Year : 2016 | Volume
: 21 | Issue : 1 | Page : 62--63
Management of gambling addiction
Shivangi Mehta, Ajeet Sidana, Krunali Ukey
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
Department of Psychiatry, Level-5, Block-D, Government Medical College and Hospital, Sector-32, Chandigarh - 160 030
Gambling is defined as staking something on a contingency. Many traders are gambling without even knowing it. Health professionals need to consider the harmful effects of gambling considering that gambling can destroy families and has medical consequences. A 40-year-old bank manager diagnosed initially with mood disorder with two attempts of self-harm in the past 3 years was eventually diagnosed as a case of gambling addiction using both the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria and Problem Gambling Severity Index. The participant's gambling urges were not caused by any “trigger” incident, were independent of mood disorder, and were so severe to lead him to deliberate self-harm. Even after adequate trial of two mood stabilizers from different classes including lithium, the patient neither showed improvement in mood symptoms nor his gambling behavior; however, patient's gambling behavior and mood symptoms both showed marked improvement following start of naltrexone up to a dose of 100 mg/day and were maintained at 6-month follow-up with gradual decline in craving for gambling as monitored on Problem Gambling Severity Index. Gambling addiction appears to be a very serious problem and can cause significant problems in the lives of people it affects and their family members.
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Mehta S, Sidana A, Ukey K. Management of gambling addiction.J Mental Health Hum Behav 2016;21:62-63
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Mehta S, Sidana A, Ukey K. Management of gambling addiction. J Mental Health Hum Behav [serial online] 2016 [cited 2021 Nov 29 ];21:62-63
Available from: https://www.jmhhb.org/text.asp?2016/21/1/62/182093
Gambling is a common term for all hazardous games that include playing for stakes in the hope of winning (i.e., taking a risk in the hope of gaining an advantage or a benefit). The etiology of gambling addiction, still under study, is hypothesized to be a complex biopsychosocial disorder with multiple associated factors as sociocultural background, personality, and associated symptoms of other mental disorders. Although there is no intake of a substance that causes dependence or visible physical difficulties, still gambling is considered dependence due to similarities as loss of control over gambling, preoccupation with gambling, adverse social consequences that disrupt most areas of the person's life, tolerance, withdrawal, participation in self-help groups during treatment, stigmatization, repeated attempts despite loss, irrational behavior to attain the finances. About 76% of pathological gamblers have comorbid major depressive disorder and 28% have comorbid recurrent depressive episodes; however, the severity of depressive episodes does not correlate with the amount of money spent. There is also increased risk of suicide in pathologic gamblers.
Studies have shown that out of the various pharmacological treatments (opioid antagonists, selective serotonin re-uptake inhibitors, and mood stabilizers), opioid antagonists are most effective in reducing the urge to gamble. An open-label treatment suggested the efficacy of naltrexone, a food drug administration-approved treatment for alcohol and opioid dependence, in reducing the intensity of urges to gamble, thoughts about gambling, and the behavior itself when given in high doses (range: 50–250 mg/day; mean dose: 157 mg/day). Here, the authors have reported a case of gambling addiction who responded well to treatment with naltrexone.
A male patient S. C., aged 40 years, married for 10 years, studied up to M.SC (Electronics), belonging to middle socioeconomic status Hindu, nuclear family, working as a manager in a bank started trading in shares initially for extra earning and would intermittently invest money in trading of shares; however, for the past 3 years, the patient has left his job and has been investing money in trading of shares repeatedly despite heavy losses. After every loss, he would feel bad yet again would not stop from reinvesting despite repeated efforts by his family (wife and sisters) to stop him. When his family started being strict with him and stopping him from encashing property and accounts, he would threaten them with suicidal ideations.
He was taken to a local practitioner who put him on antidepressants. The patient would then blame the medications for hampering his judgment and cognitive decline on further losses in trading. On being refused money by his wife and sisters, he slashed his wrist with knife. The patient had been admitted twice in lieu of suicidal ideations and attempts and started on mirtazapine and lithium for depressive symptoms with suicidality. The patient would abstain from trading for less than a month and would revert to trading soon after discharge from hospital with increased family dysfunction and poor compliance to treatment.
In the third admission, with review of the case, the main problem was found to be focused on trading of shares which the patient could not resist and felt excited whenever he thought of investing money in shares. His current thoughts were logical and normal besides ideas about trading. The mood was slightly dysphoric and grandiose initially (Young Mania Rating Scale score 7 and subsequently zero). He reported suicidal ideation only if he was stopped from trading.
There was nothing significant in respect to personal history. There was no history of chronic medical or neurological illnesses.
There was no history of mental illness in the family. The patient's physical examination was normal, except fresh-stitched wounds on both the wrists. His routine investigations, including chest X-ray, electrocardiogram, magnetic resonance imaging of the brain, were normal. The final diagnosis of gambling addiction was arrived as per-Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria and Problem Gambling Addiction Severity Index.
The patient was started on lithium which had to be stopped when the patient developed delirium and then started on carbamazepine 400 mg/day and naltrexone up to 100 mg/day (starting both with lower doses and gradually titrated up) with which the patient's desire to trade was found to decrease, and gradually, he was able to abstain even after discharge. He was abstinent from gambling 6 months after discharge from the hospital with gradual decline in craving for gambling.
Problem gambling has been conceptualized and defined as an addiction because of the surface similarities between gambling problems and alcohol and other drug problems. Rosenthal's definition which is also the foundation for the influential diagnostic and statistical manual's criteria for problem gambling states: A progressive disorder characterized by a continuous or periodic loss of control over gambling; a preoccupation with gambling and with obtaining money with which to gamble, irrational thinking; and a continuation of the behavior despite adverse consequences. This definition being behaviorally based sees gambling as a disorder and captures most of the important behaviors seen with severe problem gambling. Pathological gambling and substance abuse have common characteristics as (1) repetitive or compulsive engagement in a behavior despite adverse consequences, (2) diminished control over the problematic behavior, (3) an urge or craving prior to engagement in the behavior, and (4) a hedonic thrill when taking part in the behavior. These features helped reclassification of pathological gambling as a behavioral addiction.
A 12-week double-blind placebo-controlled trial of naltrexone demonstrated superiority to placebo in 45 subjects who were pathological gamblers. Naltrexone (mean dose: 188 mg/day) was effective in reducing the frequency and intensity of gambling urges, as well the behavior itself. A separate analysis showed that naltrexone was more effective in gamblers with more severe urges than in those who described their urges to gamble as moderate.
Thus, through this case report, we see that the problems as gambling when seen through the frame of gambling addiction (as a recent diagnosis in DSM-5) can be treated with higher dose of naltrexone (100 mg) which reduces the craving for gambling significantly and prevents the further financial debts and improves psychosocial functioning.
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Conflicts of interest
There are no conflicts of interest.
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