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Impulse Control Disorders in Medical Settings

Abstract and Keywords

Impulse control disorders (ICDs) and conditions with impulse control features provide a challenge in terms of identification, treatment, and follow-up when mental health specialists are in short supply. Medical settings, in particular the largest, primary health care, provide an opportunity to address many impulse-affected conditions currently poorly assessed and treated in health care settings. Barriers to intervention for ICDs in primary health care are time constraints; understanding of the etiology, symptoms, and appropriate interventions; the health and social costs; and prioritizing of training in and treatment of conditions perceived as more serious or appropriate to a primary health care service. These barriers may possibly be overcome in primary care settings, and in this chapter, a model to address problem gambling is described.

Keywords: impulsivity, health care, primary care, interventions, gambling

Impulse Control Conditions

Impulse control disorders (ICDs) comprise a small group of recognized mental health conditions; a newer and developing group that may also be considered in the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM); and, lastly, a much wider group of recognized mental health disorders that have impulse control features. Many of the newer conditions, such as Internet overuse, currently appear to have some acceptance within the broad category of addiction (Block, 2008). Aspects of compulsion have been identified within ICDs. Another view is that these conditions exist within an obsessive-compulsive spectrum, providing possibly a complex explanation of their etiology and treatment (Grant & Potenza, 2006; Hollander, 1993; Stein et al., 2006).

Recognized ICDs include pathological gambling, trichotillomania, kleptomania, pyromania, and intermittent explosive disorder. Other conditions that have similarities include compulsive buying, compulsive sexual behavior, compulsive gaming, and compulsive Internet use. Compulsive Internet use can also be subcategorized into a range of expanding cross-linked behaviors, including Internet pornography addiction, chat room addiction, Internet gaming addiction, Internet gambling, and texting and e-mail addictions. Conditions with impulsive or compulsive features but categorized within another field are wide-ranging and include obsessive-compulsive disorder, substance use disorders, schizophrenia, personality disorders, conduct disorder, paraphilias, and mood disorders (APA, 2000; Grant & Potenza, 2006).

The heterogeneity of these disorders provides a rich source of future research; however, the widespread clinical criteria can also present a challenge to those working in nonpsychiatric clinical settings. Recent research has found that every third patient in primary care showed signs of psychiatric symptoms, such as depression or anxiety, or of alcohol problems, indicating substantial opportunity as well (p. 414) as evidence of substantial need (Nordstrom & Bodlund, 2008).

Primary Care Settings

Medical settings are widespread, including medical centers, hospitals, specialist medical services, and, more recently, medical services integrated with other disciplines, such as psychological and clinical social services (WHO, 2008).

The most accessible medical settings are categorized as primary care. They are the first point of contact of the public with the medical system and are often generalist in perspective. Although the health professional who typically represents primary care settings is the family doctor or general practitioner (GP), many other health professionals may support the delivery of a primary care service. These include nurses (general practice nurses, community nurses, and nurse practitioners), social workers, psychotherapists, physiotherapists, opticians, and others, including pharmacists, midwives, and dentists. Although attempts are made to define primary care services, there is “in practice no absolute or consistent view about whether particular settings and services are part of primary health care or not” (COA, 2008, p. 10).

Accessibility and Opportunity to Treat

Primary services may allow a very high proportion of the public access to skilled services. Examples include the United Kingdom, where 86% of all health needs are managed, with 15% of the entire population seeing their family or general practice (GP) physician in a two-week period (RCGP, 2004), and Australia (COA, 2008) and New Zealand (MOH, 1999), where at least 80% of the population access their GP annually. There is now a blurring in primary care of traditional boundaries between curative care, preventive medicine, and health promotion (WHO, 2008).

In the past, mental health issues were not well addressed in primary services. This situation has changed in generalist services, with improvement in screening, greater awareness of the burden of illness that patients carry, and strategies to manage mental health disorders in general practice (Khin et al., 2003). The National Comorbidity Survey Replication (Kessler, et al., 2004) found that people with mental health or substance abuse disorders were more likely to be treated in a primary care setting; 22.8% of them were treated by a primary care physician, a nurse, or another generalist, compared with 16% who were treated by a social worker, psychologist, or counselor and just 12% by a psychiatrist (Kaplan, 2005).

Continuity of Care

The opportunity to inquire about previous health issues during subsequent patient visits (referred to as longitudinality) has been found to be critical to better health outcomes (WHO, 2008; Starfield, 1998). In reaction to the complexity of patients’ needs, including mental health and multicomorbidity, there has been an increased focus on more comprehensive and person-centered approaches and continuity of care. The organizing of primary care networks and centers enables accessibility for both sick and healthy patients, and may involve the primary care provider in coordinating with other levels of care (WHO, 2008).

Screening for Mental Health Disorders in Primary Dare

Many GPs rely on the presence of physical symptoms to identify psychiatric disorders. Although there is a strong relationship between physical symptoms and disorders, GPs’ ability to recognize psychiatric disorders using this method has been found to be low (Rasmussen et al., 2008). A range of mental health screens have been used in primary care settings, commonly to identify depression, anxiety, or clinical stress (Leon et al., 1996). These are relatively brief and often self-administered. They include the Kessler K10 (10 items), which targets distress that may be due to depression or anxiety; the Patient Health Questionnaire (PHQ-9; 9 items), which targets depression: and the General Anxiety Disorder Scale (GAD-7; 7 items), which targets anxiety. Recently, because of the need in primary care for very brief, easy-to-interpret tools, there has been a drive to develop even briefer screens, such as the four-item Brief Health Questionnaire to identify depression and anxiety (Lang et al., 2009).

