Are Your Patients Suffering from Problem Gambling?
5-Question Short Screen for physicians
Assessment and Treatment: Information for Physicians
The expansion of gambling venues in Ontario has increased concerns among health-care professionals about the potential harms gambling causes both to individuals and communities. With gambling expansion comes an increase in the number of people experiencing problems. When someone isn’t feeling well – physically, emotionally or mentally – their first call is often to their doctor. Patients will not usually link their health issues to their gambling. A study by Pasternak (1999) of primary-care settings in Wisconsin found that more than 80% of patients had gambled and 6.2% met the criteria for gambling disorders. Problem gambling can affect the physical and psychological health of patients, as well as their families and others who are part of their daily lives. Physicians are therefore in a good position to identify patients who have gambling-related health problems and to assist them.
The Expanding Role of Health-care Providers
The Ontario government is changing the way health care is delivered in this province. The newly formed Local Health Integrated Networks (LHINs) are not-for-profit corporations that work with local health providers and community members to determine the health service priorities of their regions. Their role is to plan, fund and integrate local health services. In addition, the government has funded Family Health Teams. These interdisciplinary teams of physicians and other health-care providers, such as nurse practitioners, nurses, social workers, and mental health and addiction counsellors, will work together to treat more patients presenting with a wider variety of health issues. This new model of health care will result in more and more people with addiction and mental health issues accessing primary-care physicians for their treatment. Primary-care workers will inevitably become more involved in the identification, support and referral of these patients, some of whom will have gambling problems.
Overview of Gambling and Problem Gambling
A recent survey by the Responsible Gambling Council (Wiebe, 2005) reported that 63.3% of Ontarians gamble at least once a year. Even though most people gamble responsibly, some experience problems. This same study found that 253,857 people in Ontario experience moderate problems with gambling and 78,110 experience severe problems with gambling. An additional 5.8% were classified as “at-risk” for problem gambling. For every person who suffers with problem gambling, it is estimated that 6 people are negatively impacted by his or her behaviour. This calculation reveals that nearly one million people in Ontario are negatively affected by problem gambling.
Pathological gambling, as defined in the DSM-IV, represents the most severe pattern of excessive or destructive gambling behaviour. The term “problem gambling” refers to a less-severe pattern of gambling that interferes with a person’s daily life activities.
How Problem Gambling Affects Health
Problem gambling is not just about losing money. Gambling problems can affect a person’s physical, emotional and mental health, yet patients rarely make the connection between their gambling behaviour and their health concerns. A significant number of people affected by problem gambling also suffer from concurrent substance use disorders and psychiatric conditions (e.g., attention deficit hyperactivity disorder, depression and anxiety). Physicians who understand the symptoms, impact and dynamics of problem gambling will be better able to effectively assess the patient’s problem and make appropriate treatment or referral interventions.
The Role of Health-care Professionals
Physicians can play a key role in the treatment of gambling problems by recognizing the early signs, encouraging patients to seek help and providing information about useful resources. Identifying patients with gambling problems is part of the overall spectrum of health care provided by physicians. As a health-care provider, a physician’s role already includes caring for patients with substance use disorders, and this should extend to caring for patients with gambling problems. Because of their regular and long-term contact with patients, primary-care physicians are in a unique position to recognize patients who might be experiencing gambling problems, and to provide information, treatment and referral. The early identification of problem gambling improves patients’ outcomes and reduces the harm to themselves and their families.
There are a variety of signs that indicate a patient has a problem with gambling. These include complaints about headaches, back pain, gastrointestinal disorders and insomnia, as well as diet and nutrition issues. Mental health complaints like depression, anxiety, sleep disturbances and other physical symptoms associated with stress can also be a result of problem gambling. Including questions about gambling in your patient assessment should be as routine as asking about a patient’s alcohol and tobacco use, particularly for patients with risk factors, such as present or previous problems with substance use, depression and anxiety (concurrent disorders). Primary-care physicians should consider asking all high-risk patients about their gambling habits.
There are several tools available to assist in the screening process. The DSM-IV provides diagnostic criteria for pathological gambling, consisting of 10 diagnostic indicators. A gambling problem is diagnosed when a patient exhibits 3 or more behaviours; a score of 5 or more indicates a probable pathological gambler.
CAMH has also developed a 5 Question Short Screen. If a patient scores 3 or more, you can be very confident that he or she has a gambling problem.
Interventions
Two standard treatment approaches are used by therapists and counsellors. The first is brief solution-focused therapy, a short-term intervention that attempts to help the client effect change by identifying immediate solutions to concrete problems. The second treatment approach is cognitive behavioural therapy; this form of therapy attempts to identify the client’s distorted thinking and replace it with more rational, adaptive thoughts and beliefs. Many people with gambling problems have a host of other issues that will need to be addressed. Concurrent disorders such as depression, anxiety, ADHD and substance use are common. The financial implications of gambling frequently cause a client’s relationship to suffer. Problem gambling therapists also provide counselling to family members who have been hurt financially and emotionally by a significant other’s gambling. Referrals to credit counselling services can be beneficial. Mutual-aid support groups like Gambler’s Anonymous and Gam-Anon offer services in many communities across Ontario.
Resources: Where to Find Help
The Ministry of Health and Long-Term Care funds 49 agencies across Ontario to provide specialized problem gambling treatment programs. These programs are free and offer a variety of services, such as individual, group and phone counselling. Counselling is also available to family members when the person with the gambling problem chooses not to access treatment. For the program nearest to you, call the Ontario Problem Gambling Helpline at 1-888-230-3505.
ProblemGambling.ca developed by the Problem Gambling Project at CAMH is an informative web site that provides comprehensive information for several audiences. These include people experiencing problems with gambling, concerned significant others, allied professionals (such as doctors, addiction counsellors, social workers and financial counsellors), and researchers and individuals interested in information about problem gambling.
For more information about the programs and services of the CAMH Problem Gambling Project call (416)535-8501 x4550.
See Also: CAMH Knowledge Exchange
References
Pasternak, A.V. & Fleming, M.F. 1999. Prevalence of gambling disorders in a primary care setting. Archives of Family Medicine 8: 515–520.
Wiebe, J., Mun, P. & Kauffman, N. 2006. Gambling and Problem in Ontario 2005. Toronto: Responsible Gambling Council.
Ministry of Health and Long-Term Care. http://www.health.gov.on.ca/
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.
Problem Gambling – Part I: Patient Screening and Assessment by Colleen Tessier, Bruce Ballon, MD Centre for Addiction and Mental Health, Problem Gambling Project References
Problem Gambling – Part II: Treatment and Referral by Brenda Teasell, Bruce Ballon, MD, FRCPC Centre for Addiction and Mental Health, Problem Gambling Project References
Dr. Bruce Ballon, FRCPC, is head of youth addiction services at CAMH, and a lecturer at the University of Toronto. An award-winning psychiatrist and author, Dr. Ballon has received numerous awards for his work in psychotherapy and the humanities.
Brenda Teasell is a problem gambling therapist and trainer in the Problem Gambling Project at the Centre for Addiction and Mental Health.
Colleen Tessier is senior project co-ordinator for the CAMH Problem Gambling Project. For the past 12 years at CAMH, Ms. Tessier has been working with communities across the province in the field of health promotion and prevention, and is involved in the development of customized training for professionals working in the field of health promotion, prevention, and addiction.
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