Introduction

A substantial change is about to occur in the provision of services for problem gambling services in New Zealand. Legislation (the Gambling Act) that was enacted by September 2003 will move prevention, protection and treatment of problem gambling into the arena of public funding. The Ministry of Health has assumed responsibility for the coordination of problem gambling with responsibility within the Ministry shared between the Mental Health and Public Health Directorates. Funding of services and programmes will be ring-fenced from a levy on the gambling industry, with the amount estimated at $15-20m over the next year. Although this is a substantial increase in available funding, existing specialist problem gambling treatment services will shortly be required to compete for that money. Competition may come from services that provide treatment for alcohol and other drug misuse (AOD), or provide mental health services. In addition, with the redirection towards health promotion, there will be a focus upon early intervention with these services able to offer opportunistic interventions.

Should AOD And Mental Health Services Be Interested?

Many addiction and mental health services may understandably feel that they are already over-provided with clients and too under-resourced to take up a new area of addictive behaviour. Following a recent period of development of competencies, career paths for AOD workers, staff retention difficulties and merger with mental health divisions of District Health Boards, there may not be a strong motivation to complicate matters further with the provision of a new, relatively small health service.

A closer inspection of the opportunity suggests that these services should not be too quick to dismiss the possibility as being without merit. Although problem gambling has a relatively new profile, there is a growing interest in the field that has identified a number of factors that would warrant a further interest of both AOD and mental health services.

Aspects Of Problem Gambling Treatment That Suggest Further Enquiry

A growing problem
Research suggests that the prevalence of problem gambling ranges between 1%-2% of the population for the serious stage of behaviour (the Axis 1 mental health disorder, Pathological Gambling; DSMIV 312.31) (1) with possibly a similar percentage experiencing a sub-clinical degree of gambling problems. This clinical prevalence (1%-2%) may compare with 3%-5% of the population dependent upon alcohol (2). There is strong evidence to support that increased access to gambling correlates positively with the prevalence of problem gambling (3), (as has been demonstrated with alcohol), and whereas the causation question may remain open (4), access to gambling as well as spending on gambling is rapidly increasing both in New Zealand and overseas. This compares with the relatively stable access to alcohol, barring age of access adjustments, and the estimates of the national consumption.

Co-existing alcohol problems
Research indicates that there may be a considerable overlap between problem gambling and alcohol misuse (5). Between 10%-20% of those seeking help for alcohol use problems may also have gambling problems, while between 20%-50% of those seeking help for gambling problems may be experiencing alcohol use problems (6). Clients of these services may not voluntarily disclose these co-existing problems unless an appropriate enquiry is made. If such an enquiry is not made, the client may draw the conclusion that it is irrelevant, and fail (along with their counsellor) to note that slips or relapses occur because of the influence of the untreated problem (7). In New Zealand, gambling licences for intensive gambling modes are generally granted to organisations with liquor licences, with the exception of some TAB’s and Internet gambling. This results in dually addicted clients frequenting environments dangerous to their continued well-being.

Co-existing mental health problems
Once the gambling has progressed to meet the criteria of pathological gambling, many other mental health problems have been found to co-exist. These include depression (25% or more), anxiety (50%), suicidal ideation (estimate 20% of pathological gamblers attempt suicide), other drug misuse (over 10%), and many personality disorders (8) (9). If the problem gambling behaviour is not identified, stressors associated with continued gambling will tend to exacerbate other mental health problems due to stress that results from problematic gambling (10).

This has also been raised in the substantial body of research presented by the Australian Productivity Commission (1999) (3):

“Counselling for problem gambling will need to also deal with these comorbidities, and treatment for other dependencies may need to take into account secondary gambling problems that may not be transparent”

and

“It underlines the complex causality of problems experienced by problem gamblers. Problem gambling may exacerbate other dependencies, and they in turn may exacerbate problem gambling”

Co-existing physical health problems
Problem gamblers appear to have poor physical health that may also be attributable to their gambling behaviour. These include peptic ulcer disease, hypertension, cardio-vascular problems, migraines as well as musculo-skeletal problems (11) (12). Loss of sleep is a common side-effect of the gambling behaviour that may also lead to drug and alcohol misuse to enforce sleep.

Social problems
Problem gambling commonly accompanies loss of employment (due to unreliability or dishonesty arising from gambling), family problems, criminal offending, isolating behaviour, and losses of important social and career opportunities. These outcomes can lead to both more intensive gambling (self medicating) and to deterioration in mental and physical health (12).

