Pathological Gambling A Critical Review Committee on the Social and Economic Impact of Pathological Gambling Committee on Law and Justice Commission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1999 Notice Committee Acknowledgments Contents Executive Summary NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by the National Gambling Impact Study Commission. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data Pathological gambling : a critical review / Committee on the Social and Economic Impact of Pathological Gambling [and] Committee on Law and Justice, Commission on Behavioral and Social Sciences and Education, National Research Council.            p. cm.      Includes bibliographical references and index.      ISBN 0-309-06571-2 (hardcover)      1. Compulsive gamblingUnited States. I. National Research Council (U.S.). Committee on the Social and Economic Impact of Pathological Gambling. II. National Research Council (U.S.). Committee on Law and Justice.      RC569.5.G35 P38 1999      616.85'841dc21                               99-06598 Additional copies of this report are available from the National Academy Press, 2101 Constitution Avenue, N.W., Lock Box 285, Washington, D.C. 20005. (800) 624-6242 or (202) 334-313 (in the Washington Metropolitan Area). This report is also available online at http://www.nap.edu Printed in the United States of America Copyright 1999 by the National Academy of Sciences. All rights reserved. Committee on the Social and Economic Impact of Pathological Gambling CHARLES F. WELLFORD (Chair), Center for Applied Policy Studies and Department of Criminology and Criminal Justice, University of Maryland COLIN CAMERER, Division on Humanities and Social Sciences, California Institute of Technology LINDA B. COTTLER, Department of Psychiatry, Washington University School of Medicine SARA KIESLER, Department of Social and Decision Sciences, and Human Computer Interaction Institute, Carnegie Mellon University MARK W. LIPSEY, Department of Psychology and Human Development, Vanderbilt University EILEEN M. LUNA, American Indian Studies Programs, University of Arizona BARBARA ANN MELLERS, Department of Psychology, Ohio State University CLINTON V. OSTER, JR., School of Public and Environmental Affairs, Indiana University DAVID RADOS, Owen Graduate School of Management, Vanderbilt University RICHARD J. ROSENTHAL, Department of Psychiatry, University of California, Los Angeles HOWARD J. SHAFFER, Division on Addictions and Department of Psychiatry, Harvard Medical School JEROME H. SKOLNICK, Faculty of Law, New York University School of Law KEN WINTERS, Department of Psychiatry, University of Minnesota SAMUEL C. McQUADE III, Study Director MELISSA BAMBA, Research Associate GLENDA TYSON, Project Assistant Committee on Law and Justice CHARLES F. WELLFORD (Chair), Center for Applied Policy Studies and Department of Criminology and Criminal Justice, University of Maryland RUTH DAVIS, The Pymatuning Group, Inc., Virginia DARNELL HAWKINS, Department of African American Studies, University of Illinois at Chicago PHILIP HEYMANN, Center for Criminal Justice, Harvard Law School CANDACE KRUTTSCHNITT, Department of Sociology, University of Minnesota MARK LIPSEY, Department of Psychology and Human Development, Vanderbilt University COLIN LOFTIN, School of Criminal Justice, State University of New York at Albany JOHN MONAHAN, School of Law, University of Virginia DANIEL NAGIN, H. John Heinz III School of Public Policy and Management, Carnegie Mellon University JOAN PETERSILIA, School of Social Ecology, University of California, Irvine PETER REUTER, School of Public Affairs, University of Maryland WESLEY SKOGAN, Center for Urban Affairs, Northwestern University CATHY SPATZ WIDOM, Departments of Criminal Justice and Psychology, State University of New York at Albany KATE STITH, School of Law, Yale University MICHAEL TONRY, School of Law, University of Minnesota CAROL PETRIE, Study Director MELISSA BAMBA, Research Associate KAREN AUTREY, Senior Project Assistant Acknowledgments The following persons, many who prepared papers or presentations for the committee, are acknowledged and thanked for sharing their expertise on pathological gambling, and for giving of their time to participate in and support the public workshops hosted by the National Research Council: Curtis L. Barrett, University of Louisville Alex Blaszczynski, The Liverpool Hospital, Sydney, Australia Carl Braunlich, Purdue University David Comings, City of Hope Medical Center, Duarte, California Sue Cox, Texas Council on Problem and Compulsive Gambling, Richardson Renee Cunningham-Williams, Washington University School of Medicine Jeff Derevensky, McGill University, Montreal, Canada Carlo C. DiClemente, University of Maryland, Baltimore County William