A review of two measures of pathological gambling in the United States

Development of the Gambling Disorder Identification Test (G-DIT): Protocol for a Delphi Method Study

Background

Research on the identification and treatment of problem gambling has been characterized by a wide range of outcome measures and instruments. However, a single instrument measuring gambling behavior, severity, and specific deleterious effects is lacking.

Objective

This protocol describes the development of the Gambling Disorder Identification Test (G-DIT), which is a 9- to 12-item multiple-choice scale with three domains: gambling consumption, symptom severity, and negative consequences. The scale is analogous to the widely used Alcohol Use Disorders Identification Test (AUDIT) and the Drug Use Disorders Identification Test (DUDIT).

Methods

The G-DIT is developed in four steps: (1) identification of items eligible for the G-DIT from a pool of existing gambling measures; (2) presentation of items proposed for evaluation by invited expert researchers through an online Delphi process and subsequent consensus meetings; (3) pilot testing of a draft of the 9- to 12-item version in a small group of participants with problem gambling behavior (n=12); and (4) evaluation of the psychometric properties of the final G-DIT measure in relation to the existing instruments and self-reported criteria of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), among individuals with problem gambling and nonproblematic recreational gambling behaviors (n=600). This protocol article summarizes step 1 and describes steps 2 and 3 in detail.

Results

As of October 2018, steps 1-3 are complete, and step 4 is underway.

Conclusions

Implementation of this online Delphi study early in the psychometric development process will contribute to the face and construct validity of the G-DIT. We believe the G-DIT will be useful as a standard outcome measure in the field of problem gambling research and serve as a problem-identification tool in clinical settings.

International Registered Report Identifier (IRRID)

RR1-10.2196/12006

Retaining Pathological Gamblers in Cognitive Behavior Therapy Through Motivational Enhancement

Treatment for pathological gambling is in its infancy. Several cognitive and behavioral interventions have shown promise, but high attrition and relapse rates suggest that gamblers requesting treatment are not uniformly committed to change. This article describes an exploratory study with 9 severe pathological gamblers—in their majority horse race bettors—who were recruited from a community treatment center. The gamblers were treated with a hybrid intervention consisting of motivational enhancement and cognitive behavior therapy. All gamblers were retained in treatment and during a 12-month follow-up period. This retention rate was significantly higher than that of a control group of gamblers who received treatment as usual in the same community setting. Of the gamblers who received the experimental treatment, 6 maintained total abstinence during the 12-month follow-up period, 2 were significantly improved, and 1 remained unimproved. In addition to changing their gambling behavior, many clients made successful lifestyle changes. The possible benefits of combining a motivational intervention with cognitive behavior therapy are discussed.

College student beliefs about wagering: an evaluation of the adolescent gambling expectancies survey

Expectancy theory posits that decisions to engage in a given behavior are closely tied to expectations of the outcome of that behavior. Gambling outcome expectancies have predicted adolescent gambling and gambling problems. When high school students' outcome expectancies were measured by Wickwire et al. (Psychol Addict Behav 24(1):75-88 2010), the Adolescent Gambling Expectancy Survey (AGES) revealed five categories of expectancies that were each predictive of gambling frequency and pathology. The present study aimed to explore if the AGES could be successfully replicated with college students. When administered to a diverse college student population, factor analyses identified five factors similar to those found in the high school sample. Several factors of the AGES were also found to predict gambling frequency and gambling problems for college students. Gambling frequency and gambling activity preference were also addressed.

Epidemiological surveys of pathological gambling: Critique and suggestions for modification

Epidemiological studies of problem and pathological gambling were examined for their accuracy. Fundamental flaws and biases were found in these surveys. These include problems with survey instruments; nonresponses and refusal bias; the exclusion of institutionalized populations; exclusion of other groups; and failure to protect against denial on the part of the respondent when others are present near the telephone. Based on the issues discussed, one can reasonably be expected to assume that most epidemiological surveys seriously underestimate the extent of problem and pathological gambling. Alternative strategies for addressing these issues are discussed. These strategies include the use of field interviews, surveys of institutionalized populations, frequent player surveys and significant other surveys. The value and potential problems of these approaches are also discussed.

