Problem gambling: individual interventions in public health context

GAMBLING is a significant public health issue globally and particularly in Australia, which has the highest rates of gambling expenditure per capita in the world.

Analyses of official statistics were produced most recently for the 2017–18 financial year, when Australians lost $25 billion (summary table D) across products including electronic gaming machines ($12.7 billion), casinos [table games] ($4.9 billion), race betting ($3.5 billion), and sports betting ($1.0 billion).

These losses represent major sources of revenue for the gambling industry and Australian governments, with gambling taxation in Victoria, for example, comprising $1.6–$2.0 billion annually over recent years. This equates to 6.5–8.5% of all taxation revenue for the state.

Such amounts can be attributed to high exposure to gambling products and marketing in Australian jurisdictions. For example, Australia has been estimated to have 18% of the world’s electronic poker machines, which are distributed throughout communities in venues such as pubs and clubs (except in Western Australia). Gambling marketing is also pervasive with Victorian data indicating 948 gambling advertisements broadcast daily on free-to-air television in 2021. This does not count vast exposures via gambling sponsorship of sports clubs or events and on social media.

Gambling losses are not distributed evenly within the community, with analyses of the Household, Income and Labour Dynamics in Australia (HILDA) Survey in 2018 identifying that only 35% of adults spend money gambling in a typical month. Smaller numbers report gambling regularly on “high intensity” products (excluding lotteries), with 7.4% of adults reporting any spend on electronic gaming machines, relative to 6.4% for race betting, and 4.6% for sports betting. Such findings suggest that gambling losses are concentrated in small subsets of the population, which are distinguished by factors such as age, employment and disadvantage. For example, when compared with all Australian adults, regular electronic gaming machine gamblers are likely to be older, retired, living in areas of high disadvantage, and report government benefits as the main source of income.

Gambling problems, harms and treatments

In many instances, gambling can escalate to problematic levels characterised by persistent maladaptive behaviour that precede negative consequences or harms (eg, significant debt, relationship breakdown). These problems can be viewed as falling along a continuum of severity, which includes clinically significant conditions that may be described in terms of problem gambling or gambling disorder, as well as subclinical problems characterised by at least some problematic behaviour or harms.

Although studies suggest 7–8% of Australians annually report gambling problems across the continuum (although 1% report problem gambling), there are far higher rates among regular gamblers. For example, analyses of HILDA data indicate that 41.5% of regular electronic gaming machine players report gambling problems across a continuum, relative to 40.7% among those who spend money sports betting, and 44.7% among individuals who play casino table games. As such, rather than being framed as unusual occurrences, gambling problems should be viewed as common issues among Australians who are regularly exposed to these hazardous products.

Individual mental health treatments have traditionally had major roles in policy responses to harms from gambling, and target individuals at the extreme end of the continuum who have already experienced significant negative consequences. Gambling help services typically provide forms of psychological treatment that have demonstrated benefits in randomised trials. For example, our 2012 Cochrane review considered best available trials of psychological interventions for problem gambling and identified moderate to large short term benefits of cognitive behavioural therapies, as well as motivational interviewing approaches, albeit to a lesser extent.

However, these trials were commonly characterised by wait-list control groups that can inflate estimates of treatment benefits, while short term follow-up periods suggested uncertainty about the durability of gains. Although more recent searches have identified studies across subsequent years, this additional evidence remains modest, and it does not appear that the basis for conclusions in 2012 has substantially changed.

To a lesser extent, pharmacological interventions have also featured in literature on treatment options for problem gambling. However, this approach has been brought into focus by our recent Cochrane review of pharmacological therapies for problem gambling, which provides the gold standard reference for “what works” in treatment.

This involved a comprehensive search for randomised trials that identified 17 studies of problem gambling comparing any category of pharmacological intervention with a placebo or alternative drug treatment. Most studies (70%) were from the US and none were from Australia.

