Prevention Efforts: Role of the Clinician Marc Potenza, MD, PhD Mark D. Griffiths, PhD, CPsychol
The importance of prevention efforts in medical practice is profound. While prevention efforts targeting mental health and addictive disorders are widely used, limited data are available on their effectiveness. In the area of substance abuse prevention, there have been large-scale, structured investigations into the effectiveness of individual programs (e.g., Drug Abuse Resistance Education or project DARE (Clayton et al. 1996)) and annual surveys examining related behaviors (e.g., National Household Drug Abuse Survey (Substance Abuse and Mental Health Services Administration 2002)). However, much less work has been done in the prevention realm for problem or pathological gambling. Thus, while prevention efforts exist for pathological gambling (PG), they are limited in comparison to other areas in the field of mental health and addictive disorders, and their effectiveness at reducing or eliminating problem and pathological gambling among adult populations has not been adequately investigated to date. The aim of this chapter is to review some prevention efforts aimed at adult problem and pathological gambling, highlighting the relevance for the general psychiatrist. For prevention efforts targeting adolescent or teen gambling, problem gambling and PG, see chapter 13. Prevention has historically been divided into three stages (United States Prevention Task Force 1996). The term primary prevention has been used to describe measures employed to “prevent the onset of a targeted condition” (United States
Prevention Task Force 1996). Secondary prevention has been used to describe measures that “identify and treat asymptomatic persons who have already developed risk factors or pre-clinical disease but in whom the condition is not clinically apparent” (United States Prevention Task Force Force 1996). Tertiary prevention has been used to describe efforts targeting individuals with identified disease in which the goals involve restoration of function, including minimizing or preventing disease-related adverse consequences (United States Prevention Task Force Force 1996). These divisions of prevention thus focus on different targets, with primary efforts tending to target the general population, secondary efforts at-risk or vulnerable groups, and tertiary efforts individuals with an identified disorder. Given that treatment can be considered a form of tertiary prevention and that behavioral and pharmacological treatments are covered elsewhere in this book (see chapters 11 and 12), we will focus our discussion of tertiary prevention on “early” efforts, such as gambling helplines and casino self-exclusion practices, that help guide many individuals who are treatment-naïve into treatment settings and minimize harm to identified individuals with gambling problems, respectively.
Primary Prevention Typically considered the most cost-effective form of prevention as it helps reduce suffering, cost and burden associated with a disorder (United States Prevention Task Force Force 1996), primary prevention efforts include health protection education and counselling. Primary prevention efforts related to problem and pathological gambling have generally involved education initiatives. Examples include television commercials,
billboards, bus tails, posters, postcards and other initiatives targeted at increasing public awareness (Griffiths 2002). Despite widespread use, most primary prevention efforts in gambling have not been empirically validated. It has been suggested that organizations examine the effectiveness of their interventions; e.g., through random telephone surveys (Griffiths 2002). Information concerning the effectiveness of an intervention might include: the number of people hearing the advertisement, the extent to which they understand the message, its usefulness or appropriateness, and the extent to which the message prompts behavioral changes (Griffiths 2002). The content and impact of primary prevention is strongly influenced by knowledge of the impact of the behavior or disorder being prevented. For example, prevention efforts targeting tobacco smoking cessation have changed significantly as more information concerning the health impact of tobacco smoke has become available (Slovic 2001). Unfortunately, few large-scale, well-designed studies have investigated the health impact of different levels or types of gambling (e.g., recreational, problem, and pathological) (National Research Council 1999). Data from existing large-scale surveys are emerging; for example, an association between problem and pathological gambling and unemployment and welfare receipt, bankruptcy, arrest, incarceration, poor or fair physical health, and mental health treatment was found in the Gambling Impact and Behavior Study (Gerstein et al. 1999; Potenza et al. 2001b). Despite the emerging data from the Gambling Impact and Behavior Study and other recently published, well-designed large surveys supporting an association between problem and pathological gambling and adverse measures of functioning (particularly substance use disorders) (Cunningham-Williams et al. 1998; Welte et al. 2001), these
