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PATHOLOGICAL GAMBLING Gambling addiction: screening for this health problem • Pathological gambling is a chronic, progressive disease which can be complicated by addiction and can even be fatal.

Many people gamble but not all of them have a gambling problem.

• Pathological gambling affects the patient physically, professionally, emotionally, financially, and spiritually. The family suffers and children can be affected for life.

People who become addicted to gambling can be categorised as having a health problem.

• Among Montréal’s adult population, about 1% show enough symptoms to be considered pathological gamblers. This rate is even higher among adolescents.

Diagnosis, treatment, and secondary prevention are indicated for these individuals and people close to them.

Determining factors A pathological gambler’s history often includes a parent who had a gambling problem or who was absent, negligent, or abusive. In general, pathological gamblers have more adaptation problems and have difficulty with problem solving. For them, gambling often represents a refuge where they can escape from their day-to-day problems, and alleviate their deepest psychological pain. Most of the time, they believe that they can influence, predict, or control the outcome of the game.

Whether it is government-sponsored or not, access to gambling is another important factor. Among the various types of games available, video lotteries and slot machines seem to be more addictive than other types. Therefore, the fact that currently, in Montréal, 7300 of these machines are accessible (4300 video lottery machines and 3000 slot machines) is significant.

Since modern society offers fewer collective life experiences, gambling is more broadly symptomatic of a quest for meaning and happiness satisfied by money, which is valued in our society. Moreover, to a gambler, gambling can appear to be prestigious, and provide a sense of belonging and support from a group, thereby encouraging regular participation.

As a result of these problems, and of economic loss and accumulating debt, stress makes family and other relations “sick”. Spouses might receive threatening telephone calls from creditors or have to work more to pay back loans taken out jointly. They may often feel that their trust has been betrayed. Sometimes the children of gamblers will even

develop psychological problems and perpetuate the cycle. In general, gamblers and their families suffer for many years before asking for help. Gamblers may even go as far as killing themselves to put an end their problems.

Related issues Other problems often accompany problem gambling. Depression, alcoholism, drug abuse, suicidal ideation, and negative character traits are often found among gamblers. In addition, 60% of pathological gamblers have previously committed crimes to support their gambling habit.

February 2002

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Keep your eye opens and stay alert! Pathological gamblers rarely complain to physicians about this health issue. Instead, they may consult for symptoms related to the following problems: stress, anxiety, depression, sleeping problems, gastrointestinal problems, financial or marital problems, alcoholism, drug abuse, or suicidal ideation. Among all the diagnostic options to con-

sider, the possibility that a patient is suffering from a gambling problem should also be explored. When inquiring about the patient’s lifestyle, the physician should ask clearly and directly if he or she gambles and if gambling is a problem. If need be, we suggest you follow these steps:

Symptomatology suggests gambling: ask about gambling habits

Does the person have a gambling problem? Is the person suicidal?

Suspicion: proceed with the mini screening test

Positive: check for suicidal ideation

Presence of suicidal ideation: suggest treatment or refer to a crisis centre

Is the person open to treatment?

Denial is particularly common among people with an addiction. To reduce the propensity for denial: • talk about dependency as you would about other health problems; • avoid the words “pathological” and “compulsive”;

What should you do? Does the person gamble?

Can we offset denial?

Negative: give the patient information, evaluate other morbidity

• tell these patients that gambling is a common form of entertainment but that sometimes it becomes a progressive disease that affects other important aspects of life; • offer to complete the mini screening test with them, to help evaluate if their health is affected by gambling problems. If a patient is reluctant to complete the test in your office, give him or her a copy to bring home. You can then bring up the issue again at a later date. The hotline number for Gambling: Help and Referral is on the questionnaire.

No suicidal ideation: give support and suggest treatment

Accepts treatment: refer (see page 4)

Refuses treatment: give information

Provide follow-up

Gambling problems can be associated with several comorbid disorders. You should evaluate their presence and eventually make a decision about a more thorough investigation, treatment, or appropriate referrals.