The prevalence of problem and pathological gambling: A critical analysis

Prevalence of pathological gambling refers to the percentage of cases of pathological gambling occurring in the community at a given time. Prevalence studies conducted in different principalities throughout the world are reviewed, and it is found that none of them conforms to this definition of prevalence. The major error in all but the most recent surveys conducted is identified as the use of questions which ask whether gambling-related problems have ever occurred rather than whether they are currently occurring. This error will lead to an over-estimation of the prevalence of pathological gambling in society. The second major error identified in nearly all studies involves the accuracy of the screens being used to assess whether or not an individual is a pathological gambler. Concerns about the efficiency of the South Oaks Gambling Screen have not yet been satisfactorily resolved. None-the-less, the widespread use of the South Oaks Gambling Screen has made a valuable contribution to international comparisons of prevalence studies. Future work that explores the emerging relationship between levels of personal expenditure on gambling, types of gambling product and gambling-related problems are recommended.

Psychosocial health and gambling problems among men and women aged 16-24 years in the Swedish National Public Health Survey

BACKGROUND

This study aimed to explore the association between psychosocial health, gambling and gambling problems in a nationally representative sample of Swedish youth aged 16-24 years. Another aim was to examine whether these associations were different between young men and women.

METHODS

Data were from the cross-sectional Swedish National Public Health Survey in 2004-07. With a response rate of 60.1%, the sample consisted of 19 016 youth. Using a sex-stratified multinomial logistic regression, we estimated associations between psychosocial health variables and gambling and gambling problems.

RESULTS

Among males, we found that the higher the alcohol consumption, the higher the likelihood of gambling and gambling problems. Men with high alcohol consumption had an almost four times higher likelihood of gambling problems than men with no or low alcohol consumption (OR 3.94, 95% CI: 2.17-7.14). Moreover, young male victims of violence were more than twice as likely to have gambling problems than non-victims (OR 2.35, 95% CI: 1.39-3.99). Among young women, we found an inverse association between high alcohol consumption and gambling problems (OR 0.15, 95% CI: 0.05-0.44), opposite that of the young men. Furthermore, psychological distress (OR 6.15, 95% CI: 2.15-17.60) and suicidality (OR 2.88, 95% CI: 1.16-7.17) were associated with higher probabilities of gambling problems among young women.

CONCLUSION

Alcohol use, violence victimization and poor mental health are associated with gambling problems among Swedish youth, however, with important sex differences. Prevention of youth gambling should consider sex differences and psychosocial health in addition to gambling.

The NODS-CLiP: a rapid screen for adult pathological and problem gambling

OBJECTIVES

To describe and evaluate tests of the performance of the NODS-CLiP, an efficient standardized diagnostic interview instrument for adult pathological and problem gambling. SETTING AND SAMPLES: Identical batteries of diagnostic questions about gambling behavior, motives, and thoughts were administered to participants in eight general adult population field studies conducted in the United States between 1999 and 2003, including six state-level random-digit-dial (RDD) telephone surveys, one national RDD survey, and one in-person systematic random sample survey of commercial gambling patrons in eight states. Total survey N = 17,180. Response rates ranged from 24 to 71%.

MEASURES

Data from all experienced gamblers (N = 8,867) were re-analyzed to compare diagnostic status derived from the 17-item NORC Diagnostic Screen for Gambling Disorders (NODS), a validated DSM-IV-based instrument, with results from all 2- to 4-item subsets of NODS items.

RESULTS

Three NODS questions pertaining to loss of Control, Lying, and Preoccupation (the "CLiP"), requiring one minute to administer, identified virtually all pathological gamblers and most problem gamblers diagnosed by the complete NODS. The CLiP has excellent sensitivity and specificity for NODS constructs.

CONCLUSIONS

A two-stage NODS-CLiP procedure appears quite promising as an efficient epidemiological instrument for general population research and clinical triage for gambling disorders.

