Dr Rob Skelly, consultant physician at Royal Derby Hospital, explains the links between Parkinson’s disease and gambling addiction and how physicians can best support patients.
The increased risk of gambling addiction has been highlighted in the media as COVID-19 has taken hold in the UK, with concerns that increased social isolation and a reduction in the availability of support services will lead to more problem gambling. Gambling companies in the UK have reacted by committing not to advertise on TV or radio while the lockdown continues.
But it is the links between Parkinson’s disease and gambling addiction where there is clear evidence about how we as physicians can help patients. Pathological gambling is seven times more common in people with Parkinson’s disease than the general population, occurring in 3.4–6.1% of these individuals.1
In a similar way to other addictions, gambling addiction typically sees stakes escalate and gambling taking up more time to the detriment of relationships and work. Pathological gamblers may suffer significant financial losses – more than they can afford – and become socially withdrawn.2
About a quarter of people with Parkinson’s have a history of gambling that precedes Parkinson’s diagnosis.3 Pathological gambling occurs in about 6% of Parkinson’s patients on dopamine agonists (eg ropinirole, pramipexole, rotigotine, apomorphine) and 2% of those on other drugs used to treat Parkinson’s (mainly L-dopa). The delay between starting dopamine agonist treatment and onset of impulse control problems (including gambling) may be 4–5 years.4
What factors should physicians consider when prescribing and screening?
Risk factors for pathological gambling in Parkinson’s include:
- young age at onset
- male sex
- family or personal history of alcohol misuse
- family history of problem gambling, novelty seeking behaviour and drug-induced mania.5,6
Because of the potentially devastating consequences of gambling disorder, a careful risk assessment should be undertaken before prescribing medication. Younger men with a personal or family history of problem gambling or alcohol misuse are at higher risk and alternatives to dopamine agonists should be considered.
If problem gambling is detected, dopamine agonist treatment should be reduced. Dose reduction should continue until the problem improves. Often the dopamine agonist needs to be stopped altogether. Up to 19% of patients can suffer a withdrawal syndrome (drug craving, agitation, sweating, depression, panic attacks, pain and postural hypotension) when dopamine agonists are stopped so a gradual reduction in dose is preferred.7 Nurse therapist-led cognitive behaviour therapy can reduce symptom severity and psychiatric morbidity8 and should be offered, as many people with Parkinson’s continue to have problem gambling after stopping dopamine agonist treatment.
During follow up, people with Parkinson’s who are taking any dopaminergic medication (not just dopamine agonists) should be screened for pathological gambling and other impulse control disorders.9 The 2019 national Parkinson’s audit reported that 80% of patients on dopamine agonists and 69% on other dopaminergic treatments were given written information about impulse control disorders.10 Enquiry needs to be made in a non-stigmatising way. Positive responses to questions about depression might provide an opening to ask about financial difficulties and gambling. Validated screening tools such as the Questionnaire for Impulsive-Compulsive Disorders in Parkinson’s Disease (QUIP) can be used.11
What advice should be given to patients?
On starting any dopaminergic medication, patients should be warned about the risk of problem gambling and other impulsive control disorders (binge eating, compulsive shopping, hyperlibidinous behaviour). Ideally this advice should be given orally in the presence of a family member who can help monitor emergence of abnormal behaviours. The advice about risk of problem gambling should also be given in written form, for example clearly documented in a letter to the patient and copied to the patient’s GP.
People taking Parkinson’s medications, particularly those at high risk of impulsivity should be informed about stimulus control and environmental protections. These include setting self-imposed limits with gambling firms and setting spending/credit limits with banks.12 Additional advice for members of the public on using these tools is available from the National Gambling Helpline on 0808 8020 133.
- Balconi M, Angioletti L, Siri C, Meucci N, Pezzoli G. Gambling behavior in Parkinson's Disease: Impulsivity, reward mechanism and cortical brain oscillations. Psychiatry Res 2018;270:974–80.
- Djamshidian A, Cardoso F, Grosset D, Bowden-Jones H, Lees AJ. Pathological gambling in Parkinson's disease--a review of the literature. Mov Disord 2011;26:1976–84.
- Gallagher DA, O'Sullivan SS, Evans AH, Lees AJ, Schrag A. Pathological gambling in Parkinson's disease: risk factors and differences from dopamine dysregulation. An analysis of published case series. Mov Disord 2007;22:1757–63.
- Antonini A, Chaudhuri KR, Boroojerdi B et al. Impulse control disorder related behaviours during long-term rotigotine treatment: a post hoc analysis. Eur J Neurol 2016;23:1556–65.
- Voon V, Thomsen T, Miyasaki JM et al. Factors associated with dopaminergic drug-related pathological gambling in Parkinson disease. Arch Neurol 2007;64:212–6.
- Weintraub D, Koester J, Potenza MN et al. Impulse control disorders in Parkinson disease: a cross-sectional study of 3090 patients. Arch Neurol 2010;67:589–95.
- Yu XX, Fernandez HH. Dopamine agonist withdrawal syndrome: A comprehensive review. J Neurol Sci 2017;374:53–5.
- Okai D, Askey-Jones S, Samuel M et al. Trial of CBT for impulse control behaviors affecting Parkinson patients and their caregivers. Neurology 2013;80:792–9.
- NICE. Parkinson's Disease Quality Standard [QS164]. London: NICE, 2018. [Available from: www.nice.org.uk/guidance/qs164/chapter/Quality-statements.
- Parkinson's UK. UK Parkinson's Audit – Summary Report 2019.
- Evans AH, Okai D, Weintraub D, Lim SY, O'Sullivan SS, Voon V et al. Scales to assess impulsive and compulsive behaviors in Parkinson's disease: Critique and recommendations. Mov Disord 2019;34:791–8.
- Advice on self-exclusion and other tools to reduce gambling harms available from www.begambleaware.org/safer-gambling