Calling for worldwide adoption of Gambling Disorder Screening Day

Gambling Disorder creates substantial harm to individuals and society due to a constellation of financial, relational, psychological, and other consequences (Langham et al. 2016; Browne et al. 2017). Marginalized communities disproportionately bear the burden of gambling-related harm and are more likely to experience Gambling Disorder (Abbott 2017). As with other mental health conditions, early detection and intervention of Gambling Disorder hold the potential to interrupt the course of illness. However, both individual gamblers and their healthcare providers lack awareness of the signs, symptoms, natural course, and treatability of Gambling Disorder (Pulford et al. 2009; Gainsbury et al. 2014; Manning et al. 2020; Katayama et al. 2022). Mass screening events, such as those developed for other mental health conditions, have been demonstrated to educate the public, connect people to treatment at an earlier stage of illness, and catalyze healthy behavior change. In this editorial we argue that people with Gambling Disorder and their loved ones will benefit from expanded participation in a dedicated screening day around the world.

Wilson and Junger (1968) established that there are tremendous health and economic benefits for the mass screening for chronic, noncommunicable disease. They suggested that ten conditions exist under which mass screening will be beneficial. These conditions included the following four central and unique issues: (1) that the condition is an important health problem, either because of its high prevalence or because it causes very serious consequences for those affected, or both, (2) that suitable screening methods exist, are acceptable to the population, and present minimal costs and burden, (3) that the condition is recognizable at an early stage, and (4) that effective treatments are available for those whose health conditions are recognized. Clinicians and researchers have recognized that these conditions apply to many mental health problems. Accordingly, mass screening day events have been developed for depression, anxiety, alcohol use disorder, eating disorders, and more (e.g. Jacobs 1995).

Mass screening for Gambling Disorder is important because it often goes undiagnosed and untreated. This results partly from the lack of awareness mentioned above, alongside shame/stigma, lack of access to behavioral health, and other barriers (Gainsbury et al. 2014; Loy et al. 2018; Bijker et al. 2022). However, many people with gambling-related problems seek treatment for other somatic and behavioral health problems. One U.S. national study reported, for example, that although none of those who were identified as meeting lifetime diagnostic criteria for Gambling Disorder reported seeking treatment for those problems, about half were involved in behavioral treatment for so-called emotional problems (Kessler et al. 2008). This suggests that increasing screening for gambling-related problems in healthcare and other settings (e.g. college wellness centers, recovery coaching, substance use helplines) might be beneficial for those struggling with gambling problems on their own. Around the world, Gambling Disorder continues to receive less attention than other behavioral health disorders. Fortunately, as we detail below, Gambling Disorder is a condition that meets many of Wilson and Junger’s (1968) criteria for effective mass screening, including the four central and unique criteria we emphasized above.

• (1) Importance of the problem

Public health professionals, researchers, treatment providers, and others have recognized that gambling-related problems create devastating problems for those who struggle with gambling and those around them (Shaffer and Martin 2011). Consequences of gambling-related problems include experiences like bankruptcy, disrupted family and other interpersonal relationships, justice involvement, poor work performance, and more (Langham et al. 2016). Gambling-related problems are highly likely to co-occur with other mental health problems, like depression, anxiety, personality disorders, substance use disorders, and trauma (Kessler et al. 2008), complicate recovery from these conditions, and share a potent relationship with self-harm experiences, including suicide ideation and attempts (Wardle and McManus 2021; Edson et al. 2022). Rates of lifetime Gambling Disorder are reported to range from less than 1% to slightly over 1%; however this prevalence rate could be higher depending on measurement issues (Harrison et al. 2020), and often varies with temporal and regional exposure to gambling (LaPlante and Shaffer 2007). As opportunities for legal gambling grow around the world, widespread marketing and advertising that typically accompanies gambling expansion ensures that its reach will be broad and touch many individuals, even those who are most vulnerable to developing gambling-related problems (Bouguettaya et al. 2020). Professional recognition of gambling as a public health problem must grow to keep pace with the rapid worldwide expansion of commercial gambling opportunities (Wardle et al. 2021).

