Gambling, gaming, and behavioural addictions — the AU general-practice approach

Behavioural addictions — gambling disorder, gaming disorder, and compulsive sexual behaviour disorder — present regularly in Australian general practice, often disguised behind depression, relationship breakdown, or financial crisis. Australia’s gambling environment is uniquely intense: with the highest gambling losses per capita in the world, nearly one in a hundred adults meets criteria for gambling disorder, and that group carries a suicide risk five to ten times the general population. The majority will not raise the issue themselves; brief routine screening changes the conversation.

A. Core clinical — the AU general-practice framework

Behavioural addictions share the core features of substance use disorders: compulsive engagement, impaired control, continued behaviour despite harm, tolerance, and prioritisation over other activities. Neuroimaging confirms dopaminergic reward circuit involvement with frontal-striatal dysregulation — the same circuitry implicated in alcohol and opioid dependence.

Gambling disorder is the only behavioural addiction in the main text of both DSM-5-TR and ICD-11. The DSM-5-TR requires at least 4 of 9 criteria over 12 months: gambling with increasing amounts (tolerance); restlessness or irritability when attempting to stop; repeated failed attempts to control gambling; preoccupation with gambling; gambling when distressed; returning to chase losses; lying to conceal the extent; jeopardising a relationship, job, or opportunity; and relying on others to relieve gambling-caused financial problems. Severity is mild (4–5 criteria), moderate (6–7), or severe (8–9).

Epidemiology in Australia (AIFS): approximately 1% of adults meet criteria for gambling disorder; approximately 3% are at-risk problem gamblers. Australia has the highest gambling losses per capita worldwide — approximately $1,300 per adult per year, largely from electronic gaming machines (pokies). The male-to-female ratio is roughly 2–3:1 in clinical samples, though women are a growing proportion in online gambling. Electronic gaming machines account for around 50% of total gambling losses; sports betting is the fastest-growing category.

Clinical clues in general practice: unexplained financial difficulties; partners or family members reporting secrecy and mood change; frequent absences or late nights; borrowing money or selling possessions; mood symptoms (depression, anxiety) refractory to standard treatment; and adolescents with school problems, excessive screen time, or micro-transaction spending.

Screening tools: The 2-item Lie/Bet screen has high sensitivity for gambling disorder in general practice: “Have you ever had to lie to people important to you about how much you gambled?” and “Have you ever felt the need to bet more and more money?” One positive response warrants further assessment with the 9-item Problem Gambling Severity Index (PGSI); a score of 8 or above indicates problem gambling.

B. Gaming disorder and compulsive sexual behaviour disorder

Gaming disorder was added to ICD-11 in 2018 (Internet Gaming Disorder appears in DSM-5-TR Section III for further study). ICD-11 requires a pattern of persistent or recurrent gaming with impaired control, increasing priority given to gaming over other activities, and continuation despite negative consequences, causing significant impairment in personal, family, social, educational, or occupational functioning, usually over at least 12 months. Lifetime prevalence estimates range from 1–9% depending on diagnostic criteria used. Comorbidity with ADHD, depression, anxiety, and autism spectrum conditions is high. The Internet Gaming Disorder Scale Short-Form (IGDS9-SF) is the standard screening tool. Family therapy is the treatment of choice for adolescent gaming disorder.

Compulsive sexual behaviour disorder (CSBD) entered ICD-11 as an impulse control disorder (not an addictive disorder). Criteria require a persistent pattern of failure to control intense, repetitive sexual impulses or urges for at least 6 months, causing significant distress or impairment. DSM-5-TR did not include CSBD. Important clinical context: distress arising purely from moral judgements about sexual behaviour does not qualify; the diagnosis requires genuine functional impairment. Risk of pathologising normative sexual variation, including LGBTIQ+ expression, warrants careful framing.

Comorbidity across all behavioural addictions is the rule, not the exception: depression, anxiety, PTSD, ADHD, substance use disorders, and bipolar disorder all co-occur at elevated rates. Parkinson’s disease patients on dopamine agonists (pramipexole, ropinirole) or levodopa can develop gambling disorder, hypersexuality, binge eating, or compulsive shopping as an iatrogenic complication of dopaminergic over-stimulation — this must be asked about directly at every general practice review of affected patients.

C. Treatment

Cochrane reviews confirm that CBT is the most effective treatment for gambling disorder, with moderate effect sizes sustained at 12-month follow-up. CBT targets erroneous beliefs about probability (the “gambler’s fallacy”), develops urge-control and relapse-prevention strategies, and addresses the cognitive distortions that sustain problematic gambling. Motivational interviewing is effective for engagement and is particularly useful as a brief intervention in general practice — even a single session improves readiness to change.

