Millions of Americans are problem gamblers—so why do so few people ever seek treatment?

The opportunity to gamble has moved from a trip to Vegas, to a drive to a local casino, to the phone in your pocket. And if you’re a sports fan, nudges to place bets have become nearly impossible to ignore, with sports gambling ads and promos routinely appearing on TV, social media, sports radio and in arenas.

The stunning expansion of sports wagering following decades of casino expansion certainly gives any rational person reason to pause.

For most bettors, gambling is an occasional form of entertainment—Powerball tickets when the jackpot swells to $1 billion, Super Bowl squares with co-workers, a birthday trip to the casino.

But for other people, the possibility of developing a gambling disorder looms.

To what extent should Americans be worried?

To gamble is to be human

A nuanced answer begins with the fact that gambling has been popular for a long, long time.

Evidence of gambling has been found in ancient cultures around the world. Archaeologists have unearthed dice marked with pips, or dots, in Mesopotamia that date back to 1300 B.C. Historians have located records of dice games in Greek and Indian cities before 400 B.C.

In North America, one Navajo myth tells the story of Noqoìlpi, or “the gambler.” Informal gambling games and lotteries were common in the American Colonies, including lotteries to fund the Continental Army.

In the U.S., sports and gambling have long been intertwined. In the decades after the Civil War, pool halls were set up near Western Union stations so gamblers could easily place bets on horses. And sports like baseball and boxing became hugely popular in the 19th century, in part because they attracted action from bettors.

For as long as there’s been gambling, there has also been problem gambling.

Several writers in ancient India highlighted the consequences of habitual gambling. Over 150 years ago, Dostoyevsky famously wrote “Crime and Punishment” to pay off gambling debts. And in the 20th century, sports betting imploded the careers of baseball legends “Shoeless” Joe Jackson and Pete Rose.

When problems arise

I describe this history because it shows that humans have always seemed to find a way to gamble, whether it’s legal or not. And, inevitably, some bettors will experience harm or a gambling disorder.

I direct the Institute for Gambling Education and Research, where we focus on the treatment of gambling disorder and gambling problems.

Psychologists have only recently begun to view problem gamblers as a form of addictive behavior, in which gambling urges, tolerance and withdrawal are akin to how substance use disorders unfold. Researchers have found that brain imaging data and symptom patterns of problem gamblers are similar to those of people who are addicted to drugs or alcohol. Gamblers can build a tolerance, meaning that they need to gamble more and bet in higher amounts in order to maintain the same levels of excitement. And attempts to cut back or stop can lead to emotional struggles.

There are also financial and social ramifications to gambling disorder.

Distress about money is the most frequently cited reason people start questioning whether they have a problem. But other symptoms include damage done to relationships, deterioration in mood and the physical costs of this distress. Problem gamblers often lie about or hide their gambling, which can make it difficult for loved ones to recognize.

The best prevalence research shows that somewhere between 1% and 2% of the U.S. adult population, or 2 to 4 million adults, will experience a gambling disorder in their lifetime. Another 3% to 5%, or 5 to 9 million people, will, at some point in their lives, report a subclinical problem, which means that some gambling disorder symptoms are present but the psychiatric diagnosis is not warranted.

Despite some hand-wringing over the expansion of sports betting, I believe any increase in the rate of problems is likely to be temporary. A review of 30 years of research on the prevalence of problem gambling and gambling disorder reveals a pattern. More gambling availability tends to lead to a spike in the number of people reporting gambling issues in the short term. However, populations tend to adapt over time; the rate of gambling problems decreases accordingly.

It will be interesting to see whether the same pattern plays out for sports betting.

Barriers to treatment

My team also operates an outpatient clinic where we treat people with gambling disorder. Our research and therapy sessions have pointed to some encouraging news, along with a few barriers.

The good news is that treatment, particularly when it includes cognitive behavioral techniques, significantly reduces gambling disorder symptoms and psychological distress. While long-term treatment is recommended, an effective course of treatment is about eight to 10 sessions.

Yet there are still roadblocks. People are often hesitant to try treatment; those who do frequently drop out.

People are often unaware they have gambling problems, even when they report having symptoms of problem gambling. We don’t exactly know why. The impact, though, is substantial. Only about 10% of individuals with a gambling problem ever seek treatment. As a comparison, the rate of seeking help among those with substance use disorders runs somewhere between 10% and 50%. It’s considerably lower than those experiencing depression and anxiety, 70% to 90% of whom will seek treatment.

We also know that gambling disorder is one of the most stigmatized mental health concerns. We find that people tend to blame someone who has developed gambling problems, and view them as dangerous or untrustworthy. By contrast, someone experiencing depression and anxiety is less likely to be blamed for their problems.

The other challenge is the rate at which people discontinue treatment before completing the standard course of therapy. For most mental health concerns, 20% who start a psychological treatment fail to continue in that treatment. By comparison, the dropout rate for gambling harms is nearly double: 39%.

We believe that dropout rate is not explained by people not wanting to put in the work to change. Instead, the relationship with the therapist and ambivalence about the progress being made tend to derail the course of treatment. Finances are also a real problem. Patients might not be able to afford their appointments, or their insurance doesn’t cover a diagnosis of a gambling disorder.

Gaps in knowledge and funding

About a decade ago, a friend who is an alcohol researcher observed that the thinking and research about gambling was about four decades behind where it is for alcohol. The gaps in knowledge were evident. We still don’t have good models for how a gambling problem develops, or how to conceptualize an addiction without a substance. We don’t know the long-term effects of experiencing gambling problems and gambling disorder. And we don’t fully understand the extent to which improvements from treatment are maintained.

While researchers around the world are chipping away at these knowledge gaps, there continue to be huge challenges—not the least of which is that gambling regulations keep changing and new forms of gambling are always emerging.

More importantly, there is little funding available to learn more about gambling disorder—and almost no funding from the U.S. government. In 2022, the National Institutes of Health invested over $570 million to study alcohol use problems.

The amount the NIH budgeted to study gambling?

Zero.

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