Review
Pathological gambling and mood disorders: Clinical associations and treatment implications

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Abstract

Background

The rapidly expanding gambling business has resulted in an increasing number of gamblers, and the problem is likely to get worse in the future. Traditionally, mood and gambling symptoms have been known to overlap. In the present review we attempt to examine the diagnostic associations and implications for treatment.

Method

Selected published papers on the frequencies of mood disorders among patients who have gambling disorder or gambling disorder among patients who have mood disorder have been reviewed. Recently emerging new treatment methods for gambling disorder have been reviewed and a brief summary has been added.

Results

SCID based study results show a close link between gambling and mood disorders. The prevalence of manic disorder reaches to approximately one fourth of the pathological gambling disorder population. The prevalence of depression is much higher, reaching to over half of the population in some studies.

Limitations

The studies included in the present paper involve inpatients, outpatients, subjects recruited through advertisements and prison populations. Thus the data need to be interpreted as such. Standardized assessment instruments are not used in all studies. Methodological issues such as primary or secondary nature of depression have not been addressed adequately in these studies. The findings, however, offer new insights for the assessment and treatment of complicated gambling disorder cases.

Conclusions

A high prevalence rate of manic and depressive disorders has been recorded among pathological gambling disorder patients. A rational treatment approach to each defined subset of complicated gambling disorder is discussed.

Introduction

Published evidence suggests that some patients with a depressive disorder resort to gambling as a means of escaping depressive symptoms. The literature also documents that gambling may be associated with a manic episode. Within DSM-IV, an additional diagnosis of pathological gambling is allowed only if the gambling is not better accounted for by a manic episode. The above statements suggest that gambling in some cases is secondary to underlying mood disorders, and that the longitudinal clinical course of pathological gambling may be affected by the clinical course of an underlying mood disorder. In this regard, a book written by Winokur et al. (1969) titled “Manic depressive illness” is of special interest. In this book the authors describe gambling symptoms of five relatives of people suffering from manic-depressive illness (see below). It is a detailed and thoughtful description of gambling symptoms not found among contemporary publications. The special occasion for which this paper is written calls for a full transfer of these core descriptions to the present article. Additionally, in this paper we review the published papers that describe the relationship between pathological gambling and mood disorders. We also discuss diagnostic and treatment implications associated with these published findings.

Clinical description of compulsive gambling in manic depressive family members (Winokur et al. (1969), Manic Depressive Illness. Mosby, St. Louis. Printed with permission by Elsevier Press).

Among the male relatives of three female manic patients, five compulsive gamblers were found. The gamblers were the patients' fathers in three cases, a brother in one case, and a paternal uncle in another. The absence of base rates for “compulsive gambling” makes it difficult to assess whether these persons are over-represented in our sample, but clinical experience indicates that this syndrome is unusual in the general population. These gamblers were not discovered in a systematic fashion but were diagnosed during the open-ended part of the interview administered to the patients and their families; therefore, the true prevalence, even among our families, is unknown. Three of these gamblers were interviewed personally (2 fathers and 1 brother), and two case histories were obtained from family members. The life history and psychopathology in all of these gamblers were strikingly similar.

The gamblers showed neither unusual permissiveness nor rigidity in their upbringing, and gambling was universally disapproved. They all began gambling for money during late adolescence and quickly became noted for their interest in cards. They tended to associate with other teen-agers with similar interests; however, none of the patients had unusual school or legal difficulties. All gamblers graduated from high school without missing a grade; three attended college; two managed to obtain professional degrees. Throughout their schooling they gambled three to five times weekly, and this pattern continued during their adult life. Most gambling was done in the company of friends, but all five of them had frequently visited illegal casinos. None were ever arrested.

They all married during their early 20s, and it quickly became apparent that gambling was an insurmountable problem to their families. In four of the five cases, their wives were forced to work and maintain separate accounts. One gambler reported winning $300 on his wedding night and a further $800 during his honeymoon.

All the families reported chaotic finances and frequent bankruptcies as a result of the gambling. Three stormy marriages ended in divorce after an average of 12 years (separations were frequent). One gambler, age 35 years, was recently separated from his wife.

In all but the youngest gambler (age 33 years) frequent attempts were made to stop gambling without success. The gambling-free intervals lasted up to 6 months. The families and those gamblers interviewed all referred to a desire to stop gambling and an inability to control their gambling behavior once they started to play (i.e., loss of control). “Binges” of 48 h or more were common (with catnaps); and the games usually ended due to physical or financial exhaustion.

The most common pattern observed was for the gambler to begin playing in the late afternoon and continue late into the night and next morning. Weekends were often completely spent in gambling.

At the time of the study, two of these gamblers were dead (ages 61 and 64 years) and three were alive (ages 59, 61, and 33 years). Only one gambler (age 59 years) stopped gambling (with “great effort”) at age 45 but still had the “urge.” He was a teetotaler as regards games of chance even when money was not involved. The two gamblers who died gambled up until their terminal hospitalization.

The families felt the gamblers were good providers and gentle fathers when they were “winning” but hostile and irritable when losing. It seemed that their total existence was bound up with and fluctuated according to their compulsion.

None of the gamblers drank pathologically and all agreed that drinking heavily precluded gambling successfully. All the gamblers interviewed felt they were generous to a fault with their winnings but did not win “too often”.

In view of the strong family history of affective disorder, evidence for affective abnormalities was sought in these patients, yet little could be found. They were not hypomanic, unusually cyclothymic, or depressed, and none had ever had a clinical psychiatric illness. One gambler saw a psychiatrist for treatment of his gambling compulsion but was unable to afford more than a few sessions.

Many similarities between compulsive gambling and alcoholism were observed in these patients, including loss of control, binges, lifelong compulsive devotion to their habits, and a chaotic social result of their behavior.

Those gamblers who were interviewed were charming, quick-witted individuals, and all were excellent raconteurs. Their histories agreed in essence with those of their families. They all felt their compulsions had been destructive and uncontrolled, yet they boasted about their winnings. As in alcoholism, pious contrition was a frequent response to the marital difficulties they experienced.

Section snippets

Association of mood disorders and pathological gambling

Some authors have argued that pathological gambling (PG) patients share symptomatic and pathophysiological features with mood disorders. Published evidence indicates that the incidence of bipolar (8–31%) and unipolar disorder (28–76%) is significantly higher among patients who have PG compared to the overall population (see Table 1). However, the relationship is unclear and complex. McElroy et al., 1992, McElroy et al., 1995a, McElroy et al., 1996 reported a series of papers that portray how PG

Treatment implications

Treatment research in pathological gambling is still in an infantile stage. Two of the prevailing gambling treatment strategies involve psychotherapy and pharmacotherapy. Pharmacological treatments have primarily focused on the use of SSRI's. Kim and Grant recently reviewed the published SSRI treatment studies in gambling disorder by Hollander and others. Several open-label and case studies have indicated improvement with SSRI's (Kim and Grant, 2001, Grant and Kim, 2002). Three double-blind

Discussion

Pathological Gambling Disorder, like so many other DSM-IV psychiatric disorders, probably represents heterogeneous disorders with a variety of etiological roots. The primary goal of the present paper is to limit the study to the subsets in which there is an overlap between pathological gambling and mood disorder. Mood symptoms, be it manic or depressive, are bound to influence motivation to gamble and gambling behavior. Gambling behaviors, on the other hand, are also likely to modulate mood

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