Barriers to Seeking Help for Gambling Problems: A Review of the Empirical Literature

A mixed method study exploring similarities and differences in general and social services-specific barriers to treatment-seeking among individuals with a problematic use of alcohol, cannabis, or gambling

INTRODUCTION

The treatment gap for addictive disorders is one of the largest in health care. Several studies have investigated barriers to treatment for different addictive disorders, but very few studies conducted have explored whether the barriers differ depending on substance or behavior or if they are common among all addictive disorders. In Sweden, addiction care is provided both by the healthcare and social services, where the latter is common, but also less popular. To our knowledge, there are no studies exploring whether the barriers are different depending on where the treatment is given.

AIM

The aim was to thoroughly explore both which general and social services-specific barriers to treatment that are common, which barriers that differs, and how the barriers are described among individuals with a problematic use of alcohol, cannabis and/or gambling.

METHOD

A mixed method convergent parallel design was conducted. For the quantitative measures, surveys including the validated Barriers to Treatment Inventory as well as questions regarding barriers in the Swedish multi-provider landscape, were collected from individuals with a problematic use of alcohol (n = 207), cannabis (n = 51), and gambling (n = 37). In parallel, 17 semi-structured interviews from the same population were conducted and analyzed with thematic analysis. Thereafter, the quantitative and qualitative data was compared, contrasted, and at last, interpreted.

RESULTS

The quantitative data showed that the largest general barriers in all groups were privacy concern and poor availability, and the largest barriers for seeking help from the social services was stigma, unawareness of what is offered, and fear of consequences for all groups. The qualitative data resulted in five general barriers: stigma, ambivalence, accessibility, fear of consequences, and lack of knowledge about addiction and its' treatments, and three barriers specifically towards social services: social services reputation, fear of meeting acquaintances, and lack of knowledge. The themes were developed from data from all groups, but different aspects of the themes were mentioned by different groups.

CONCLUSION

There are details and aspects that differentiates both the general and social service-specific barriers to treatment between individuals with a problematic use of alcohol, cannabis, and gambling, but in large they perceive similar barriers.

Emotional Dysregulation, Shame and Guilt Predict Severity of Gambling Among a Population of Gamblers

Over the last few years, gambling has diversified, particularly with the arrival of legislation authorizing online gambling in 2010 in France. Psychology has been very interested in emotional regulation strategies, and more recently and more sparsely in the presence of shame and guilt. Through an observational study (N = 1955) shame, guilt, and emotional regulation were assessed among gamblers. We found that (i) Less guilt is associated with problem gambling, (ii) Shame-proneness is similar regardless of the type of gamblers, (iii) Every facet of emotion regulation indicates less effective strategies for problem gamblers excepted for a behavior oriented to a goal. These results suggest the importance of shame or guilt as predictors of problem gambling, as well as processes underlying emotion regulation.

Lived Experience Performance to Reduce Stigma, Enhance Understanding of Gambling Harm and Change Attitudes and Behaviours of Professionals and Community Members

Gamblers and their family members or friends (affected others) can experience stigma and shame due to gambling which can result in a reluctance to seek timely support. However, gamblers and affected others access intersecting health services and talk to friends or family, thereby providing opportunities for early intervention. Three sides of the coin is a group of storytellers with lived experience of gambling harm who use dramatic performance to share personal stories to enhance the understanding of gambling-related harm in allied professions and the broader community. They do this to encourage attitude and behaviour change so that gamblers and affected others receive empathy and support during encounters with these groups. A mixed-methods study was used to explore whether these performances were successful in increasing understanding and changing attitudes and behaviour of allied professionals and the community in the short and longer-term. Data collected immediately post-performance revealed that performances increased understanding of gambling, and improved attitudes and behavioural intent of audience members in relation to gamblers and affected others. Professionals also reported an increased willingness and confidence to discuss gambling harm with clients. Follow-up data demonstrated potential longer-term impact, with respondents continuing to report more positive attitudes towards those affected by gambling harm and professionals being confident to explore gambling issues in their clients and provide appropriate referrals. These finding demonstrate that performance based on lived experience can be a powerful education tool, encouraging deep connection to the issue, resulting in a nuanced understanding and sustained attitudinal and behavioural change.

A Self-Applied Psychological Treatment for Gambling-Related Problems via The Internet: A Pilot, Feasibility Study

The main purpose of this study was to evaluate the feasibility of an online psychological intervention for individuals with gambling-related problems, supported by ecological momentary assessments and interventions (EMAs and EMIs), along with weekly phone-calls, before conducting a randomized controlled trial. Participants were required to complete 3 of the 8 modules of the program based on cognitive-behavioral therapy (CBT) and extensions and innovations of CBT. The study measured the outcomes of feasibility (i.e., reach, appropriateness, technology literacy and technology usability, fidelity, and adherence). In terms of reach, 19.8% (n = 11) of the initial population met the inclusion criteria and completed the three modules (mean age = 41; 90.9% men). The perceived appropriateness and the technology usability after the first use were both excellent, fidelity and adherence to the online treatment (73.3%) were adequate. Adherence to the EMAs and the weekly phone calls were more modest (54.51% and 66.67%, respectively). The results of the present study show that an online treatment for gambling problems enhanced by EMA and EMI might be feasible but challenges were noted in terms of reach and adherence to these assessments and calls. These challenges are important to consider for future trials and the scalability of treatments for individuals with gambling disorders.

