It might seem like a bit of harmless fun to most of us, but to some, gambling has become an overwhelming problem. The problem is compounded when mental health issues are combined with this addictive behaviour and further complicated when sufferers are directly targeted by gambling organisations that portray a fun and winning atmosphere, yet this is very far from the truth.
From when I was a tender and bright-eyed 18-year-old working at the main casino here, I knew something wasn’t right about the way gambling works. In fact, I only lasted three months working there as I couldn’t tolerate the misery I was seeing on a daily basis.
When does gambling become a problem?
The American Psychiatric Association (APA) defines gambling disorder as repeated problematic gambling behaviour that causes significant problems or distress. It becomes an addiction for some people, with the same effects as an alcoholic gets from alcohol – they can crave gambling the way someone craves alcohol or other substances. The compulsion to gamble can lead to problems with money, relationships, work and legal issues. It is also often a hidden behaviour, making diagnosis and treatment difficult.
To be diagnosed with a gambling disorder, at least four of the following behaviours need to be present in the past year (APA, 2018):
- Need to gamble with increasing amount of money to achieve the desired excitement
- Restless or irritable when trying to cut down or stop gambling
- Repeated unsuccessful efforts to control, cut back on or stop gambling
- Frequent thoughts about gambling (such as reliving past gambling experiences, planning the next gambling venture, thinking of ways to get money to gamble)
- Often gambling when feeling distressed
- After losing money gambling, often returning to get even (referred to as “chasing” one’s losses)
- Lying to conceal gambling activity
- Jeopardising or losing a significant relationship, job or educational/career opportunity because of gambling
- Relying on others to help with money problems caused by gambling
Current research is showing that gambling disorder is similar to substance-related disorders in clinical expression, brain origin, comorbidity, physiology and treatment. Symptoms can subside but can then return with even stronger feelings. The disorder does tend to run in families but environmental factors may also contribute. Symptoms can begin as early as adolescence or as late as older adulthood. Men are more likely to begin at a younger age and women are more likely to begin later in life (APA, 2018).
Is it a big problem?
Various studies show that at any one time, 1% of the adult Australian population satisfy the clinical criteria for problem gambling. A further 4% are at a significant risk. This may not seem high, but the real issue is that problem gambling is markedly over-represented with other co-morbid psychological problems and 57.5% of problem gamblers in these studies were shown to have substance use disorders (Thomas, 2014). Younger men are over-represented as problem gamblers, as are people from Aboriginal and Torres Strait Islander backgrounds and those from lower income settings.
It has the potential to become a bigger problem as Australia has a high number of gambling venues and gambling opportunities. Australia has one electronic gaming machine (EGM) per 118 people, the UK has one per 404 and Switzerland has one per 1,796 people. If you ever watch sport, you will also know you cannot avoid betting talk and advertisements while watching the game, with some betting promotions now placed within the broadcast itself.
The Victorian Responsible Gambling Foundation (via a report issued by the Queensland Government) showed that in 2015-16:
- total gambling expenditure in Australia increased from $22.734 billion in 2014–2015 to $23.648 billion in 2015–2016 (a 3.9% increase)
- per adult gambling expenditure in Australia increased from $1,241.86 to $1,272.81
- total electronic gaming machine expenditure in Australia increased from $11.589 billion to $12.074 billion (a 4.2% increase)
- total sports betting expenditure in Australia increased from $815 million to $921 million (a 13.0% increase)
- sports betting has more than doubled in expenditure from 2010-11 to 2015-16
Expect to lose! Gambling is irrational behaviour
Part of the issue with problem gamblers is that it is irrational behaviour. Most of us know that it’s unlikely we will win – the house always wins – but an addicted gambler will not consider this. To put this in perspective, here are some of the actual odds of winning in common scenarios, according to the Victorian Responsible Gambling Foundation (VRGF):
- Winning top prize on a poker machine: 1 in 9,765,625 (typical prize $5,000)
- Winning first division Tattslotto: 1 in 8,145,060 (typical prize $300,000 to $1m+)
- Winning first division Powerball: 1 in 54,979,155 (typical prize $3m – $15m)
- Winning single zero in casino roulette: 1 in 37 (typical prize $180)
- Winning the joker on the casino big wheel: 1 in 52 (typical prize $240)
Compare this with the odds of some non-gaming related scenarios:
- Dying of heart disease: 1 in 3 people
- Having a back problem: 1 in 4.8 people
- Having some form of cancer in the last 12 months: 1 in 6.3 people
- Being stung or bitten by something in the last 4 weeks: 1 in 55 people (and that’s in a country like Australia where everything is trying to kill us!)
