Prevalence of gambling disorder

Due to the absence of research data, the prevalence of gambling in Ireland is unknown. According to the National Lottery Annual Report (National Lottery 2013), it is estimated that 64% of all adults played National Lottery in Ireland in 2012. The Institute of Public Health in 2010 estimated that between 0.6% and 1% of Irish people have gambling problems (Institute of Public Health in Ireland 2010). Around 0.2–1.2% of the world population are reported to meet the criteria for pathological gambling (Shaffer et al. Reference Shaffer, LaBrie, LaPlante, Nelson and Stanton2004). According to the British Gambling Prevalence Survey, it is reported that 73% (35.5 million) of the adults in United Kingdom engaged in some form of gambling activity in 2010. The British National Lottery was the most common gambling activity (59% in 2010), followed by buying scratch cards (24%). Only 5% of people gambled on the internet while 4% used fixed odds betting terminals (Wardle et al. Reference Wardle, Moody, Spence, Orford, Volberg, Jotangia, Griffiths, Hussey and Dobbie2011). The next gambling prevalence survey results are expected to be published in 2014.

Using the DSM–IV criteria, the prevalence of problem gambling in adults aged 16 years and above in United Kingdom was 0.9% (451 000 aged 16 years and above) and 0.7% using the PGSI Problem Gambling Severity Index in 2010 (Wardle et al. Reference Wardle, Moody, Spence, Orford, Volberg, Jotangia, Griffiths, Hussey and Dobbie2011). In Australia, using the Canadian Problem Gambling Index, the prevalence of problem gambling was estimated to be 0.5–1% (80 000–160 000 adults) and a further 1.4–2.1% being at moderate risk of problem gambling (230 000–350 000 adults) (Productivity Commission 2010). If we extrapolate the United Kingdom prevalence to Ireland using the 2011 population census of Ireland, around 25 000 to 32 000 people suffer from gambling disorder in Ireland. These numbers are significant due to the paucity of services addressing gambling disorder and the proposed changes in gambling legislation.

Gambling legislation and proposed gambling control bill 2013

According to the Gaming and Lotteries Act of 1956, the maximum stake allowed in licensed amusement halls and funfairs is 6 penny per player and the maximum prize is 10 shillings. Hence in practice, this act is not enforced by the Irish State (Department of Justice, Equality and Law Reform 2008). The Irish Government over the last several years set up different task forces, groups, and committees on gambling with no change being made to the existing gambling legislation in Ireland until now. The last report titled ‘Options for Regulating Gambling’ published in December 2010, recognised the need for change to the existing outdated gambling laws and the potential dangers of gambling, but did not ignore the financial benefits of a well regulated gambling industry (Department of Justice 2010).

Finally in July 2013, the Government published the general scheme for the Gambling Bill. Under the proposed bill (Department of Justice 2013) which includes betting and gaming, the number of casinos in Ireland will be limited to 40 and no casinos will be permitted to have more than 15 tables. This rules out super casinos like the one that was proposed for Two-Mile-Borris (http://www.rte.ie/news/2013/0715/462577-gambling-control-bill/). In line with current trends, this bill has separate provisions for remote gambling including on-line and telephone gambling. Furthermore, this bill separates bingo from lotteries (currently bingo is a lottery). Another significant part of the planned legislation is the complete ban on fixed odds betting terminals. Fixed odds betting terminals are mechanical devices in which a person can bet a minimum amount with fixed odds of winning and there is always a ceiling on the amount a person can win. Games like roulette, bingo and simulated horse racing can be played on these mechanical devices and they are a common sight in betting shops. Since 1986, National Lottery has been governed by a separate Act of the Irish Constitution and this new bill does not apply to the National Lottery which is currently regulated by a 2013 Act (Irish Statute Book 2013).

