Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

For information on how this guideline will be implemented, see the implementation statement.

1.1 Case identification, initial support, referral and assessment

Stigma

1.1.1

Recognise that stigma, shame and fear of disclosure can prevent people who are experiencing gambling-related harms from talking about gambling, and from seeking and accessing support and treatment. In addition, stigma may be a particular issue for certain groups such as people from marginalised, minority or under-represented groups.

For recommendations on overcoming stigma, see the section on improving access to treatment.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review I: access.

Asking about gambling

These recommendations are for healthcare professionals and social care practitioners in all settings including the criminal justice system.

1.1.2

Consider asking people about gambling (even if they have no obvious risk factors for gambling-related harm) when asking them about smoking, alcohol consumption or use of other substances (for example, as part of a holistic assessment or health check, when registering for a service such as with a GP or in contacts with social services).

1.1.3

Ask people about gambling in the following situations because they may be at increased risk of gambling-related harm:

  • when 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)

  • when they are taking medicines that may affect impulse control, for example, dopamine agonists for Parkinson's disease, or aripiprazole for psychosis; see NICE's guideline on Parkinson's disease for advice on managing and monitoring impulse control disorders as an adverse effect of dopaminergic therapy

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

  • when they present in any setting with problems relating to alcohol or substance dependence, especially use of cocaine

  • when they are at risk of or experiencing homelessness

  • when they share that they have financial concerns

  • when there are concerns about safeguarding issues or violence, including domestic abuse

  • when they share that there is a family history of gambling that harms or alcohol or substance dependence.

1.1.4

Consider asking people about gambling if they may be at increased risk of harm:

  • because they have a neurological condition or acquired brain injury that leads to disinhibition or increased impulsivity

  • because they are a young person who has recently left home for the first time

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

1.1.5

Take into account that having multiple risk factors may have a cumulative effect and further increase the person's chances of experiencing gambling-related harms.

1.1.6

Use direct questions to ask people about gambling, such as: 'Do you gamble?' or 'Are you worried about your own or another person's gambling?'. Be aware that some people may find it difficult to talk about gambling.

For a short explanation of why the committee made these recommendations and how they might affect services, see the .

Full details of the evidence and the committee's discussion are in evidence review A: factors suggesting harmful gambling and evidence review B: tools for identification and assessment of harmful gambling.

Referral and triage

These recommendations are for healthcare professionals and social care practitioners in all settings including the criminal justice system. They may also be relevant to commissioners and providers of gambling treatment and gambling support services.

1.1.16

Consider referring people experiencing gambling that harms via an NHS triage service, for triage and allocation to an appropriate level of service.

1.1.17

When discussing support or treatment with the person, tell them that self-referral, via an NHS triage service or the national gambling helpline, is an option.

1.1.18

Recognise that gambling severity can vary over time and recent onset or short periods 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.

1.1.19

Consider referring affected others to gambling treatment or support services, depending on their level of need.

For a short explanation of why the committee made these recommendations and how they might affect services, see the .

Full details of the evidence and the committee's discussion are in evidence review B: tools for identification and assessment of harmful gambling.

Assessment of gambling that harms

These recommendations are for providers of gambling treatment services.

1.1.20

Consider using an up-to-date validated tool to assess gambling that harms (examples include the Problem Gambling Severity Index and the South Oaks Gambling Screen).

1.1.21

Discuss the person's gambling with them and assess the following:

  • gambling history (when the gambling started and how it has progressed, including when the frequency or intensity increased)

  • type(s) and location of gambling activities

  • current frequency of gambling (for example, days per week or hours per day)

  • medical history, including physical and mental health, neurodevelopmental history, acquired brain injury, comorbidities, and alcohol or substance dependence

  • childhood development and family history

  • current mental health and the relationship with gambling-related harms (see recommendation 1.5.7)

  • the impact of gambling on their mental health (for example, depression, anxiety and insomnia) and their physical health

  • risk of suicide, including any past attempts

  • financial impact of gambling (for example, money spent on gambling as a proportion of income, borrowing or stealing money for gambling)

  • how gambling affects other aspects of their life (for example, social functioning, interpersonal relationships, employment, education and whether it has led to any involvement in crime)

  • psychological functions of gambling for them, or the motivation for gambling

  • factors that may contribute to continued gambling (for example, triggers and cravings, and how thoughts and emotions may have been influenced)

  • role of advertising and marketing in contributing to gambling

  • alignment to ICD-11 or DSM-5 criteria for gambling disorder

  • reasons for seeking support, motivation to change and expectations and goals of treatment

  • safeguarding issues or concerns

  • immediate needs (for example, help with housing, food and debts).

1.1.22

Assess whether current pharmacological therapy may be contributing to gambling that harms (for example, aripiprazole and medicines for Parkinson's disease). Think about reducing or optimising these medicines in consultation with the relevant specialist services.

1.1.23

Develop a case formulation, care plan and safety plan (if needed) with the person based on the results of the assessment, including any immediate actions that can be taken (see recommendation 1.1.14).

For a short explanation of why the committee made these recommendations and how they might affect services, see the .

