1. Gambling disorder: challenges and opportunities ANDERS HÅKANSSON, MD, PHD. LUND UNIVERSITY. MALMÖ ADDICTION CENTER.

2. Gambling disorder / pathological gambling DSM-5: Gambling disorder –Substance-related and addictive disorders ICD-10: Pathological gambling –Habit and impulse disorders (along with pyromania, kleptomania, trichotillomania)

3. Levels of gambling and gambling problems Level 0 gambling: never gambled Level 1 gambling: ”social” gambling, without any problems –majority of the general population Level 2 gambling: gambling problems (guilt, debts…) –may correspond to ’harmful use’/’abuse’ – no dependence Level 3 gambling: compulsive gambling, fullfills diagnostic criteria –Petry et al., 2005

4. Prevalence of pathological gambling and problem gambling Ever gambled: 60-90% i the Western world Sweden –pathological gambling currently 0.6%, lifetime 1.2% –pathological gambling + problematic gambling: currently 2%, litetime 3.9% (10% in young males) –Taiwan: currently 2.7-4%, lifetime 4-6% »Petry et al., 2005

5. Psychiatric and SUD co-morbidity in problematic gambling Among patients with pathological gambling or problematic gambling: –28% alcohol abuse/dependence –17% drug abuse/dependence –23% depression –37% anxiety disorders »Petry et al., 2005

6. Problematic gambling in SUD patients Lifetime history of pathological gambling in SUD rehab patients in the US: 20% 1 out of 6 ever sought treatment »Leavens et al., 2014 Review of studies in SUD patients in Western countries: –15% level 2 gambling (’problem gambling’) –14% level 3 gambling (’gambling disorder’)

7. DSM-5 4 out of 9 criteria 4-5 criteria: mild gambling disorder 6-7 criteria: moderate gambling disorder 8-9 criteria: severe gambling disorder

8. DSM-5 Gambling disorder – diagnostic criteria 1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement. 2. Is restless or irritable when attempting to cut down or stop gambling. 3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling. 4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).

9. DSM-5 Gambling disorder – diagnostic criteria 5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed). 6. After losing money gambling, often returns another day to get even (“chasing” one’s losses). 7. Lies to conceal the extent of involvement with gambling. 8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling. 9. Relies on others to provide money to relieve desperate financial situations caused by gambling.

10. DSM-5 vs DSM-IV? Crime criterion removed from DSM-5 diagnosis Little impact on total prevalence of the disorder in the general population »Granero et al., 2014 5.6% of clinical DSM-5 patients did not meet criteria for DSM-IV »Jiménez-Murcia et al., 2015. In preparation. Clients endorsing the criminal acts criterion have a more severe gambling problem »Ledgerwood et al., 2007

11. Swedish prevalence data: Swelogs 2008/2009: –72% past-year prevalence of any gambling –53% more than once a month –Estimate of past-year pathological gambling 0.6%, problem gambling 1.4% –Risk factors of problem gambling: male gender, age<25 yrs, lower education, born abroad, resident in major city »Abbott et al., 2014

12. Gender differences Similar rates of gambling prevalence in the population, but more intense gambling patterns in males Disordered gambling around 3 times more common in males

13. Gender differences Higher rates of gambling severity, psychiatric comorbidity, SCL-90 symptom scores, suicidal behaviour in women Women more likely to have depression or anxiety comorbidity Women less likely to have SUD comorbidity Connection alcohol-gambling most pronounced in males

14. Gender differences Comparable severity in women and men applying for treatment Later onset but more rapid progression of gambling problems in women »Ladd & Petry, 2002; Toneatto & Wang, 2009 Comparable treatment outcome in psychosocial and medical treatment Some data indicating a more severe prognosis in women and lower treatment satisfaction »Toneatto & Wang, 2009

15. Gambling disorder in Parkinson’s disease Impulse control disorders in 9.3% in Parkinson’s disease (vs 1.6% in the general population) Complication of dopamin-enhancing treatment

16. CLiP Har du någonsin haft en period på två veckor eller mer när du har lagt mycket tid på att tänka på ditt spelande om pengar eller på att planera framtida spelinsatser eller vadslagning om pengar? (Preoccupation) Har du någonsin försökt sluta spela om pengar, skära ner eller kontrollera ditt spel om pengar? (Loss of control) Har du någonsin ljugit för familjemedlemmar, vänner eller andra om hur mycket du spelar (om pengar) och hur mycket pengar du har förlorat på spel? (Lying) Sensitivity: 96% (men), 91% (women) »Volberg et al., 2011

17. Lie-Bet Lie-Bet – two screening questions Har du någonsin känt behov av att satsa mer och mer pengar på spel?  ja  nej Har du någonsin varit tvungen att ljuga för dina närstående om hur mycket du spelar?  ja  nej Reported to have very high sensitivity (>0.9) and specificity (>0.9) »Johnson et al., 1998

18. Treatment evidence Cochrane Review in 2012: 14 studies CBT vs control (11 studies) 0-3 months: medium to very large effect on financial loss 9-12 months: no significant effect (one study) MI vs control (4 studies) 0-3 months: significant effect on financial loss 9-12 months: significant effect on gambling frequency (one study) »Cowlishaw et al., 2012

19. Pharmacological treatment? Naltrexone –Ntx as needed vs placebo as needed – no effect »Kovanen et al., 2016. RCT. N=101 –Review paper: Significant but small effect (associated with earlier year of publication and non-adherence to ITT procedures) » Bartley and Block, 2013.

20. Pharmacological treatment? Nalmefene –40 mg but not 20 mg superior to placebo. »Grant et al., 2010. –25 mg clearly superior to placebo (59 vs 34% improved) »Grant et al., 2006.

21. Pharmacological treatment? Lack of effect (in few studies) –SSRIs –Antipsychotics –Bupropion »Yip & Potenza, 2014

22. Current challenges and research gaps Little clinical data in settings with little structured treatment Need for further treatment trials in gambling disorder –psychosocial interventions –pharmacological trials Adapted treatment to different problem levels and comorbidity status? Primary and secondary prevention – what works? Clarification of treatment responsibility in Sweden

23. Thank you for your attention anders_c.hakansson@med.lu.se