Gambling-related harms

• They present in any setting with a mental health problem or concern, in particular thoughts about self-harm or suicide, depression, anxiety, psychosis and bipolar disorder, post-traumatic stress disorder (PTSD), personality disorder, or attention deficit hyperactivity disorder (ADHD).

• They take a medicine that may affect impulse control, for example dopamine agonists for Parkinson's disease, or aripiprazole for psychosis. NICE's guideline on Parkinson's disease covers managing and monitoring impulse control disorders as an adverse effect of dopaminergic therapy.

• They present with problems relating to alcohol or substance dependence, especially use of cocaine.

• They are at risk of or experiencing homelessness, or share that they have financial concerns.

• There are concerns about safeguarding issues or violence, including domestic abuse.

• They share a family history of gambling that harms, or of alcohol or substance dependence.

• At each key contact with the criminal justice system (for example the police, probation services, courts and prisons).

• Anyone, even with no obvious risk factors, when asking about smoking, alcohol or other substances, for example at a health check or when registering with a GP.

• A neurological condition or acquired brain injury that leads to disinhibition or increased impulsivity.

• A young person who has recently left home for the first time.

• Current or past occupation, for example armed forces personnel, veterans, people working in the gambling or financial industry, and sports professionals.

⚠️ Common pitfall

• Waiting for the patient to raise it.

• Stigma, shame and fear of disclosure can prevent people from talking about gambling, and from seeking and accessing support.

• Stigma may be a particular issue for people from marginalised, minority or under-represented groups.

• Use direct questions, such as “Do you gamble?” or “Are you worried about your own or another person's gambling?”

• Do they bet more than they can afford to lose, need to gamble with larger amounts of money to get the same feeling, or try to win back money they have lost (chasing losses)?

• Type and location of gambling, and how often they gamble now (for example days per week or hours per day)?

• When it started and how it has progressed, including when the frequency or intensity increased?

• Triggers and cravings, and what gambling does for them (their motivation for gambling)?

• Money – spending on gambling as a proportion of income, and borrowing or stealing money for gambling?

• Mental health – depression, anxiety and insomnia, and how these relate to the gambling?

• Suicide risk – ask directly about suicidal ideation and intent, and about any past attempts?

• Wider impact – relationships, employment, education, and any involvement in crime?

• Safeguarding issues and immediate needs (for example help with housing, food and debts)?

➤ "What has made you seek help now, and what would you like to change or get out of treatment?"

➤ "Is anything worrying you or stopping you from getting help? Many people feel ashamed or afraid to talk about gambling."

➤ Considerable or immediate risk to themselves or others → refer urgently to specialist mental health services or a crisis team, via the emergency services if necessary

➤ Anyone experiencing gambling-related harms → ask directly about suicidal ideation and intent. Gambling and gambling-related harms can be a dominant risk factor for suicidal ideation and suicide attempts, even in the absence of other risk factors.

➤ A recent gambling episode → the risk of suicide may be highest immediately after a gambling episode

➤ Relapse after treatment → can be distressing for the person and may lead to suicide or self-harm

➤ Safeguarding concerns → any one of:

• Violence or domestic abuse

• Economic abuse or coercive behaviour

• Neglect of children

→ confidential information may need to be shared without the person's consent in certain circumstances, for example if they or others may be in danger

➤ Recent onset, or a short period of less intense gambling, even after a period of abstinence → can lead to severe harms in some people and may require referral to a gambling treatment service

• Mental state – people experiencing gambling that harms may present with both physical and mental health conditions, in particular depression, anxiety and suicidal ideation.

• Risk – assess the risk of suicide, including any past attempts (see Red Flags).

Gambling can cause problems with your relationships, your physical and mental health and your money, and it is common to feel shame or fear when talking about it.
Support and treatment are available, and recovery is possible. Gambling treatment and support services are usually free, although some charges may apply (for example, for prescriptions). In England you can refer yourself to an NHS gambling clinic, or ask us for information on services in your area.
Gambling services keep what you tell them private and confidential, although they may need to share information without your agreement in certain circumstances, for example if you or someone else may be in danger.
If gambling is seriously affecting your mental health and you need help urgently, get urgent help straight away.