During times of debate about sponsorship of sporting and other events by the alcohol industry, it is of interest that this Bill has provisions for sponsorship of events by the gambling industry. Also this Bill provides age restrictions for gambling and employing people in gambling industry (18 years or above for both). Another part of the Bill is the plan for a ‘Social Fund’ provided by the service license holders and administered by a new state entity, the Office for Gambling Control, Ireland (OGCI). This Office will be answerable to the Minister for Justice, Equality and Defence and will be supervised by a ‘Socially Responsible Gambling Committee’ which is to include people from outside the gambling industry. This fund plans ‘to promote socially responsible gambling’ and ‘assist in counter-acting the ill-effects of gambling’. According to the proposed bill, OGCI under the Minister will be the regulating body for issuing licenses, enforcement and other provisions under this bill. The Minister for Justice also hopes to include through this bill, powers to prohibit or restrict certain games or devices in the future if they are found to be detrimental, including those that are not currently in use.

Gambling disorder: an impulse control disorder or a medical disorder?

The proposed bill assumes greater significance with the recent classification of Gambling Disorder under Substance Use Disorders in DSM 5 (American Psychiatric Association (APA) 2013). Gambling disorder was previously classified as a ‘disorder of impulse control’ in the DSM IV (APA 1994). This classification is a major step in recognising the addictive nature of gambling and its similarities with other addiction behaviours. Gambling disorder has been long considered a medical disorder along with other addictive behaviours by experts in this field. This has been strengthened by the recent policy statement on the definition of addiction by the American Society of Addiction Medicine which defined addiction (including gambling) as a ‘primary, chronic disease of brain reward, motivation, memory and related circuitry’ (ASAM 2011). To support this, functional imaging and neuropsychological studies in problem gamblers have suggested that the ventro-medial pre-frontal cortex may be involved in cognitive features of gambling like the effects of ‘near-miss’ outcomes in gambling (Lawrence et al. Reference Lawrence, Luty, Bogdan, Sahakian and Clark2009; Potenza Reference Potenza2001). Significantly, the prevalence of pathological gambling in Parkinson’s disease described as being secondary to dopamine agonists has been reported to be 1.7–7%. This is relatively high when compared with the prevalence of pathological gambling in the general population which is around 1% (Fujimoto Reference Fujimoto2008). Interestingly, the role of dopamine in the aetiology of gambling has also been supported by recent case reports which describe an increase in gambling activity with the partial agonist antipsychotic Aripiprazole (Smith et al. Reference Smith, Kitchenham and Bowden-Jones2011). All these strengthen the case for gambling disorder to be classified as a medical disorder with other addiction behaviours rather than as a ‘habit and impulse control disorder’ (as classified under ICD10). It is also to be remembered that problem gambling short of pathological gambling (defined as Gambling Disorder under DSM 5) can also produce individual and societal consequences, including progression to pathological gambling, at which level the ability to control one’s own behaviour diminishes.

Co-morbid conditions and risk factors for gambling

The prevalence of depression is reported to be around 50% among those with pathological gambling and anxiety disorders have also been commonly reported among pathological gamblers (Kim et al. Reference Kim, Grant, Eckert, Faris and Hartman2006). Furthermore, manic disorder has been described to be prevalent among nearly one-fourth of those with a diagnosis of pathological gambling (Lesieur & Anderson Reference Lesieur and Anderson1995) although a diagnosis of mania should exclude the diagnosis of pathological gambling. Of significance, the risk of suicide increases in gamblers with nearly 48–70% having thoughts of suicide and up to 20% having a history of para-suicidal attempts (Frank et al. Reference Frank, Lester and Wexler1991). Also, in non-clinical samples, alcohol-related problems were found to be prevalent among nearly 40% of those with pathological gambling in their life time (Abbott et al. Reference Abbott, Williams and Volberg1999).