An alternative approach is a regular health screener, especially for asymptomatic conditions. An example is the “lifestyle” screener, the Case-find and Help Assessment Tool (CHAT), which is completed by patients (24 items). It is a composite questionnaire that inquires about nine mental health and lifestyle behavior topics, combining 9 one- or two-question screens, followed by a help option question (BPAC, 2009; Goodyear-Smith et al., 2008). Although screening in primary care settings is common, evidence of its effectiveness is often not strong. In the U.S. Preventative Services Task Force screening recommendations for the Mental Health (p. 415) Conditions and Substance Abuse category, only smoking cessation is strongly recommended, with depression and alcohol misuse falling at the lower recommended level. Depression intervention includes screening and follow-up, while the recommendations for alcohol misuse include screening and behavioral interventions. Notably, screening in primary care for both illicit drug use and suicide risk is not recommended because of insufficient evidence for or against the effectiveness of routine screening for these problems (USPSTF, 2008; USPSTF, 2004). The Preventative Services Task Force supports the screening of some mental health conditions with features of impulse control deficits, such as alcohol misuse and tobacco use. There is insufficient evidence at this stage for the screening of other conditions (illicit drug use and suicide risk) and no advice regarding problem gambling or other ICDs.

ICDs and Primary Care

Similarities in the symptoms of ICDs described in the DSM-IV include an increasing sense of tension or arousal prior to the behavior, followed by pleasure, gratification, or relief during the behavior and then by regret, self-reproach, or guilt. However, there is a rider that this description applies only to “most” of these ICDs, and that negative cognitions and emotions following these behaviors may or may not occur (APA, 2000; WHO, 1992).

The WHO International Statistical Classification of Diseases and Related Health Problems (10th Revision; ICD-10) categorizes specific ICDs under Habit and Impulse Disorders that are not classifiable under other categories, and that are characterized by repeated acts that have no clear rational motivation, cannot be controlled, and generally harm the patient’s own interests and those of other people (WHO, 1992). These disorders are further described as being poorly understood from a causation perspective and as being grouped together only because of broad similarities of description, not because they appear to share other important features. In ICD-10, pathological gambling, pyromania, kleptomania, and trichotillomania are specifically described, with a remaining catchall category for unspecified habit and impulse disorders.

Trichotillomania

Although disorders involving the hair are common in primary care practices (Kordon et al., 2003), cases of trichotillomania in this setting are unusual, although not unknown. Behavioral therapy and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) or clomipramine have been compared, with habit reversal therapy being found superior to pharmacotherapy (Bloch et al., 2007). A recent study of N-acetylcysteine found a statistically significant reduction in symptoms. The authors stated that behavioral therapy in conjunction with pharmacotherapy warrants further research for what appears to be a disease requiring long-term therapy (Grant et al., 2009b). Although continued care in primary care settings may appear appropriate for this condition, behavioral therapies, even though they are effective, may exceed the time available in primary care, while pharmacotherapy, with or without behavioral therapy, appears to require further evidence of effectiveness. In this climate of uncertainty concerning the treatment approach and possible time requirements, even though the symptoms of hair pulling are obvious if uncovered, it appears likely that primary care health providers will refer the patient to specialist mental health providers for treatment. The same conclusion might be reached for compulsive skin picking, although similar symptoms can occur with abuse of methamphetamine and other drugs (formication), which may require even further assessment.

Intermittent Explosive Disorder

Aggressiveness and loss of control disproportionate to the stimulating event is again unusual, and symptoms may overlap with withdrawal effects from abuse of methamphetamine and other drugs (Kessler et al., 2006). Kessler and colleagues (2006) identified a lifetime prevalence of intermittent explosive disorder of 7.3% and a 12-month prevalence of 3.9%, with 28.8% of individuals having received treatment for their anger. Comorbidity with attention deficit hyperactivity disorder (ADHD) was found to be high (19.6%–22.5%); therapy with long-acting stimulants has been suggested as appropriate. Once again, the effects are similar to those of withdrawal from drug abuse, which may or may not be a consideration; however, this possible overlap may complicate primary care intervention and influence the preference for referral.

Kleptomania and Pyromania

Both of these conditions are relatively rare; they are often found in forensic treatment services rather than in primary care. Levels of lifetime diagnoses of kleptomania are high. Treatment is not definitive; a combination of pharmacotherapy and psychotherapy may be appropriate (Dannon et al., 2004; Koran et al., 2007). Naltrexone has been found to (p. 416) be effective in the treatment of kleptomania (Grant et al., 2009a). The difficulty of identifying kleptomania and pyromania outside of a forensic situation, and assessing these and coexisting conditions suggests that they will rarely be addressed in primary care settings; referral to a specialist is the likely consequence.

