Gambling Disorders

The American Psychiatric Association uses the term “pathological gambling” to describe the clinical disorder characterized by a persistent and recurring failure to resist gambling behavior that is harmful to the individual and concerned others (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). This diagnosis identifies the most severe form of the disorder, or level 3 as categorized by scientists. Level 2 refers to individuals who experience problems with their gambling but do not meet the criteria laid out by the diagnostic manual. Numerous studies published since the mid-1990s have found that while the vast majority of Americans are level 1 gamblers—i.e., can gamble without experiencing adverse effects—there exists a small percentage of people who are identified as level 3 or pathological gamblers. These studies have established the prevalence rate of pathological gambling as close to 1 percent of the U.S. adult population. Despite the tremendous expansion of casino gambling in the U.S. in recent years, numerous studies have indicated that the prevalence rate has remained stable. Examples of these studies include:

• A 1997 meta-analysis by Harvard Medical School’s Division on Addictions, which estimated 1.29 percent of the adult populations of the U.S. and Canada could be classified as having serious pathological gambling problems. (Shaffer, H.J., Hall, M.N., and Vander Bilt, J. “Estimating the prevalence of disordered gambling behavior in the United States and Canada: a meta-analysis.” Boston: Presidents and Fellows of Harvard College. 1997. Shaffer, H.J., Hall, M.N., and Vander Bilt, J. “Estimating the prevalence of disordered gambling behavior in the United States and Canada: A research synthesis.” American Journal of Public Health, 89, pp. 1369-1376. 1999.)
• A study conducted by the National Research Council of the National Academy of Sciences for the NGISC re-analyzed the data from the Harvard Medical School meta-analysis in order to isolate the estimates for the United States and found a pathological gambling prevalence rate of 0.9 – 1.5 percent. (National Academy Press. Pathological Gambling: A Critical Review. 1999.)
• A study published in the Journal of Clinical Psychiatry in 2005, which estimated a lifetime prevalence rate of pathological gambling at 0.42 percent based upon data derived from a sample of more than 43,000 U.S. residents aged 18 and older. The authors also concluded that, “Pathological gambling is highly comorbid with substance use, mood, anxiety, and personality disorders, suggesting that treatment for one condition should involve assessments and possible concomitant treatment for comorbid conditions.” (Petry, N.M., Stinson F.S., Grant B.F. “Comorbidity of DSM-IV Pathological Gambling and Other Psychiatric Disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions.” Journal of Clinical Psychiatry, 66(5). May 2005.)
• In a 2008 study published in Psychological Medicine, researchers reported a pathological gambling rate of 0.6 percent and a problem gambling rate of 2.3 percent. These findings are consistent with other previously published large-scale prevalence studies. Researchers also found a high rate of concurrent psychiatric problems among disordered gamblers, as well as evidence that disordered gamblers often start gambling at an earlier age than those who can gamble responsibly. (Kessler, R.C., Hwang, I., Labrie, R., Petukhova, M., Sampson, N.A., Winters, K.C., & Shaffer, H.J. DSM-IV pathological gambling in the National Comorbidity Survey Replication. Psychological Medicine, 38(9), 1351-60. Sept 2008.)

Additional research on gambling disorders and the potential effect of casinos on the public health has revealed the following:

• “Probable pathological gambling rates may actually have fallen in Connecticut, and have certainly not risen, during a period in which one of the largest casinos in the world was opened in the state.” Follow-up studies in Louisiana, South Dakota, Michigan, Minnesota, Oregon, Texas, Washington, British Columbia and South Africa uncovered similar results. (WEFA Group. A Study Concerning the Effects of Legalized Gambling on the Citizens of the State of Connecticut. June 1997.)
• In its final report to the NGISC, the Public Sector Gaming Study Commission summarized the evidence as follows: “In short, there is no solid basis for concluding that the wider legalization of gambling, which has cut into illegal gambling and friendly betting, has caused a concomitant increase in pathological gambling. In fact, it appears that pathological gambling is quite rare within the general population, [and] it does not appear to be increasing in frequency.” (Public Sector Gaming Study Commission. Final Report of the Public Sector Gaming Study Commission. p. 35. 2000.)
• A 2008 study published in Psychology of Addictive Behaviors found that the current prevalence rates of pathological gambling are not higher near a casino than they are far away from it. Researchers concluded that, “in a setting in which many types of gambling activities are available, casino proximity in itself does not appear to explain the rate of gambling-related problems.” (Sévigny, S., Ladouceur, R., Jacques, C., Cantinotti, M. “Links between casino proximity and gambling participation, expenditure, and pathology.” Psychology of Addictive Behaviors. Vol 22(2), pp. 295-301. Jun 2008.)

Recent research has shown that disordered gambling behavior might be a manifestation of an underlying addiction syndrome that accounts for all addictions, meaning addictions—whether to drugs, alcohol, food, shopping or gambling—are all related. According to this model, all addictive disorders generally follow the same development pattern and share similar risk factors and consequences. In fact, many individuals who suffer from gambling addiction also suffer from other addictions, a phenomenon known as comorbidity. (Shaffer, H.J., LaPlante, D., LaBrie, R., Kidman, R., Donato, A., and Stanton, M. “Toward a syndrome model of addiction: Multiple expressions, common etiology.” Harvard Review of Psychiatry, 12, pp. 367-374. 2004.) 

The concept of addiction as syndrome and the recognition of comorbidity in disordered gamblers holds promise for the diagnosis and, particularly, the treatment of gambling disorders. Already, significant research has indicated that pharmaceutical treatments used to treat drug abuse may be effective at treating some cases of disordered gambling. (Grant, J.E., and Kim, S.W. “Medication Management of Pathological Gambling.” Minnesota Medicine, 89(9), pp. 44-48. 2006.)

Addictions researchers also are developing practical applications of their work. Drs. Alex Blaszczynski, Robert Ladouceur and Howard Shaffer developed a science-based strategic framework, called the Reno Model, to guide responsible gaming policy. The Reno Model sets out principles to guide industry operators, health service and other welfare providers, interested community groups, consumers, and governments and their related agencies in the adoption and implementation of responsible gaming and harm minimization initiatives, with the aim of reducing both the incidence and prevalence of gambling-related harm in the community. (Blaszczynski, A., Ladouceur, R., and Shaffer, H.J. “A science-based framework for responsible gambling: The Reno model.” Journal of Gambling Studies, 20(3), pp. 301-317. 2004.)

Approximately one third of pathological gamblers experience natural recovery, meaning they recover without seeking or accepting formal treatment. (Slutske, W.S. “Natural Recovery and Treatment-Seeking in Pathological Gambling: Results of Two U.S. National Surveys.” American Journal of Psychiatry. 163:297-302, February 2006.)

For more information on disordered gambling, visit the National Center for Responsible Gaming website at www.ncrg.org.