• (2) Suitability, acceptability, and cost of screening instruments

In both mass screening settings and routine clinical settings, screening methods will be suitable only if they reliably detect previously undetected cases (Wilson and Junger 1968). This requires high sensitivity, even at the expense of elevated false positive rates relative to diagnostic instruments. Additionally, time constraints often dictate that screeners select brief (i.e. 1-5 item) instruments. Fortunately, as reviewed by Dowling et al. (2019), several suitable brief Gambling Disorder screening instruments are available. Screeners should consider the setting, age of the target population, intended timeframe (e.g. lifetime vs. past year vs. past month), and available clinical resources when selecting a particular instrument. Diagnostic accuracy coefficients are available for 20 brief screening instruments (Dowling et al. 2019), including the Brief Problem Gambling Screen (BPGS, Volberg and Williams 2011), National Opinion Research Center Diagnostic Screen for Gambling Disorders – Loss of Control, Lying and Preoccupation scale (NODS-CLiP, Toce-Gerstein et al. 2009), NORC Diagnostic Screen for Gambling Disorders – Loss of Control, Lying and Preoccupation 2 scale (NODS-CLiP2, Volberg et al. 2011), NORC Diagnostic Screen for Gambling Disorders – Preoccupation, Escape, Chasing and Risked Relationships scale (NODS-PERC, Volberg and Williams 2011), and Problem Gambling Severity Index (PGSI) Short Form (Volberg and Williams 2012). Our research center developed the 3-item Brief Biosocial Gambling Screen (Gebauer et al. 2010), or BBGS, which we recommend due to its brevity, ease of administration, psychometric properties, and ease of interpretation (Brett et al. 2014; Castrén et al. 2015; Dowling et al. 2019; Langan et al. 2019). Future research efforts should include validating the BBGS and other instruments among diverse international samples and making revisions to ensure cultural relevancy.

• (3) Ability to recognize the problem at an early stage

Although those at the most severe end of the gambling-related problems continuum are generally most in need of clinical support, those experiencing at-risk/subclinical Gambling Disorder are more prevalent among the population, contribute to most of the population-level harm (Browne et al. 2017), and require accurate screening and early intervention. Fortunately, one validated screening instrument (the 3-item PGSI-Short Form; Volberg and Williams 2012) was designed to identify subclinical cases and at least eight instruments are suitable for doing so (Dowling et al. 2019). The PGSI-Short Form includes two items tapping gambling consequences: feeling guilty about one’s gambling and receiving criticism about one’s gambling. These consequences might appear early in the course of the disorder, relative to other experiences such as developing tolerance, having to borrow money to support one’s gambling, and facing health problems. As Volberg and Williams (2012) note, more research is needed regarding the use of these items for identifying early-stage Gambling Disorder cross-culturally, because individual cultures’ moral stance toward gambling will influence experiences of guilt and criticism.

• (4) Availability of effective treatments

Systematic reviews suggest the availability of efficacious psychological treatment for gambling (Pallesen et al. 2005). Although psychopharmacological treatments show much promise, behavioral interventions such as Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI) are optimal for the first approach (Yip and Potenza 2014). For example, a meta-analysis of randomized controlled trials of Motivational Interviewing suggested that it is associated with gambling reductions up to a year after treatment (Yakovenko et al. 2015). Those providing substance use disorder treatment are especially encouraged to offer brief CBT- and MI-based interventions for clients experiencing comorbid gambling-related problems (Petry et al. 2008). Those experiencing at-risk/subclinical gambling can also benefit from using evidence-based self-help tools (e.g. LaBrie et al. 2012; Division on Addiction 2023b). Research also suggests the possibility of safer gambling practices, which would be useful guidance during screening events for people who are at-risk for developing Gambling Disorder. Hing et al. (2019) identified nine practices associated with reduced experience of gambling harm. Practices to adopt include stopping when gambling is no longer fun, keeping a household budget, having a dedicated budget to spend on gambling, having diverse hobbies and interests for leisure time, avoiding gambling when depressed or upset, and identifying a fixed amount to spend when gambling. Practices to avoid include researching systems and strategies for success at gambling, using gambling to make money, and using cash advances on credit cards to gamble.

Gambling Disorder screening Day: Key learnings

In 2014, the Division on Addiction at Cambridge Health Alliance, a Harvard Medical School teaching hospital, launched a grassroots effort to advance Gambling Disorder Screening Day on the second Tuesday of March each year (LaPlante 2014). We accomplished this launch by identifying potential local and U.S. national supporters who might have been able to facilitate screening events and/or assist with promoting the event to increase our reach. Over the years, in response to feedback from screeners and supporters, we have developed and continually expanded a set of multimedia resources (Division on Addiction 2023b). Individuals and organizations across the U.S. embraced Gambling Disorder Screening Day, and the event is beginning to garner international recognition and support (Division on Addiction 2023a). Specifically, since the inception of Gambling Disorder Screening Day, we have observed confirmed support and screening events in about half of U.S. states and four countries. We also received ad hoc promotional support through social media and other avenues far beyond these locations.