Pathological Gambling

Persistent and recurrent maladaptive gambling has been recognized as a possible ICD that could be addressed within a primary care setting and viewed as a chronic medical condition (Morasco et al., 2006; Potenza et al., 2002; Sullivan et al., 2006). With the increase in harm that occurs as the problem gambling progresses, there is a strong benefit in identifying the condition at an early stage (Wardle et al., 2007). Kessler and colleagues (2008) found that 96.3% of problem gamblers had at least one other lifetime mental health disorder, indicating a population with a strong health need. In addition, Zimmerman et al. (2006) found that among psychiatric outpatients, pathological gamblers were significantly more likely to be affected by another ICD; the prevalence rate for coexistence was 20%. Kessler et al. (2006) found that pathological gamblers had an even higher rate (42.3%) of disorders with impulse control deficits (oppositional-defiant, conduct, attention deficit hyperactivity, or intermittent explosive disorders).

Primary Health Care Challenges

General practitioners or family physicians are considered to be in a good position to identify ICDs such as problem gambling, especially given their ability to address the personal, family, and social problems that the gambling may cause (Kramer, 1997; Sullivan et al., 2006; Unwin et al., 2000). With the advent of newer types of impulse disorders such as Internet addiction, which have raised growing concerns in medical settings throughout the world, GPs may have a further role to play (Block, 2008; Petry, 2006). However, there are several barriers to the treatment of ICDs in primary care. These will now be discussed.

Time Limitations

One of the major impediments to addressing ICDs is the limited time that busy primary health providers have to identify, address or intervene, to discuss health issues and give feedback. General practitioners and other health professionals may often be restricted to 15–20 minutes per patient, and in a busy practice, extended consultation results in delays for other patients, increased stress for other sick patients, and even overrunning deadlines for clinic consultation. The scarcity of GPs in many countries often requires them to prioritize time, since the next patient may have a more important and more curable illness; at the same time, there is a broad focus on patients, their families, and community health (Bowman, 2009). In a time allocation study in the United States, the average time for 390 consultations was 17.4 minutes, covering 6.5 topics per session. Of over 2500 topics, more than 70% were biomedical, 12% were psychosocial, 7% were personal habits, and less than 4% were mental health concerns (Tai-Seale & McGuire, 2006).

General practitioners have indicated that lack of time was the greatest barrier to their intervening in gambling problems in their patients or their family members, especially if coexisting depression was identified (Sullivan et al., 2006). A possible solution may be referral to other health professionals in the practice with sufficient time, provided that GPs are willing to allow greater nurse or medical assistant involvement in the patient’s care (Aspy et al., 2008). Additional funding to address mental health issues would also help by reducing the GP’s workload or adding trained health care professionals to the primary care center.

Screening

Early principles of screening for asymptomatic conditions stated that the condition should be a significant health problem and that the natural history of the condition should be understood (Whitby, 1974; Wilson & Jungner, 1968). There has been a growing demand in preventive services for evidence of the effectiveness of the screening outcome, especially in reducing morbidity or mortality, before assigning limited clinical resources (Harris et al., 2001). Other important considerations are the prevalence of the condition and the effectiveness of treatment for identified patients.

Impulse control disorders are diverse, their natural history is not well understood, and there is incomplete evidence that screening will reduce their associated morbidity or mortality. Therefore, as a group, ICDs face challenges in being prioritized for screening. However, GPs have indicated that they have a role in helping patients with gambling problems, provided that training is available, and patients (p. 417) have acknowledged that this is an appropriate role for GPs (Sullivan et al., 2006). Screening of less obvious problems remains important, as it has been recognized that patients are more likely to present with problems other than psychological ones (Kordon et al., 2003). Screens, however, have to be user friendly for medical settings; that is, they must be quickly administered, scored without delay and without the need to resort to scoring matrices, be valid, and have utility. In addition, patients need to overcome the shame or guilt that may result in denying their symptoms. A unifying feature of the ICDs is that there is discomfort in disclosing the behaviors. By describing the behavior as a health issue, and by normalizing the inquiry to one relevant to the setting and, if possible, the presenting condition, the screen may become more sensitive.

Skills/Training Needs

For many primary health generalists, the ability to identify and intervene in core mental health conditions is a challenge. Those generalists who feel untrained or not competent to address the disorders may not be motivated to intervene. General practitioners are generally required to continue their training throughout the life of their practice, but they can decide which training to select. For many, qualifications for reregistration will follow training courses, with the professional college providing approval. Therefore, it is often necessary to make a case for specific training points and obtain approval from the college. This approval has been obtained for specific stand-alone training (Sullivan et al., 2006), but it is more likely to be integrated into the general practice if ongoing approval is obtained. Practice guidelines have been developed for GPs in some Australian states for screening and intervening in problem gambling, but currently this remains the exception to the rule (Jackson & Thomas, 2009).

Stigma

As with many substance addictions, impulse control disorders may be perceived as retaining some degree of control, raising a perception of self-indulgence. Furthermore, in the absence in impulse control disorders of the chemical present in substance addictions, no attribution can be directed toward control by the chemical over the behaviour to mitigate this negative perspective. In addition, patients may be embarrassed about disclosing such behavior, even to a health professional, and may also fear the labeling that such a diagnosis may bring.

Knowledge

Impulse control disorders comprise an expanding group of behaviors that have many differing symptoms, displayed in different settings but otherwise covert, and have different appropriate interventions. Few GPS have the knowledge to intervene effectively with ICD patients.