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Prévention en pratique médicale, February 2002

Gambling problems? A mini screening test... A gambler who is at risk presents one or several of the following behaviours: 1. Are you constantly preoccupied with past gambling or planning the next venture, or thinking of ways to get money with which to gamble?

6. After losing money gambling, do you often return another day to get even ("chasing" one's losses)?

Gambler

7. Have you ever lied to family members or others to conceal the extent of involvement with gambling?

Symptomatic 1 or 2 behaviours (4% of Montrealers)

8. Have you ever committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling?

Problem 3 or 4 behaviours (2% of Montrealers)

4. Are you restless or irritable when attempting to cut down or stop gambling?

9. Have you ever jeopardised or lost a significant relationship, job, or educational or career opportunity because of gambling?

Pathological 5 behaviours or more (1% of Montrealers)

5. Do you gamble to escape from your problems or from an unpleasant frame of mind?

10. Do you ever rely on others to provide money to relieve a desperate financial situation caused by gambling ?

2. Do you need to gamble with increasing amounts of money in order to achieve the desired excitement? 3. Have you made repeated unsuccessful efforts to control, cut back, or stop gambling?

Adapted from the American Psychiatric Association. (1996) Mini DSM-IV. Diagnostic criteria (Washington, DC, 1994).

Are people close to the gambler affected? People close to pathological gamblers, rather than gamblers themselves, are often the one who consult physicians with a long list of of symptoms that could also be masking the true nature of their problems (see insert).

“Someone who buys a lottery ticket on Monday for a Friday draw has twice as many “chances” of dying before the draw than of winning the jackpot.”

• They feel that their life with their spouse is a nightmare. • They have threatened to leave their spouse. • They hide money to make sure they have enough to live on. • They feel guilty about their spouse’s gambling activities. • They check on their spouse’s activities and look through his or her personal belongings. • They does not believe what their spouse says anymore. • The household is constantly bothered by bill collectors.

Prévention en pratique médicale, February 2002

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Jean Dion, Le Devoir, 8 February 1999

Resources in Montréal The prevalence of gambling Gambling: Help and Referral (514) 527-0140 outside Montréal 1 (800) 461-0140

24/7 hotline Information (free) Referral (free) Help line (free)

Maison Jean-Lapointe (514) 288-2611

Crisis centre (free) Outpatient treatment (free) Inpatient treatment (costs associated)

Centre Dollard-Cormier (514) 385-0046

Outpatient treatment (free)

Orientation Praxis Inc. (514) 723-2585

Outpatient treatment (free)

Foster Pavilion (514) 486-1304

Outpatient treatment (free) For English-speaking clientèle

Chinese Family Service of Greater Montréal (514) 861-5244

Telephone hotline (free) Prevention (free) Outpatient treatment (free)

Gamblers Anonymous (GA) (514) 484-6666 www.gamblersanonymous.org

Support group for gamblers (free)

Gam-Anon (514) 484-6666

Help for family and friends of gamblers (free)

is two to four times higher among youth than among adults. If you are interested in issues of youth gambling, we recommend that you visit

the

International

Centre for Youth Gambling Problems and High-Risk Behaviors web site at: www.youthgambling.com (the site includes a section in French)

Given that treatment services for compulsive gamblers in Montréal have recently been reorganised, this list of resources may change in the future. Gambling: Help and Referral can give you the most up-to-date information.

révention en pratique médicale

Other useful references A publication of the Direction de la santé publique de Montréal-Centre in collaboration with the Association des médecins omnipraticiens de Montréal, as part of the Prévention en pratique médicale programme coordinated by Doctor Jean Cloutier.