The medication classes included antidepressants (selective serotonin reuptake inhibitors and bupropion; nine studies), opioid antagonists (naltrexone and nalmefene; six studies), mood stabilisers (lithium and topiramate; four studies), and atypical antipsychotics (olanzapine; two studies). Data from these studies provided limited support for benefits of certain medication classes, with opioid antagonists associated with moderate improvements in symptom severity, while there were two small studies suggesting possible benefits of the atypical antipsychotic olanzapine.

In contrast, the review produced no clear evidence of benefits of antidepressants or mood stabilisers.

The aforementioned conclusions were framed in relation to a series of important caveats. First, the findings for all medication classes were characterised by low to very low certainty evidence, which reflects few trials and high risk of bias and inconsistency across studies. Thus, the magnitude of the benefits of opioid antagonists remains unclear and there is also uncertainty about atypical antipsychotics, given that findings were based on two small studies. Similarly, there is uncertainty about the lack of benefits of other medication classes, including mood stabilisers.

Second, most studies excluded participants with common comorbid mental health disorders. This is not uncommon in early studies of the efficacy of interventions, which often involve strict inclusion criteria that yield homogenous samples (with controlled conditions relaxed subsequently in studies in real-world settings). However, such criteria are likely to have major impacts on the generalisability of gambling treatment trials, given around 75% of patients who seek such treatment also report at least one other Axis I disorder (commonly mood, alcohol and anxiety disorders). It also remains plausible that pharmacological management of depression could reduce gambling behaviour in instances where depressive disorders are comorbid (eg, where individuals gamble to escape negative mood states).

Third, there are questions remaining about the tolerability of medications, with some studies providing limited data regarding adverse effects and dropout. Adverse effects for antidepressants and opioid antagonists were reasonably typical for these agents, with side effects of opioid antagonists including nausea, dry mouth, constipation, insomnia, dizziness, headache and diarrhoea.

By contrast, there was little consistency in adverse effects reported for mood stabilisers and atypical antipsychotics. Rates of dropout due to adverse effects were also highest for opioid antagonists, followed by antidepressants, atypical antipsychotics, and mood stabilisers. The lower dropout rate for atypical antipsychotics is unexpected given significant adverse effects typically associated with these agents, including sedation, weight gain and metabolic side effects, orthostatic hypotension, anticholinergic side effects, extrapyramidal side effects and hyperprolactinemia. It remains uncertain whether careful risk–benefit calculations would favour use of atypical antipsychotics for many patients with gambling disorder.

Policy and practice implications in the Australian context

The review findings are likely to have various implications across international jurisdictions, and thus should be considered in relation to important features of the Australian context.

These include a modest tradition of prescribing for gambling problems in Australia, and thus a limited role currently for pharmacological interventions in the gambling treatment system. This includes gambling help services that are mainly funded by state government agencies, often via hypothecated taxes on gambling revenue. Such services provide psychological supports that are embedded in counselling services that are not usually medically supervised.

Although we know of no published data regarding the extent of prescribing for gambling in other parts of the service system, there are no products approved by the Therapeutic Goods Administration for use with gambling, which means that any prescribing is “off-label” and likely associated with out-of-pocket costs and additional requirements (eg, ongoing monitoring).

Furthermore, the Royal Australian College of General Practitioners have not endorsed guidelines that relate to gambling, and it seems unlikely that pharmacological therapies for gambling would be common in primary care. In contrast, the Royal Australian and New Zealand College of Psychiatrists has adopted a position that tentatively endorses use of the opioid antagonist naltrexone when considered as part of a holistic treatment plan. As such, to the extent that there is prescribing for gambling problems in Australia, it presumably occurs in limited settings such as private psychiatric clinics or in public mental health services that have medical oversight.

The consideration of pharmacological therapies for gambling in Australia is thus in effect a discussion of the potential role of these of interventions relative to existing (psychological) treatment options.

Although randomised trials indicate that psychological treatments for gambling tend to have benefits in the short term, it remains unclear how closely interventions in help services typically reflect evidence-based programs. Moreover, a recent report from the Victorian Auditor General’s Office identified limited data regarding outcomes of such help services, and thus uncertainty about whether these are effective overall. Given additional evidence that less than a quarter of Australians who experience problem gambling annually access help services, it seems that pharmacological therapies may have useful roles in expanded service settings and could lead to more people benefiting from treatment.

