Problem gambling: what can
psychiatrists do?
Dr Sanju George
Consultant and honorary senior lecturer
in addiction psychiatry, Solihull
Focus of this talk
• Why psychiatrists should do more and what
they can do to help Britain’s problem gamblers
Declaration of interests
• I am on the National Responsible Gambling Strategy
Board (advises the Government on education,
research and treatment aspects of gambling) – views
expressed here are my own and not the Board’s
• I (my NHS Trust) was awarded a grant by the
Responsible Gambling Fund (now the Responsible
Gambling Trust) to study the gaps in identification of
gambling problems by mental health professionals.
Definition of gambling
• Gambling is betting something of value
(usually money) on an event (usually a game)
whose outcome is unpredictable or
determined by chance.
Gambling in Britain
• Nearly 70% of Britons had participated in at
least one gambling activity in the past 12
months.
• Most popular gambling activities were
National lottery (57%), scratch cards (20%),
betting on horse races (17%) and fruit/slot
machines (14%).
Gambling in Britain
• Gambling, for the large majority is a normal
and socially – sanctioned leisure activity
• But for a significant minority, gambling can
progress from being a recreational activity to
being a problem or addiction.
• 0.9% of the population are problem gamblers
and an additional 7.3% are ‘at risk’ gamblers
Definition of problem gambling
• Gambling that disrupts or damages personal,
family or recreational pursuits
The gambling continuum
Gambling disorder in DSM V
• Will be re-classified in DSM-5 in the category
of addictive disorders.
• Terminology will change to gambling disorder
Why should psychiatrists do more?
• 1. Co-morbidity:
– Around 50% of problem gamblers also suffer from a
co-existing psychiatric disorder - most common
conditions are depression, anxiety, substance misuse
and personality disorders.
– Patients seeking treatment for psychiatric disorders
are much more likely than the general population to
suffer from gambling problems – e.g. prevalence of
gambling problems among treatment-seeking
substance misusers is between 5% and 30%
Why should psychiatrists do more?
• 2. Despite such high rates of comorbidity
gambling problems often go undetected and
unaddressed, possible reasons: patients’
reluctance to discuss gambling behaviours
(due to shame, stigma and guilt); and
psychiatrists’ lack of awareness and
knowledge of the condition.
Why should psychiatrists do more?
• 3. Problem gambling if untreated can have
wide ranging negative impacts on the
individual (physical and psychiatric disorders
and financial difficulties), family (interpersonal
relationship problems, domestic violence, and
negative impact on children) and society
(crime and absenteeism at work)
Why should psychiatrists do more?
• 4. There are easy to use screening tools and
brief psychological interventions for problem
gambling that can be readily used in mental
health settings.
• 5. Early intervention can very often result in
significantly positive outcomes
What can psychiatrists do?
• Psychiatrists can and should attempt to screen
their patients (at least the high risk ones) for
problem gambling, and when patients screen
positive, offer brief psychological
interventions where possible, and where this
is not feasible refer them to specialist services.
Screening for problem gambling
• There are several gambling screening tools
available but there is no one ‘gold standard’
measure.
• The Problem Gambling Research and Treatment
Centre (2011) evaluated the brevity, sensitivity,
validity and reliability of 16 of the better known
problem gambling screening tools and came up
with a short list of 7 ‘recommended’ tools
Screening for problem gambling
• Categorized into short, medium and long
screening tools
• Short: these consist of three or fewer
questions.
• Medium: 9 questions
• Long: 14 to 21 questions
A short gambling screening tool: the
Lie/Bet questionnaire
• Have you ever felt the need to bet more and
more money?’
• Have you ever had to lie to people important
to you about how much you gamble?
• An affirmative response to either question is
considered a positive screen and identifies a
person with gambling problems
The Birmingham Adult Gambling Screen (BAGS)
(Orford, J, George, S, and Rusling, L, 2011).
• In the past 12 months how often….
1) Have you bet more than you could really afford to lose?
Almost always (3) most of the time (2) some of the time (1) never (0)
2) Have people criticised your betting, or told you that you have a gambling
problem, whether or not you thought it is true?
Almost always (3)
most of the time (2)
some of the time (1)
never(0)
3) Have you felt guilty about the way you gamble or what happens when
you gamble?
Almost always (3)
most of the time (2)
some of the time (1) never
(0)
Scoring BAGS
• The scoring range for the screen is zero to nine.
• A score of zero means no problem, a score of one
suggests a possible gambling problem, and we
suggest offering information to those people who
score one on gambling responsibly (could use the
RCPsych leaflet on problem gambling)
• A score of two or more indicates problem
gambling, warranting a brief psychological
intervention and/or referral to a specialist
service.
Brief interventions for problem
gambling – what are they?
• Brief interventions (BIs), are by definition brief
psychological interventions designed for use
with people who use addictive substances or
engage in behaviours (such as gambling)
problematically but who have not yet
developed a full-blown addiction.
Brief interventions for problem
gambling - Rationale
• The rationale is that such brief interventions
will prevent the progression of the addictive
disorder, and they are ideal low - cost, high volume interventions that can be delivered by
non-specialists in non-specialist settings.
Birmingham Gambling Intervention
Tool (B – GIT)
• Easy to use BI tool, originally developed by
Petry and recently adapted for use in the UK
(Rusling L, George S, Orford J, 2011)
• Only takes 10 to 15 minutes
B – GIT : Step 1
• In step 1 the concept of gambling continuum
and the meaning of these terms are explained
to the patient.
• Then, using a pi chart the person is given a
percentage breakdown of how people gamble
- i.e. relative breakdown of non-gamblers,
recreational gamblers, at risk gamblers and
problem gamblers in the general population.
Step 1
Step 1
B – GIT : Step 2
Step 2 involves discussing the harms
associated with problem gambling: these
include financial harms, family harms, health
harms and negative impact on work.
figure
B – GIT : Step 3
• Step 3 consists of discussing simple and
practical measures to reduce gambling such
as:
– limiting the amount of money one spends
gambling
– reducing the amount of time and days spent
gambling
– not to view gambling as a way to make money
– to spend time instead doing other non-gambling
activities.
B-GIT – Step 3
Where BIs are not feasible or
sufficient
• Refer to gambling treatment services.
Themes for further discussion
•
•
•
•
Current treatment provision
Future commissioning
Specialist vs generic treatment services
Ethical aspects of funding treatment services
Conclusion
• Problem gamblers often go unrecognised and
un helped in psychiatric settings
• Untreated problem gambling can have
significant adverse consequences
• Early interventions can improve outcomes
• Psychiatrists should do more (screening and
brief interventions) to help problem gamblers
Useful web links
1. Royal College of Psychiatrists’ information leaflet
(www.rcpsych.ac.uk/metal
healthinfo/problems/problemgambling.aspx)
2. GamCare (www.gamcare.org.uk)
3. Gamblers Anonymous
(www.gamblersanonymous.org.uk)