investigations provide little information on: 1) the natural history of gambling behaviors; and 2) the nature of the associations. Information from these areas will be very important in conceptualizing gambling within a public health perspective (see chapter 1) and generating guidelines for healthy gambling as there currently exist for alcohol consumption (Korn 2000; Korn and Shaffer 1999; Shaffer and Korn 2002; United States Department of Agriculture 2000a; United States Department of Agriculture 2000b;). Although the strongest data exist for an association between adverse measures of health and well-being and problem or pathological levels of gambling, there have been suggestions of adverse health measures in association with gambling in general or within specific gambling venues. For example, a high proportion (83%) of casino-related deaths were found to be sudden cardiac deaths, raising the possibility that, in the authors’ words, “gambling activities can be hazardous to one’s health, particularly among elderly cardiac patients” (Harvard Medical School Division on Addictions 2000; Jason et al. 1990). Direct examination of the relationship between gambling and cardiac health is warranted, particularly as: 1) gambling has been shown to lead to sustained (over several hours of gambling) increases in cortisol and blood pressure (Meyer et al. 2000); and, 2) the use of automated defibrillators in casinos has been reported to be an effective preventative measure in enhancing survival following sudden cardiac arrest (Potenza et al. 2002a; Valenzuela et al. 2000). A separate or related general health risk associated with gambling includes tobacco smoke exposure at casinos and other gambling venues. Direct analysis of environmental tobacco smoke in casinos and bingo halls has found significant levels of nicotine and mutagens, with measures of airborne mutagenicity correlating highly with
nicotine concentrations (Kado et al. 1991). Casino employees have reported second-hand smoke as a health concern (Keith et al. 2001), and casino employees' description of significant exposure to second-hand smoke is supported by the demonstration of postshift increases in serum cotinine levels (Shaffer et al. 1999; Trout et al. 1998). Given the association between gambling and tobacco smoking, particularly problem and pathological gambling and nicotine dependence (Crockford and el-Guebaly 1998; Cunningham-Williams et al. 1998; Petry and Oncken 2002; Potenza et al. in press), tobacco smoke exposure should be a consideration in the conceptualization of healthy gambling guidelines. Some primary prevention efforts targeting children and adolescents could influence adult gambling behaviors and thus warrant mentioning. For example, one prevention program involving 289 high school students employed didactic delivering of gambling-related information about gambling (Gaboury and Ladouceur 1993). The study showed that the intervention improved students’ knowledge, generated a more realistic attitude towards gambling, and resulted in lower gambling severity. A related study demonstrated that among 115 participants chosen at random in a shopping mall, a brochure on gambling provided new information about problem gambling, at risk behaviors, and the availability of specialized gambling help (Ladouceur et al. 2000b). A third study designed to correct misconceptions and increase knowledge about gambling involved 424 adolescents, used a video format, and found that the intervention had a positive effect in increasing knowledge and in modifying misconceptions towards gambling (Ferland et al. 2002). Despite these promising initial results, it is unclear if positive effects will be maintained into adulthood or if the same interventions employed
on adolescent populations would be effective for adults. Research on prevention programs outside of the gambling field has suggested that regardless of delivery mode (didactic lecture, videotapes, posters, pamphlets, guest speakers etc.), the ‘information only’ approach has relatively little effect on behavioral change (Evans and Getz in press). Another feature to be considered in primary prevention is the impact of gambling availability on the development of problem and pathological gambling. Gambling has persisted over time in all cultures despite changes in social attitudes and laws permitting or prohibiting gambling (Potenza and Charney 2001c) (see Chapter 2). Over the past several decades, there has been a rapid increase in the availability of legalized gambling in the United States and other areas of the world (Potenza et al. 2001b). Data suggest that concurrent with the increase in availability there have been increases in the rates of recreational, problem and pathological gambling (Gerstein et al. 1999; Shaffer and Hall 2001). For example, a meta-analysis of prevalence estimate studies in North America found higher estimates of problem and pathological gambling in studies performed from 1994-1997 than those from 1977-1993 (Shaffer and Hall 2001). The extent to which gambling should be regulated and/or restricted remains an area of active debate, with the decisions holding considerable potential impact on public health and prevention efforts. In summary, although primary prevention efforts related to adult gambling exist, they are relatively few in number, particularly when considering the public health impact of problem and pathological gambling. Moreover, current and future efforts would benefit from empirical validation and additional information on the nature of the mediating factors between gambling and health measures (i.e., potential causality). Such
information could lead to guidelines for healthy gambling and more informative and effective public awareness campaigns.