1. Advise that support and treatment are available and recovery is possible.

2. Ask directly about suicidal ideation and intent, and act on any risk (see Red Flags and Special Notes).

3. Offer initial help and support, depending on the setting, the severity of the harms and the level of concern. This could include:

• Information on gambling-related harms

• Encouraging and supporting them to seek help, for example from their healthcare provider or social worker

• Signposting to the NHS website, gambling support groups, local authority resources and the national gambling helpline, some of which can be accessed anonymously

• Referring or signposting them to gambling support and gambling treatment services (see Referral Pathways)

4. Consider brief motivational interviewing if they are reluctant to access services.

5. Discuss practical self-exclusion:

• Blocking software or tools to prevent online gambling

• Blocking marketing messages

• Self-exclusion from casinos, arcades and betting shops

• Blocks on gambling payments through their bank account

• Limiting access to money, for example agreeing that a family member will take control of finances

6. Consider advice on how and where to get help with:

• Finances, including debt management

• Housing, employment and legal issues

• Domestic violence or other harms to family relationships, including economic abuse and coercive behaviour

• Gambling-related harms, including stigma, may also have a severe impact on family members and affected others.

• NG248's recommendations on case identification, initial support and referral also apply to them.

• Services should give them information on how to support the person who gambles, and how to get help for their own mental health and for practical issues such as financial support.

• Services should offer them support, including:

→ help and advice both by themselves and with the person who gambles, if both agree

→ techniques to manage their own distress and prioritise their needs

→ support to engage in non-judgemental communication with the person who gambles

🔑 Key principle – relapse is not failure

• Relapse is common, and it is not shameful: it may be part of a recovery journey or a learning event.

• Having a plan in place to recover quickly increases confidence and reduces shame.

➤ No medicine for a GP to start

→ The only medicine in NG248's treatment recommendations, naltrexone, should be started by, or under the supervision of, an appropriately qualified and experienced specialist.

➤ Naltrexone – specialist only

→ Consider naltrexone to reduce gambling severity if:

• psychological therapy has not achieved the desired outcomes after an appropriate course has been completed, or

• the person has repeated relapses despite having received an appropriate course of psychological therapy.

→ In January 2025 this was an off-label use of naltrexone.

→ Consider continuing psychological therapy in combination with naltrexone.

➤ When starting naltrexone

→ Check that kidney and liver function are within normal ranges.

→ Check that the person is not taking opioids, and advise them to avoid opioids while taking naltrexone.

→ Consider an initial dose of 25 mg once a day for 3 days, then 50 mg once a day for 4 to 6 months.

→ Agree a follow-up plan to monitor effectiveness, safety and side effects, for example regular liver function tests and the onset of chest pain or palpitations.

➤ Medicines that may be contributing

→ Gambling treatment services should assess whether current medicines may be contributing to gambling that harms, for example aripiprazole and medicines for Parkinson's disease.

→ They should think about reducing or optimising these medicines in consultation with the relevant specialist services.

📌 Safety – when there is a risk of self-harm or suicide

• Tell them about the known link between gambling-related harms and suicide.

• Put in place a safety plan to help them manage the acute risk (see NICE's guideline on self-harm: assessment, management and preventing recurrence).

• Assess whether they have social support, for example from family or friends, and consider mobilising it, balancing the possible benefits and risks of involving family members or carers with the person's rights.

• Advise them to seek further help if the situation deteriorates.

• The Office for Health Improvement and Disparities (OHID) has estimated between 117 and 496 suicides associated with problem gambling or gambling disorder each year in England.