Genetics play an important role in gambling disorder and are considered a significant risk factor. To support this, meta-analysis of twin and family studies on gambling showed a significant familial association of gambling disorder among sons of gambling fathers (Walters Reference Walters2001). Shared genetic vulnerability has also been demonstrated by increased levels of substance misuse disorders among first degree relatives of those with pathological gambling (Petry et al. Reference Petry, Stinson and Grant2005). According to the British Gambling Prevalence Survey 2010, being male, young, a cigarette smoker and having parents with gambling problems was the common profile of problem gamblers (Wardle et al. Reference Wardle, Moody, Spence, Orford, Volberg, Jotangia, Griffiths, Hussey and Dobbie2011). In addition, the Productivity Commission of Australia describes the risk factors for problem gambling to include increased accessibility to legalised gambling, being less than 25 years of age, living in an urban area, being socially disadvantaged and being separated, divorced and unemployed (Productivity Commission 1999).

Gambling disorder and its societal implications

In addition to above co-morbid health conditions, gambling disorder impacts on societal issues such as property crime, divorce, unemployment and bankruptcy. In a study conducted among pathological gamblers, two-thirds of those with a history of criminal offences reported doing so as a direct consequence of their gambling activity (Blaszczynski et al. Reference Blaszczynski, McConaghy and Frankova1989). For every pathological gambler, 10–15 others around that person are directly affected. When it reaches a certain intensity, society bears the cost in terms of social welfare, treatment service, gardai and prison services (Lesieur Reference Lesieur1998). Furthermore, gambling disorder affects spouses in a number of ways such as loss of trust, financial worries, future worries, lack of intimate relationship and eventually leads to divorce in many cases (McComb et al. Reference McComb, Lee and Sprenkle2009). Although a small percentage of pathological gamblers commit serious offences, most crimes are otherwise non-violent property crimes such as forgery, fraud, larceny, embezzlement and tax evasion (Blaszcynski & Silove Reference Blaszcynski and Silove1996). Bankruptcy is another major issue associated with gambling disorder. Estimates of bankruptcy associated with pathological gambling ranges from 45.4% in Las Vegas to 23% in Wisconsin and Connecticut in the United States (Schwer et al. Reference Schwer, Thompson and Nakamuro2003). In addition, unemployment is a major issue associated with gambling disorders and it has been estimated that up to 40% of those with gambling disorder are unemployed (Bland et al. Reference Bland, Newman, Orn and Stebelsky1993). Moreover, it has been reported that only around 20% of pathological gamblers are effective at work when they continue in employment (Politzer et al. Reference Politzer, James and Sandra1981).

Screening for gambling disorders

Although ICD 10 is still used by many health professionals in Ireland, it is not the best one for diagnosing gambling disorder. With the recent publication of DSM 5, gambling disorders could be better diagnosed using those criteria. Alternate criteria would include South Oaks Gambling Screen although it has been reported to over diagnose gambling disorders (George et al. Reference George, Henrietta Bowden-Jones, Orford and Petry2013a). Gamblers Anonymous (GA) use a questionnaire consisting of 20 questions. However, due to time constraints in busy outpatient psychiatry clinics, short questionnaires like NODS-CLiP (Toce-Gerstein et al. Reference Toce-Gerstein, Gerstein and Volberg2009) can be used. It consists of three questions:

1. 1. Have there been periods lasting 2 weeks or longer when you spent a lot of time thinking about your gambling experiences, or planning out future gambling ventures or bets?

2. 2. Have you ever tried to stop, cut down, or control your gambling?

3. 3. Have you ever lied to family members, friends or others about how much you gamble or how much money you lost on gambling? And if so has this happened three or more times?

Importantly, NODS-CLiP has been reported to identify virtually all pathological gamblers and 90% of problem gamblers (Toce-Gerstein et al. Reference Toce-Gerstein, Gerstein and Volberg2009).