Secondary Prevention Secondary prevention efforts involve measures that target individuals with risk factors for or pre-clinical forms of a disorder. Here we will extend this definition to consider efforts directed toward vulnerable although not necessarily high-risk groups; e.g., older adults. Secondary prevention measures in general constitute important interventions in general medical settings. For example, brief screening instruments like the CAGE have demonstrated efficacy within general medical settings in facilitating the identification and treatment of individuals with alcohol use problems (Fiellin et al. 2000). Although it is likely that generalist physicians encounter individuals with gambling problems in their provision of clinical care, the extent to which they are trained to examine for or feel comfortable in assessing gambling problems warrants consideration. For example, a survey of 180 health care providers found 96% reporting knowledge of problem and pathological gambling but only 30% inquiring about gambling problems when a patient presents with stress-related symptoms (Christensen et al. 2001). A separate study of directors of health ministries, medical school officials and experts in the area of substance use and gambling disorders examined office resource needs and cited lack of awareness, knowledge, education, and training in the area of pathological gambling as the most important challenges or barriers confronting physicians (Rowan and Galasso 2000). The authors described a need for enhanced
physician training in gambling disorders during all levels of medical training, including through Continuing Medical Education courses. A significant group of gamblers report health problems as a direct result of their gambling. Possible adverse health consequences of gambling for both the gambler and their partner include depression, insomnia, intestinal disorders, migraines, and other stress-related disorders (Griffiths 2001; Griffiths et al. 1999; Lorenz and Yaffee 1986; Lorenz and Yaffee 1988). General practitioners routinely ask patients about smoking and drinking but gambling is generally not discussed (Setness 1997). Mounting evidence suggests that in order to provide optimal care, medical practitioners within all areas, and particularly general medical and psychiatric disciplines, require an awareness of the potential impact of gambling upon health and well-being and the information and skill necessary to identify, refer and/or treat individuals affected by problem or pathological gambling. Together, the data suggest that gambling in its most excessive forms should be conceptualized, much like drug addiction, as a significant medical condition (McLellan et al. 2000; Potenza et al. 2001b; Potenza et al. 2002a). Efficient screening methods for problematic gambling behaviors could be of significant value in general medical settings. Several brief screening instruments for problem and pathological have been developed, and preliminary data suggests that the Early Intervention Gambling Health Test (EIGHT), an eight-item, self-report questionnaire has high sensitivity and specificity within a primary care setting (Potenza et al. 2002a; Sullivan 2000) (see Appendix). Although it is too early to develop practice guidelines for problem and pathological gambling prevention efforts within a general medical setting, generalist physicians could regularly assess patients’ gambling histories,
sensitively broach the topic of the possible existence of gambling problems with those patients suspected of engaging problematically in gambling, thoughtfully motivate individuals with gambling problems to seek treatment, and appropriately refer individuals with gambling problems to a self-help group (e.g., GA: 1-800-266-1908 or http://www.gamblersanonymous.org), a local gambling treatment program, and/or a gambling helpline (e.g., National Council on Problem Gambling helpline: 1-800-5224700 or http://www.ncpgambling.org) to facilitate engagement in locally available gambling treatment (Potenza et al. 2002b). Brief screening instruments could also be of significant utility in other settings, including mental health and addiction treatment offices, jails and other forensic facilities, and gambling venues. Individuals within these settings should be aware of the high rates of problem and pathological gambling in specific groups; e.g., males, adolescents, and individuals with histories of incarceration or psychiatric (including substance use) disorders. Given the high rates of co-occurrence of gambling and other psychiatric disorders, screening of individuals with problem or pathological gambling for other psychiatric disorders (and vice versa) could enhance tertiary prevention efforts: providing treatment that more effectively reduces the harm associated with each disorder. Individuals attending gambling venues, particularly pari-mutuel settings, have been found to have high rates of problem and pathological gambling (Gerstein et al. 1999). As such, they represent important areas for secondary prevention efforts. Towards these ends, many gambling venues train their staff to identify potential problem or pathological gamblers and advertise within the facilities methods for patrons to obtain
help (e.g., through gambling helplines and/or self-exclusion programs, as described below). Specific populations, although at arguably lower risk, might require unique prevention efforts. For example, gambling problems are more prevalent in men than women, and there exist gender-related differences in problem gambling behaviors; e.g., women generally beginning to gamble and developing problems with gambling later in life, and developing problems more frequently with non-strategic, machine-based forms of gambling like casino slots (Potenza et al. 2001a; Taveres et al. 2001). As such, prevention efforts for men and women might preferentially target specific venues or age groups. Similarly, older adults are less likely to gamble, develop gambling-related problems, and report problems associated with gambling when acknowledging a gambling problem but more likely to engage in and develop problems with specific forms of gambling; e.g., casino slot machine and sweepstakes gambling (Desai et al. submitted; Gerstein et al. 1999; Mendez et al. 2000; Potenza et al. submitted). Accordingly, specific secondary prevention efforts for older adults might be needed; e.g., screening for problem or pathological gambling within extended care facilities with older adult populations or listing in large print problem gambling referral sources on casino slot machines (Potenza et al. submitted). Within health care settings, specific groups of older adults might be at increased risk for gambling problems; e.g., several case reports have described the emergence or worsening of problem or pathological gambling in individuals being treated with pro-dopaminergic agents for Parkinson’s Disease (Gschwandtner et al. 2001; Molina et al. 2000; Seedat et al. 2000). Further research is needed to investigate the effectiveness
of secondary prevention efforts targeting these and other high-risk or vulnerable populations of adults.