Young adult gambling behaviors and their relationship with the persistence of ADHD

Young adulthood is a period renowned for engagement in impulsive and risky behaviors, including gambling. There are some indications that young adults exhibit higher gambling rates in comparison to older adults. Problem gambling has also been linked to ADHD. This longitudinal study examines the relationship between gambling and ADHD among an epidemiological sample of young adults (n = 235; males = 179, females = 56) aged 18-24. Results indicate that individuals who report childhood ADHD symptoms which persist into young adulthood experience greater gambling problem severity than participants with no ADHD or those with non-persistent ADHD.

Reflections on accuracy

The difference between test accuracy and predictive accuracy is presented and defined. The failure to distinguish between these two types of measures is shown to have led to a misguided debate over the interpretation of prevalence estimates. The distinction between test accuracy defined as sensitivity and specificity, and predictive accuracy defined as positive and negative predictive value is shown to reflect the choice of the denominator used to calculate true positive, false positive, false negative, and true negative rates. It is further shown that any instrument will tend to overestimate prevalence in low base rate populations and underestimate it in those populations where prevalence is high. The implications of these observations are then discussed in terms of the need to define diagnostic thresholds that have clinical and policy relevance.

Prevalence of pathological gambling in Quebec in 2002

OBJECTIVE

To assess gambling behaviours and the problems associated with pathological gambling among the adult population of Quebec in 2002.

METHOD

In Phase 1 of this 2-phase study, a total sample of 8842 adults was assessed. We used the South Oaks Gambling Screen (SOGS), adapted for telephone interview, to assess one-half of the sample; the other one-half was evaluated with the Canadian Problem Gambling Index (CPGI). In the study's second phase, we compared the classifications obtained from these screening instruments with classifications obtained by a psychologist using a semistructured clinical telephone interview.

RESULTS

The results indicate that the prevalence of pathological gambling in 2002 (at which time 0.8% of the adult population were classified as probable pathological gamblers) did not differ from the proportion obtained in 1996 (1.0%), despite the significant decrease in gambling participation in 2002 (81% vs 90% in 1996). The most popular gambling activities were buying lottery tickets (68%), participating in fundraising draws (40%), gambling in casinos (18%), playing cards with family or with friends (10%), playing bingo (9%), and playing video lotteries (8%). The findings obtained from the SOGS and the CPGI revealed that the 2 instruments perform similarly when identifying pathological gambling prevalence. However, the results of the semistructured clinical telephone interviews differed from the results obtained with the screening instruments: 82% of the gamblers initially identified as probable pathological gamblers by the SOGS or the CPGI were not confirmed by a clinical interview.

CONCLUSION

The discrepancy between the results of the screening questionnaires and the clinical evaluation is significant, and this difference needs to be addressed before further cross-sectional or longitudinal studies are conducted.

Prevalence estimates of adolescent gambling: a comparison of the SOGS-RA, DSM-IV-J, and the GA 20 questions

Concerns over the rising prevalence of adolescent gambling problems have become more commonplace. A recent meta analysis of studies examining adolescent prevalence rates by Shaffer and Hall (1996) has suggested that between 77-83% of adolescents are engaging in some form of gambling behavior with between 9.9% and 14.2% of youth remaining at risk for a serious gambling problem. Their results further suggest that between 4.4% and 7.4% of adolescents exhibit serious adverse gambling related problems and/or pathological gambling behavior. Comparisons of studies are often difficult due to the use of alternative measures, differing classification schemes, and nomenclature. The present study examined the gambling behaviors of 980 adolescents who were administered three screening measures used with adolescents; the SOGS-RA, DSM-IV-J, and the GA 20 Questions. The DSM-IV-J was found to be the most conservative measure identifying 3.4% of the population as problem/pathological gamblers while the SOGS-GA identified 5.3% and the GA 20 Questions identified 6% of youth as experiencing serious gambling problems. The degree of concordance amongst the measures, gender differences, and classification systems are discussed.