Coexisting Issues

It is axiomatic that if ICDs are relatively rare disorders, or perceived to have a relatively low burden of illness, they are unlikely to motivate screening. Therefore, ICDs may become identified only by serendipitous general inquiry or by direct disclosure by a patient.

Medication

An appropriate medical intervention that has recognized effectiveness may encourage screening and intervention by a primary health provider. Conversely, the absence of any such intervention may discourage such screening.

Funding

A barrier to intervention in mental health issues is funding to compensate for the extended time that may be required for optimal care. In addition, time spent screening for ICDs may result in assessment of fewer core disorders and/or less prevalent disorders (Holmwood, 1998). Access to and confidence in specialist referral services may also affect whether those in primary care screen for ICDs (Khin et al., 2003).

Primary Care Intervention in Alcohol Use Disorders

Alcohol use disorders have impulse control features but are commonly perceived as addictions (Derevensky, 2007). Interventions for these conditions may inform strategies to intervene in problem gambling, and perhaps in other ICDs, in primary care settings.

Screening for alcohol and other drug misuse in primary care settings is common (Mintzer et al., 2007; Yarborough, 2001). However, it remains underused, particularly for identification of hazardous alcohol use (Kypri et al., 2008).

Alcohol misuse has been assessed using questions embedded in general health questionnaires (Goodyear-Smith et al., 2004) or in brief screens such as the long-used four-item CAGE for alcohol dependence (Berks & McCormick, 2008; Ewing, 1984). The single question recommended by the (p. 418) National Institute on Alcohol Abuse and Alcoholism and validated in primary care is the briefest one to date and has sought to address the underdiagnosis of alcohol problems in primary care:

“How many times in the past year have you had X or more drinks in a day?” (where X is five for men and four for women, and more than one time being a positive response; Smith et al., 2009; Taj et al., 1998)

A recent report concerning the challenges of screening for alcohol in primary care settings in Norway describes issues that could be generalized to other countries. The use of a brief intervention package was piloted; lack of confidence was found to be a major barrier. General practitioners believed that they were more competent to give advice on smoking than on alcohol abuse. This belief was combined with the lack of time available to give more intensive counseling on alcoholism. The GPs also preferred selective interventions for suspected high-risk consumption symptoms than more generalized brief interventions (e.g., general screening), which were also considered to be intrusive for their patients. Financial incentives for the additional counseling were also considered to be lacking; one example was a successful incentivized tobacco intervention strategy, although the authors noted that this was not always the case when a green prescription (diet and exercise) project was incentivized (Bringedal & Aasland, 2006). The authors concluded that, for Norwegian GPs, addressing a disorder such as alcohol misuse in an integrated treatment strategy was more appropriate and acceptable than brief intervention for the specific disorder.

Problem Gambling Interventions in Primary Care

Problem Gambling Screening

A variety of brief screens are available for the identification of problem gambling (SACES, 2005). Specialist GP problem gambling screens include items embedded in the 10-item composite CHAT screen, the MULTICAGE-CAD4, the 1-item PGRTC screen, and the 8-item EIGHT screen (Goodyear-Smith et al., 2008; Jackson & Thomas, 2009; Thomas et al., 2008; Rodríguez Monje et al., 2009; Sullivan, 2007).

The multicage-cad4

The MULTICAGE-CAD4 is a self-completed screen that measures eight forms of addiction behavior risk (alcohol, other drugs, gambling, Internet addiction, video game addiction, eating disorders, compulsive shopping, and sex addiction) in a primary care setting. It was described as suitable for primary health care centers to identify often hidden addictions in patients presenting for other purposes (Rodríguez Monje et al., 2009).

The eight screen

The Early Intervention Gambling Health Test (EIGHT) screen was developed for GPs in the 1990s and was designed to be completed in approximately 1 minute. Responses were restricted to two options (yes or no) in order to maintain brevity in its completion and its scoring. A score of 4 or more identified a problem; however, later research categorized scores into gambling or problem gambling (Sullivan, 2007). False positives were found to be low in a range of settings, including primary care, when the screen was measured either against other screens or against a clinical assessment by an experienced therapist. The EIGHT screen has been examined in a number of primary care settings, with positive responses from GPs, nurses, and patients (Penfold et al, 2006; Sullivan et al, 2000).

The pgrtc screen

A one-item screen developed by the Problem Gambling Research and Treatment Centre was adapted from the Canadian Problem Gambling Severity Index (CPGI). The single question “Have you ever had an issue with your gambling?” was correlated with the full CPGI. A sensitivity of 78.5% and a specificity of 96.4% were found. Twenty-two of 94 (23.4%) positives on the single screen were also on the CPGI and were true positives, while the balance (76.6%) were false positives. It was concluded that for a low-prevalence condition these were acceptable outcomes, with few cases of problem gambling missed by the single screen (Jackson & Thomas 2009).

Chat

Composite health screens offer an important resource for the busy practitioner to assess a range of conditions in a brief, valid questionnaire. Such screens may be provided routinely or periodically to all patients or as needed. Composite screens are administered routinely and do not require indicators for use when applied in a generalist setting.