Chevalier, S. & Allard, D. (2001) Jeu pathologique et joueurs problématiques. Le jeu à Montréal. Montréal. Direction de la santé publique. • free report in its entirety (in French only): www.ccsa.ca/rapportjeuf.htm

This issue is produced by the Planning Unit. Head of the unit: Michel Mongeon Editor-in-chief: Dr. Serge Nault Editor: Yolande Marchand Graphic design: Manon Girard Translation: Sylvie Gauthier Texts by: Denis Allard, Serge Chevalier Dr. Olivia Hernandez-Sanchez, Dr. Serge Nault Contributors: Dr. Jean-Pierre Villeneuve, Rina Gupta, Dr. Jacques H. Roy

• free summary report: http://www.santepub-mtl.qc.ca/Publication/synthese/rapv5n1_eng.pdf

www.santepub-mtl.qc.ca

révention en pratique médicale

1301 Sherbrooke St. East, Montréal, Quebec H2L 1M3 Telephone: (514) 528-2400 http://www.santepub-mtl.qc.ca Email: [email protected] Legal deposit – 1st trimester 2002 Bibliothèque nationale du Québec National Library of Canada ISSN: 1481-3742 Agreement number: 40005583 Association des Médecins Omnipraticiens de Montréal

A twice-monthly column on the web. 4

Prévention en pratique médicale, February 2002

Mini screening test

Are you living with a compulsive gambler?

1. Do you find yourself constantly bothered by bill collectors? 2. Is the person in question often away from home for long, unexplained periods of time? 3. Does this person ever lose time from work due to gambling? 4. Do you feel that this person cannot be trusted with money? 5. Does the person in question faithfully promise that he or she will stop gambling; beg, plead for another chance, yet gamble again and again? 6. Does this person ever gamble longer than he or she intended to, until the last dollar is gone? 7. Does this person immediately return to gambling to try to recover losses, or to win more? 8. Does this person ever gamble to get money to solve financial difficulties or have unrealistic expectations that gambling will bring the family material comfort and wealth? 9. Does this person borrow money to gamble with or to pay gambling debts? 10. Has this person's reputation ever suffered due to gambling, even to the extent of committing illegal acts to finance gambling? 11. Have you come to the point of hiding money needed for living expenses, knowing that you and the rest of the family may go without food and clothing if you do not? 12. Do you search this person's clothing or go through his or her wallet when the opportunity presents itself, or otherwise check on his/her activities? 13. Does the person in question hide his or her money? 14. Have you noticed a personality change in the gambler as his or her gambling progresses? 15. Does the person in question consistently lie to cover up or deny his or her gambling activities? 16. Does this person use guilt induction as a method of shifting responsibilities for his or her gambling upon you? 17. Do you attempt to anticipate this person's moods, or try to control his or her life? 18. Does this person ever suffer from remorse or depression due to gambling, sometimes to the point of self-destruction? 19. Has the gambling ever brought you to the point of threatening to break up the family unit? 20. Do you feel that your life together is a nightmare?

Yes

No

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Adapted from Gam-Anon questionnaire.

If you have answered “YES” to 6 or more of these questions, you are probably living with a pathological gambler. You can get help by calling Gambling: Help and Referral at (514) 527-0140 or 1 (800) 461-0140.

Prévention en pratique médicale, Supplement, F e b r u a r y 2 002

Mini screening test

Do you have a gambling problem? Yes

No

1. Are you constantly preoccupied with past gambling or planning the next venture, or thinking of ways to get money with which to gamble?

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2. Do you need to gamble with increasing amounts of money in order to achieve the desired excitement?

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3. Have you made repeated unsuccessful efforts to control, cut back, or stop gambling?

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4. Are you restless or irritable when attempting to cut down or stop gambling?

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5. Do you gamble to escape from your problems or from an unpleasant frame of mind?

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6. After losing money gambling, do you often return another day to get even ("chasing" one's losses)?

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7. Have you ever lied to family members or others to conceal the extent of involvement with gambling?

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8. Have you ever committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling?

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9. Have you ever jeopardised or lost a significant relationship, job, or educational or career opportunity because of gambling?

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10.Do you ever rely on others to provide money to relieve a desperate financial situation caused by gambling ?

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Adapted from the American Psychiatric Association. (1996) Mini DSM-IV. Diagnostic criteria (Washington, DC, 1994).

If you have answered “YES” to 5 or more of these questions, you probably have a gambling problem. You can get help by calling Gambling: Help and Referral at (514) 527-0140 or 1 (800) 461-0140.

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