The risk and development of work disability among individuals with gambling disorder: a longitudinal case-cohort study in Sweden

BACKGROUND

This longitudinal register study aimed to investigate the association between gambling disorder (GD) and work disability and to map work disability in subgroups of individuals with GD, three years before and three years after diagnosis.

METHODS

We included individuals aged 19-62 with GD between 2005 and 2018 (n = 2830; 71.1% men, mean age: 35.1) and a matched comparison cohort (n = 28 300). Work disability was operationalized as the aggregated net days of sickness absence and disability pension. Generalized estimating equation models were used to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the risk of long-term work disability (>90 days of work disability/year). Secondly, we conducted Group-based Trajectory Models on days of work disability.

RESULTS

Individuals with GD showed a four-year increased risk of long-term work disability compared to the matched cohort, peaking at the time of diagnosis (AOR = 1.89; CI 1.67-2.13). Four trajectory groups of work disability days were identified: constant low (60.3%, 5.6-11.2 days), low and increasing (11.4%, 11.8-152.5 days), medium-high and decreasing (11.1%, 65.1-110 days), and constant high (17.1%, 264-331 days). Individuals who were females, older, with prior psychiatric diagnosis, and had been dispensed a psychotropic medication, particularly antidepressants, were more likely to be assigned to groups other than the constant low.

CONCLUSION

Individuals with GD have an increased risk of work disability which may add financial and social pressure and is an additional incentive for earlier detection and prevention of GD.

Gambling and Migration - The Role of Culture and Family

Problem gambling (PG) is a public health concern with severe repercussions for the individual, concerned significant others and the society. Foreign borns generally gamble less but are overrepresented among those with PG. Previous research has suggested that other factors, such as socio-economic status, might explain this, but also that cultural factors might play a role in the relationship to gambling and the development of PG. This qualitative study using content analysis investigates the experiences of and opinions about gambling and PG among 12 males living in Sweden with a migrant background in Afghanistan, the Middle East and North Africa. The results were show that the acculturation process could be a factor in developing PG, as well as a cultural values regarding money and wealth. PG was seen as more stigmatized in the origin country, and the family played a more important role in the rehabilitation of PG compared to the general population. The results of this study could be used to inform preventive and clinical programs to better reach people with a migrant background.

Treatment seeking for gambling disorder in nationwide register data - observations around a major shift in legislation

Background

Treatment seeking for gambling disorder is known to be low and there has been a lack of longitudinal research regarding treatment opportunities. The present study aimed to assess possible changes in treatment uptake after a formal introduction of gambling disorder in social services and health care legislations, by using register data, including patient characteristics with respect to socio-demographics and comorbidities.

Methods

Nationwide register data were collected for the years 2005-2019, describing diagnoses in specialized out-patient health care and in in-patient hospital care. Numbers and characteristics of patients with gambling disorder were followed longitudinally. Also, a new legislation for treatment by public institutions was introduced in 2018, and data were compared for the years before and after the shift in legislation, both nationally, for each of the three major urban regions, and for the rest of the country. Comparisons were made with respect to concurrent mental health comorbidities, age and gender.

Results

The number of out-patient gambling disorder diagnoses increased over time, but without any significant step changes around the shift in legislation. Over time, patients were younger, became more likely to have gambling disorder as their primary diagnosis, and less likely to have mental health comorbidities, whereas gender distribution did not change. Among the smaller group of patients diagnosed in in-patient settings, mental health comorbidity increased over time. Despite gradual changes over time, no changes in demographics were seen around the actual shift in legislation, although the psychiatric comorbidity appeared to increase after this change.

Conclusion

After the introduction of gambling disorder in the responsibility of social services and health care settings in Sweden, the number of patients diagnosed with gambling disorder increased only modestly. Likely, further implementation of gambling disorder treatment is required in the health care services. Also, longer longitudinal studies are needed in order to understand to what extent patients not seeking health care treatment are received by municipal social services or remain outside the treatment system.

Exploring the Precipitating Events and Gambling-Related Activities that Prompt Problem Gamblers and Spouses/Cohabitants to Contact a Gambling Helpline

Gambling helplines have progressed to offer support and brief interventions for both the problem gambler (PG) and their spouse/cohabitant (S/C). S/Cs play an important role in assisting their partner with their recovery from a gambling disorder. However, few studies have investigated the concerns of both PGs and S/Cs who contact gambling helplines. The purpose of this study is to examine the reasons, gambling activities, and gambling locations/venues endorsed by PGs and S/Cs who contacted a state-wide gambling helpline. 938 individuals (809 PGs; 129 S/Cs) from the state of Florida contacted the Florida Council on Compulsive Gambling helpline to discuss gambling-related concerns. Helpline contacts (calls, texts, e-mails, and live chat interactions) between the period of July 1st, 2019, to June 30th, 2020, were examined. Callers/contacts provided information related to their demographic characteristics, the precipitating event leading to contact, the PG's primary gambling activity, and venue most often used by the PG. Chi-square tests were utilized to examine relationships and gender differences between PGs and S/Cs. Significant differences were found between the precipitating events for contacting the helpline and primary gambling locations/venues identified by PGs and S/Cs. Furthermore, gender differences were observed in the primary gambling activities and gambling locations/venues endorsed by the PG and S/C. The results suggest that PGs and S/Cs held different reasons when contacting the helpline. Future research should delve deeper into these disparities in order to build intervention programs tailored to the needs of both PGs and their S/Cs.

