Minneapolis and St. Paul, Minn., can appear to be a mecca for gamblers.
There are casinos like Mystic Lake and Treasure Island and a new parimutuel
betting method that is dazzling gamblers. There are pull tabs, where gamblers
simply pull tabs out of a machine to see whether they are a winner.
But the Twin Cities, Las Vegas, and Atlantic City are far from the only
places where Americans can woo Lady Luck.
Legalized gambling has been mushrooming throughout the country over the
past 10 years. "It is happening everywhere in the nation as we
talk," Suck Won Kim, M.D., a professor of psychiatry at the University
of Minnesota and a problem-gambling authority, told Psychiatric News."
Almost every county in the nation now has some form of legalized
gambling. Local and state officials see it as an easier way to boost revenue
than is raising taxes."
Moreover, as legalized gambling has soared and as new forms of
gambling—parnet—have become available, there is reapathological
gambling may have also
"Howard Shaffer's group at Harvard analyzed more than 100
prevalence-estimate studies [of pathological gambling] performed over the past
30 years in North America," Marc Potenza, M.D., Ph.D., an assistant
professor of psychiatry and director of the problem-gambling clinic at Yale
University, said in an interview. "These studies have been performed
from the late 1970s through the late 1990s. When they compared prevalence
estimates for pathological gambling derived from mid-1990s studies with
prevalence estimates for pathological gambling derived from late 1970s to
early 1990s studies, they found statistically significant differences, with
higher estimates of pathological gambling in more recent studies."
Paralleling this putative increase in pathological gambling, however, is
some good news—the area of problem-gambling research, which is in its
infancy, has soared during the past five to 10 years.
"There are some very good people who have been studying alcoholism
and substance addiction who have moved into the field of gambling," said
Jon Grant, M.D., J.D. Grant is an assistant professor of psychiatry at Brown
University and director of the impulse control disorders clinic at Butler
Hospital in Providence, R.I.
Further, this spiral in research has produced some helpful insights into
For example, twin studies suggest that problem gambling has a genetic
component. The genetic component in turn may consist of a vulnerability to
addiction, since people with problem gambling often have family members with
other kinds of addictions. The addiction vulnerability may be related to
impaired impulse control, since brain areas crucial for impulse
control—the ventromedial prefrontal cortex (including the ventral
anterior cingulate)—seem to activate less in pathological gamblers than
in individuals without a gambling problem.
Thanks to the recent surge in pathological-gambling research, treatments
that can help counter problem gambling are also starting to be identified.
In the medication domain, they fall into three categories—SSRI
antidepressants, mood stabilizers, and opiate antagonists—suggesting
that pathological gambling may be an obsessive-compulsive spectrum disorder, a
bipolar spectrum disorder, and an addiction disorder rolled into one.
Specifically, some studies have found that SSRI antidepressants can
decrease thoughts about gambling and urges to gamble, whereas other studies
have not. "So the SSRIs are probably helpful in a subgroup of gamblers,
particularly those who have really compulsive urges to gamble," said
Eric Hollander, M.D., a professor of psychiatry and director of the
compulsive, impulsive, and anxiety disorders program at Mount Sinai School of
Medicine in New York.
Lithium can help problem gamblers who have mild mood swings reduce both
their gambling urges and their mania, a double-blind, placebo-controlled study
showed. It was headed by Hollander and published in the January American
Journal of Psychiatry.
"It turns out that a substantial subgroup of gamblers have highs and
lows," said Hollander. "When people gamble, it tends to be
associated with a lot of emotional arousal, and when people are in a sort of
hypomanic or mild high state, they are much more likely to go ahead and act on
their impulses to gamble."
Hollander and his team are launching a large multicenter trial to see
whether the mood-stabilizing anticonvulsant topiramate can help people with
gambling problems, since it has already been shown to help people with some
other impulse-control problems such as alcohol abuse, binge eating, and
pathological aggression (Psychiatric News, February 4).
Regarding the opiate antagonists, several years ago Kim and his colleagues
published results of a double-blind, placebo-controlled trial testing the
opiate antagonist naltrexone (already approved by the Food and Drug
Administration for the treatment of alcoholism) on problem gamblers.
Naltrexone was found to be superior to placebo in countering symptoms of
the disorder. However, the medication caused liver enzyme problems in subjects
who took over-the-counter pain medications at the same time. So subsequently,
the related and putatively safer opiate antagonist nalmefene was tested on
problem gamblers in a multicenter trial. Results are "quite
promising," said Grant, who headed the trial. He will be submitting his
results to a peer-reviewed psychiatric journal.
Even with the progress made in understanding and in treating pathological
gambling, there is still an urgency for more advances.
"We need to identify specific genetic factors involved in
pathological gambling and how genetic factors and environmental factors
interact in the development of the disorder," Potenza said.
"We still do not know—and to me this is a fascinating
phenomenon—why some people, when they start gambling, go precipitously
downhill, whereas other people do not," said Kim. "We are looking
into it and why it is happening. What brain mechanisms are involved? I think
we can design this study to get at least some answers."
"It seems that there are extremely high rates of gambling in younger
populations, particularly teenagers and college students," Hollander
observed. "There may be a transition from video gaming to Internet
gambling. And we need to understand that a bit more."
Cognitive-behavioral therapy can help problem gamblers, several American
and Canadian studies have found. However, "one current difficulty with
cognitive-behavioral therapy is standardization—a manual is not widely
available or utilized," Potenza said. "Thus, it's hard to make
sure that people seeking treatment are receiving an empirically validated
treatment and that this treatment is the same from location to
Although Gamblers Anonymous meetings are held in virtually every state now,
scientific evidence substantiating its effectiveness is sparse.
"What is the most effective treatment for problem gambling?"
Grant asked. "We don't know that yet." ▪