and the other selective serotonin reuptake inhibitors (SSRIs) can switch depressed patients into a manic phase or bring out an underlying bipolar disorder, there was concern that the medication might exacerbate their emotional instability, particularly in the higher dose (250 mg/day) administered to the nonresponders. The authors recommended that, in future studies in which pathological gamblers are to be given SSRIs, subjects with bipolar disorder should be excluded. Overall, these results suggest that medication may be of some benefit, but more systematic randomized studies are clearly needed. Long-term follow-up (one to two years) is also recommended.

Neurobiological studies (also discussed in Chapter 4) suggest the involvement of serotonin, norepinephrine, and dopamine in pathological gambling. The medications used in the above studies target one or more of these neurotransmitter systems. The norepinephrine system has been associated with arousal and novelty-seeking, dopamine with reward and motivation, and serotonin with impulsivity and compulsivity (Hollander et al., 1998). Another avenue of approach suggested by these studies is the use of medication to treat comorbid conditions. In practice, this is probably the most frequently cited reason for putting gamblers on medication. Comorbid disorders for which medications are commonly prescribed include depression, bipolar disorder, and attention-deficit hyperactivity disorder.

Rosenthal (1997) discussed indications for using medication in the treatment of pathological gamblers. Although some patients experience withdrawal symptoms, including prominent physical symptoms, (Wray and Dickerson, 1981; Meyer, 1989; Rosenthal and Lesieur, 1992), they do not need to be medicated. Also, some gamblers report frequent and intense cravings. Rosenthal (1997) reviewed several approaches to a pharmacotherapy of cravings. One of the most promising involves agents that block the excitement or pleasure of the addictive drug. The best known of these blocking agents is naltrexone, an opioid antagonist used in the treatment of alcoholism. It has also been used in treating those addicted to cocaine and heroin. The effectiveness of the drug in treating pathological gamblers is currently being investigated under controlled conditions by Suck-Won Kim at the University of Minnesota (Kim, 1998).

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