Much Ado About Nothing? The Role of Land-Based Gambling Venue Employees in Facilitating Problem Gambling Harm Reduction and Help-Seeking

Over the past decade, greater emphasis has been placed on the role of the land-based gambling industry to respond to problem gambling behaviour in their venues. Despite this, there is a lack of clear information advising best practice responses by gambling venue employees. This article reviews strategies, practices, and policies employed by land-based gambling venues concerning their employees' role in preventing gambling-related harm and responding to problem gambling behaviours. A systematic search strategy was applied to source peer-reviewed literature which identified 49 articles. The synthesised results were arranged and presented across five categories: (1) the identification of gamblers with potential problems in the venue; (2) gambling venue staff responses to gamblers with potential problems; (3) gamblers' perspectives around venue responsibilities and interactions with gamblers with potential problems; (4) corporate social responsibility programs and the identification of gamblers with problems in the venue; and (5) gambling venue staff needs. The results suggest that most activity performed by venue staff concerning their response to problem gambling is limited to observing and documenting risky behaviours and then discussing this internally with other venue staff. Action which moves beyond this, such as approaching and interacting with identified gamblers of concern, rarely occurs. The results of this review suggest that a focus on the identification and intervention specifically with identified gamblers of concern is a particularly unhelpful aspect of the role of venue staff. The results also indicate that a re-thinking of the role frontline staff play in addressing problem gambling is necessary.

Anticipated Motives for Gambling Treatment in Adults from the U.S

Prior works note that identifying problematic play is a leading barrier to treatment seeking, contributing to low treatment rates in those with gambling problems (e.g., Bijker et al., 2022; Suurvali et al., 2012a). While research has looked at treatment seekers' motives for treatment (Gainsbury et al., 2014; Suurvali et al., 2012b), the situations or signs (anticipated motives) individuals look for that suggest they would need treatment in the future remains unknown. Participants were gamblers (N = 1,791) from a census-matched U.S. sample of adults who reported no concerns about their gambling. Participants completed questions assessing how much money they would have to lose while gambling to think they might have a problem and what factors might motivate them to pursue treatment for gambling problems in the future. Participants reported a wide range of financial loss that would suggest they had a problem, and higher income men who gambled more frequently reported higher necessary losses. There was little variation in endorsement (40-60%) of 14 situations that may lead them to seek treatment in the future (e.g., felt guilty). However, income, gender identity, and problem gambling behavior were linked to the endorsement of some of these anticipated motives, with some differences in endorsement between those engaging in high- and low-level problem gambling. Collectively, results are consistent with the inference that many individuals may not be aware of what problematic gambling would look like for them, though income, gender identity, and problem gambling behavior may impact their consideration of anticipated motives.

Guided versus unguided chatbot-delivered cognitive behavioral intervention for individuals with moderate-risk and problem gambling: A randomized controlled trial (GAMBOT2 study)

BACKGROUND

Internet-based interventions can be a promising option for individuals with problem gambling facing barriers to seeking help. This study aimed to directly compare the effects of therapist-guided Internet interventions with unguided ones on gambling-related behavior, cognition, and stage of change including help-seeking intention.

METHODS

We conducted a participant-blinded randomized controlled trial of therapist-guided versus unguided groups with a 12-week follow-up. Both groups received self-help chatbot-delivered cognitive behavioral therapy. Additionally, at baseline and weeks 1, 2, 3, and 4, the guided group received personalized feedback messages from therapists based on their gambling diary and questionnaire responses. The unguided group received reminders of assessments from research assistants. The primary outcome was the change in scores on the Gambling Symptoms Assessment Scale (G-SAS) over 12 weeks. Secondary outcomes included the stage of change including help-seeking intention, money wagered, gambling frequency, and gambling-related cognitions.

RESULTS

We included 139 participants with a mean Problem Gambling Severity Index total score of 14.6 and a mean G-SAS total score of 27.0 who sought information about gambling problems. Both groups demonstrated substantial decreases in their G-SAS scores from baseline to week 12 (-10.2, 95% CI: -7.67 to -12.7 for the guided group, and 11.7, 95% CI: -9.05 to -14.3 for the unguided group). However, we did not find a significant between-group difference (1.49, 95% CI: -2.20 to 5.17). Regarding the stage of change including help-seeking intention, there were also no between-group differences.

CONCLUSIONS

Minimum therapist support did not have an additive effect on the self-help chatbot intervention on gambling symptoms, behavior, and the stage of change including help-seeking intention.

Exploring the psychosocial characteristics of women with gambling disorder through a qualitative study

Introduction

Gambling disorder is a behavioral addiction that has been primarily male, but in the last few years, the age of onset has been equated between the sexes. The profile of female gamblers could be different from that of men. Consequently, this study analyzes the testimonies of women with gambling disorder to determine their specific characteristics (gambling motives, gambling preferences, and associated pathologies).

Method

The sample comprises 18 women with gambling disorder aged between 30 and 68. Three discussion groups were held, and a "blind" inductive process was carried out to extract categories. The Atlas.Ti 22.0 program was used to recode and analyze the data.

Results

Results show that women may start gambling due to abuse suffered in childhood, and often family members initiate women into gambling. Likewise, the onset of gambling could be a maladaptive way to manage negative emotions. Also highlighted is the predominance of feelings of social stigmatization, which can be reflected in women's choice of games where they are not visible. Comorbidity with other disorders such as depression, anxiety, bipolar disorder, personality disorders, and the use of other substances are noteworthy.

Discussion

The factors explaining why female gamblers do not seek treatment compared to male gamblers are analyzed. More studies on women's experience with gambling are needed to address the specific characteristics of gambling disorder in women.