The Case-finding and Help Assessment Tool (CHAT) screens for nine lifestyle and mental health conditions, including pathological and subclinical problem gambling, depression, anxiety, alcohol misuse, other drug misuse, smoking, abuse and violence, (p. 419) anger problems, and physical inactivity. These conditions are addressed in 24 items, allowing a wide range of inquiry in a relatively brief period, generally about 2 minutes. For each condition, one question asks if the patient wants help with that item (no/yes, but not today/yes; Arroll et al., 2005; see Table 31.1).

Alcoholism commonly coexists with problem gambling, as do anxiety and depression, smoking, and other drug abuse. For many of the issues screened for in the CHAT, embarrassment, shame, or guilt exist; by embedding these questions in a range of conditions, these barriers may be reduced. The screen is self-administered, and has been applied (p. 420) in a number of general practice settings and in a range of populations in New Zealand. There, the CHAT has been included as a recommended screening and case-finding tool in the Best Practice Guideline (BPAC, 2009). The CHAT has also been provided in the Australian government’s Department of Health and Aging Risk Factor Resource Kit for use in general practice; in the development of the Canadian HealthCheckPlus, a real-time Internet-based health screening resource; and in the strategy to integrate alcohol screening into family medicine in Missouri, in the United States (J. Walker; personal communication).

Table 31.1 Case Finding and Help Assessment Tool (CHAT)

Please choose the answer that most correctly applies to you

CHAT Questions

Response Options

Positive

How many cigarettes do you smoke on an average day (tick no if you do not smoke)

None

less than 1 a day

1–10

11–20

21–30

31-more

>10 cigarettes a day

Do you ever feel the need to cut down or stop your smoking?

No/Yes

Yes

Do you want help with your smoking?

No/Yes, but not today/Yes

Yes, but not today/Yes

Do you ever feel the need to cut down on your drinking alcohol?

(tick no if you do not drink alcohol OR do not feel the need to cut down)

No/Yes

Yes

In the last year, have you ever drunk more alcohol than you meant to?

No/Yes

Yes

Do you want help with your drinking?

No/Yes, but not today/Yes

Yes, but not today/Yes

Do you ever feel the need to cut down on your non-prescription or recreational drug use?

(tick no if you do not use other drugs OR do not feel the need to cut down)

No/Yes

Yes

In the last year, have you ever used non-prescription or recreational drugs more than you meant to?

No/Yes

Yes

Do you want help with your drug use?

No/Yes, but not today/Yes

Yes, but not today/Yes

Do you sometimes feel unhappy or worried after a session of gambling?

(tick no if you do not gamble OR do not feel unhappy about gambling)

No/Yes

Yes

Does gambling sometimes cause you problems?

No/Yes

Yes

Do you want help with your gambling?

No/Yes, but not today/Yes

Yes

Over the last 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?

Not at all

Several days

More than half the days

Nearly every day

More than half the days/Nearly every day

Over the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?

Not at all

Several days

More than half the days

Nearly every day

More than half the days/Nearly every day

Do you want help with this?

No/Yes, but not today/Yes

Yes, but not today/Yes

Over the last 2 weeks have you been worrying a lot about everyday problems?

No/Yes

Yes

Do you want help with your anxiety or worrying?

No/Yes, but not today/Yes

Yes, but not today/Yes

Is there anyone in your life of whom you are afraid or who hurts you in any way?

No/Yes

Yes

Is there anyone in your life who controls you and prevents you doing what you want?

No/Yes

Yes

Do you want help with any abuse or violence that you are experiencing?

No/Yes, but not today/Yes

Yes, but not today/Yes

Is controlling your anger sometimes a problem for you?

No/Yes

Yes

Do you want help with controlling your anger?

No/Yes, but not today/Yes

Yes, but not today/Yes

As a rule, do you do less that 30 minutes of moderate or vigorous exercise (such as walking or a sport) on 5 days of the week?

No/Yes

No

Do you want help with getting more exercise?

No/Yes, but not today/Yes

Yes, but not today/Yes

Responses

Any positive to a question warrants a further enquiry or assessment for that health issue.For example:

  • for a positive relating to alcohol we recommend use of the scored tool AUDIT (Alcohol Use Disorders Identification Test)

  • for a positive relating to depression we recommend use of the scored tool PHQ-9 (Primary Health Questionnaire-depression)

  • for a positive relating to anxiety we recommend use of the scored tool GAD-7 (General Anxiety Disorder-7)

Source: © Department of General Practice & Primary Health Care, The University of Auckland

Enquiries: Dr Felicity Goodyear-Smith.

In most cases, the items were extracted from existing brief screens that had previously been independently validated in primary care settings. Overall, there was positive feedback from patients, with comments that the CHAT raised their awareness and was nonthreatening, brief, and clear. General practitioners also reacted positively, with over 90% saying that they would use it in their practice. Acceptability appeared high, with just (p. 421) 0.4% of patients objecting to the question on abuse, compared with 15% or more objecting to such questions found in other research. Of those who self-identified gambling problems, half wanted help from the practitioner the same day, while the remainder wanted help at another time.