Full details of the evidence and the committee's discussion are in evidence review B: tools for identification and assessment of harmful gambling.

1.2 Information and support

These recommendations are for providers of gambling treatment and gambling support services.

For more guidance on communication and giving information, including providing accessible information, see NICE's guidelines on patient experience in adult NHS services and service user experience in adult mental health. For advice on discussing risks and benefits, see NICE's guideline on shared decision making.

1.2.1

Provide unbiased information to people who are experiencing gambling-related harms (including affected others) to support their treatment and recovery. This could include information on:

  • why people gamble and what induces them to continue gambling or return to gambling, despite the harm; include information on the addictive nature of gambling, effects on the reward system in the brain and how the gambling industry and advertising may incentivise, encourage and promote gambling behaviour

  • the different types of gambling activities, how different products are targeted to different groups of people (for example, in-game sports betting is promoted mainly to young men and some online games are promoted mainly to women) and how the addictive characteristics and harm of different gambling products and environments may vary

  • that it is common to feel shame or fear and to experience stigma when disclosing gambling harms

  • the harms that can be caused by gambling, for example, distress; impact on self-esteem, self-control, decision making and mental health; the potential for increased risk of suicide, debt and possible involvement in crime

  • how to recognise the potential harms associated with gambling, including the link with mental health conditions, and alcohol or substance dependence

  • what services are available for gambling-related harms (including crisis services for people at risk of suicide; voluntary sector organisations or social care services; and national, regional or local treatment services) and how to access them (see the recommendations on referral and triage)

  • how to access other sources of support for gambling-related harms (for example, informal support from family and friends, peer support groups and online forums)

  • how to access practical support (for example, debt services, financial help and advice on how to avoid gambling sites, inducements and marketing).

1.2.2

Discuss with people experiencing gambling-related harms:

  • their reasons for seeking support and treatment and how these can help to motivate them to change

  • that recovery is achievable (for example, sharing positive testimonies, stories and films and providing access to people who have recovered from gambling-related harms).

1.2.3

Provide unbiased information to affected others, including:

  • how they can support the person who is experiencing gambling that harms

  • how they can be supported by gambling treatment services, healthcare providers, voluntary sector organisations or social care services, either with the person experiencing gambling that harms or by themselves

  • how they can access help for themselves, including support for their own mental health and practical issues such as financial support.

1.2.4

Provide information and support in ways that the person prefers, for example, at face-to-face consultations or online, such as through websites, apps or social media.

1.2.5

Service providers should ensure that information:

  • is well promoted and signposted in local and national health and social care services, as well as in the wider community, including in the criminal justice system

  • can be accessed anonymously.

For a short explanation of why the committee made these recommendations and how they might affect services, see the .

Full details of the evidence and the committee's discussion are in evidence review C: information and support.

1.3 Models of care and service delivery

These recommendations are for commissioners and providers of gambling treatment and gambling support services.

Gambling treatment services

Gambling treatment services will be commissioned by the NHS but may be provided by a range of providers, including the NHS or voluntary sector organisations. At the time of publication (January 2025), only the specialist gambling clinics are commissioned by the NHS. However, there is a planned reconfiguration of gambling treatment services. There will therefore be a period over which this change will be fully implemented (see the implementation statement).

1.3.1

Gambling treatment services should include:

  • specialist gambling clinics, which will usually provide assessment, information, treatment and support, including case management, for people with a greater severity of gambling-related harms or a greater severity 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, which will usually provide treatment and support for people experiencing gambling-related harms, including affected others, but with lower levels of gambling-related harms or complexity than specialist gambling clinics.

Gambling support services

Gambling support services may be commissioned by the NHS or may operate independently and be provided by a range of providers, including the NHS or voluntary sector organisations.

1.3.2

Gambling support services should provide information and support to people experiencing gambling-related harms, including affected others. This support may include brief interventions, peer support, advice and signposting and referring to other services, including gambling treatment services.

All services

1.3.3

Gambling treatment and support services should be provided to meet the needs of people with different levels of gambling-related harm.

1.3.4

People should be offered the appropriate level of care to meet their needs, based on the severity of their gambling (including the Problem Gambling Severity Index score if available), presence of comorbidities, other co-occurring needs, and according to their preferences.

1.3.5

Gambling treatment and support services should be commissioned and provided without influence or involvement from the gambling industry, ensuring there are no conflicts of interest between the commissioners and providers of services and the gambling industry.

1.3.6

Commissioners and service providers should ensure that all services:

  • allow for the prompt and ongoing assessment of the risk and severity of gambling-related harms, including the risk of suicide and self-harm

  • take into account the needs of the individual to ensure that people are offered the relevant support and treatment, referring people to other services such as specialist gambling clinics if necessary

  • deliver timely support so that treatment can start as soon as possible after assessment

  • provide easy access to treatment, including for people who may otherwise find it difficult to access services (for example, people experiencing homelessness, people in the criminal justice system and in military service); see the recommendations on improving access to treatment

  • are multidisciplinary and provide coordinated support for people experiencing gambling-related harms across mental and physical health services and local authorities, including social care and the criminal justice system, with agreed protocols for sharing information between providers

  • work with services for people with learning disabilities, mental health conditions (such as PTSD or severe ADHD), alcohol or substance dependence, or acquired cognitive impairments (see recommendation 1.5.8)

  • provide support and treatment for as long as needed, including follow-up and aftercare support

  • support the integrated delivery of services across providers, to ensure that people do not fall into gaps in service provision.