"To me, it was Just a Vice". Stigma and Other Barriers to Gambling Treatment in Piedmont, Italy

In Piedmont (northwestern Italy), as in the rest of the Western world, only a small percentage of the estimated problem gamblers (10-20%) turn to a treatment service to overcome their addiction issues. The study sought to gain a better understanding of the cultural factors that stand in the way of seeking help, thorough qualitative in-depth individual interviews with gamblers both in and out of treatment. A total of 30 interviews were conducted in three different health districts, most via video-call. Data were then analyzed using an abductive approach. The findings appear to indicate that the processes of stigma affecting problem gamblers and public gambling treatment services are the main barriers to seeking help. According to the interviewees, awareness of the problem is a necessary but not sufficient motivator for embarking on treatment, since social stigmatization leads them to hide the problem. Moreover, self-stigmatization processes seem to undermine the sense of self-efficacy that plays a key role in recovery. To encourage help-seeking, the study thus suggests that priority should be given to efforts to reduce stigma, i.e., through informational and educational measures together with advocacy interventions, which aim primarily to reframe the gambling problem, shifting responsibility from the individual to the collective level.

"I was Treated by the Program, the Therapist, and Myself": Feasibility of an Internet-Based Treatment Program for Gambling Disorder

The majority of people with problematic gambling behavior never seek or receive professional help. Internet-based treatment approaches have been shown to help patients overcome practical and psychological barriers associated with face-to-face therapy. In this uncontrolled pilot study, we explored the feasibility of the eight-module therapist-guided internet-based treatment program SpilleFri ("Free from Gambling") for patients with gambling disorder (GD). We included 24 patients seeking treatment at a Danish hospital-based treatment clinic. The focus of the feasibility study was evaluation of recruitment and retention rates, data completion rates, treatment response, satisfaction, and program utility. In addition, a series of semi-structured interviews were conducted to explore patient-perceived acceptability and potential barriers to treatment completion and positive outcome. Treatment acceptability among therapists was examined in a focus group interview. Sixteen of the included patients completed the program, yielding an acceptable treatment dropout rate (29.17%), and 82.35% of treatment completers provided full data at all assessment points. Overall, patients were satisfied with the treatment received, and patient interviews highlighted multiple psychological as well as practical benefits associated with the treatment form and content. Patients with more severe gambling symptoms at baseline might be more likely to drop out before treatment completion than patients with less severe symptoms. The results suggest that SpilleFri may be a feasible alternative to face-to-face treatment for GD. However, the uncontrolled design and small sample size of the study limit the robustness of the findings. In the future, the effect of SpilleFri treatment should be examined in a randomized controlled trial.Clinical trial registrations: The study protocol was prospectively registered at clinicaltrials.gov (TRN: NCT05051085; registration date: September 21, 2021).

Dissociative experiences reduce online problem gambling treatment effectiveness

AIMS

To determine whether dissociative experiences moderate online problem gambling treatment effectiveness, and to characterize the temporal persistence of the relationship between dissociation and problem gambling.

DESIGN

Repeatedly measured self-report data on a guided online cognitive behavioral therapy for problem gambling collected on four occasions: before treatment, after treatment, and at 6- and 12-month follow-ups.

SETTING AND PARTICIPANTS

The data (N = 1243, 59.2% males) were collected in Finland between 2019 and 2021.

MEASUREMENTS

The primary outcome variable was the self-reported level of problem gambling. The predictors were the treatment phase and dissociative experiences, their interaction, and the demographic covariates of age, education, income, and gender.

FINDINGS

Problem gambling scores and dissociative experiences declined significantly following treatment and remained low through the follow-ups (retention rates: 52.6% [post-treatment], 26.3% [at the 6-month follow-up], and 16.1% [at the 12-month follow-up]). However, the treatment was significantly less effective in reducing problem gambling for individuals who kept experiencing dissociation after the treatment.

CONCLUSIONS

Dissociation is an integral sign of problem gambling severity and sustained dissociative experiences may significantly reduce the long-term effectiveness of online problem gambling treatments. Treatment efforts should be customized to account for individual differences in dissociative tendencies, and future research should broaden the study of dissociative experiences to other behavioral addictions.

Nationwide, Multioperator Self-Exclusion and Psychiatric Comorbidity in Patients with Gambling Disorder: A Retrospective Chart Review Study from a Regional Treatment Unit

Gambling disorder is an addictive disorder that has been shown to have a detrimental effect on an individual's health, social, and financial situations. Voluntary self-exclusion is one way for patients to reduce harm in gambling disorder, but breaching one's self-exclusion appears to be common. In January 2019, Sweden launched a nationwide, multioperator self-exclusion instrument called Spelpaus (literally "game break"). Spelpaus is unique to Sweden, and there is limited research on the use of this type of nationwide, multioperator self-exclusion services, also in relation to gambling disorder and mental health. There is a reason to follow the clinical picture of treatment seeking for gambling disorder over time, and this study aims to explore clinical characteristics of patients seeking clinical gambling disorder treatment, including sex distribution and mental health comorbidity, as well as the use of Spelpaus amongst patients with gambling disorder and how frequently users gambled despite ongoing self-exclusion, in relation to sex and psychiatric comorbidities. A retrospective chart study was carried out on patients presenting to a regional gambling disorder treatment unit. Information regarding self-exclusions using Spelpaus, gambling despite self-exclusion, and the method of gambling despite self-exclusion as well as psychiatric comorbidities were extracted from medical records. Females were markedly more likely to report overall psychiatric comorbidities (48% vs. 25% among males, p < 0.001), affective, neurotic/anxiety-related (p < 0.001), and behavioral/emotional (p = 0.028) diagnoses and more likely to have two or more diagnoses excluding gambling disorder (p = 0.001). From 120 patients from whom information regarding self-exclusion was present, 114 (95%) had chosen to self-exclude. From the 114 self-excluders, 67 reported to have gambled despite self-exclusion, with unregistered websites being the most common method. Self-exclusion was not significantly related to sex (p = 0.146) or to psychiatric comorbidities (p = 0.178). In conclusion, psychiatric comorbidity was particularly common in female gambling disorder patients and gambling despite self-exclusion was common. Gambling regulations should be improved to help self-excluders avoid being able to gamble on unlicensed gambling operators. Further research should focus on sex differences and the association with psychiatric comorbidities.