Recurring anecdotal feedback suggests that one barrier to recruiting screening hosts is concern about how to respond to positive screens. Although we have expanded our resource kit to provide guidance, the field of gambling studies needs to develop clinical practice guidelines that cover, among other topics, accepted clinical practices that are both unique to Gambling Disorder and common across expressions of addiction. Better education and training about skills that transfer from the treatment of substance use disorders to the treatment of Gambling Disorder could improve provider confidence and assuage concerns about responding to positive screens.

Concluding thoughts

Mass screening events have yielded successful public health outcomes, such as the promotion of evaluation and treatment engagement for a number of undertreated conditions. We suggest that, similarly, Gambling Disorder might benefit from a concerted effort to promote a dedicated Screening Day around the world. Such an effort is consistent with potential population-level solutions, such as stricter regulations and product safety requirements and decreased availability (Wardle et al. 2019), because both approaches aim to reduce the total burden of harm caused by gambling.

As we approach the ten-year anniversary of Gambling Disorder Screening Day in the U.S. on March 14, 2023, we intend to promote the continued expansion of screening for gambling-related problems and, in particular, this event. Our hope is that greater worldwide involvement with Gambling Disorder Screening Day primarily will benefit people who gamble and people who have gambling-related problems. Ideal benefits include increased awareness about the potential for gambling to become a serious problem, the identification of personal risk for or current experience of gambling-related problems, and increased access to in-depth evaluation for Gambling Disorder and, when necessary, treatment. Secondarily, we aspire for this event to inspire researchers and others to continue to improve our knowledge about Gambling Disorder; screening tools for this problem, especially for the early detection of problems; and intervention resources to make gambling safer and treat gambling-related problems when they do occur.

Disclosure statement

The Division on Addiction at Cambridge Health Alliance currently receives funding from DraftKings, Inc., a sports betting and gaming company; Entain PLC (formally GVC Holdings PLC), a sports betting and gambling company; EPIC Risk Management; Foundation for Advancing Alcohol Responsibility, a not-for-profit organization founded and funded by a group of distillers; Massachusetts Department of Public Health, Office of Problem Gambling Services via Health Resources in Action; National Academy of Medicine; National Institutes of Health (National Institutes of General Medical Sciences, and Drug Abuse, and Mental Health) via The Healing Lodge of the Seven Nations; and Substance Abuse and Mental Health Services Administration via the Addiction Treatment Center of New England. During the past 5 years, the Division on Addiction has also received funding from David H. Bor Library Fund, Cambridge Health Alliance; City of Seattle; Fenway Community Health Center, Inc.; Greater Boston Council on Alcoholism; Integrated Center on Addiction Prevention and Treatment of the Tung Wah Group of Hospitals, Hong Kong; Kimley-Horn; Massachusetts Department of Public Health, Bureau of Substance Addiction Services; Massachusetts Department of Public Health, Bureau of Substance Addiction Services via St. Francis House; the Massachusetts Gaming Commission, Commonwealth of Massachusetts; MGM Resorts International via the University of Nevada, Las Vegas; and Substance Abuse and Mental Health Services Administration via the Gavin Foundation.

During the past five years, Heather Gray has served as a paid grant reviewer for the National Center for Responsible Gaming (NCRG; now the ICRG), received honoraria funds for preparation of a book chapter from Universite Laval, received travel funds and honoraria from the ICRG, received travel funds from the Alberta Gambling Research Institute, received speaker fees from the Responsible Gaming Association of New Mexico and the University of Iowa, and received course royalty fees from the Harvard Medical School Department of Continuing Education. She is a non-paid member of the New Hampshire Council for Responsible Gambling.

During the past five years, Debi LaPlante has served as a paid grant reviewer for the National Center for Responsible Gaming (NCRG; now International Center for Responsible Gaming), received travel funds, speaker honoraria, and a scientific achievement award from the ICRG, has received speaker honoraria and travel support from the National Collegiate Athletic Association, received honoraria funds for preparation of a book chapter from Universite Laval and for an invited Raschkowan webinar from McGill University, received publication royalty fees from the American Psychological Association, and received course royalty fees from the Harvard Medical School Department of Continuing Education. She was a non-paid member of the New Hampshire Council for Responsible Gambling.

Additional information

Funding

Preparation of this manuscript was not funded by any specific grant, contract, or gift.