Magazine article Clinical Psychiatry News

Practical Psychopharmacology: Diverse Strategies Helpful in Pathological Gambiling. (Psychopharmacology)

Magazine article Clinical Psychiatry News

Practical Psychopharmacology: Diverse Strategies Helpful in Pathological Gambiling. (Psychopharmacology)

Article excerpt

When the call to "place your bets" proves irresistible, the result can be financial catastrophe, family disintegration, and even suicide.

A persistent and recurrent maladaptive pattern of behavior severe enough to meet DSM-IV criteria for pathological gambling afflicts approximately 1.6% of the general population. Among psychiatric patients, the reported rate is several times higher.

No medication has been approved for the condition and controlled data are limited, but several different classes of drugs-including mood stabilizers, selective serotonin reuptake inhibitors (SSRIs), and opiate antagonists-appear effective.

The diversity reflects the mixed nature of the disorder and the heterogeneity of patients. "Gamblers come in many sizes and shapes," said Dr. Jon E. Grant, chief of impulse control disorders at Butler Hospital, Providence, R.I. "No one size fits all."

Few seek help specifically for their gambling problems. "People are embarrassed about it," said Nancy Petry, Ph.D., professor of psychiatry at University of Connecticut, Farmington. "Many go to the psychiatrist for depression or anxiety and don't mention gambling."

Responses to simple questions, like "How frequently do you gamble?" and "How much do you spend on gambling in a typical month?" may indicate the need for further assessment with a standard instrument. It is particularly important to screen patients in high-risk categories, such as adolescents and those with substance abuse disorders, she said.

Dr. Grant is alerted to the issue by patients' references to financial difficulties, particularly in the context of mood problems or substance abuse. "This is often a coded message: 'Please ask about gainbling.'" Dr. Grant said that patients are often eager to discuss their gambling, even though most won't initiate the conversation.

"Some are dying to talk about it," he said.

Although DSM-IV criteria and standard instruments like the South Oaks Gambling Screen require a minimum number of symptoms to establish a diagnosis of pathological gambling (PG), Dr. Grant has found pharmacotherapy to be helpful for patients with "problem gambling," a condition that requires fewer symptoms for diagnosis.

The choice of medication depends on the patient's presentation. In individuals whose gambling cravings or urges are clearly marked, he considers the opiate antagonist naltrexone as first-line treatment.

Usually, dosages well in excess of the recommended 50 mg/day are required. Dr. Grant administers a mean of 150 mg to patients participating in his studies. He starts with a daily dosage of 50 mg and raises it by 50mg/day every 2 weeks. Nausea is common at the start of treatment but usually resolves within 1 week. Nausea may be mitigated if the drug is taken with food; if severe, it maybe treated with ondansetron (Zofran) or prochlorperazine (Compazine).

Concerns about hepatotoxicity mandate careful liver enzyme monitoring at baseline, after exposure to 100 mg/day of naltrexone for 1 month, twice more in the first 6 months of treatment, and every 36 months after that.

The risk of hepatotoxicity is greatly reduced if patients restrict over-the-counter analgesics to occasional use, Dr. Grant said.

The response to naltrexone--a reduction in the urge to gamble and the "rush" experienced from winning--should be apparent after 2 weeks on an appropriate dosage, he said. …

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