Prevalence of gambling disorder and its correlates among homeless men in Osaka city, Japan

Internationally, the prevalence of gambling disorder has been reported to be higher among homeless people than the general population; however, little is known about the factors associated with gambling disorder in this population. The present study aimed to investigate the prevalence of gambling disorder and its associated factors among homeless men using shelters in Osaka City. A cross-sectional survey was conducted from 30 to 2018 to 4 January 2019, using the 2017 Japanese National Survey of Gambling (JNSG) questionnaire, supplemented with questions about homeless experiences, drinking, and smoking. Using the South Oaks Gambling Screen, the presence of gambling disorder was determined by a score ≥ 5 out of 20. Multivariate logistic regression was conducted to explore factors associated with lifetime gambling disorder. Lifetime and past-year prevalence of gambling disorder among 103 participants was 43.7% (95% confidence interval [CI]: 34.5-53.3) and 3.9% (95% CI: 1.5-9.6), respectively, which are higher than the 6.7% and 1.5% found among men in the 2017 JNSG. Reasons reported for currently gambling less were primarily financial. Factors associated with lifetime GD included "more than 20 years since the first incidence of homelessness" (adjusted odds ratio [AOR]: 4.97, 95% CI: 1.50-16.45) and "more than five incidences of homelessness" (AOR: 4.51, 95% CI: 1.06-19.26). When homeless individuals with gambling disorder try to rebuild and stabilize their lives, the presence or resurgence of gambling disorder may hinder the process and pose a risk of recurring homelessness. Comprehensive support services for homeless individuals with gambling disorder are required. (250 words).

Smartphone Apps for Problem Gambling: A Review of Content and Quality

Purpose of review

Problem gambling can have profound consequences for affected individuals, yet only a small proportion of people with problem gambling seek treatment. Mobile phone applications (apps) may provide an effective and scalable therapeutic option. The purpose of this study was to evaluate publicly available mobile apps aimed at improving problematic gambling behavior.

Recent findings

To date, there are no published studies that have evaluated the quality of publicly available smartphone apps for problem gambling in the US. There is thus a significant gap in knowledge of existing apps for addressing problem gambling.

Summary

This study included a review of 14 problem-gambling-specific apps. Apps that incorporated cognitive-behavioral therapy concepts and in-app communities were associated with better aesthetics and information quality scores. Additionally, in-app communities were associated with better engagement scores. Our results highlight the importance of evidence-based and engaging features in apps designed to help people with problem gambling.

Motivating factors and barriers to help-seeking for casino gamblers: results from a survey in Swiss casinos

Introduction

Gambling can have serious consequences for many aspects of a person's life. Yet relatively few people with gambling problems seek help. This study examines the extent to which exclusion from casino venues among other factors may act as a motivator for further help-seeking among casino gamblers (both landbased and remote) with at-risk or disordered gambling behavior. In addition, the barriers that prevent gamblers from accepting help are examined.

Methods

Gamblers from Swiss casinos completed a written questionnaire twice, at 6-month intervals. The questions included whether they had sought help in the past 6 months.

Results

For those with a SOGS-R rating of 1 or over (n = 173) at the second survey point, a difference in help-seeking was found between the excluded and non-excluded gamblers (p < .001), suggesting that exclusion may be a motivator for help-seeking. Reported differences in levels of debt (p = .006), recognition of gambling problems (p = .010) and severity of gambling-related problems (p = .004) can be taken to suggest that other motivating factors may also influence help-seeking behavior. With regard to the support sought, the most frequently used forms of support were specialized addiction counseling centers (39.5%), followed by self-help groups (21.1%) and remote counseling centers (10.5%). In terms of barriers, reasons relating to attitude, such as denial, appear to pose greater barriers than treatment-related concerns.

Discussion

From a public health perspective, an overarching strategy is required to increase the share of help-seekers among casino gamblers through targeted measures.

