Problem Gambling and Families: A Systematic Review

This article reviews the prevalence of gambling and related mental disorders from a public health perspective. It traces the expansion of gambling in North America and the psychological, economic, and social consequences for the public's health, and then considers both the costs and benefits of gambling and the history of gambling prevalence research. A public health approach is applied to understanding the epidemiology of gambling-related problems. International prevalence rates are provided and the prevalence of mental disorders that often are comorbid with gambling problems is reviewed. Analysis includes an examination of groups vulnerable to gambling-related disorders and the methodological and conceptual matters that might influence epidemiological research and prevalence rates related to gambling. The major public health problems associated with gambling are considered and recommendations made for public health policy, practice, and research. The enduring value of a public health perspective is that it applies different 'lenses' for understanding gambling behaviour, analysing its benefits and costs, as well as identifying strategies for action. Harvey A. Skinner (160, p. 286)

To help refine the definition and diagnosis of gambling disorders, we investigated the distribution among US gamblers of the 10 DSM-IV criteria for Pathological Gambling. We drew data from two stratified random surveys (n = 2417, n= 530) of gambling behavior and consequences among community-based samples of US adults. A fully structured questionnaire, administered by trained lay interviewers, screened for the life-time prevalence of problem and Pathological Gambling. Per DSM-IV definitions, anyone meeting five or more of 10 itemized criteria was considered a pathological gambler. We analyzed these criteria among all gamblers who met one or more criteria (n = 399). Most gamblers who met only one or two criteria reported 'chasing their losses'. At subclinical levels (three to four criteria), gamblers also reported elevated rates of gambling-related fantasy: lying, gambling to escape and preoccupation. Pathological gamblers with five to seven criteria reported marked elevations of loss of control, withdrawal symptoms and tolerance (internalizing dimensions of dependence); risking their social relationships and needing to be bailed out financially (externalizing dimensions). Most of the highest-level pathological gamblers (eight to 10 criteria) reported committing illegal acts to support gambling. Dependence in a biobehavioral sense appears to be a hallmark of Pathological Gambling, but it marks only one threshold in a qualitative hierarchy of disorders beginning with a common subclinical behavior, 'chasing'. Epidemiological assessments and future DSM revisions might consider explicit recognition of a problem gambling disorder, identifying people presenting some cognitive symptoms of Pathological Gambling but not clear signs of dependence. Pathological gamblers in turn appear to have two distinct levels of severity.