March 14, 2011 (Vienna, Austria) — Most pathological gamblers who respond to a 6-month trial of pharmacotherapy remain relapse free for the next 6 months without the use of medication, new research presented here at EPA 2011: 19th European Congress of Psychiatry suggests.
The study showed that only 17 of 43 patients relapsed during follow-up. Relapse was defined as a gambling episode at any time during the medication-free follow-up period.
"Our findings suggest that relapse is uncommon in gamblers who respond to pharmacologic treatment," Pinhas N. Dannon, MD, professor of psychiatry at Tel Aviv University and head of the Psychiatry Research Department at Beer Yaakov MHC, Israel, told Medscape Medical News.
Although the mechanisms of the remission are not clear, changes in central nervous system transmitters induced by drug therapy may play a role, he noted. Each of the 4 medications used in the study acted on at least one of several neurotransmitters, such as dopamine (bupropion sustained-release and naltrexone), serotonin (fluvoxamine, bupropion sustained-release), norepinephrine, γ-aminobutyric acid, and glutamate (topiramate), all of which have been implicated in the etiology of pathological gambling.
"It is possible that drug treatment may have led to changes in these neurotransmitters, which persevered after treatment was stopped," he said.
Dr. Dannon added that alterations in neuromotivational pathways secondary to drug treatment may also contribute have contributed to remission.
Common and Disabling Disorder
Pathological gambling is a relatively common impulse control disorder, affecting 1.0% to 3.4% of US adults. The condition can be highly disabling to the individual and society and commonly leads to suicide attempts, job loss, marital and family problems, legal problems, and criminal behavior. It is also chronic and progressive and most often affects males.
A broad range of pharmacologic agents has been shown to be effective for the short-term treatment of this disorder, including selective serotonin reuptake inhibitors (SSRIs), antiepileptic drugs (AEDs), atypical antidepressants, and opioid antagonists.
Effective treatment for pathological gambling with widely varied pharmacologic agents supports the observation that pathological gambling has features that are commonly seen with obsessive-compulsive spectrum disorders, other impulse control disorders, and addiction disorders.
For the study, Dr. Dannon and colleagues determined the relapse rate in pathological gamblers who had responded to a 6-month course of drug treatment and then underwent a 3-month, open-label, continuation phase and a 6-month, medication-free, follow-up phase.
All patients had been diagnosed as being pathological gamblers per Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria, which include recurrent and maladaptive gambling. They also had a South Oaks Gambling Screen score of 5 or higher.
Most patients did not relapse during the 6-month, medication-free, follow-up phase. Three of 6 patients who had initially responded to the SSRI fluvoxamine relapsed. Relapses also occurred in 3 of 9 patients treated with the AED topiramate, 7 of 18 with the atypical antidepressant bupropion sustained-release, and 4 of 10 with the opioid receptor antagonist naltrexone.
There were no significant differences in long-term outcome among the 4 treatment groups.
Heterogeneous Disorder
Dr. Dannon pointed out that the finding that most patients in all treatment arms had sustained remission of symptoms at 12 months bolsters prior research suggesting that pathological gambling is a heterogeneous disorder and may respond to different classes of medication.
He cautioned that although important study strengths include the longitudinal follow-up of individuals during a 12-month period and the high retention rate of the study participants, the results may be weakened somewhat by the lack of a medication-free placebo control group.
The lack of a placebo control means it is not possible to definitively exclude the possibility that remission occurred as part of the natural history of the disorder. Also, remission of symptoms was partially based on patient reports, thereby introducing the potential for observer bias.
Finally, he said that additional research in a larger number of patients and with a placebo- controlled design is needed to verify the findings. He also said that it is important to explore the potential for newer drug therapies to treat pathological gambling.
'Promising' Results
Virgilio Arenas, MD, director of the Division of Addiction Psychiatry and the Addiction Psychiatry Training Program at Northwestern Memorial Hospital in Chicago, Illinois, told Medscape Medical News that the findings are "promising" but emphasized that more information is needed before it is possible to determine their clinical relevance.
"We need more details about, for example, ethnicity and the type of gambling the population engaged in, otherwise it’s difficult to make a conclusion about the generalizability of the findings," he said.
"We know there is a wide range of psychological, social, and economic problems associated with pathological gambling. Also, some studies have suggested that genetic, familial, sociological, and individual factors may play an important role in pathological gambling. In addition, research has suggested that not all forms of gambling are the same and that the "reward" system may not be activated the same way with different gambling behaviors," he added.
Nonetheless, said Dr. Arenas, it was interesting that most patients did not relapse during the medication-free phase — a finding that may suggest that certain gambling behaviors "have a good chance" of responding to medication.
Finally, Dr. Arenas commented that although he has not seen many pathological gamblers at his clinic, those individuals he has seen tend to present with something other than a gambling addiction as their primary problem.
"The few patients whom I have treated here have had a moderate to severe substance abuse issue or mental health problem and have used a combination of psychotropics and cognitive behavioral therapy, which has produced mixed results in terms of their gambling addiction," he said.
Dr. Dannon and Dr. Arenas have disclosed no relevant financial relationships.
EPA 2011: 19th European Congress of Psychiatry: Abstract FC18-01. Presented March 14, 2011.
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