.

Features that may indicate gambling disorder or problem gambling

• Problematic gambling behaviour that is repeated and persistent, usually over a period of 12 months or more—this can be online or offline
• A lack of control over gambling activity, possibly including unsuccessful attempts to control or stop it that is associated with restlessness or irritability
• A preoccupation with gambling, and/or the prioritisation of gambling over other interests and activities
• Continued gambling in spite of its negative consequences, such as to a person’s relationships, financial situation, or health
• ‘Chasing’ losses, by returning to gamble after losing money in an attempt to regain it
• Associated feelings of distress (such as helplessness, guilt, anxiety, or depression), which either lead to or result from their gambling activity
• Lying to others to hide the extent of their gambling, and/or relying on others to help them with difficult gambling-related financial situations
• Loss of, or risk to, a career, relationship, or educational opportunity as a result of gambling
• The gambling not being better explained by a manic episode.

Prevalence

Gambling issues impact more people than many would assume. Data from the 2021 Health Survey for England suggest that 0.3% of the adult population engages in problem gambling, and 2.8% are gambling at ‘at-risk’ levels. 

Effects of Problem Gambling 

There are several harms to physical and mental health that are associated with gambling.

• Increased alcohol consumption and other substance misuse
• Increased risk of dying from any cause
• Suicidal thoughts, and death from suicide
• Self-harm
• Stress-related disorders
• Anxiety
• Depression
• Sleep problems

Identification of At-Risk Groups

There are various risk factors that should be considered when identifying patients who are more likely to be impacted by gambling-related harms. Men are generally more likely to participate in problem gambling than women.

The risk is also higher for people with lower socioeconomic status, as well as for people who are in prison. People in certain careers are also at increased risk of gambling-related harms—these include people working in gambling-related occupations, professional athletes, firefighters, and those who are either in the armed forces or are veterans.

Other risk factors include a family history of gambling disorder, use of drugs or heavy use of alcohol, mental health conditions such as depression and anxiety, and being of a Black, Asian, or other minority ethnic background.

Parkinson’s Disease and Associated Medications

Gambling issues are also associated with certain medical conditions and medications. Most notably, gambling disorders are seven times more common in people with Parkinson’s disease (PD) than in the general population. Around one-quarter of people with PD have a history of gambling that predates their PD diagnosis, and around 6% of people taking dopamine agonists (such as ropinirole, pramipexole, rotigotine, or apomorphine) develop gambling pathologies.

Impulse control issues such as problem gambling often occur up to 4–5 years after starting dopamine agonists and are also an issue (although less commonly so) with other drugs used to treat PD, such as levodopa.

People with PD will see their GP often, so the GP may be the first person that they or their families or carers first come to with concerns about gambling or other impulsive behaviour, so it is important that primary care practitioners know about the risks.

The following recommendations are notable for primary care:

Clinicians are advised to undertake a careful risk assessment before prescribing medication for PD, being aware of risk factors such as young age at onset, smoking, a family or personal history of alcohol abuse, or a family history of problem gambling, novelty-seeking behaviour, or drug-induced mania—if any of this information is in a patient’s notes, it would be useful to mention this in an initial referral letter.

Consider alternatives to dopamine agonists if the risk is particularly high, such as for a relatively young male patient with a family history of problem gambling or alcohol issues

Reduce dopamine treatment if problem gambling is detected – these decisions should always be made in secondary care and may lead to the drug needing to be stopped

Consider nurse-therapist-led cognitive behavioural therapy (CBT) in conjunction with stopping medication.

Screen all patients with PD for pathological gambling and other impulse control disorders at follow up, using non-stigmatising language.

Warn patients and their relatives about the risk of problem gambling and other impulse control disorders (such as binge eating, hyper libidinous behaviour, or compulsive shopping) when medication is started, and give this information in written form, copied to the patient’s GP.