Eadington, University of Nevada Richard Evans, University of Houston Don Feeney, Minnesota State Lottery, Roseville Joanna Franklin, National Council on Problem Gambling, Washington, DC Peter Goyer, Cleveland Medical Center, Ohio Mark Griffiths, The Nottingham Trent University, Nottingham, Australia Rina Gupta, McGill University, Montreal, Canada Matthew A. Hall, Harvard Medical School Erik Hollander, Mt. Sinai School of Medicine, New York Durand F. Jacobs, American Board of Professional Psychology, California Norm Kruedelbach, Veterans Administration Medical Center, Ohio Robert Ladouceur, Université Laval, Quebec, Canada Henry Lesieur, Institute for Problem Gambling, Middletown, Connecticut Scott Lukas, McClean Hospital, Cambridge, Massachusetts Janet Mann, American Academy of Health Care Providers in the Addictive Disorders, Cambridge, Massachusetts Richard McCleary, University of California at Irvine Lia Nower, Washington University Judy Patterson, American Gaming Association, Washington, DC Marcus D. Patterson, American Academy of Health Care Providers in the Addictive Disorders, Cambridge, Massachusetts William Rhodes, Abt Associates Inc., Cambridge, Massachusetts I. Nelson Rose, Whittier Law School Lori Rugle, Trimeridian Inc., Carmel, Indiana William Semple, Cleveland Medical Center, Ohio Randy Stinchfield, University of Minnesota Medical School Bradley Stoner, Washington University Rodger Svendson, Minnesota Institute of Public Health, Anoka Jack Thar, Indiana Gaming Commission, Indianapolis Tony Toneatto, Addiction Research Foundation, Calgary, Canada Joni Vander Bilt, Harvard Medical School Rachel Volberg, Gemini Research, Northhampton, Massachusetts Lynn Wallisch, Texas Commission on Alcohol and Drug Abuse, Austin Robert Wildman, Dickson, O'Bryan, Dugan and Associates, Nevada Harold Wynne, Wynne Resources, Edmonton, Alberta, Canada Kurt Zorn, Indiana University This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the Report Review Committee of the National Research Council. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their participation in the review of this report: John Bailar, Irving B. Harris Graduate School of Public Policy Studies, University of Chicago; Robert Boruch, Graduate School of Education and Wharton School, University of Pennsylvania; Philip J. Cook, Sanford Institute of Public Policy, Duke University; Stephen Cornell, Udall Center for Studies in Public Policy, University of Arizona; John Dombrink, Department of Criminology, Law, and Society, University of California, Irvine; Reid Hastie, Center for Research on Judgment and Policy and Department of Psychology, University of Colorado; John Kihlstrom, Department of Psychology, University of California, Berkeley; Robert S. Lawrence, School of Medicine and School of Hygiene and Public Health, Johns Hopkins University; Scott O. Lilienfeld, Department of Psychology, Emory University; John Monahan, Professor of Law, Psychology, and Legal Medicine, University of Virginia School of Law; Eric J. Nestler, Professor of Psychiatry and Neurobiology, Yale University School of Medicine; Henry W. Riecken, Professor of Behavioral Sciences, University of Pennsylvania School of Medicine (emeritus); and Lee N. Robins, Department of Psychiatry, Washington University of School of Medicine. Although the individuals listed above have provided constructive comments and suggestions, it must be emphasized that responsibility for the final content of this report rests entirely with the authoring committee and the institution. The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council. Contents Executive Summary 1 1   Introduction 7 2   Gambling Concepts and Nomenclature 15 3   Pathological and Problem Gamblers in the United States 63 4   Research on the Origins of Pathological and Problem Gambling 107 5   Social and Economic Effects 156 6   Treatment of Pathological Gamblers 192 7   Organization and Technology of Gambling 237 Appendixes A   Gamblers Anonymous Twenty Questions 271 B   Diagnostic and Statistical Manual of Mental Disorders Criteria for Pathological Gambling 273 C   Legal-Age Gambling Opportunities and Restrictions 283 D   Summary of Treatment Literature 313 E   Gamblers Anonymous Meetings by State 317 F   Biographical Sketches 319 Index 326 Executive Summary Gambling in America has deep cultural roots and exists today as a widely available and socially accepted recre-ational activity. Over 80 percent of American adults now report having gambled sometime during their lifetimeon casino games, lotteries, sports betting, horse racing and off-track betting, and other gambling activities. It is estimated that in 1997 they collectively wagered more than $551 billion. This market has increased the intensity of competition for gambling dollars among state-sponsored