Excellence at UMMC in Addressing Problem Gambling

This article is a part of University of Maryland Rounds, which features clinical and research updates from the University of Maryland School of Medicine and University of Maryland Medical Center. See more Rounds articles.

For some people, gambling isn’t a pastime, it’s a problem, one that comes with a medical diagnosis. Yet there is no typical patient. A problem gambler may be a young college student or an elderly woman, a CEO or an unemployed man, a stay-at-home mom hooked on lottery tickets or a widower who plays slot machines for hours.

In recognition of the severity of the problem, the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) that was revised two years ago by the American Psychiatric Association (APA) reclassified what was called Pathological Gambling in the section on Impulse Control Disorders, renaming it as Gambling Disorder and moving it to the section on Substance-Related and Addictive Disorders. Under this heading, gambling is the only condition included in a new category on “behavioral addictions,” sharing features with other addictions that include how the disorder presents clinically, its comorbid conditions, the stimulation of the brain’s reward system and approaches to treatment.

“What’s different with gambling addiction compared with other addictions is that there may be nothing that you will see physically, like shaking in a person who has an alcohol problem,” explains Christopher Welsh, M.D., an addiction psychiatrist and associate professor of psychiatry at the University of Maryland School of Medicine and the medical director of the Maryland Center of Excellence on Problem Gambling.

The figures for gambling participation in Maryland are sobering. A 2010 survey of households in the state that evaluated the prevalence of gambling reported that 15.3% of the population gambled weekly within the last year, 21.9% gambled monthly, and almost 90% had gambled at some point during the year. The types of gambling they engaged in ranged from casino gambling and the lottery (67.5% each) to sports events (32.9%), private games (30.2%) and horseracing (29.5%), as well as other forms of gambling. The report estimates that in Maryland, 3.4% of adults (about 150,000) have some degree of problem with gambling.

The Maryland Center of Excellence on Problem Gambling, a program of the University of Maryland School of Medicine’s Department of Psychiatry, is a valuable resource for people who think gambling has spun their lives out of control and those who have been identified with a gambling addiction.

Identifying the Problem

While the terminology has changed since the APA first classified problematic gambling as a mental disorder in 1980, the characteristics of gambling disorder remain essentially the same. The person has experienced periodic or continued loss of control over his or her gambling, including the amount of time and money spent; the problem is progressive; and the person continues to engage in destructive gambling behaviors in spite of being aware of the negative consequences. People who gamble in this way experience emotional distress; develop difficulties with their marital, personal and work relationships, often lying to cover up the problem; face financial difficulties as gambling depletes paychecks and savings; and sometimes face legal difficulties as a result of borrowing or stealing money to cover losses.

Gambling addiction also takes a physical toll. It is associated with a number of medical comorbidities including high blood pressure, gastrointestinal stress-related problems like ulcers, substance abuse disorders and sleep disorders, and has a high association with mood and anxiety disorders. But the mention of these concerns and their connection to gambling may not readily come up in a clinical encounter. “It’s a hard behavior to screen for. What’s important for the physician to understand is that many of these patients don’t think that what they do is gambling, like buying lottery tickets, for example. So if you ask the patient if they gamble they may say ‘no,’” says Dr. Welsh. If a gambling problem is suspected, “It’s important to bring up questions about financial issues, or how they spend their leisure time as you’re taking the patient’s social history. If you ask in a non-judgmental way with the intent to help the person deal with whatever their problems are, some people will open up.”

Getting Help

Two events in 2007 significantly influenced the place of gambling in the state of Maryland. The first was the adoption of Senate Bill 3, Maryland Educational Trust Fund — Video Lottery Terminals, that authorized the state to allow casino gambling. The second was the passage of two other bills allocating dedicated monies from gambling be placed in the Casino Problem Gambling Fund to be overseen by the Department of Health and Mental Hygiene

In 2012, the University of Maryland School of Medicine received an initial three-year, $5 million grant to establish the Maryland Center of Excellence on Problem Gambling, with a goal of creating a comprehensive statewide resource. This grant was just renewed for another three years. The Center provides a free 24-hour help line (1-800-GAMBLER) that is completely confidential. Often a person or family member will make the call, or a practitioner who identifies the problem in the office will make a referral. Callers are offered assistance in finding a mental health counselor trained in gambling addiction and a Gamblers Anonymous meeting in their area. 

Part of the charge of the Center is to train behavioral health professionals in diagnosing and assisting people with gambling addiction. So far the training has focused on mental health counselors, with plans to broaden the reach by offering training to other types of clinicians in the near future.

Although the new disease classification recognizes the existence of a gambling disorder, in most areas services for mental health and substance abuse are separate in terms of funding and treatment. It can often be unclear if a person needs to seek help for a gambling problem, an alcohol problem or both. What part of their insurance covers these services may also be unclear. “It’s still a struggle here in Maryland, as in other states, to figure that out. Part of what our Center does is help someone find the best place to get treatment that suits their needs,” Dr. Welsh says. “If the person with a gambling problem also has an alcohol problem, they would go to a substance abuse treatment center that has counselors who are trained to deal with gambling.”

Another mission of the Center is to increase public awareness about the symptoms of problem gambling and explain how to get help. This is accomplished through public service radio, television and on-line ads, billboards and educational videos. One film in particular, developed through a collaboration between the Center and MedSchool Maryland Productions called “Understanding Joy: The Devastation of a Gambling Addiction,” brings the message forcefully home. It is available on the Center’s website.

Do More Casinos Mean More Problem Gamblers?

Casino gambling is on the rise in Maryland. In 2012, Maryland had three casinos with slot machines. During that year, gross gaming revenues increased 142.6% over the previous year, largely due to the opening of the Maryland Live! Casino in Anne Arundel County and a full year of operation at the Casino at Ocean Downs and the addition of table games in the casinos. The Horseshoe Casino opened in Baltimore in 2014, and another is under development in Prince George’s County. It can certainly be said that greater availability of gambling opportunities has led to more participation in gambling, and will likely continue
to do so.

The question of whether an increase in opportunities for gambling is associated with an increase in problem gambling has been widely addressed in the global literature, with the frequent conclusion that such an association does exist. “We’re definitely getting more calls to the Center related to casinos, but are there more people with a problem or is it just more visible?” asks Dr. Welsh. For some people, the growing availability of places to gamble might mean switching or expanding their gambling — from buying lottery tickets to slots at casinos — potentially increasing their chances of developing a bigger problem. The Center is tasked with doing research on the impact of gambling in the state. A prevalence study to be conducted after the MGM Casino at National Harbor in Prince George’s County opens in 2016 promises to be revealing.

To reach Dr. Christopher Welsh at The Maryland Center of Excellence on Problem Gambling, call 667-214-2120.