A new instrument to measure cognitive distortions in video lottery terminal users: the Informational Biases Scale (IBS)

This paper reports on the development of a new scale, the Informational Biases Scale (IBS), to measure cognitive distortions such as the illusion of control, gambler's fallacy,illusory correlations, and the availability heuristic in video lottery terminal (VLT) players. Ninety-six VLT players recruited from bars in New Brunswick took part in the study. Their average (lifetime) South Oaks Gambling Screen score was in the probable pathological gambler range. The 25-item IBS was shown to have good internal consistency reliability. An exploratory principal components/factor analysis revealed the variability of the IBS to be accounted for by mainly one factor. The construct validity of the instrument was supported by the finding that IBS scores were uniquely determined by measures of gambling addiction and negative affect. The IBS should prove useful in both research and clinical settings involving VLT gamblers.

Fifteen years of problem gambling prevalence research: What do we know? Where do we go?

This paper charts the rapid growth of problem gambling prevalence research in North America and internationally. Looking beyond the overall prevalence of problem gambling in the general population, the results of these studies support the notion of a link between the expansion of legal gambling opportunities and the prevalence of problem gambling as well as the notion that the characteristics of problem gamblers change in response to changes in the availability of specific types of gambling. The results of these studies also challenge existing concepts and definitions of problem gambling. In the future, it will be important to improve how problem gambling prevalence research is done. Such work is likely to include changes in how we measure gambling problems as well as requiring us to take steps to overcome obstacles in achieving representative samples of the population and obtaining valid and accurate information.

20 Questions of Gamblers Anonymous: A Psychometric Study with Population of Spain

The authors present a psychometric study of the questionnaire proposed by the Gamblers Anonymous organization for the self-assessment of problem gambling. The study was carried out in Spain with two samples: one of 127 problem gamblers (mean age: 41.67; sex: 78.7% men; mean duration of the problem: 5 years) and the other of 142 social gamblers (mean age: 38.46; sex: 60% men). The questionnaire was self-applied, in the presence of one of the investigators in case any doubts arose. The results indicate that it is a good screening instrument, with high reliability (Cronbach's alpha = 0.94), good covergent validity (the correlation with the SOGS questionnaire is high (r = 0.94; p < 0.001)), good factorial validity (the questionnaire's structure is unidimensional and coherent (just one factor explains more than 50% of the variance)), and its discriminative power is high (diagnostic efficacy = 98.88%). The study offers a comparative analysis of this instrument with other measures of problem gambling, emphasizing its extraordinary performance.

The South Oaks Gambling Screen: a review with reference to Australian use

The South Oaks Gambling Screen (SOGS) is a psychometric instrument widely used internationally to assess the presence of pathological gambling. Developed by Lesieur and Blume (1987) in the United States of America (USA) as a self-rated screening instrument, it is based on DSM-III and DSM-III-R criteria. This paper describes the origins and psychometric development of the SOGS and comments critically in relation to its construct validity and cutoff scores. Reference is made to the use of the SOGS in the Australian setting, where historically gambling has been a widely accepted part of the culture, corresponding to one of the highest rates of legaliZed gambling and gambling expenditure in the world. An alternative approach to the development of an instrument to detect people who have problems in relation to gambling is proposed.

Reliability, validity, and classification accuracy of the South Oaks Gambling Screen (SOGS)

The South Oaks Gambling Screen (SOGS) was originally developed to screen for pathological gambling in clinical settings; however, its use has expanded to other purposes, settings, and populations, including prevalence studies of pathological gambling in the general population. Questions have been raised about the accuracy of the SOGS with its use in these new settings and populations. The purpose of this study is to examine current estimates of the reliability, validity, and classification accuracy of the SOGS in two different samples: (a) a general population sample (N= 803) and (b) a gambling treatment sample (N = 1,589). DSM-IV diagnostic criteria served as the standard against which to measure the SOGS classification accuracy and both the SOGS and DSM-IV diagnostic criteria were administered to participants. The SOGS was found to have satisfactory reliability with coefficient alphas of .69 and .86 in the general population and gambling treatment samples, respectively. The SOGS demonstrated satisfactory validity by differentiating between the general population and the gambling treatment sample and by exhibiting high correlations with DSM-IV diagnostic criteria and moderate correlations with other measures of gambling problem severity. The SOGS demonstrated good to excellent classification accuracy in the gambling treatment sample, but had poorer accuracy in the general population sample with a 50% false positive rate. The SOGS overestimated the number of pathological gamblers in the general population, as compared to DSM-IV diagnostic criteria.