1.3.7

Commissioners and providers should ensure that the workforce delivering support and treatment services for people experiencing gambling-related harms is trained and competent to do so (for example, cognitive behavioural therapy [CBT] should be delivered by psychologists or accredited CBT therapists; see recommendation 1.5.9).

1.3.8

Service providers should routinely collect and publish nationally agreed standardised sets of data on people entering services for gambling-related harms, including waiting times, demographics, baseline data on type of gambling and severity of gambling-related harms, and treatment outcomes.

For a short explanation of why the committee made these recommendations and how they might affect services, see the .

Full details of the evidence and the committee's discussion are in evidence review D: models of care and service delivery.

1.4 Improving access to treatment

These recommendations are for commissioners and providers of gambling treatment and gambling support services.

Overcoming stigma

1.4.1

To lessen the impact of stigma and to support access to treatment:

  • use a person-centred, empathic, non-judgemental approach and

  • discuss with people any fears or concerns that are preventing them from seeking help, and having or continuing with treatment.

1.4.2

To help people feel more comfortable and reduce stigma when accessing treatment, consider modifying treatments or their delivery for different groups, including making reasonable adjustments. Depending on local needs, this may include providing:

  • sex or gender-specific services such as women-only groups

  • vocation-specific services such as veterans' groups

  • groups for affected others

  • culturally sensitive services that are tailored to the needs of local communities and take into account factors such as ethnic background and religion

  • treatments for gambling-related harms in separate locations from services for alcohol or substance dependence.

Supporting access for people with mental health problems

1.4.3

Recognise that people with mental health problems (for example, PTSD, depression or anxiety) may find it more difficult to access support and treatment for gambling-related harms.

1.4.4

Ensure that treatment for gambling-related harms is coordinated with treatment for any coexisting alcohol or substance dependence or mental health problems (see recommendation 1.5.8).

Supporting and encouraging access and engagement

1.4.5

Ensure that referral and treatment pathways are simple and easy to access. To enable this, the pathways should:

  • be accessible through self-referral or referral by practitioners in a variety of settings (see the recommendations on referral and triage)

  • take into account the needs of particular groups, for example, by providing access for people in the criminal justice system

  • be designed to minimise drop-out and maximise engagement, for example, by avoiding a requirement to complete multiple steps to gain access to treatment.

1.4.6

Explain to people accessing treatment that:

  • gambling treatment and support services are usually free, although some charges may apply (for example, for prescriptions)

  • all conversations are private and confidential, although it may be necessary to share confidential information without their consent in certain circumstances (for example, if they or others may be in danger).

1.4.7

Encourage access to and engagement with treatment by starting evidence-based interventions as soon as possible after identifying gambling-related harms.

1.4.8

Encourage engagement with interventions by providing treatment in a location and using a delivery method that reflects the person's needs and preferences (for example, individual sessions if group therapy is not available or suitable, in person or via phone or video conferencing).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review I: access.

1.6 Relapse and ongoing support

These recommendations are for commissioners and providers of gambling treatment and gambling support services.

1.6.1

Recognise that relapse in people whose gambling has decreased after treatment can be distressing for the person and may lead to suicide or self-harm.

1.6.2

Discuss the risk of relapse with people experiencing gambling that harms. Include that:

  • relapse is not shameful and it may be part of a recovery journey or learning event

  • relapse does not indicate individual failure, and having a plan in place to recover quickly increases confidence and reduces shame

  • relapse can occur because of individual or environmental factors

  • understanding the causes and triggers which may lead to relapse, including exposure to advertising and marketing, may be helpful

  • skills and techniques can be taught during treatment to reduce the chance of relapse (for example, using blocking tools, stimulus control and strategies for coping with high-risk situations).

1.6.3

Continue to provide support, follow-up, and rapid re-entry to therapy after a course of psychological or pharmacological treatment according to the person's needs and preferences.

1.6.4

Consider additional treatment or support for people:

  • where the agreed outcomes have not been achieved through the original intervention

  • who may be at higher risk of relapse

  • who have lapsed or relapsed.

1.6.5

Discuss with the person what additional treatment or support they may need. This could include:

  • additional sessions of an intervention (for example, CBT)

  • other support such as peer support or support groups

  • support with ongoing harms (for example, relating to employment, finance, health, housing, relationships or legal issues), which may be provided by voluntary sector organisations.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review H: relapse prevention.

1.7 Interventions and support for families and affected others

These recommendations are for commissioners and providers of gambling treatment and gambling support services.

1.7.2

Offer support to affected others, including:

  • the opportunity to receive help and advice both by themselves and with the person experiencing gambling that harms (if that is what they both agree to)

  • techniques to manage their own distress and prioritise their needs

  • support to help them engage in non-judgemental communication with the person experiencing gambling that harms.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review G: interventions for families and affected others.