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Clinical practice is busy. People arrive with all manner of health problems and the basic requirement of the role is to help. There are increasing pressures to address a variety of different public health concerns within an already hectic schedule. And now, another suggestion to add to this workload — gambling.1–4 What has gambling got to do with health?
Concerns have been raised that the prevalence of gambling problems has increased as access has been made easier. Gambling gives rise to clear social costs and there is an obvious need to protect children and young people. The involvement of large scale criminal organisations cannot be tolerated.5 The consumer protection and financial implications for individuals and their families operating in unregulated markets merit concern. Policy makers have been slow to respond, but the results of recent action taken are not yet known.4 Allowing the promotion of an activity that causes societal harm will probably be balanced with the potential for revenue generation by politicians.
Despite these valid social concerns, what does gambling have to do with health? Pathological gambling is a known diagnostic category.5 Problem gambling is enmeshed in other addictive behaviours, most notably drinking and smoking.3,6 There are a variety of other mental health concerns of varying severity, from stress and depression through to increased risk of suicide among people with more serious gambling concerns.3,6 The financial difficulties associated with gambling can have direct and indirect health consequences, including the triggering of depressive episodes and creating barriers to accessing healthcare services. The impact is more likely to be most profound among poor and otherwise vulnerable populations. Thus, gambling problems are likely to be implicated in a range of existing clinical presentations,6 and it would appear that the numbers are increasing.
Although encouraging initiatives exist, the extent of gambling problems is likely to overwhelm capacity. The British Medical Association recently recommended that dedicated NHS provisions should be expanded nationally.4 Services for problem gamblers are currently at an early stage of development, so a large need remains unmet. Can, or should, GPs fill this gap? There are possibilities for screening and brief interventions, however, time and wider resource constraints make the widespread adoption of new activities unlikely. The larger question is whether addressing gambling problems fits within the role of the GP. It is conceivable that GPs with special interests may choose to become involved in areas such as this, but should the profession as a whole accept this responsibility? Where should the line be drawn between health care and social problems?
As researchers interested in the secondary prevention of addictions and not GPs, we do not have a particular view on this issue. Gambling problems are very topical and as concerns have escalated the possible role of GPs has been reconsidered.3 For other addictive behaviours, such as smoking and drinking, the generally agreed practice is to screen to identify the occurrence and severity of any problems. For those that are less severe there is the option of providing brief interventions directly within general practice, perhaps involving other healthcare professionals (for example, practice nurses). For those with more severe problems, referral to specialist care is merited.
Given the likelihood that similar recommendations will be made for gambling, GPs will be faced with this issue. We do not yet know to what extent gambling problems are contributory factors to current levels of presentations within general practice in the UK, although data from other countries suggests that this will not be trivial.1–3 As a result, it is not clear what priority, if any, should be given to this problem. Evidence that problem gamblers have poorer health indicates that vigilance for gambling issues may be good clinical practice. Before doing so, however, it is important to recognise that these issues take the role of the GP into new territory, which although may be enthusiastically embraced by a minority, may well be uncomfortable for the majority.