- An Australian person dying in a terrorist attack: 1 in 333,333 people
- Being killed by lightning: 1 in 1,603,250
Yes, you have a much higher chance of being killed by lightning than ever winning Tattslotto or top prize on a poker machine. But some people still do it. The bottom line is, no matter what type of gambling you’re doing, you should always expect to lose.
The advertising problem
Gambling advertising has a habit of normalising the behaviour, so it’s not seen as an issue to sit around with friends and talk about who’s favourite to win or if the underdog can win. According to the Standard Media Index, the gambling industry spent $234.5 million on advertising in Australia in 2016, up from $89.7 million in 2011. This excludes sponsorships and in-program content, such as during live sport broadcasts.
In Australia, advertisements for betting products are not permitted during TV programs classified G or lower from 6 to 8.30 am and 4 to 7 pm, or in programs directed at children between 5 am and 8.30 pm. However, these restrictions currently exclude news and sport broadcasts. Why is this relevant? A 2016 VRGF-funded study “Child and parent recall of gambling sponsorship in Australian sport” collected data from children and parents at community sporting venues in NSW and Victoria. They found:
- 75% of 8- to 16-year-olds interviewed could name at least one gambling brand, and 25% could name four or more.
- Study participants were able to describe incentives offered by bookmakers, such as ‘bonus bet’ offers and ‘cash back’ deals, which likely contributed to their belief that you could not lose from gambling. This perception is not limited to young people. Incentives or inducements are a form of marketing used to attract new customers or to trigger further gambling. They can lead to people underestimating the risks they are taking.
- Another 2016 study reported that 75% of 8- to 16-year-olds thought gambling was a normal or common part of sport.
Why the issue with young people?
Research shows that gambling is one of the first ‘risky activities’ that adolescents engage in, even prior to experimenting with alcohol and drugs, or engaging in sexual behaviour. Those who start gambling earlier are more likely to develop severe gambling problems. Rossen et al. (2016) found that 24.2% of secondary school students had gambled in the last year and 4.8% had two or more indicators of unhealthy gambling. There were also socio-economic status (SES) impacts found here too where the lower the SES, the more likely it was that gambling was problematic.
Sagoe et al. (2017) states that being male, showing higher physical and verbal aggression and having more symptoms of depression were associated with greater odds of belonging to the risky and problem gambling class at age 17.
A Canadian study from Temcheff, Derevensky, St-Pierre, Gupta, & Martin (2014) revealed that problem gambling was viewed as the least serious adolescent risk behaviour by most professionals and few reported feeling confident in their abilities to deal with youth gambling problems – meaning it largely goes undetected and untreated. However, the majority of professionals felt they have a significant role to play in the prevention of youth gambling problems and many endorsed receiving continuing education of the issue. Parents and teachers also feel less concerned about gambling than they do about smoking or drinking. It appears that there needs to be greater awareness of the link between problem gambling and mental health issues.
Comorbidity is defined as the co-occurrence of one or more disorders in the same person either at the same time or in some causal sequence (Department of Health, Australian Government, 2018). Comorbidity poses significant issues for the identification and treatment of problem gambling because of the high case complexity. Most people with problem gambling have one or more additional disorders that require intervention in their own right. For this reason, it has been proposed that people with problem gambling should be screened for other psychological disorders and vice versa. Many people with problem gambling are missed because their symptoms are masked by other disorders and often hidden from practitioners because of shame considerations. For example, the research that is available suggests that suicide risk is strongly elevated for problem gamblers. But there is a conflict of interest as the government collects licence fees and taxes from gambling revenue, while regulating the industry, operating treatment services and running public health interventions (Thomas, 2014). So, who can be relied upon to truly work at resolving these issues?
A study by Maas (2016) shows mood and anxiety disorders to be strongly associated with gambling problem severity. It also shows that a person’s SES has a strong association with the degree of problem gambling – those with greater resources experience fewer problems as a result of their gambling participation. The findings also suggest that those with less education experience more problems with gambling.
A study from Manning et al. (2017) from eight outpatient mental health services in Victoria revealed that patients with drug-use disorder had over four times the risk of problem gambling. It also overlapped with other addictive behaviours, as problem gamblers exhibited significantly higher rates of nicotine and illicit drug dependence. Patients diagnosed with a psychotic disorder, bipolar or Borderline Personality Disorder (BPD) had double the risk of problem gambling.
Results from a 2014 Victorian Responsible Gambling Foundation study indicated a statistically significant association between gambling symptoms and lifetime major depression, and marginally significant links with lifetime panic disorder, specific phobia and Generalised Anxiety Disorder (GAD). There were also significant links between problem gambling and avoidant, antisocial, borderline, narcissistic and schizoid personality disorders. Substance users in treatment with any of these diagnoses reported up to four times the number of pathological gambling symptoms when compared to those without.