However, in the context of requirements for medical supervision, as well as the risk of side effects, it would also seem sensible to position these as second line treatments that are considered when psychological therapies are not available or have failed to produce improvements in gambling symptoms or behaviour.

The expansion of evidence-based treatments for gambling should be a priority in Australia because of the high levels of gambling harm, which highlights a pressing need for initiatives to reduce such negative consequences. These may be positioned in relation to public health frameworks that identify different levels of intervention that should all feature in comprehensive policy responses to harms from gambling. They include programs for individuals who are already experiencing gambling problems and encompass treatment services and interventions for the severe end of the continuum, and low intensity programs for subclinical or at-risk gambling. Individual interventions featured prominently in early attempts to articulate public health approaches to gambling, although comprising smaller parts of recent accounts that have emphasised environmental drivers of gambling harms.

Proposed policy interventions at this level target features of the accessibility, design and marketing of gambling products; for example, via regulation and reductions in the distribution of electronic gaming machines, mandatory pre-commitment schemes for machines (which may involve caps on expenditure), as well regulations on marketing that limit times and platforms for gambling advertising. This literature has also addressed commercial factors that provide conditions for harm, including relationships with the gambling industry and policymakers (eg, via taxation revenue) and researchers (eg, via project funding), which create conflicts of interest and opportunities to distort public health agendas. Proposed interventions addressing these issues include policies requiring researchers to provide full disclosures of funding sources, restrictions on researchers and government representatives attending forums or conferences supported by the gambling industry, and policies requiring de-identified data about gambling products to be made available to researchers as a condition of licensing (removing the need for relationships with industry to access data).

Although the evidence associated with strategies for responding to these drivers of gambling harm is underdeveloped, the bases for relevant policies are strengthened by parallels with responses to other harmful products, such as tobacco and alcohol.

When positioned in the context of a public health framework, individually focused treatments including pharmacological therapies can be viewed as having small but important roles in comprehensive strategies that are needed to reduce gambling harms. This role for treatment in responding to gambling problems and reducing future harm is essential to recognise, along with the need for sustained investment and initiatives to increase access and embed principles of continuous improvement in help services.

The latter may involve enhanced programs of training and supervision to ensure services align with best-practice psychological treatments, as well as standardised outcome monitoring systems that can track and provide feedback on client progress and may be paired with external clinical quality assurance. They may also include targeted care coordination programs that should enhance access to services for co-occurring conditions, as well as medical providers who could prescribe pharmacological treatments in limited circumstances.

However, it is critical to recognise that gambling treatments must not be considered in isolation from other levels of intervention and should not comprise the major form of policy response to gambling harm.

There must also be vigilance for attempts to use such programs to divert attention away from the harmful features of gambling products or environments. Policy interventions at this level are urgently needed to prevent harms from gambling, and are likely to involve major overall reductions in gambling revenue and taxation.

Accordingly, these policies are likely to be opposed or delayed by both industry and government agencies with vested financial interests.

Although there is no inherent reason that high quality evidence-based treatments for gambling should preclude other forms of public health interventions, it is critical that vested interests are recognised and that any discussion of new treatment approaches does not distract from the need for policies that address the environmental and commercial drivers of gambling harms. The treatment research advocated by our Cochrane review must therefore be seen as a compliment to rather than substitute for preventive policy research and action.

Sean Cowlishaw is a Senior Research Fellow at the Phoenix Australia Centre for Posttraumatic Mental Health at the University of Melbourne’s Department of Psychiatry.

Greg Roebuck is a Psychiatry Registrar at the Phoenix Australia Centre for Posttraumatic Mental Health at the University of Melbourne’s Department of Psychiatry.

Dr Rahul Khanna is a psychiatrist and Director of Innovation and Medical Governance at the Phoenix Australia Centre for Posttraumatic Mental Health at the University of Melbourne’s Department of Psychiatry.

Dr John Cooper is a consultant psychiatrist at the Phoenix Australia Centre for Posttraumatic Mental Health at the University of Melbourne’s Department of Psychiatry.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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