An Australian Primary Health Strategy

The representative body for general practice in the state of South Australia, General Practice SA Inc., developed a resource kit for members to intervene in problem gambling issues with their patients (GSA, 2009). The kit allows the members, including GPs, practice nurses, and mental health clinicians, to screen for problem gambling. It then gives them the option of either treating the condition within the primary practice or referring the patient to a specialist who treats problem gambling. A poster is provided for the practice waiting room to both legitimize the topic for patients and to encourage patient inquiry. The members of General Practice SA have learned that statistically, problem gambling in Australia exceeds stroke and coronary heart disease combined and is comparable in prevalence to type 2 diabetes. A series of resources are provided to primary care health professionals, including a manual of information about problem gambling in a Frequently Asked Questions format (e.g., “Who is at risk?”) and a range of brief documents describing the etiology of problem gambling, reasons to screen, assessment and treatment options, and information about legal options for gamblers and their families. A brief summary of the various manuals is provided for utility, a referral pathway or intervention algorithm, and a poster for the patients’ waiting room with the statement “Talk to us. We can help you deal with gambling problems: if you, or someone you care about, have a gambling problem, take the first step and talk to your GP, Nurse or Health Worker.”

There is another incentive for the physician in that, in addition to the consultation fee, a further payment is generated by first identifying the gambling problem and then completing a Mental Care Plan (Medicare Item No. 2710) before referring the patient to a mental health clinician. The clinician may be employed by the general practice; therefore, training these clinicians (who are also targeted by the resource kit) is incentivized. These clinicians may also establish their own cooperative arrangements with specialist problem gambling services. The members of these services, even if they are unlikely to be registered medicare providers, will receive the client referral.

Who to screen?

Patients who should be screened include those who raise the topic following the poster’s suggestion, who present with any of a range of at-risk conditions, or who belong to one of the following at-risk categories:

  1. 1. Patients presenting with symptoms of problem gambling described in the kit

  2. 2. Those with a severe mental health disorder, as identified by an appropriate score on the Kessler Psychological Distress Scale K10, a measure of stress level (Kessler et al., 2003)

  3. 3. Members of culturally and linguistically diverse communities

  4. 4. Indigenous people

  5. 5. Employees of gambling establishments

  6. 6. Women experiencing grief, trauma, or loneliness who also present with depression or anxiety

  7. 7. Young males who, in the absence of substance abuse issues, present with stress, anxiety, and financial problems

  8. 8. Middle-aged men with substance abuse issues

The primary care health professional is requested to ask the following questions (PGRTC questions): “Have you ever had an issue with gambling?” or “Has anyone in your family ever had an issue with gambling?”

Assessment

Patients who respond yes to the first question (their own gambling is causing problems) are either offered an assessment by the primary health care professional or referred to a specialist problem gambling service or mental health program provider selected from the regional list provided in the kit. The assessment can then be completed either by the patient, using the EIGHT screen, or by the health professional using the PGSI.

Treatment

Following assessment of the patient’s gambling by the health professional or the external agency, the patient is offered a choice of treatment options:

  • Treatment within the practice, using recognized psychotherapy such as motivational interviewing or cognitive behavioral therapy (CBT), together with strategies such as self-exclusion from gambling venues and, if appropriate, a Protection Orders Scheme for family members affected by a member’s gambling.

  • (p. 422)
  • Sharing treatment with the gambling treatment service or mental health program; this may have particular relevance when the patient is also affected by coexisting health issues that may or may not abate as a result of ending the problem gambling behavior.

  • External treatment only by referral to a problem gambling treatment provider or a mental health program.

The kit includes a referral note resource in which health professionals can provide details of their primary health care practice, together with other information that may impact the treatment.Usually, the preferred option is that the problem gambling treatment specialist provides the assessment and the therapy. If the practitioner is confident, then this may be provided within the practice.

To date, there has been no formal review of the use of the kit, with GPs indicating willingness to screen and refer rather than assess and treat. There has been less enthusiasm among GPs participating in problem gambling training, possibly due to the competing need to deal with other health issues. However, there is a possibility that mental health clinicians in each practice, or practice nurses (in 70% of the SA practices) or their practice managers, may be willing to consider this role. The project did not provide for this option, but it may be possible in the future (J. Walker; personal communication, July 21, 2009).

This strategy is also being developed in another Australian state, Victoria, where the Melbourne Division of General Practice is building on the SA problem gambling intervention kit (J. Walker; personal communication, July 20, 2009).

This approach will rely on the GP’s recognition of the symptoms and his or her willingness to introduce the topic into the consultation. An alternative approach is that those with more time available, such as practice nurses, mental health clinicians in primary care settings, or other primary care practitioners, will be given the responsibility for assessment and treatment following appropriate training. Of particular interest in demonstrating the utility of this strategy will be the extent to which patients presenting with the identified at-risk symptoms or those belonging to the at-risk populations are invited to respond to the brief screen, as well as their responses and the outcomes that follow. An additional screen that may be offered to patients who agree to help with assessment could be the Concerned Others Gambling Screen (COGS; Sullivan et al, 2007), which can identify effects of others’ problem gambling on family members and offer various forms of help for the patient to choose from (Sullivan et al, 2007; Sullivan et al., 2006).

Interventions Following Identification of Problem Gambling

Few problem gamblers seek treatment (Slutske, 2006). In the absence of stronger evidence for drug intervention, the PGRTC recommends that those patients identified as problem gamblers be referred to specialist problem gambling services.