Individual differences and predictors of general awareness in problem gambling

In Canada, up to 3% of individuals have or are at risk of gambling disorder. Among these individuals, a lack of awareness of their problem gambling is a common barrier to treatment and negatively affects treatment adherence. A secondary analysis was conducted on data from 1346 individuals (mean age = 43.4, SD = 14.4; 54.3 % male) with problem gambling who did and did not perceive having a problem with their gambling as assessed by the fifth item of the Problem Gambling Severity Index, "In the past twelve months, how often have you felt that you might have a problem with gambling?" Additionally, we investigated predictors of increased general awareness at 12-month follow-up. At baseline, individuals who perceived a problem with their gambling experienced more gambling-related harms (OR = 1.714), had greater total gambling losses (OR = 1.067), were more likely to have a family history of problem gambling (OR = 2.143), experienced a greater loss of control (OR = 1.313) and more often gambled alone than with others (OR = 0.879), accounting for 26.6 % of the variance in general awareness. Baseline problem awareness was positively associated with attempts to cut down or control gambling at follow-up (χ²=11.350,p<.001), but negatively associated with remission (χ²=18.392,p<.001). Increases in awareness were related to an increase in the number of gambling-related harms, gambling involvement, impaired control, and lower educational attainment, explaining 35.5% of the variance in increased general awareness. The results indicate that experiencing more gambling-related harms increases the salience and awareness of problem gambling, and that awareness is also associated with an individual's gambling context, their loss of control, and their level of gambling involvement. The findings highlight the importance of gambling harms as they pertain to general awareness and suggest that improving the recognition of gambling harms could be beneficial for the prevention and intervention of gambling disorder.

The Effects of the Presence of Others on Risky Betting in a Laboratory Gambling Task Among High-Risk Gamblers: A Cross-over Randomized Controlled Trial

We explored the effects of the presence of and cooperation with others on risky betting in a laboratory-based gambling task among high-risk gamblers. Specifically, we compared risky betting under solo, parallel, and cooperation conditions using a stratified randomized, cross-over design. Stratification was conducted according to participant age and gender. The participants were 40 Japanese adults (20 women, 20 men; mean age = 46, SD = 12.80). In the experiment, each participant conducted the Game of Dice Task (GDT) individually (solo condition), in parallel with another participant (parallel condition), and working together with another participant (cooperation condition). Linear mixed modeling results showed that when we controlled for previously specified covariates, there were no significant differences among the solo, parallel, and cooperation conditions regarding risky betting (parallel: estimates = 0.10, SE = 0.79, p = .900; cooperation: estimates = 0.95, SE = 0.79, p = .232). However, post-hoc analysis showed a significant difference between the solo and cooperation conditions regarding the number of times participants chose the riskiest bet (parallel: estimates = 0.18, SE = 0.52, p = .739; cooperation: estimates = 1.13, SE = 0.53, p = .035). Thus, we found that neither the presence of nor cooperation with others decreased risky betting in the GDT among high-risk gamblers. However, we did observe that participants displayed the riskiest betting behavior (i.e., selecting the single choice) in the GDT during the cooperation condition, compared with the solo condition.

Prevalence and Possible Predictors of Gambling Disorder in a Sample of Students in the Healthcare Professions

The Italian version of the South Oaks Gambling Screen questionnaire (SOGS) and a socio-demographic questionnaire were administered to a sample of 275 healthcare professions students aged 19 to 58 years (mean age = 22.17; females = 81.1%) to address the research objectives: to examine the prevalence and correlates of problem gambling in a population of university healthcare professions students in Italy. Among the sample, 8.7% (n = 24) of participants showed problem gambling and 1.5% (n = 4) pathologic gambling. Lottery and scratch cards were the most frequent type of gambling in the sample, followed by cards and bingo. Compared to females, males tend to be more involved in problem gambling and pathological gambling. Males tend to be more involved than females in different types of gambling (such as cards, sports bets, gambling at the casino). Pathological gambling is positively associated with gender, being students lagging behind the regular schedule of exams and parents' level of education. These findings have important implications in terms of prevention and intervention on gambling and pathological gambling. Universities should make available educational programs and counselling services to address this issue.

Global prevalence of help-seeking for problem gambling: A systematic review and meta-analysis

BACKGROUND AND AIMS

Multiple studies have examined barriers and facilitators to help-seeking, but the prevalence of help-seeking for problem gambling (PG) is not well established. We aimed to estimate the international prevalence of help-seeking for PG among the general population and among subgroups of people at risk for PG (i.e. low-risk, moderate-risk and PG).

METHODS

Systematic search of grey literature (through gambling repositories, gambling research institutes and Google) and peer-reviewed literature (through ProQuest, PsycINFO, PubMed and Scopus) for gambling prevalence studies that reported on help-seeking for PG. This review adhered to the Preferred Reporting Items for Systematic Review and Meta-Analyses. Studies used representative sampling methods to determine the prevalence of gambling participation and data collection 2010 onward. Twenty-four studies met the inclusion criteria. The main outcome was population prevalence of help-seeking for PG. Help-seeking was defined as any intentional action to change gambling behaviours, including professional services (inclusive of in-person or distance help), non-professional help (e.g. from family and friends) and self-help. Subgroup analyses were conducted to explain variability in help-seeking prevalence estimates.

RESULTS

Measurement of help-seeking was inconsistent across included studies and, overall, there was high risk of bias. We estimated a general population help-seeking prevalence for PG of 0.23% (95% CI, 0.16-0.33). Prevalence estimates were significantly higher in studies assessing lifetime (0.50%; 95% CI, 0.35-0.71) compared with current help-seeking (0.14%; 95% CI, 0.10-0.20, P < 0.001), but there was no evidence of difference in prevalence estimates by gambling participation, region, type of help-seeking, or year of data collection. Compared with people with low-risk gambling (0.27%; 95% CI, 0.07%-1.04%), prevalence estimates were significantly higher in those with moderate-risk (3.73%; 95% CI, 2.07%-6.63%) and problem gambling (20.63%; 95% CI, 12.89%-31.35%, P < 0.001).

CONCLUSIONS

One in 25 moderate-risk gamblers and 1 in 5 people with problem gambling have sought help for problems related to their gambling.

