Blackjack, bankruptcy, and near divorce
Mr. R., 37, started gambling during college. He often bet on sporting events with friends. The gambling was sporadic and apparently did not cause any problems in his life.
Over the next 3 or 4 years, he started visiting the local casino every couple of months with friends and playing blackjack. He occasionally won, but even if he lost he was able to return home without being preoccupied by the experience.
During the past year the frequency with which he gambled had increased. Prior to treatment, he was going to the casino 2 or 3 nights per week. Although he intended to gamble only for a few hours and spend no more than $100 each visit, Mr. R. usually spent most of the evening at the casino and squandered $500 to $1,000 per night. Mr. R. reported daily—and severe—urges to gamble. He would often see a billboard for the casino while driving home from his job as an accountant. The advertisement triggered his urges; instead of going home, he would drive to the casino.
While at work, Mr. R. spent so much time thinking of ways to win at gambling—which tables to play, how to lay the bets, which “lucky” shirt to wear—that he could not complete his assignments in a timely manner. He found it difficult to stay at work, even when he had meetings. Instead, when he felt urges to gamble, he would leave early.
Mr. R. felt ashamed of his gambling and kept it a secret from his wife. If unable to gamble when he had urges, he felt anxious and irritable. Because of his gambling, he missed family functions and lied to his wife and family.
Although married for only 3 years, his wife had already talked about divorce. Mr. R. had significant credit card debt and had to file for bankruptcy. Only then did he tell his wife about his gambling problem.
After telling his primary physician he was depressed, Mr. R. was treated with citalopram 20mg/d. The medication helped his mood but did not decrease his urges to gamble or alter his gambling behavior.
When he presented to our clinic, Mr. R. was off medication and still gambling 2 or 3 times per week. He was then treated with naltrexone 25mg/d for 2 days, then 50mg/d. Because of a possible drug-drug interaction with naltrexone, he agreed to stop taking over-the-counter nonsteroidal analgesics. After 2 weeks, the dosage was increased to 100mg/d taken in the morning with food. Mr. R. reported that his urges to gamble, although still present, were significantly reduced.
After another 2 weeks, the dosage was increased to 150mg/d. Mr. R. reported that his urges to gamble were gone. Without the urges, he was able to stop gambling. Liver function tests were performed every 2 weeks for the first 2 months of treatment and every month thereafter for 3 months.
This case illustrates many of the clinical features of pathological gambling, defined by persistent and recurrent maladaptive patterns of gambling behavior. The disorder often goes undiagnosed and untreated, though preliminary data suggest that it may be relatively common. The lifetime prevalence of pathological gambling is 1.6% among adults, and 3.9% among those younger than 18.1 Pathological gamblers usually experience painful financial losses and perhaps as a consequence have high rates of bankruptcy, divorce, and criminal behavior.2 They also often suffer from comorbid mood, anxiety, and alcohol use disorders.3 In fact, the suicide rate in cities with established, legal casinos is 2 to 4 times higher than in cities without.4
How to identify the pathological gambler
Pathological gambling is often a secret disorder. If left untreated, it frequently becomes a chronic condition. To make the diagnosis, use the simple screening instrument shown in (Table 1).5 The patient is likely to be suffering from pathological gambling disorder if he or she answered five or more of the questions “yes.” The last two questions are useful when trying to determine if someone has a gambling problem that is not readily apparent. Some people gamble in binges—for example, they may only gamble when they have available funds. These people may, however, be significantly impaired by the cravings or urges to gamble even though they may not have gambled for weeks.
Data suggest that the male-to-female ratio in pathological gambling is approximately 2:1. Gambling usually begins in early adulthood, with males tending to start at an earlier age. Although many pathological gamblers take several years to develop a problem, almost one-half report feeling “addicted” within a year after starting to gamble.2 Females appear to develop pathological gambling disorder in a shorter time.