However, brief interventions for problem gambling for those who do not wish to participate in more intensive treatment, or for practitioners with limited time to offer, have been shown to be effective (Petry et al., 2008). A 10-minute advice session with a therapist in which gambling problems, risks, and ways to avoid risky situations are discussed was found to be as effective as longer sessions, and improvements persisted at the 9-month follow-up. This supports the effectiveness of brief interventions within the time constraints of medical settings.

Unwin and colleagues (2000) stated that family physicians should have heightened awareness of the impact of problem gambling, and of screening and treatment options. They recommended screening patients for problem gambling who presented with depressive or alcohol problems and addressing the risk of suicide. Family support was sought to help the patient follow the treatment recommendations, and the gambler and family were referred to Gamblers Anonymous and Gam-Anon. Specific therapy involved pharmacological treatment of coexisting disorders, such as depression, and therapies such as behavioral therapy, cognitive therapy, and CBT, or referral to specialist problem gambling treatment services. The stated low adherence to advice from referral physicians suggested that the family physician who identifies the gambling and coexisting health issues may often be required to address the gambling problems (Sullivan et al., 2007).

In another study, following brief training in screening and provided with a manual with information, referral resources, and screening and other brief interventions based on motivational interviewing strategies (Sullivan, 2003; Sullivan et al., 2006), GPs screened patients to identify those affected by their own or a family member’s gambling. Patients were receptive to inquiries about their gambling, while GPs were surprised at the numbers of patients and their families affected by gambling problems. Although most GPs referred these patients to (p. 423) specialist problem gambling treatment services, they considered their interventions to be effective. The greatest barrier identified was the time required to address both the gambling and the coexisting depression, which was also screened for.

Medication and problem gambling

A number of pharmacological interventions have been studied as a treatment for pathological gambling. Serotonin reuptake inhibitors, such as clomipramine, citalopram, and fluvoxamine, which are effective in treating obsessive-compulsive disorder, have been found to have only modest effects on pathological gambling. A small number of studies of mood stabilizers (lithium and carbamazepine) in problem gambling have indicated moderately positive outcomes, while findings of recent studies of opioid antagonists (naltrexone) have been mixed (Grant et al., 2008a, 2008b; Toneatto et al., 2009). N-acetylcysteine has also been considered a possible treatment for reward-seeking behaviors such as problem gambling (Grant et al., 2007). A meta-analysis of studies up to 2006 found that pharmacological interventions for pathological gambling were more effective than placebos, although there were no differences in effectiveness among the three main classes of these drugs (antidepressants, opiate antagonists, and mood stabilizers; Pallesen et al., 2007). However, studies have shown that nonpharmacological treatments have larger overall effects than pharmacological treatments (Leung & Cottler, 2009).

With a high prevalence of mood disorders, anxiety disorders, and drug misuse in those affected by gambling, it is possibe that these coexisting problems may be promoting the development, maintenance, and relapse of problem gambling.

In the absence of a recognized medication for problem gambling, the medical focus will be on the treatment of coexisting conditions. If these conditions are treated with established medical regimens, this may also have a positive effect on the gambling.

Referral

The role of the GP in referral, particularly in mental health issues, has been to assess, educate the patient about the condition, provide effective referral, and monitor the patient’s long-term progress (Blashki et al., 2003a). Referral to specialist services has often been the preferred response of GPs (Sullivan et al., 2006). It is the recommended response in the South Australian GP project unless a specialist is available for both assessment and therapy (GSA, 2009a).

The development of specialist treatment settings for problem gambling, with qualified clinicians, professional competency standards, evidence-based therapies, and ready accessibility, has helped address the reluctance that GPs may have had concerning the referral of their patients or shared-care arrangements being established for their patients. In many cases, specialist problem gambling treatment providers will establish on-site arrangements with health centers to facilitate the referral and shared-care arrangement.

Psychotherapy

Psychological treatment for patients in general practice can be available from GPs and other primary care health professionals who have both the time and training to deliver it. In this setting, approaches for mental health issues include supportive problem solving, when the problem is able to be solved, or CBT when the problem is due to a distorted perception or belief (Mynors-Wallis et al., 2000). Often a Socratic rather than an advice role may initially be a different expectation for both the primary care provider and the patient, so as to draw the solution out of the patient in a more psychological treatment approach (Blashki et al., 2003b). Limited and specific CBT, often termed cognitive behavioral strategies, that enable the primary care provider to address unrealistic perceptions and negative patterns of thinking can be provided without intensive training (Blashki et al., 2003c; Nathan & Gorman, 1998).

For many GPs, time constraints are a barrier to psychotherapy. In primary care practices the primary care team is generally led by the GP, with expertise in interpreting patients’ health needs, planning their care, and referring them to other health providers. Such providers could be practice nurses within the health center, generalist mental health clinicians within the center, or specialist mental health clinicians externally based but also possibly integrated within the center (Gilmer et al., 2009). In the United Kingdom, nurses, although usually employed by GPs, are now forming nurse teams that are aligned with and located within the general practice, although not employed by it. They may have specific roles, including screening and chronic disease management (Hoare et al., 2008). Specialist training for nurses employed as behavioral psychotherapists has been available for over 30 years in the United Kingdom, and nurses who have received appropriate training have been perceived as suitable primary care practitioners to treat patients with gambling problems (Tolchard & Battersby, 2001). (p. 424) Brief intervention by mid-level health professionals, usually nurses, has often been used in primary care for hazardous and harmful alcohol use (Babor et al., 2005; Grucza et al., 2008; Peltzer et al., 2006, 2008). Another possibility is that community pharmacists can provide brief interventions (in alcohol abuse) if appropriate training is available (Sheridan et al., 2008).