Enquiries and Brief Interventions

As with any diagnosis, gambling disorder cannot be identified unless it is asked about. A simple question, such as ‘Are you worried that you are gambling too much?’, can be effective for identifying potential gambling-related issues, and this kind of simple question is increasingly being used in NHS online questionnaires.

It may be beneficial to view this question as the first point in the framework of Very Brief Advice (VBA), an evidence-based tool that can easily fit into a routine GP appointment and has been shown to help with smoking cessation. The three parts of VBA, as adapted to gambling, would be as follows:

• Ask—ask the patient a simple question about whether they gamble, and whether they are concerned about it
• Advise—tell the patient that there is help available, and explain how they can get it
• Act—signpost or refer the patient to an appropriate service if they are interested, and ensure that they understand where to access support if they are not interested.

VBA is a type of ‘brief intervention’, a term generally referring to a short, nonconfrontational conversation between a clinician and their patient about their behaviour and its associated harms. 

Brief interventions have been shown to work for a number of addictive behaviours, including problem gambling, alcohol abuse, smoking, and drug misuse, and GambleAware has produced a gambling-specific brief intervention guide that generally aligns with the core concepts of VBA.

Assessing Severity

The primary method of assessing the severity of a person’s gambling is detailed below. There are nine questions, which all score from zero (never) to three (always). A score of eight or above indicates that the person is a problem gambler, with scores of 3–7 indicating moderate risk and 1–2 indicating low risk. A zero result indicates someone who gambles with no negative consequences.

• Do you bet more than you can afford to lose?
• Do you need to gamble with larger amounts of money to get the same feeling?
• Have you tried to win back money you have lost (chasing losses)?
• Have you borrowed money or sold anything to get money to gamble?
• Have you wondered whether you have a problem with gambling?
• Has your gambling caused you any health problems, including feelings of stress or anxiety?
• Have other people criticised your betting or told you that you had a problem with gambling (regardless of whether or not you thought it was true)?
• Has your gambling caused any financial problems for you or your household?
• Have you ever felt guilty about the way you gamble or what happens when you gamble?

Language

This article has used several terms, including ‘gambling disorder’, ‘gambling issues’, ‘gambling-related harms’, and ‘problem gambling’, all of which are used relatively interchangeably in the associated literature. However, certain phraseology, particularly the term ‘problem gambling’, may actually be stigmatising, and clinicians should consider moving away from this kind of wording.

Discussing ‘gambling-related harms’ that may be impacting the person and those around them (for example, friends, relatives, and colleagues) is generally a more sensitive approach. 

Treatment and Support

Once a problem is identified, treatment options will depend on what is available locally, whether the patient is willing to travel or access help remotely, and the severity of their gambling issues. There are four main treatment routes:

The voluntary sector — particularly for those with low-to-moderate harm—charitable organisations, such as GamCare, can provide counselling, brief interventions, peer support, and ongoing support to help with the prevention of relapse, as well as further counselling after a relapse.

The NHS Primary Care Gambling Service—this is a service in South London, which is run by a multidisciplinary team including mental health nurses, GPs, a consultant psychiatrist, and people with lived experience of gambling-related harms. Patients can self-refer, or a referral can come from a GP or other agency. Sessions may be individual or in a group, and the service also provides aftercare, including relapse prevention and a peer support group. The service can be accessed face to face, on the phone, or online.

Secondary care NHS services—in the NHS long term plan, NHS England pledged to open 15 gambling clinics by 2023/2024. As of November 2022, seven have been opened in Leeds, Sunderland, Manchester, Southampton, Stoke-on-Trent, Telford, and London (a national clinic). These services offer various therapeutic options, including psychiatric review, CBT, psychodynamic psychotherapy, couples and family therapy, support groups, and medication.

Residential services—these are relatively intense recovery programmes primarily offered by the charity Gordon Moody. They are not free services; however, for those on certain benefits, most of the cost can be covered. The NHS webpage covering problems with gambling signposts to this service.