Epidemiology of problem gambling in Prince Edward Island: a Canadian microcosm?

OBJECTIVES

To gather information that describes the extent of gambling and problem gambling in Prince Edward Island (PEI), to rigorously analyze the relation between gambling activities and problem gambling, to document cognitive and emotional correlates of problem gambling, and to identify an at-risk gambling group.

METHOD

We selected a random, stratified sample (n = 809) to represent the adult population of PEI. We administered both the South Oaks Gambling Screen (SOGS) and an early version of the Canadian Problem Gambling Index (CPGI) to participants who had gambled.

RESULTS

The current rate of problem gambling was 3.1%. Problem gamblers were likely to be under age 30 years, to be single, and to report cognitive, emotional, and substance abuse correlates. Multiple-regression analysis identified a unique and substantial relation between problem gambling and video lottery terminal (VLT) use. We identified a group of at-risk gamblers (scoring 1 or 2 on the SOGS), comprising 14% of the sample.

CONCLUSIONS

Gambling and problem gambling patterns in PEI resemble those in most other provinces. The relation found between problem gambling, VLT use, and cognitive, emotional, and substance use correlates should apply to the greater population as well.

Epidemiology of behavioral dependence: literature review and results of original studies

The extension of the definition of dependence leads to the consideration of some impulsive disorders as a form of dependence disorder. This pathological condition is characterized by the repetitive occurrence of impulsive and uncontrolled behaviors. Other clinical characteristics are failure to resist an impulse, drive or temptation to perform some act harmful to oneself and/or others, an increasing sense of tension or excitement before acting out, and a sense of pleasure, gratification or release at the time of the behavior or shortly thereafter. Behavioral dependences most often described are pathological gambling, kleptomania, trichotillomania and compulsive buying. Studies using a specific assessment scale, the South Oaks Gambling Screen, distinguished problem gambling from pathological gambling. Social gamblers spend 5% of their money and pathological gamblers 14 to 45%. Prevalence of 'problem gambling' is 4% and pathological gambling 2%. Several studies have suggested that the incidence of pathological gambling is eight to ten times greater in alcohol-dependent patients than in the general population. No systematic study has assessed the prevalence of kleptomania. Data come from case reports. Among subjects arrested after a theft, prevalence of kleptomania varied between 0 and 24%. Trichotillomania prevalence rate is 0.6% among students. Studies using less restrictive diagnostic criteria found a prevalence rate of 3.4% in women and 1.5% in men. The disorder is often unrecognized; 40% of the cases are not diagnosed and 58% of the patients have never been treated. Prevalence studies of compulsive buying found a rate between 1 and 6% in the general population. Compulsive buying is significantly more frequent among women (90% of the cases). Study of family history of compulsive buyers showed a high frequency of alcohol-dependence disorder (20%) and depression (18%). In all cases of behavioral dependence disorders, a high level of impulsivity and sensation-seeking could determine an increased risk.

Review of research on pathological gambling

The literature including a number of review articles was examined for answers to the questions, have distinctive personality test profiles of pathological gamblers been identified, do pathological gamblers have control over their behavior, have studies of alcoholism and addiction increased understanding of compulsive gambling, and has psychotherapy or Gamblers Anonymous been successful for them? Much more information is needed to build on what research on these questions has yielded.

Prevalence estimates of pathological gambling in Quebec

Pathological gambling was officially defined and recognized as a psychiatric illness by the American Psychiatric Association in 1980. This survey reports the results of a province-wide study in Quebec based on telephone interviews using standardized assessment instruments with 1,002 subjects. The current prevalence of pathological gambling is 1.2%. The results also show that 88% of the respondents have gambled at least once in their life. The implications of these results for the prevention and treatment of this debilitating disorder are discussed.