lotteries and commercial gambling enterprises, leading to legalization in some states in which gambling had previously been voted down. Presently, gambling in some form is legal in all but 3 states, casinos or casino-style games are available in 21 states, and 37 states have lotteries. Resistance by many state legislatures to casino gambling and state-sanctioned sports betting continues, but state and tribal governments are increasingly relying on gambling revenues. Although the recent institutionalization of gambling appears to have benefited economically depressed communities in which it is offered, gambling has social and economic costs. Two major concerns of public health and other policy officials are whether, in the currently expanding gambling environment, the number or proportion of pathological gamblers in the United States is in creasing and the possible effects of pathological gambling on individuals, families, and communities. The charge to the Committee on the Social and Economic Impact of Pathological Gambling was to identify and analyze the full range of research studies that bear upon the nature of pathological and problem gambling, highlighting key issues and data sources that can provide hard evidence of their effects. Pathological gambling differs from the recreational or social gambling of most adults, who view it as a form of entertainment and wager only small amounts. In 1975, the Commission on the Review of the National Policy Toward Gambling estimated that less than 1 percent of the U.S. population were "probable compulsive" gamblers. Pathological gambling was first included as a mental health diagnosis in 1980 in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the official publication of the American Psychiatric Association, classified in the section on disorders of impulse control. It was described as a chronic and progressive failure to resist impulses to gamble, characterized by undesirable outcomes ranging from borrowing money from family or friends and losing time at work, to being arrested for offenses committed to support gambling. Much of the literature examined by the committee on pathological gambling also reflects the American Psychiatric Association's conceptualization of pathological gambling as a disorder characterized by people's continuous or periodic loss of control over their gambling behavior, a preoccupation with gambling and with obtaining money with which to gamble, irrational thinking, and a continuation of the behavior despite adverse consequences. The current description of pathological gambling in DSM-IV characterizes pathological gambling in relatively precise operational terms; provides the basis for measures that are reliable, replicable, and sensitive to regional and local variation; distinguishes gambling behavior from other impulse disorders; and suggests the utility of applying specific types of clinical treatments. Moreover, the DSM-IV criteria appear to have worked well for clinicians for the past five years. However, because it is a clinical description with little empirical support beyond treatment populations, there still are problems with its use to define the nature and etiology of pathological gambling and when trying to estimate prevalence. The Committee on the Social and Economic Impact of Pathological Gambling has conducted an extensive review of the relevant scientific literature. The committee concludes that pathological gambling is a significant enough problem to warrant funding support for a more sustained, comprehensive, and scientific set of research activities than currently exists. The availability of legal gambling has increased sharply in the past 20 years. More people are gambling, and they are wagering more. As a result, there is increased concern about pathological gambling. Clinical evidence suggests that pathological gamblers engage in destructive behaviors: they commit crimes, they run up large debts, they damage relationships with family and friends, and they kill themselves. With the increased availability of gambling and new gambling technologies, pathological gambling has the potential to become even more widespread. A greater understanding of this problem through scientific research is critical. Recent methodological and theoretical advances in epidemiology, medicine, and the social and behavioral sciences should aid this understanding. The committee estimates that 1.5 percent of adults in the United States, at some time in their lives, have been pathological gamblers. We estimate that, in a given year, 0.9 percent of adults in the United States, or 1.8 million, are pathological gamblers. Men are more likely than women to be pathological gamblers, and the proportion of pathological gamblers among adolescents is higher than it is among