Tertiary Prevention Tertiary prevention efforts, involving reducing disorder-related harm in affected individuals, include treatment efforts, and behavioral and pharmacological therapies for pathological gambling are described elsewhere in this book. “Early” tertiary prevention efforts involve moving individuals with recently-recognized gambling problems into treatment (e.g., through gambling helplines) and non-treatment-related methods for helping individuals with gambling problems refrain from gambling (e.g., through availability and maintenance of casino self-exclusion policies). Gambling helplines are widely used in the United States and elsewhere in the world (Griffiths et al.1999; Potenza et al. 2000; Sullivan et al. 1994; Sullivan et al. 1997). For example, the gambling helpline operated by the Connecticut Council on Problem Gambling (CCPG), serving predominantly Connecticut and two nearby states, routinely receives over a thousand phone calls per year from callers requesting help with gambling problems (Potenza et al. 2000; Potenza et al. 2001a), and this volume is considerably less than those experienced by helplines from other states and the National helpline. .In Connecticut, the majority (approximately 85%) of callers reporting a gambling problem report never having attended self-help or professional treatment for a gambling problem (Potenza et al. 2000; Potenza et al. 2001a). Individuals calling the CCPG gambling helpline are routinely referred for self-help and professional treatment, and consequently, the gambling helpline facilitates the entry of individuals with recently-recognized
gambling problems into treatment. Given that the toll-free number for the CCPG gambling helpline is advertised in general (e.g., on billboards and buses) and prominently at all gambling venues in the state (e.g., at casinos, pari-mutuels, and lottery points of purchase and on the backs of lottery tickets), helplines can serve to bridge primary, secondary and tertiary prevention efforts. Information from helpline callers can help enhance prevention efforts. For example, very few adolescents call the CCPG gambling helpline, suggesting that other prevention efforts might be needed to identify adolescents with gambling problems and provide them with appropriate treatment. Data suggest that other groups (e.g., Hispanic and African American men) are under-represented in the CCPG gambling helpline sample (Potenza et al. 2001a). Differences have been observed in data obtained from helplines serving other geographic regions. For example, a study of data from the gambling helpline in the United Kingdom (UK) indicates that adolescents use the gambling helpline to a greater degree than they do the CCPG helpline, and that women less frequently use the UK gambling helpline as compared with the CCPG helpline (Griffiths et al. 1999; Potenza et al. 2001a). The precise reason for the apparent differences in the findings from the UK and US are not known but could involve differences in subject populations, advertising, or gambling behaviors; e.g., adolescents in the UK as compared with those in the US more frequently gamble on fruit/slot machines, and fruit or slot machine gambling problems are frequently acknowledged in the UK and CCPG samples, respectively (Griffiths et al. 1999; Potenza et al. 2001a). The extent to which under-represented populations might be effectively targeted (e.g., through changes in advertising such as the listing of helpline contact information in Spanish and
English to reach more Hispanic men) requires direct examination. In addition, further work is needed to examine directly the effectiveness of helplines with regard to treatment referral follow-up. That is, information obtained from callers willing to be called back several months following initial contact with the helpline would be valuable in assessing the extent to which problem gamblers have benefited from the helpline intervention. Self-exclusion policies exist in casinos around the world, including North America. Although the precise rules and regulations vary according to geographic location and individual casino, they generally involve voluntary self-exclusion for a period of time (e.g., 6 months to five years) at the risk of being arrested (e.g., for trespassing) if the excludee is found on premises (Ladouceur et al. 2000a). Little research has been performed on the effectiveness of casino self-exclusion practices. The only research article examining the effectiveness of a casino self-exclusion program involved 220 self-selected individuals (Ladouceur et al. 2000a). Respondents were predominantly male, middle-aged and married, and the majority (95%) were pathological gamblers according to South Oaks Gambling Scale scores (Ladouceur et al. 2000a). Although the majority (97%) reported believing they would refrain from casino gambling during the self-exclusion period, reports from prior excludees (24% of the sample) suggested otherwise (Ladouceur et al. 2000a). Specifically, 36% of the prior excludees reported casino gambling during their prior exclusion period (Ladouceur et al. 2000a). However, 30% of the prior excludees reported complete gambling abstinence during the prior exclusion period (Ladouceur et al. 2000a). Future research is needed to define factors predictive of success in casino self-exclusion programs, and to enhance the effectiveness of enforcing the agreements.
Conclusions Prevention efforts aimed at reducing or eliminating adult problem and pathological gambling are at a relatively early stage of development. .Increased knowledge regarding the impact of different types/levels of gambling behaviors on health and well-being would be extremely valuable in generating guidelines for healthy gambling and primary prevention efforts. An increased understanding of high-risk and vulnerable populations, facilitated through biological, psychological/psychiatric and social investigations, and the natural histories of gambling behaviors within these groups will help enhance secondary and early tertiary prevention efforts. As in other fields of medicine, the effectiveness of individual prevention strategies will need to be empirically validated. Targeted efforts in these areas should lead to a decrease in suffering attributable to problem and pathological gambling.
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