• Considerable or immediate risk to themselves or others → refer urgently to specialist mental health services or a crisis team, via the emergency services if necessary

• Consider referral via an NHS triage service, for triage and allocation to an appropriate level of service

• Tell them that self-referral, via an NHS triage service or the national gambling helpline, is an option; in England they can also self-refer to an NHS gambling clinic

• Specialist gambling clinics → a greater severity of gambling-related harms or of co-occurring needs, such as mental health conditions, suicidality, previous trauma, neurodiversity, learning disabilities, and alcohol or substance dependence

• Community-based gambling treatment services → lower levels of gambling-related harms or complexity, including affected others. NG248 says gambling treatment services should include these, but in January 2025 only the specialist gambling clinics were commissioned by the NHS.

• Gambling support services → information, brief interventions, peer support, advice, and signposting or referral to other services

• The level of care is based on the severity of gambling (including the Problem Gambling Severity Index [PGSI] score if available), comorbidities, other co-occurring needs and the person's preferences

• National Gambling Helpline (run by GamCare): 0808 8020 133, free, 24 hours a day, 7 days a week, for information, support and counselling

• Other services listed on the NHS website: GambleAware, the Primary Care Gambling Service, GamLearn, Gamblers Anonymous and ChapterOne

• Citizens Advice Bureau for advice on issues including finances and gambling, and the National Debtline for help with debts

• Affected others → consider referring them to gambling treatment or support services, depending on their level of need; NHS gambling clinics in England also support family and friends

• The NHS website also lists GamAnon (meetings), GamFam (a lived experience support network) and Gambling with Lives (support for people bereaved by gambling-related suicide)

🧭 AKT – high-yield facts

• NICE NG248 (January 2025) covers people aged 18 and over who gamble, and affected others of all ages.

• Problem Gambling Severity Index (PGSI), as used in the Gambling Survey for Great Britain (2023):

→ 8 or more = “problem gambling” (2.5% of people aged 18 and over in Great Britain)

→ 1 to 7 = elevated risk of harm (a further 12%)

• Validated tools named by NICE: the PGSI and the South Oaks Gambling Screen.

• NICE wording: ask about gambling in higher-risk situations; consider asking anyone, alongside questions on smoking and alcohol.

• Medicines that may affect impulse control: dopamine agonists for Parkinson's disease and aripiprazole.

• Offer group cognitive behavioural therapy (CBT), usually 8 to 10 sessions; individual CBT, usually 6 to 8 sessions, if a group is not wanted, possible or suitable.

• Naltrexone (consider; specialist; off-label in January 2025): 25 mg once a day for 3 days, then 50 mg once a day for 4 to 6 months; check kidney and liver function and that the person is not taking opioids.

• Suicide risk may be highest immediately after a gambling episode.

🎯 SCA

A 32-year-old man attends asking for something to help him sleep. Asked directly about gambling, he admits to online sports betting most nights. He has borrowed money from his sister to cover losses and is behind with his rent.

After a large loss last week he thought his family “would be better off without me”. He has no plan and says he would not act on it. He is ashamed, asks you not to tell his partner, and is unsure whether he needs “proper treatment”.

The challenge is to ask about gambling and suicide risk directly and without judgement, respond to his shame, and agree a practical plan he is willing to act on.

A strong consultation:

• Uses direct, non-judgemental questions about his gambling, its harms and his finances.

• Asks directly about suicidal ideation and intent, tells him about the link between gambling and suicide and that the risk may be highest straight after a gambling episode, and agrees a safety plan.

• Explores his ideas, concerns and expectations and his own reasons for change, using brief motivational interviewing if he is reluctant.

• Explains confidentiality and its limits, and discusses the possible benefits and risks of support from family or friends while respecting his choice.

• Agrees practical steps: self-exclusion (GamStop, blocking software, a bank block on gambling payments), debt advice, the National Gambling Helpline, and referral via an NHS triage service or self-referral.

• Safety-nets: advises him to seek help at once if things get worse.

• Shows empathy and respect for his autonomy throughout.