Gambling disorder
Gambling addiction was reclassified as ‘Gambling Disorder’ in DSM 5 (American Psychiatric Association, 2013) within the new ‘Substance-Related and Addictive Disorders’ section. Prior to this it was situated in the ‘Impulse Control Disorders’ section which includes the disorders trichotillomania and pyromania. This was to due to a significant amount of evidence presented to the DSM 5 working group on the overlap of Gambling Disorder with alcohol and substance addictions. Key clinical features of Gambling Disorder substantially overlap with those of alcohol and substance addictions. Tolerance, irritability on cutting down, repeated unsuccessful efforts to control, preoccupation, distress, lies, loss of relationships, loss of occupation, loss of opportunities and relying on others to relieve financial distress are all clinical features that are equally prominent in Gambling Disorder as they are in alcohol and substance addiction. In addition, Gambling Disorder and substance addictions share similar psychiatric comorbidities (Petry et al. Reference Petry, Stinson and Grant2005). Elevated rates of psychiatric and addictive comorbidity are found in Gambling disorder (Petry et al. Reference Petry, Stinson and Grant2005; Kessler et al. Reference Kessler, Hwang, LaBrie, Petukhova, Sampson, Winters and Shaffer2008). Meta-analysis (Lorains et al. Reference Lorains, Cowlishaw and Thomas2011) indicates the highest rate of comorbidity with Gambling Disorder is nicotine dependence (60%) followed by substance use disorder (58%), any type of mood disorder (38%) and any type of anxiety disorder (37%). Furthermore, Gambling Disorder, like alcohol and drug addiction attracts considerable public stigma (Hing et al. Reference Hing, Russell, Gainsbury and Nuske2016). The reclassification of Gambling Disorder in the addictions section of DSM 5 also occurred as a result of accumulated scientific evidence revealing the underlying brain substrates in Gambling Disorder (Bowden-Jones & Clark, Reference Bowden-Jones and Clark2011). First, functional magnetic resonance imaging demonstrated impairment of ventromedial prefrontal cortex functioning, an area of the brain thought to be critical in risk processing (Potenza, Reference Potenza2008). Second, various neuropsychological data support faulty risk evaluation and persistence with gambling in the face of adverse consequences (Bowden-Jones et al. Reference Bowden-Jones, McPhillips, Rogers, Hutton and Joyce2005; Goudriaan et al. Reference Goudriaan, Oosterlaan, de Beurs and van den Brink2006; Lawrence et al. Reference Lawrence, Luty, Bogdan, Sahakian and Clark2009). The reclassification of gambling addiction in DSM 5 as an addictive disorder further strengthens calls on the current Government to modernise gambling legislation, alongside alcohol and drug legislation.
Gambling control bill 2013
Gambling in Ireland is still operated under the outdated 1931 Betting Act (Office of the Attorney General, 1931) and the 1956 Gaming and Lotteries Act (Office of the Attorney General, 1956). Under this legislation, casino gambling in Ireland is illegal however Irish casinos have sidestepped this legislation by operating as private members clubs, which are excluded from the 1956 legislation. Minister Alan Shatter, Minister for Justice, Equality and Defence approved the general scheme of the Gambling Control Bill in 2013. Continued drafting of the Bill was expected towards final enactment however a time frame was not specified. Since then, the Bill appears to have slipped from legislative priority. As the years have passed since 2013, successive governments have generally indicated that drafting of the Bill was imminent. Unfortunately there has been no movement on drafting and enactment of the Bill. One of the consequences of this inaction is that is that there is no national treatment framework for those suffering from Gambling Disorder.
Treatment and management of gambling disorder
Specialist units are required in Ireland to provide community based and residential treatment for Gambling Disorder. Referrals to these services will likely vary in severity from mild whereby 4–5 of DSM 5 diagnostic criteria for Gambling Disorder are met to severe where 8–9 are met. Severe Gambling Disorder is associated with increased suicidal ideation, suicide attempts and completed suicides (Russo et al. Reference Russo, Taber, McCormick and Ramirez1984; Black et al. Reference Black, Coryell, Crowe, McCormick, Shaw and Allen2015), hence the need at times for intensive monitoring in the inpatient setting. Clinical teams should be Consultant Psychiatrist led, multidisciplinary in nature, comprising of input from psychiatry, psychology, addiction counselling, family therapy, debt management, bereavement counselling and a range of complimentary therapies. In addition a key focus of these units should be on closing the research gap on gambling data in Ireland. Enactment of the Gambling Control Bill will provide for the establishment of a ‘Social Gambling Fund’ whereby land based and remote gambling operators based in Ireland and other jurisdictions will contribute a levy. This levy will be based on turnover of the operator and will be mandatory. As the turnover of gambling operators in general tends to be high, this should ensure the fund for service provision and research is substantial. This should hopefully enable the development of treatment services for Gambling Disorder throughout the country as well as much needed research facilities.
Conclusion
Although we currently do not have data on the prevalence of Gambling Disorder in Ireland, our clinical observations on presentations for treatment suggest it is an increasing problem. This appears to be as a result of the increased availability of gambling both within bookmakers and online. There are no current controls on the vast amount of gambling adverts in the popular media and online. Recent changes in the classification of gambling addiction to the ‘Substance Related and Addictive Disorders’ in DSM 5 is due to the overlap of Gambling Disorder with alcohol and drug addiction both clinically and scientifically. This change has added further weight to the call for implementing a modern regulatory framework for gambling in Ireland. The Gambling Control Bill of 2013 was due for drafting and enactment following the publication of its general scheme in 2013. It appears to have slipped from legislative priority since then however. The Gambling Control Bill represents a decent starting point in developing player protection and much needed treatment services and research facilities for Gambling Disorder. The sooner this bill is enacted the better.
Acknowledgements
The author, Dr. O’Gara asserts that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
Financial Support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of Interest
The author has no conflicts of interest to disclose.