adults. The committee estimates that, in a given year, as many as 1.1 million adolescents between the ages of 12 and 18 are pathological gamblers. However, the committee recognizes that adolescent measures of pathological gambling are not always comparable to adult measures and that different thresholds for adolescent gambling problems may exist. Given various ways in which pathological gambling has been operationalized in prevalence studies among adolescents, this estimate should be viewed with caution. Because the existing research on other subgroups in the population is less well developed, the committee was unable to determine the degree to which other groups, such as elderly people and poor people, have disproportionately high rates of pathological gambling. To understand changes in gambling and pathological gambling over time, as well as the nature and origins of pathological gambling, both cross-sectional and longitudinal studies of gambling will be necessary. The committee recommends that the Centers for Disease Control and Prevention and the National Institutes of Health should routinely include measures of pathological gambling in their annual surveys, and that measures of gambling and related leisure activities and outcomes (e.g., debts) should be added to other prospective, longitudinal studies on health or mental health. Doing so not only would add valuable information about gambling over time, but would also provide important information about baseline measures and other disorders that tend to cooccur with pathological gambling. Research is beginning to elucidate the onset and course of pathological gambling. For example: Pathological gambling often occurs with other behavioral problems, including substance abuse, mood disorders, and personality disorders. Recent research suggests that the earlier one starts to gamble, the more likely one is to become a pathological gambler. Pathological gamblers are more likely than nonpathologi-cal gamblers to report that their parents were pathological gamblers. These findings, in conjunction with twin studies and recent neuroscience studies, suggest that pathological gambling may be influenced by familial factors and the social environment. An accurate examination of the costs of pathological gambling requires an assessment of the costs and benefits of gambling generally. Gambling appears to have net economic benefits for economically depressed communities, but the available data are insufficient to determine with accuracy the overall costs and benefits of gambling. Pervasive methodological problems prevent firm conclusions about the social and economic effects of gambling or pathological gambling on communities, nor can the committee say whether pathological gamblers contribute disproportionately to overall gambling revenues. Similarly, the committee could not determine how legalized gambling affects community or national rates of suicide and crime. Additional studies are required to advance understanding of these important matters. Current, but limited, research indicates that pathological gamblers who seek treatment generally improve. This research is inadequate to determine whether any particular treatment approach is more effective than any other or the extent to which people recover on their own. The effectiveness of promising treatments that are emerging in the mental health field (for example, cognitive-behavioral and pharmacotherapy treatments) should be carefully evaluated. The unmet need for treatment of pathological gambling is unknown. Future research should evaluate the extent of unmet need and what barriers contribute to it, such as lack of insurance coverage, stigmatization, or the unavailability of treatment. Because pathological gambling often occurs with other disorders, such as substance abuse and antisocial personality disorder, the committee recommends that those undergoing treatment for those disorders be assessed routinely for pathological gambling. Advances in computer and telecommunications technology have increased the availability of gambling. New technology holds the potential to change the subjective experience of gambling and to increase how often, how much, and how long people gamble. Research should be conducted to assess the effects on pathological gambling of remote access to gambling (e.g., Internet gambling), new gambling machines, and gambling while alone. Overall, the committee found that much of the available research on all aspects of pathological gambling is of limited scientific value. Our conclusions are greatly influenced by a relatively small body of newer, better research that meets or exceeds contemporary standards for social and behavioral research. The future research recommended by the committee should be held to those standards.