Content and Effectiveness of Web-Based Treatments for Online Behavioral Addictions: Systematic Review

BACKGROUND

Very few people seek in-person treatment for online behavioral addictions including gaming and gambling or problems associated with shopping, pornography use, or social media use. Web-based treatments have the potential to address low rates of help seeking due to their convenience, accessibility, and capacity to address barriers to health care access (eg, shame, stigma, cost, and access to expert care). However, web-based treatments for online behavioral addictions have not been systematically evaluated.

OBJECTIVE

This review aimed to systematically describe the content of web-based treatments for online behavioral addictions and describe their therapeutic effectiveness on symptom severity and consumption behavior.

METHODS

A database search of MEDLINE, Embase, PsycInfo, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar was conducted in June 2022. Studies were eligible if the study design was a randomized controlled trial or a pre-post study with at least 1 web-based intervention arm for an online behavioral addiction and if the study included the use of a validated measure of problem severity, frequency, or duration of online behavior. Data on change techniques were collected to analyze intervention content, using the Gambling Intervention System of CharacTerization. Quality assessment was conducted using the Effective Public Health Practice Project Quality Assessment Tool.

RESULTS

The review included 12 studies with 15 intervention arms, comprising 7 randomized controlled trials and 5 pre-post studies. The primary focus of interventions was gaming (n=4), followed by internet use inclusive of screen time and smartphone use (n=3), gambling (n=3), and pornography (n=2). A range of different technologies were used to deliver content, including websites (n=6), email (n=2), computer software (n=2), social media messaging (n=1), smartphone app (n=1), virtual reality (n=1), and videoconferencing (n=1). Interventions contained 15 different change techniques with an average of 4 per study. The techniques most frequently administered (>30% of intervention arms) were cognitive restructuring, relapse prevention, motivational enhancement, goal setting, and social support. Assessment of study quality indicated that 7 studies met the criteria for moderate or strong global ratings, but only 8 out of 12 studies evaluated change immediately following the treatment. Across included studies, two-thirds of participants completed after-treatment evaluation, and one-quarter completed follow-up evaluation. After-intervention evaluation indicated reduced severity (5/9, 56%), frequency (2/3, 67%), and duration (3/7, 43%). Follow-up evaluation indicated that 3 pre-post studies for gaming, gambling, and internet use demonstrated reduced severity, frequency, and duration of consumption. At 3-month evaluation, just 1 pre-post study indicated significant change to mental health symptoms.

CONCLUSIONS

Web-based treatments for online behavioral addictions use an array of mechanisms to deliver cognitive and behavioral change techniques. Web-based treatments demonstrate promise for short-term reduction in symptoms, duration, or frequency of online addictive behaviors. However, there is limited evidence on the effectiveness of web-based treatments over the longer term due to the absence of controlled trials.

Preventive Interventions and Harm Reduction in Online and Electronic Gambling: A Systematic Review

Gambling possess both entertaining and potentially harmful aspects. It remains a challenge for public health authorities and gambling operators to recommend and implement effective evidence-based interventions to reduce gambling-related harm and prevent problematic gambling behavior. This systematic review examined studies on randomized controlled trials in this field, aiming to describe and evaluate the effect of preventive and harm-reducing interventions for online gambling and electronic gaming machines. A systematic literature search was performed in PsycINFO, PubMed, Embase, and SCOPUS. Study selection, risk of bias assessment, and data extraction were conducted by two reviewers independently, and a synthesis was performed. A total of 18 studies were included, of which the majority were limited by quality issues. The applied interventions focused on restraining gambling, providing feedback, delivering therapeutic and informative content, and priming analytical thinking. The studies varied greatly in terms of specific intervention content, study setting, participants, and outcome measures, and no consistent patterns could be detected between study characteristics and related effects. Although research in the field is growing, there is still a need for further methodologically rigorous investigation and consensus on outcome measures sensitive to effects of preventive and harm-reducing interventions.

Gender- and age-stratified analyses of gambling disorder in Finland between 2011 and 2020 based on administrative registers

Aim: Prevalence studies on gambling have largely relied on survey samples. Little is known about the diagnosed prevalence of gambling disorder (GD) based on register data. This study examines the annual prevalence rate of GD between 2011 and 2020 among Finns by gender and age. Methods: Aggregated data on the diagnosis of GD (corresponding to pathological gambling, code F63.0 in the ICD-10) were retrieved from the following national registers: Register of Primary Health Care Visits, and Care Register for Health Care, including specialised outpatient and inpatient health care, and inpatient Care Register for Social Welfare. Primary and secondary diagnoses of adults were included. Average population during a calendar year (4,282,714–4,460,177 individuals) was utilised to calculate annual prevalence. Results: The annual prevalence of diagnosed GD in the population increased from 0.005% ( n = 196) to 0.018% ( n = 804) within nine years. In 2011, the annual prevalence rate was 0.006% for men and 0.003% for women, compared to rates in 2020 of 0.025% and 0.011%. Gender discrepancy was relatively stable across years: 27.2–33.8% of the diagnoses were for women. The prevalence of GD varied between age groups within genders. GD was most prevalent among 18–44-year-olds. The prevalence rates increased the most among 30–44-year-old women. Conclusion: The extremely low prevalence rate of GD implies that the problem remains under-diagnosed, yet, it has increased among all age groups across genders, except for women aged 60 years or older. Active efforts are needed to increase awareness of GD among both primary and specialised healthcare professionals and the public for better recognition and early detection.