Researchers dealing with addictions in the United Kingdom suggest that persons with severe problem gambling should be referred to specialist problem gambling treatment services. Those with less severe problems could be treated within the primary care practice, perhaps by other health care professionals such as practice nurses (McCambridge & Cunningham, 2007).

Integration of Mental Health and Primary Care Services

Primary care settings are well suited to identify and intervene in mental health issues (MaGPIe-Research-Group, 2003). However, there are problems when people receive integrated care from both mental health specialists and general medical care providers. Often there is insufficient evidence of positive outcomes, particularly with alcohol abuse behavioral programs. In addition, the outcomes of therapy for depression and anxiety disorder involving integrated approaches generally appear to weaken over time (Butler et al., 2008). Examples of the integration of psychology and medicine, particularly in primary care, are relatively few (Kessler & Cubic, 2009). Primary care settings provide the ability to identify and address other health issues that commonly coexist with the target mental health issue and to monitor the patient’s recovery over time. However, the low prevalence of many of the specified ICDs will continue to mitigate against their identification or their inclusion in regular screening, even if strategies to integrate their treatment with specialist services are established.

The British Medical Association has recommended that the dedicated, publicly funded national health services (NHS) be expanded throughout the United Kingdom. Researchers concerned with the secondary prevention of addictions are uncertain about the extent to which GPs should contribute to this effort, and they note that it takes GPs into new areas that may not be embraced by the majority of them (McCambridge & Cunningham, 2007). However, they have stated that gambling problems may contribute significantly to the issues dealt with by GPs and may, if evidence is found to support this role, encourage the identification of problem gambling as good clinical practice (Goodyear-Smith et al., 2006; Pasternak & Fleming, 1999; Potenza et al., 2002).

A Model for Composite Problem Gambling Intervention in Primary Care

The South Australian model provides a strategy with many of the features necessary to address problem gambling in primary care settings. It addresses many of the barriers found in alcohol interventions, such as brevity of screening, funding for additional time, and tailor-made resources that can be utilized by both GPs and other health professionals in the primary care setting. The one factor that may continue to provide a challenge is the ability to identify symptoms. There is a broad range of symptoms and heterogeneous populations that are identified as at risk; further follow-up on this strategy and the proposed extension to the state of Victoria may provide evidence concerning its use. An alternative approach that could be integrated into this model is the use of a composite screener, such as the CHAT, for all clients periodically. The model could therefore provide:

  1. 1. Education on the use of the screen by all health professionals, including each of the items, their frequent interrelationship, appropriate interventions, and referral resources, with such training supported by professional organizations through credits toward continuing training requirements

  2. 2. Strategies for regular screening, provided either by paper or electronically, and a stepped process for addressing any positive responses, including those of the GP, nurse, mental health clinician, or specialist external provider sited within the primary care service who has time to provide the necessary interventions (e.g., positive responses may be provided by the GP and other center health professionals)

  3. 3. Development of brief intervention training, including resources such as homework manuals that can be given to the patient and supported by primary care health providers, to supplement any pharmacological intervention

  4. 4. Financial support for the additional time required to address problem gambling issues, which will include psychological interventions and may include more than one health professional at the center

  5. 5. Ongoing monitoring and review of the condition or conditions in subsequent consultations

(p. 425) Primary care physicians have been targeted as being in a good position to identify ICDs and raise awareness about the importance and effectiveness of treatment (Mak, 2004). For many, the next step will be referral to an external specialist mental health service, with the possibility of retaining a liaison role with that service, addressing coexisting general medical conditions, and monitoring progress during later consultations for other issues. Recently, there has been a movement to provide mental health specialists and other primary care providers with additional time and specialist training within health centers. The provision of options to treat ICDs such as problem gambling within such centers, the availability of kits and training to optimize such screening, assessment, and treatment of this condition may set an example for the treatment of other ICDs within a primary care setting. The present high public accessibility, motivation to address common coexisting conditions, ability to monitor and follow up, and increased research on ICDs focusing on evidence-based interventions may act to optimize intervention into ICDs by well-placed health providers in the future.

Future Directions

  • Impulse control disorders usually coexist with many other, often more recognizable and better-understood mental health disorders such as depression. Whether this association is causative, unidirectional (and in which direction), or bidirectional is not well understood. Further knowledge may increase the motivation to screen for ICDs and to treat or refer patients.

  • Describing some ICDs, such as pathological gambling, pyromania, trichotillomania, and kleptomania, as addictions, if similarities can be drawn, may provide the advantage of belonging to a recognized group, with common theories concerning etiology, intervention strategies, and biological, psychological, and social aspects.

  • Identifying effective pharmacological interventions that could be used in conjunction with psychotherapies would assist GPs in screening and providing other brief interventions.

  • Researching the effectiveness and efficiency of specific screens versus composite screens to identify and provide interventions for ICDs, such as the PGRTC and CHAT screens, as well as support resources, may optimize their use.

  • Identifying other primary care health practitioners in health organizations who may have a role in ICD intervention and training opportunities will enable them to intervene.

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