Gambling Disorder: An Underdiagnosed Problem

An estimated 2.5 million adults in the United States are affected by severe gambling disorder. The prevalence of gambling disorder has increased as gambling has become more accessible. As recently as 1978, gambling was only available in 2 states. In 2025, gambling is permissible in all states with the exception of Utah and Hawaii. While casinos and lotteries are the most common forms of gambling, many other options exist and include fantasy sports, horse racing and other sports betting, card rooms, and charitable gambling. Online casinos and slots gambling tend to be the most problematic. Gambling disorder was estimated to cost at least $5 billion per year in societal costs in 2000 (eg, unemployment, healthcare), but the cost is likely much higher with the legalization of sports betting by a 2018 US Supreme Court decision. Taxes paid by casinos and other gambling establishments are often substantial, creating a disincentive to address gambling in a community; however, taxes generated are estimated to be less than half of societal costs of gambling disorder. By comparison, societal costs related to alcohol use disorder are estimated to be $250 billion per year.

Risk factors for gambling disorder include substance use, mental health diagnoses, a family history of gambling disorder, lower socioeconomic status, and child abuse/neglect or witnessing physical abuse. Males tend to be slightly more affected compared to females.

The National Institute for Health and Care Excellence recommends screening for gambling disorders by asking at-risk patients, “Do you gamble?” at the same time as screening for substance use. There is insufficient evidence regarding the benefits of screening for gambling disorder.

The differential diagnosis of gambling disorder includes other mental health disorders or substance use that impact impulse control, such as bipolar disorder and alcohol use disorder. The diagnosis of gambling disorder is outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision (DSM-5-TR)  and reproduced in the recent American Family Physician article on gambling disorder. To aid in diagnosis, self-assessments have been developed that use the DSM-5-TR criteria, but they have not been fully validated.

Treatment of gambling disorder includes establishing limits on gambling. There are some short-term benefits to pharmacotherapy (eg, opioid antagonists and atypical antipsychotic medications) and psychotherapy, but long-term effectiveness is unknown. Cognitive behavioral therapy may reduce the amount of money gambled.

The National Voluntary Self-Exclusion Program allows people to apply for self-exclusion from gambling establishments and is effective across many states. A period of exclusion of at least 6 months appears to be more effective than 3 months and reduces the risk of relapse. Self-exclusion may result in complete abstinence in over 10%-80% of participants. Self-exclusion programs may also reduce the severity of gambling (including amount, duration, and frequency of gambling) and improve quality of life. Benefits of self-exclusion programs appear to be maintained at 12 months. Peer support groups, such as Gamblers Anonymous, may also be a helpful resource in recovery.