A study by Churchill & Farrell (2018) found that higher levels of gambling addiction are associated with greater levels of depression. Also, results suggest that online gambling poses a significant mental health risk compared to gambling in venues or outlets, where those that gambled online in the last 12 months, on average, reported higher levels of depression than those that did not.
Does problem gambling lead to mental health issues?
Hartmann & Blaszczynski (2018) found that psychiatric disorders can represent both a precursor and a consequence of problem gambling, and that there are underlying interactive factors, such as impulsivity, that can predict and drive both temporal sequences (happening over a sequence of time). Where co-morbid disorders are present before the onset of problem gambling, it could be that gambling was used as an emotional escape. Links between problem gambling and co-morbid conditions appear to be bidirectional for mood and anxiety disorders, substance use/dependence, alcohol use/dependence, and nicotine dependence in child, adolescent, young adult and adult populations.
Keeping a gambling problem hidden is common due to shame, embarrassment and fear of stigma, although this also hinders access to treatment, interventions and other support. A study from Hing, Russell, Gainsbury, & Nuske (2016) found that problem gambling attracts considerable public stigma, with deleterious effects on mental health and use of healthcare services amongst those affected. The issue of public stigma, or the perception of it, can stop people from ever seeking help. They can experience the mental health effects of diminished self-worth, withdraw from social support and reject treatment and other interventions. Stigma is the most cited reason for avoiding professional treatment for mental health problems, including problem gambling.
The internalisation of stigma among individuals with gambling problems tends to work in a similar way as for those with alcohol or drug problems (Gavriel-Fried & Rabayov, 2017). Another study from Hing & Russell (2017) suggests that the self-stigma of problem gambling may be driven by similar mechanisms as the self-stigma of other mental health disorders and impact similarly on self-esteem and coping. They also found that self-stigma of problem gambling increased with females and older age groups, which were also associated with electronic gaming machine problems. Lowering self-stigma can not only increase coping skills but can foster a belief that recovery is possible, and that relapse isn’t a failure.
In many respects, problem gambling is a hidden disorder. Many sufferers choose to never seek help. In fact, less than 10% ever seek treatment (APA, 2018).
Psychological treatments have been shown to be effective for patients once they engage with it. This is important as many problem gamblers have co-morbid psychological disorders, as explained earlier. Improved detection of problem gambling may be as simple as adding a question into the standard health check screening – “have you or anyone in your family an issue with gambling?”. This can unblock a reluctance to discuss the topic without judgement and an appropriate referral may then take place (Thomas, 2014).
While many are too ashamed to speak of their addiction, many are not asked. Mental health nurses are well-placed to screen for signs of problem gambling and direct the person to appropriate treatment services. Some studies have shown that clinicians tend to focus on what they perceive as immediate risk, while problem gambling is often considered a longer-term concern, or even not related to mental health (Rodda, Manning, Dowling, Lee, & Lubman, 2018).
Signs of harm
Signs of harm can appear well before gambling becomes a problem and initial signs could be:
- Having less time or money to spend on recreation and family
- Reduced savings
- Increased consumption of alcohol
- Feelings of guilt or regret
- Relationship conflict
- Reduced work or study performance
- Financial difficulties
- Feelings of shame and hopelessness (VRGA, 2018)
How is it treated?
Gambling affects people in different ways and different approaches may work better for different people. Several different types of therapy are used to treat gambling disorder, including Cognitive Behaviour Therapy (CBT), psychodynamic therapy (focusses on unconscious processes as they are manifested in a person’s present behaviour), group therapy and family therapy (APA, 2018).
Current evidence-based treatment options indicate psychological therapy as being the front-line treatment option. CBT and motivational interviewing have some supporting evidence for their effectiveness with the strongest evidence base centred on CBT (Casey et al., 2017). This study also showed that Internet-based CBT may overcome barriers that prevent individuals from seeking face-to-face help, as preliminary evidence into the efficacy of internet-based delivery of CBT versus face-to-face shows similar results.
Various studies have examined a range of medications for treatment of problem gambling but there is insufficient evidence of their effectiveness. Some medications may be appropriate for other mental health issues associated with problem gambling but they are not indicated as the primary treatment for problem gambling.
One model to consider for the delivery of effective treatment for gambling disorders is a coordinated treatment program based on the application of mental health care plans, encouraging health care practitioners to view gambling problems in the wider context of other mental health conditions and manage those conditions as a whole (Harvey, 2013).
There is no simple solution to the problem of gambling but one thing is certain – it cannot be ignored in the hope that it will work itself out. It is an addiction for some people, just as alcohol and drugs are, and we do not expect those sufferers to just stop or work it out on their own. Problem gambling is the new tobacco – do we as a society want to do something to control its impact on those that are addicted and their friends and family, or do we just hope the government will step in? Forgive the gambling reference, but the odds of trusting the government to show leadership with this are less than favourable.
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