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Testimony on Gambling Addiction by Steven E. Hyman, M.D.
Director, National Institute of Mental Health
National Institutes of Health
U.S. Department of Health and Human Services

Before the Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, and Education
June 30, 1999

Thank you for the opportunity to testify this morning about research issues related to pathological gambling. As other testimony this morning illustrates compellingly, for those who lose control and gamble compulsively, there can be devastating consequences--professionally and personally.

As the National Gambling Impact Study Commission recognizes in its report, gambling involves an array of policy, scientific, and other issues that go well beyond the clinical scientific research focus of the National Institute of Mental health (NIMH) or the National Institutes of Health (NIH). I will focus here solely on the issues within our scientific domain. We are, of course, open to scientific exchanges with other agencies so that tools, methods, and findings of importance are widely and quickly shared with those who can benefit from them. In fact, it is possible that the broader impacts that problem and pathological gambling may have on the health and welfare of individuals, families, and communities may suggest the utility of developing a more comprehensive approach within the Department of Health and Human Services to transform scientific findings into other programmatic activity.

We welcome the Commission's recognition of the importance of peer review to ensure that research funded by NIH is of the highest scientific value. Science of the highest quality is essential to the responsible use of taxpayer funds, to the credibility of the findings, and to efficient research progress in addressing all public health problems, including pathological gambling. We also welcome the Commission's encouragement of scientific knowledge that could contribute to the effective prevention of pathological gambling. Last year, NIMH, along with its sister institutes--the National Institute on Drug Abuse (NIDA) and the National Institute on Alcoholism and Alcohol Abuse (NIAAA) --issued a special Program Announcement (PA) to alert investigators of our interest in funding excellent science focused on pathological gambling. We are already planning to issue an amendment to this Program Announcement this year, and we will incorporate into our communications to the field the Commission’s recommendations for longitudinal research regarding the initiation, nature, and course of youth gambling in the context of other youth behaviors and factors. We will also incorporate the Commission’s recommendation for research on risk and protective factors for adults' transition to pathological gambling.

We at NIMH approach pathological gambling--as we do all research on pathological behavior and mental illness--in a broad context of basic and clinical research spanning multiple disciplines and diverse perspectives. We believe that our understanding of pathological gambling, like all disorders within our purview, will benefit both from research specifically targeted to its diagnosis, prevention, and treatment, as well as from a large body of other NIMH basic and clinical research that provides a relevant context. That broader body of research includes basic behavioral studies on decision-making, risk-taking, self-control, and compulsive behavior; neurobiological studies on how behaviors such as gambling alter brain funding resulting in compulsion and loss of control; clinical studies on mood disorders, compulsive behaviors, and the relationship between the two; as well as rigorous evaluation of treatments and preventive interventions and their delivery in diverse real-world settings. Indeed, as we look forward to developing further research on pathological gambling, it is important to make sure that this research benefits from knowledge, methods, and perspectives in related but more fully developed areas of basic and clinical study. These may offer clues to common biological and psychological origins, and may suggest some new avenues for prevention and treatment.

We need to understand why certain people seem to lack the mechanisms necessary to regulate their behavior with regard to gambling. Perhaps these mechanisms--or lack of them--are the same as those involved in better understood mental disorders or in addictions to alcohol or drugs of abuse. We need to find these answers in order to make real headway in developing a solid scientific foundation for understanding, diagnosing, treating, and preventing pathological gambling through research of high quality. It is very early in the development of this research field. Little is now known through rigorous research about the underlying biological and psychological features of pathological gambling, about developmental risk and protective factors, or about its natural course, effective treatments, or the prevention of relapse. But what we do know about other compulsive behaviors may offer clues.

The bulk of the NIH research is conducted through grants to researchers around the country who submit research application that are rated of high scientific merit through a rigorous scientific peer review process. Until this past fall, only a few researchers had applied to study pathological gambling. But with increased interest shown by the gambling research community, in combination with basic and clinical research in related areas, we are beginning to move forward.

I am very pleased to announce that NIMH is in the process of funding the first rigorous scientific evaluation of psychosocial treatment for pathological gamblers. This research, which received virtually the best possible rating of scientific merit in our rigorous scientific peer review process, will receive almost $1.2 million in NIMH support over 5 years. The research plan is to involve 220 pathological gamblers in a study determining whether cognitive-behavioral treatment might offer therapeutic effects over and above those obtained through Gamblers Anonymous, a self-help approach modeled on Alcoholics Anonymous. Cognitive-behavioral treatment has been found effective in use for various relevant disorders (mood disorder, conduct disorder, addictions, obsessions and compulsions) and, in a smaller scale study in Canada, with pathological gamblers. Mindful of constraints on service funding, the investigator has designed the treatment to be administered briefly (in 8 weeks). The effectiveness of providing this treatment in groups, with professional leaders, will be compared to providing it through a self-help manual. What works best for whom will also be determined. This investigator has also developed--with benefit of her multidisciplinary training in experimental psychology, prevention and addiction treatment--plans for other research concerning the treatment of pathological gamblers, and we look forward to her additional clinical research contributions.