Self-exclusion via BetStop — Australia’s national online wagering self-exclusion register launched in 2023 — and state-based venue programs reduces access and betting frequency. GPs can recommend this directly during the consultation.

Pharmacotherapy: Naltrexone 50–150 mg/day has the strongest evidence for gambling disorder (Kim and Grant RCTs) and modest evidence for CSBD. In Australia, naltrexone is PBS Authority-listed for alcohol use disorder and opioid use disorder; use for gambling disorder is lawful but off-label. SSRIs are reasonable when comorbid depression or anxiety is present. Lithium has some evidence in gambling with bipolar spectrum features. Avoid benzodiazepines in any patient with addictive disorder — SafeScript and the Real-Time Prescription Monitoring program apply.

D. Australian operations

MBS items for behavioural addiction management: Level B attendance (item 23), Level C/D consultations (items 36/44) for complex cases. Mental Health Treatment Plan preparation (item 2715) and review (item 2717) for CBT referral via Better Access, providing up to 10 psychology sessions per year (items 80000–80020; telehealth psychology 81335). ATSI Health Assessment (item 715) and 75+ Health Assessment (item 707) are opportunities for routine gambling screening. Chronic complex care involving addiction, comorbid mental illness, and social factors may qualify for a GP Chronic Conditions Management Plan (items 965/967).

Australian gambling-specific resources: Gambling Help Online (1800 858 858) — national 24/7 helpline with telephone counselling, live chat, and online forum at no cost. BetStop — national self-exclusion register for online wagering; registration is free and immediate. Gam-Anon, Family Drug Support (1300 368 186), and Relationships Australia provide support for partners and families.

Gaming and internet-use resources: eSafety Commissioner provides current resources for parents, schools, and young people on online gaming and problematic internet use. headspace is the primary pathway for young people aged 12–25. Specialist psychology clinics with technology addiction programmes exist in major cities.

E. Special populations

Adolescents: Loot boxes and in-game micro-transactions in video games create a structural bridge to gambling disorder; counsel parents of adolescent gamers. Online sports micro-betting and in-play betting are growing rapidly among 18–25-year-olds; aggressive marketing during sports broadcasts has drawn regulatory attention. The eSafety Commissioner maintains resources for schools and families.

Parkinson’s disease: Dopamine agonist-induced impulse control disorders are reversible on dose reduction or agent change. Screen at every review with direct questions: “Have you noticed any changes in urges around gambling, spending, eating, or sexual behaviour since starting your medications?” Liaise with the neurologist when impulse control disorders are identified.

ATSI communities: Remote gambling contexts — including card games and informal betting — differ from urban poker machine and online gambling patterns. Gambling Help services have culturally adapted resources; Aboriginal Health Workers and Aboriginal Community Controlled Health Organisations (ACCHOs) are important partners.

Older adults: Retirement transition, bereavement, and social isolation are vulnerability factors for late-onset gambling disorder. Online gambling removes the social friction that previously limited access; cognitive impairment can complicate assessment and consent.

When to escalate

Refer to mental health specialist or addiction medicine: gambling disorder with active suicidal ideation or suicide attempt (emergency); gambling disorder with comorbid psychosis, severe bipolar disorder, or severe substance use disorder; gaming disorder in a child or adolescent who is not responding to family therapy; CSBD requiring specialist psychosexual therapy; and Parkinson’s-related impulse control disorders requiring medication adjustment.

Contact emergency services or the Mental Health Emergency Response Line if there is immediate risk to life. The Gambling Help Online line (1800 858 858) provides crisis support 24 hours a day.

What this article is and is not

This article reflects current Australian guidelines including eTG, RANZCP, and Cochrane reviews applicable in Australian general practice. It is educational material for adults and is not a substitute for assessment and management by a qualified health professional. Behavioural addictions are complex conditions influenced by psychological, social, neurobiological, and environmental factors; individual management plans must be developed with a clinician who knows the full picture. Recovery is non-linear and relapses are part of the process, not evidence of failure.

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Sources cited

• eTG complete — Gambling and behavioural addictions
• RANZCP — Practice guidelines for behavioural addictions
• RACGP — Behavioural addiction clinical resources
• Australian Gambling Research Centre (AGRC) — AIFS
• Gambling Help Online
• BetStop — National Self-Exclusion Register
• Australian Institute of Family Studies — Gambling and gaming
• eSafety Commissioner — Online gaming and problematic internet use
• HealthDirect — Gambling
• ICD-11 — Gambling Disorder; Gaming Disorder; Compulsive Sexual Behaviour Disorder
• Cochrane — Psychological and pharmacological interventions for pathological gambling
• NCETA — National Centre for Education and Training on Addiction