Treatment approaches for gambling

Publicly funded treatment facilities for gambling disorder are very limited in Ireland and are provided largely by private hospitals and private treatment centres. GA is one self funded service available across the country and its meetings are based on the 12-step recovery programme model. However its effectiveness has been questioned due to absence of strong evidence in the treatment of gambling disorder. Also, Gam–A-Teen is a fellowship for children of those having gambling disorders and Gam-Anon is a similar one for friends and family members of those struggling with gambling (George et al. Reference George, Ijeoma and Bowden-Jones2013b). Various treatment approaches have been tried worldwide in the management of gambling with limited benefit in the long term. Cognitive behavioural therapy on an individual basis (Hodgins & Petry Reference Hodgins and Petry2004), behavioural approaches involving aversion therapy or imaginal desensitisation and GA have been reported to be beneficial in gambling disorders (Brown Reference Brown1985). Family therapy (McComb et al. 2009), psychodynamic psychotherapy (Fong Reference Fong2005), cognitive re-structuring, social skills training, problem solving and relapse prevention have also been successfully used in the management of problem gamblers (Bujold et al. Reference Bujold, Ladouceur and Sylvain1994). Although the Cochrane review on the treatment of gambling concluded that there was no clear evidence for the effective treatment of pathological gambling, it reported that cognitive behavioural therapy had better outcomes (Oakley-Browne & Mobberly Reference Oakley- Browne and Mobberly2002). Furthermore, inpatient treatment programmes have been reported to be effective only in around half of the patients at 6-month follow-up (Taber et al. Reference Taber, McCormick and Russo1987). Regarding pharmacological treatments, medications such as carbamazepine, clomipramine, fluvoxamine, naltrexone and lithium have been used with minimal effect in the treatment of pathological gambling (Kim Reference Kim1998; Petry & Armentano Reference Petry and Armentano1999; Hollander et al. Reference Hollander, Pallanti, Allen, Sood and Baldini Rossi2005). In the main, pharmacological treatments are ineffective in the treatment of gambling disorder although medications can be used to treat co-morbid mental health conditions.

Factors to be considered before enacting the proposed Gambling Control Bill 2013

1. 1. It is important that baseline epidemiological data on gambling disorder are obtained before enacting the proposed bill. This will help to assess changes over time following the implementation of the proposed Gambling Control Bill, without which future evaluation will be crippled.

2. 2. In addition, subsequent epidemiological surveys on gambling disorder and co-morbid conditions should be planned in advance of the enactment of the gambling legislation. There should be a clear mechanism in the proposed bill to study the development of gambling disorder (to include problem gambling and pathological gambling which is currently defined as gambling disorder) at regular intervals (e.g. at 2, 5, 10, 15, 20 years and so on). This should be funded by the ‘Social Fund’ as proposed in the Gambling Bill.

3. 3. In the absence of credible data on the influence of sponsorship of sporting events by the Gambling industry, this issue needs further discussion before it is incorporated in the proposed legislation.

4. 4. Although a ‘Socially Responsible Gambling Committee’ has been proposed, it needs to be better defined in terms of their functions and composition. Possibly, this committee could be established as a freestanding foundation or an independent body (perhaps in an academic setting) instead of being linked to the OGCI under the Minister for Justice, Equality and Defence.

5. 5. This independent committee or freestanding foundation should administer the ‘Social Fund’ instead of the OGCI as otherwise there will always be a risk of the revenue generated being used predominantly for general public expenditure rather than being spent on issues associated with gambling.

6. 6. Also, there should be a clearly structured plan for the use of public funds generated from gambling revenues in such a way that gambling-related problems are funded (e.g. treatment, rehabilitation, child care, spousal support, property-related problems). If excess revenues are generated, one-time expenditures that benefit society could be devised. However, this should not involve on-going expenditures.

7. 7. It is also essential to consider the potential economic implications of gambling revenues on the body politic before enacting this legislation. Law makers need to be cautious about the use of revenue generated and gambling should not be encouraged by any means for meeting the general expenditure of the state.

8. 8. Although the proposed gambling bill limits the age of gambling to 18 years or above, there should be provisions included in the bill to protect other vulnerable sections of the society such as the elderly, disabled and those with serious mental illness.

9. 9. Furthermore, there is always the possibility that nationals of other countries will use Irish gambling facilities because they are not available in their country-of-origin. Ireland could be blamed for medical and social consequences of this gambling due to such activities and the government should be willing to address such political consequences.

In summary, these recommendations arise out of problems and mistakes experienced elsewhere. An advantage of implementing the new gambling legislation at this time is to use the hard-won lessons in other nations, rather than repeating them.