Positive Aspects Of Intervention In Problem Gambling By AOD/Mental Health Workers

There are many indicators that suggest that interventions by AOD/Mental Health workers are not only appropriate, but highly desirable (13). These include:

• Problem gambling may be intrinsically interwoven with the condition/behaviour that the client is receiving help for. If addressed, this may lessen the primary treated condition while reducing the chance of relapse in the case of alcohol and drug misuse.
• Many of the skills that AOD and Mental Health workers have will be appropriate to intervene in problem gambling. Upskilling is both desirable from a career perspective as well as in the interests of the client.
• Referral completion is a common problem amongst addiction and mental health treatment providers. Providing an enhanced opportunity for the client to utilise the therapeutic connection that they have with their counsellor is a sensible and ‘best practice’ approach.
• Opportunistic screening for a non-presenting condition enables early intervention to be effected, and may avoid the development of other commonly co-existing disorders, such as depression, anxiety and physical problems, that may entrench the conditions and resist treatment if allowed to progress.
• Existing clients with previously unidentified problem gambling behaviour may continue to require substantial resources over extended periods. Research suggests that this is a common situation. Identifying and addressing the problem may result in the client’s improvement. Resources may then be available to other clients.
• As yet there has been no decision as to the devolution of the purchasing of problem gambling services from the Ministry of Health. If this were to occur, District health Boards may assume full responsibility for the provision of these services.
• Financial resources will shortly exist as a result of the Ministry of Health assuming responsibility for this domain. In addition to the beneficial results to core clients from identification and interventions for problem gambling, further funds will be available to treat the gambling aspect of the client’s needs while such funding will be independent of mainstream funding. As the prevalence of the problem is identified, there is a process to meet the financial needs through established hypothecated funding processes.

Conclusion

The advent of the change in both funding and administration of problem gambling is an opportunity for both AOD and mental Health workers to both improve the health of many of their clients and to enhance their range of skills. The outcome is likely to reduce the stress and workload of counsellors through job satisfaction (effectiveness) and targeting previously unidentified factors resulting in clients’ resistance to change (efficiency). The existing structures and previous experience that these organisations have with the new funding authority will place them in good stead to elect and be granted contracts to provide either early intervention or harm reduction for those experiencing gambling problems. That many of these clients will also be experiencing the problems that are the core work of these services are an additional advantage for both the service and the clients. Training is available to provide an interesting and effective additional skill-base for counsellors who have made their career in AOD and Mental Health.

References

(1) American Psychiatric Assn. Diagnostic and statistical manual of mental disorders. 4th Ed. Washington DC:APA, 1994

(2) O’Hagan J, Robinson G, Whiteside E. Alcohol and drug problems: handbook for health professionals. Wellington: ALAC: 1993

(3) Productivity Commission. Australia’s Gambling Industries. Canberra: AusInfo:1999

(4) Shaffer H, Korn D (2002) Gambling and Related Mental Disorders: a Public Health analysis. Annu Rev Public Health 23:171-212

(5) Lesieur H, Rosenthal R (1991) Pathological gambling: a review of the literature (prepared for the American Psychiatric Association task Force on DSM-IV Committee on Disorders of Impulse Not Elsewhere Classified). J Gambling Studies.;7(1):5-39

(6) Sullivan S (1999) Alcohol and Problem Gambling: a hidden partner in dual diagnosis. Australasian Symposium on Professional Education and Training on Alcohol and Other Drugs. (Adelaide). ALAC & NCETA, May 1999.

(7) Sullivan S & Coster G (1997) Case finding, assessment, and brief intervention in problem gambling: a role for General Practitioners. Tenth International Conference on Gambling and Risk-taking (Montreal)

(8) Sullivan S, Arroll B, Coster G, Abbott M (1998) Problem gamblers: a challenge for General Practitioners. NZ Family Physician;25:1:37-42

(9) Sellman D, Adamson S, Robertson P, Sullivan S & Coverdale J (2002) Gambling in mild-moderate alcohol-dependent outpatients. J Substance Use & Misuse 37(2):199-213

(10) Garretsen H, Plant M (1997) Primary prevention and compulsive/problem gambling: the lessons from alcohol. J Substance Abuse:2;121-3.

(11) Pasternak A & Fleming M (1999) Prevalence of gambling disorders in a primary care setting. Archives Family Medicine 8:515-20

(12) Sullivan S The GP ‘Eight’ Screen. Thesis for PhD. Auckland University, Auckland 1999 (Philson Ref W4 S952-1999)

(13) Sullivan S & Penfold A (1999) Taking a gamble with alcohol: problem gambling in an alcohol treatment environment. Cutting Edge ’99 Conference. Christchurch 13-14th August. ALAC & NCTD.