A few days ago I received my copy of the PSYCHIATRIC NEWS wherein there was an article by Dr. Jon Grant, professor of Psychiatry at the University of Chicago entitled: Gambling Disorder Not Uncommon but often Goes Undiagnosed.   A couple of days later the following slick little brochure from the Ohio Lottery Commission showed up in my mail:

Play the Games and win the CASH that IS going to let you live like a KING

It even came with a coupon which could be worth $500 when turned in along with your latest “scratch off” ticket purchase.  With the aid of a magnifying glass, I was able to read the fine print at the bottom of the brochure and noted that 1 million such brochures were printed. I believe it is reasonable to assume that there would be one out of that 1 million who would get the 500 bucks if in the unlikely event all the coupons were actually turned in. 

There was also inscribed in that fine print the Lottery commission’s oft repeated oxymoron to “play responsibly.”  That phrase, which also accompanies their ads on TV, always takes my blood near the boiling point because I don’t believe my government should be in the business of promoting addictions.  I also believe that any behavior with the potential to do harm and even destroy lives should not be encouraged. Gambling is by its very nature irresponsible. 

Afterall, we don’t instruct people to take heroin responsibly.

Yet even Dr. Grant who is editor in chief of THE JOURNAL OF GAMBLING STUDIES , says: “When done responsibly gambling can be fun, thrilling, and potentially rewarding, yet hiding in plain sight are millions of people struggling  with gambling disorder.”   However, Dr. Grant does not share with us how we can be certain that we are immune from developing gambling disorder.  I doubt there are many gambling addicted people who begin gambling with the intention to gamble irresponsibly, or who start gambling with the intention to become addicted. 

During my career I saw many patients who admitted to having gambling problems, and probably many others whom I did not diagnose for those afflicted frequently focus on unrelated symptoms, embarrassed to admit to a gambling problem.  Others may admit to gambling, but deny it is a problem.   Related financial problems are written off as a string of bad luck and denial is expressed by the typical addict’s mantra of “I can quit any time”.  They may see their only problem as simply a string of bad luck which can only be overcome by continuing to gamble in order to recoup their losses. 

One patient who comes to mind was a very pleasant 40ish single mother whom we shall call Alice.  I had been treating her for depression for several months with little success.  She had gone through a nasty divorce from an abusive husband which had taken a toll on her self-esteem.  Alice had married young, had few skills, took a low wage job, and managed to barely survive financially with minimal and erratic child support from her ex-husband.  As is often the case with those of poor self-image she became involved with another poor choice long enough for him to introduce her to the joys of gambling by taking her to a casino where she became enamored with the slot machines.  Following the breakup of that relationship, she discovered the bingo games at her church and would often do 4 or 5 cards simultaneously.  Scratch off cards and lottery tickets consumed every dollar she could find.  There had never been any mention any of gambling until she arrived for a session one day, tearful and overwhelmed with guilt. 

She confessed that she had stolen money to gamble from her teenage son.  Her intent of course was to put it back when she won, behavior all too common with those who are addicted.  Alice was referred to Gamblers Anonymous, and continued in treatment for her depression until shortly before my retirement.  When last seen she was doing well, however relapses are common.  Alice was typical of those with a significant gambling problem in that she also had another psychiatric diagnosis which leaves one with the traditional chicken-egg controversy – did gambling cause the depression or was the depression the result of the gambling problem.  

It has been estimated that 1% of the population is suffering from gambling disorder as it is described in the American Psychiatric Diagnostic and Statistical Manual of Mental Illness (DSM), although accurate statistics are difficult since many cases go undiagnosed, and are often not discovered until a family crisis uncovers the problem as had occurred with my patient.   In addition to family disruptions, bankruptcies, and homelessness, addiction to gambling also carries with it a significant mortality rate.  Rates of gambling related suicide attempts have been rated as between 12% and 30%.  Such a variation suggests we don’t know the real number, and indeed we know suicide rates are underreported due to kind hearted physicians who wish to spare families embarrassment due to the social stigmata attached to the act and to ensure that life insurance policies will be honored.  

The gambling capital of the U.S. is also according to Michelle Trudeau of National Public Radio the suicide capital of the country averaging one daily.  She reported on a Harvard study in which residents of Las Vegas had a 50% higher risk of suicide than the rest of the country and that visitors to the city were twice as likely to kill themselves.  The coroner of Las Vegas ascribes this to the fast pace of life in a boom town and downplays the effects of gambling – surprise, surprise. 

According to our Attorney General we have four different commissions that regulate gambling in my state (Ohio).  When I was a kid, gambling was illegal with the exception of horse racing which could only be wagered at the track.  In 1973, the Ohio constitution was amended to allow a state lottery.  It was passed with a great deal of ballyhoo that the profits would be used to fund schools, and who could be against such a worthy cause? However, 50 years of the lottery does not seem to have done much to change financing of education.  At least I didn’t notice any decrease in my property taxes. 

10 years ago, our first casino opened.  The rational given for legalizing such facilities was that our neighboring state, Indiana, was attracting gamblers from Ohio consequently; would we not rather have them spend their money in Ohio?  Recently, our Governor signed a bill allowing betting on sports with no rationale I could find other than they are already doing it, so why not let the government in on the action?  

It seems that gambling of some sort has always been with us, and that fleeting euphoria which overtakes us when we beat the odds seems to be hard wired.   It may be simply another example of the “pleasure principle” which Freud talked about or perhaps a feeling of superiority for after all gambling is a kind of competition.   However, gambling has a significant advantage over other forms of addiction in hooking us.  B.F. Skinner demonstrated conclusively that behavior can be modified more effectively with what he called “intermittent positive reinforcement” which is the essence of all gambling.   His experiments with rats are replicated whenever someone plays a slot machine, for as did Skinner’s rats we wait for a reward each time we pull the handle.  He demonstrated that his rats were more highly motivated when the rewards were intermittent rather than when predictable, and that such was the case with all creatures tested including humans.  He also noted that the behaviors elicited in this manner were very resistant to being extinguished.  The same principal applies with gambling which is further amplified by increasing the possible amount of the reward. 

Prior to the time when I kicked my addiction to tobacco, I frequently stopped by a neighborhood convenience store to refill my stash of pipe tobacco.  On one such occasion, I was preceded into the store by a middle-aged man who appeared to be of modest means.  He had arrived in a pickup truck which had seen better days, and the state of his bib overalls showed signs that they had also endured some tough times.  His overall appearance and demeanor suggested this guy was a working man with emphasis on the type of work which tests one’s body.  It was Friday and I assume it must have been payday, for he grabbed a six pack of Bud light, asked for a pack of Marlboros and a scratch off ticket of some kind.  He scratched off the seal, threw the ticket down and asked for another one.  Meanwhile the line behind him which included me was stretching so he stepped aside.  As I was leaving he reinserted himself in the line and bought another ticket. 

That vignette of the sweaty guy in bib overalls throwing away money that was undoubtedly earned the hard way is replayed in my mind whenever I hear that those who gamble should “play responsibly”.  During the last few years of      my career, I worked in a clinic with patients mostly with very limited incomes usually through no fault of their own.  They often shared not only their fears, and troubles, but also their yearnings.  Perhaps, the most knowledgeable people about influencing human behavior are those in the advertising industry.  They know all about Skinner’s and other experts’ research, and I confess they hit the bulls eye with that cute little pamphlet I mentioned in the beginning of this diatribe, for who living on the bottom rung of the economic ladder wouldn’t like to have the “CASH that is going to let them live like a KING?”