Questions about the nature of the underlying mechanisms in compulsive gambling, and its frequent co-occurrence with substance abuse make pathological gambling of interest to other components of NIH, such as NIDA and NIAAA. Each of these institutes has funded a research grant concerning pathological gambling. NIDA’s is concerned with pathological gambling as a non-pharmacological addiction, and is examining several relevant biological systems for clues to underlying factors that could then be targets for intervention. NIAAA’s grant involves a large survey to explore the relation of substance abuse disorders and pathological gambling in the context of community factors that include the availability of gambling.

As stated earlier, in order to stimulate more such research applications, NIDA and NIAAA joined with NIMH last summer in issuing a Program Announcement (PA) for research on pathological gambling. This PA encouraged all disciplines to consider basic, clinical, and services research in this area, and provided for a date for receipt of applications and a special review group devoted specifically to these applications. Consistent with our general experience with research grant applications in a relatively new research area, the scientific peer review of the first submissions under the PA resulted in no applications with ratings of scientific merit in the normally fundable range. Many of the applications in response to the PA were very promising, and if the applicants adequately address the various concerns of the reviewers and resubmit their applications at a later date, some may well improve sufficiently in scientific quality to be within the fundable range in the next round of review.

We feel very strongly that funding studies of low or questionable scientific quality does not advance the scientific knowledge base and is not a responsible use of taxpayers' funds. It is likely that over the next several years we will be able to support research studies of high scientific merit that will help us understand the roots of pathological gambling and offer more effective techniques for its prevention and treatment. To this end, NIMH staff provides technical assistance to investigators with promising applications. Thus, the initial submissions in response to the PA are not lost opportunities, but first steps for some on the road to funding.

NIMH staff have also been encouraging research grant applications from interested scientific investigators working in the gambling area by conducting a workshop on applying for a grant at the recent conference of the National Council on Problem Gambling held just a few weeks ago.

My testimony would not be complete without noting that NIMH also contributed financially and scientifically to the National Gambling Impact Study Commission's national survey on the social and economic costs of gambling. NIMH staff looks forward to examining the final report on the survey and its data for possible additional analyses concerning the relation of mental health variables to pathological gambling.

Pathological gambling, has complex origins and, like so many other disorders examined by NIMH researchers, requires a broad multidisciplinary approach. These disciplines span epidemiology, genetics, neuroscience, developmental psychopathology, as well as behavioral, cognitive, and social science. The kinds of questions we are encouraging researchers to answer are these:

  1. For many persons, gambling is an interesting and enjoyable activity, with no or minimal adverse effects on their finances, work, or relationships with family members and others. But for some people, gambling becomes seriously maladaptive and results in major financial losses, interferes with work, and disrupts relationships with family and others. What explains such "out of control," dysfunctional and injurious behavior? What are the underlying factors?

  2. Is it primarily a reflection of another disorder (e.g., depression) or a nonpharmacological addition, a result of social-cognitive factors (e.g., faulty cognitions and reinforcement schedules), or a reflection of other factors?

  3. What are the predisposing factors? Are there different types of pathological gamblers for which different models are required to explain their gambling? Does risk run in families, and perhaps reflect the contribution of genes?

  4. What occurs in the transition to pathological gambling at the behavioral level and in the brain? What factors influence that transition?

  5. To what extent, and in what ways, is alcohol and drug use concurrent with pathological gambling? In these cases, is the gambling and substance abuse a reflection of common or different factors, and what are the nature and interactive effects of pathological gambling and substance abuse

  6. How prevalent is pathological gambling? How is it defined? What are the reliability and validity of various definitions?

  7. What strategies are most effective for preventing pathological gambling?

  8. For pathological gamblers, what treatments are effective for this behavior and for co-occurring disorders and problems, such as and related problems?

  9. What is the effectiveness of treatments delivered in clinical and community settings?

These questions are strikingly elemental. They tell you both where we are scientifically, and where we need to go. It is a difficult research agenda. But we are on our way.

I would be happy to answer any questions.

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