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Helping Professionals

Part I : Problem Gambling Assessment and Screening for Physicians

The following articles entitled “Problem Gambling: Patient Screening and Assessment” first appeared in the March 2003 issue of the Ontario Medical Review, and “Problem Gambling - Part II: Treatment and Referral” first appeared in the June 2003 issue of the Review. They are posted online with the permission of the Ontario Medical Association.

Since 1994, the province of Ontario has experienced a widespread expansion of conventional gambling venues and the emergence of a variety of new gambling opportunities available to the public at large.

This trend has prompted significant concerns within the public health community regarding the proliferation of problem gambling. The results of a 2001 study conducted by the Canadian Centre on Substance Abuse show that approximately 340,000 people in Ontario have experienced moderate to severe gambling problems. When family members and significant others are considered, the number of Ontarians negatively affected by problem gambling escalates to more than one million.

Safe Gambling Versus Problem Gambling

Gambling may be defined as risking something of value when there is an element of chance associated with the outcome. Gambling can encompass a variety of activities, from betting at casinos and racetracks, sports betting, playing cards, bingo, slot machines, and online gambling, to purchasing lottery or scratch tickets. The 2001 survey cited above found that 83 per cent of respondents reported gambling at least once in the past year. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines pathological gambling as “persistent and recurrent maladaptive patterns of gambling behaviour that disrupt personal, family or vocational pursuits.” It is a chronic, progressive disorder that can affect not only the finances of gamblers and their families, but also their mental and physical wellbeing.  Problem gambling can be looked at in terms of a continuum of use, similar to alcohol and substance use (see diagram below). Gambling behaviours can vary within an individual’s lifetime, moving back and forth between non-problematic to severely problematic. While approximately five per cent of gamblers experience harmful involvement with gambling, or demonstrate pathological behaviours, the majority of people fall within the first three categories of the gambling risk continuum:

Gambling Risk Continuum:

1. Non-gambling: has no gambling problems.

2. Casual social gambler: gambles for recreation and excitement. It is one form of entertainment as opposed to the only form of entertainment.

3. Serious social gambling: gambles as the main form of entertainment, playing on a regular basis.

4. Harmfully involved gambling: gambles to escape, and to experience relief from problems and anxiety.

5. Pathological gambling: meets DSM-IV criteria.

Role of Physicians

Physicians often represent the problem gambler’s first point of contact in the health-care system. It is therefore important for physicians to know how to identify, refer, and support someone who may be experiencing gambling problems. Asking patients about their gambling habits should be as routine as asking about a patient’s alcohol and tobacco use. Physicians who understand the symptoms, impact, and dynamics of problem gambling will be in a better position to effectively assess the problem, and make appropriate treatment or referral interventions. Problem gambling does impact physical and mental health, although those who are directly affected often make no connection between their gambling behaviour and their health concerns. One of the challenges of diagnosing problem gambling is that gamblers are often highly skilled at hiding the fact that they are experiencing any difficulty. Unlike the tell-tale signs often associated with alcohol or substance use disorders, the nature of gambling affords the problem gambler the opportunity to continue — usually undetected — until the situation becomes too overwhelming and devastating to hide.

Centre for Addiction and Mental Health Short Gambling Screen*

1. In the past 12 months, have you gambled more than you intended?

            Yes___ No___

2. In the past 12 months, have you claimed to be winning money when

    you were not?

            Yes___ No___

3. In the past 12 months, have you felt guilty about the way you gamble,

    or about what happens when you gamble?

            Yes___ No___

4. In the past 12 months, have people criticized your gambling?

            Yes___ No___

5. In the past 12 months, have you had money arguments that centred

    on gambling?

            Yes___ No___

* Two or more “yes” responses indicate that there may be a problem with gambling and the patient should be referred for an assessment.

Identifying a Problem Gambler

The problem gambler often presents in the physician’s office complaining of physical symptoms that are related to the stress and anxiety of dealing with a gambling problem. Common symptoms are varied, and may include headaches, back pain, gastrointestinal disorders, insomnia, and diet and nutrition issues. A significant number of problem gamblers also suffer from concurrent substance use disorders and psychiatric conditions (e.g., attention deficit hyperactivity disorder, depression, anxiety). While these symptoms may be common to a variety of medical diagnoses, physicians should consider screening such patients for gambling problems — particularly if the physician’s practice is located in a community that has undergone an expansion of gambling venues.

Following are some of the health, financial, emotional, and behavioural cues that may indicate a person is experiencing gambling problems.

  • Health signs: suffering from stress-related physical ailments such as headaches, low back pain, gastrointestinal ailments, insomnia, unsatisfactory sexual relations, or depression; exhibiting poor self-care; chest and/or stomach pains.
  • Financial signs: money or valuables missing or unaccounted for; unpaid bills; cashing in RRSPs/ insurance plans; taking on a second job, but experiencing no improvement in finances.
  • Emotional signs: withdrawn from family/friends; personality changes; feelings of hopelessness and depression; being defensive, tense, worried; mounting stress; periods of feeling very low; report self-harm.
  • Behavioural signs: secretive; talks only about gambling; changes in sleep, eating and/or sexual habits; missing or falling behind in work/ school.

Screening Tools

In addition to being alert to the indicators of problem gambling, physicians may also use a variety of specially designed screening tools as a regular part of patient consultation.

The South Oaks Gambling Screen, Canadian Problem Gambling Index (CPGI), and the Centre for Addiction and Mental Health (CAMH) Short Gambling Screen, are available to assist professionals in the identification of problem gambling. The CAMH Short Gambling Screen (above) is an easy-to-use screening tool that consists of five “Yes” or “No” questions, and takes patients only minutes to complete — either independently, or with their physician. If the screen indicates that a referral is necessary, the physician may refer the patient to one of 45 agencies across the province funded by the Ministry of Health and Long-Term Care to provide specialized treatment services for those affected by problem gambling. The Ontario Problem Gambling Helpline (1-888-230-3505, or www.opgh.on.ca) can provide the location of the nearest treatment centre. Often, it is the gambler’s family members who identify the problem and seek assistance. Most treatment services will provide counselling to family members, with or without the involvement of the gambler. Another referral option is Gamblers Anonymous (GA) for problem gamblers, and Gam-Anon for their family members. These are mutual-aid support groups that offer multidimensional assistance to people affected by problem gambling. A listing of local GA chapters across Canada and around the world is available on the Gamblers Anonymous Web site (www.gamblersanonymous.org). Greater Toronto Area residents may contact Gamblers Anonymous at (416) 366-7613.

The articles entitled “Problem Gambling: Patient Screening and Assessment” first appeared in the March 2003 issue of the Ontario Medical Review, and “Problem Gambling - Part II: Treatment and Referral” first appeared in the June 2003 issue of the Review. They are posted online with the permission of the Ontario Medical Association.

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