GAMBLINGLESS IN-THE-MOMENT: Protocol for a micro-randomised trial of a gambling Just-In-Time Adaptive Intervention (Preprint)

Background

The presence of discrete but fluctuating precipitants, in combination with the dynamic nature of gambling episodes, calls for the development of tailored interventions delivered in real time, such as just-in-time adaptive interventions (JITAIs). JITAIs leverage mobile and wireless technologies to address dynamically changing individual needs by providing the type and amount of support required at the right time and only when needed. They have the added benefit of reaching underserved populations by providing accessible, convenient, and low-burden support. Despite these benefits, few JITAIs targeting gambling behavior are available.

Objective

This study aims to redress this gap in service provision by developing and evaluating a theoretically informed and evidence-based JITAI for people who want to reduce their gambling. Delivered via a smartphone app, GamblingLess: In-The-Moment provides tailored cognitive-behavioral and third-wave interventions targeting cognitive processes explicated by the relapse prevention model (cravings, self-efficacy, and positive outcome expectancies). It aims to reduce gambling symptom severity (distal outcome) through short-term reductions in the likelihood of gambling episodes (primary proximal outcome) by improving craving intensity, self-efficacy, or expectancies (secondary proximal outcomes). The primary aim is to explore the degree to which the delivery of a tailored intervention at a time of cognitive vulnerability reduces the probability of a subsequent gambling episode.

Methods

GamblingLess: In-The-Moment interventions are delivered to gamblers who are in a state of receptivity (available for treatment) and report a state of cognitive vulnerability via ecological momentary assessments 3 times a day. The JITAI will tailor the type, timing, and amount of support for individual needs. Using a microrandomized trial, a form of sequential factorial design, each eligible participant will be randomized to a tailored intervention condition or no intervention control condition at each ecological momentary assessment across a 28-day period. The microrandomized trial will be supplemented by a 6-month within-group follow-up evaluation to explore long-term effects on primary (gambling symptom severity) and secondary (gambling behavior, craving severity, self-efficacy, and expectancies) outcomes and an acceptability evaluation via postintervention surveys, app use and engagement indices, and semistructured interviews. In all, 200 participants will be recruited from Australia and New Zealand.

Results

The project was funded in June 2019, with approval from the Deakin University Human Research Ethics Committee (2020-304). Stakeholder user testing revealed high acceptability scores. The trial began on March 29, 2022, and 84 participants have been recruited (as of June 24, 2022). Results are expected to be published mid-2024.

Conclusions

GamblingLess: In-The-Moment forms part of a suite of theoretically informed and evidence-based web-based and mobile gambling interventions. This trial will provide important empirical data that can be used to facilitate the JITAI’s optimization to make it a more effective, efficient, and scalable tailored intervention.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12622000490774; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380757&isClinicalTrial=False

International Registered Report Identifier (IRRID)

PRR1-10.2196/38958

Online 8-week cognitive therapy for problem gamblers: The moderating effects of depression symptoms and perceived financial control

BACKGROUND AND AIMS

Online interventions for problem gambling are increasingly popular, but not everyone benefits from them. We describe 12 years of real-world data from an online intervention for gambling problems and aim to find out the extent to which depression, alcohol use, and sense of financial control influence the effectiveness of the program.

METHODS

We analyzed treatment effectiveness and moderators in the Finnish "Peli Poikki" program (2007-2018)-an 8-week cognitive behavioral therapy and follow-up program for problem gambling. Participants were Finnish-speaking adults over 18 years of age (N = 2011, 66.9% males). We measured the self-reported level of problem gambling, depression, alcohol use, and sense of financial control across four treatment phases (baseline, post-treatment, 6-month follow-up, and 12-month follow-up), as well as the presence of gambling debt, psychological and physiological health, years suffered from gambling problems, and demographic variables.

RESULTS

Participation grew across years with retention rates of 55%, 30%, and 19% for post-treatment and the two follow-ups, respectively. The average problem gambling scores declined significantly following treatment and remained low throughout the follow-ups. However, this decline (the beneficial treatment effect) was reversed after the follow-ups for those with high depression scores and those who felt they had no control over their finances.

DISCUSSION AND CONCLUSIONS

The Peli Poikki program is a well-functioning online intervention but less effective in the long term for participants with persisting symptoms of depression or without a sense of financial control. More attention is needed to screen and direct people with comorbidities to the appropriate services.

Evaluation of the Conversations About Gambling Mental Health First Aid course: effects on knowledge, stigmatising attitudes, confidence and helping behaviour

Background

The effects of problem gambling are wide-ranging, affecting many aspects of health and negatively impacting the person who gambles, their family and friends, and their community. People experiencing problem gambling have low rates of help-seeking and perceive many barriers to treatment, although evidence suggests that encouragement and support from friends and family can increase rates of help-seeking. Mental Health First Aid Australia’s Conversations About Gambling course aims to teach members of the public evidence-based strategies for recognising and responding to signs of problem gambling in a person they know.

Methods

This research evaluated the effects of the Conversations About Gambling course on participants’ knowledge, confidence, stigmatising attitudes, intended helping behaviour and actual helping behaviour towards a person experiencing problem gambling. Participants from Australia completed surveys before the course, immediately after the course and six months later. Changes over time (pre-course to post-course, and pre-course to 6-month follow-up) were assessed with linear mixed models. Descriptive statistics and content analyses of open-ended questions pertaining to participants’ satisfaction with the course were also produced.

Results

Between 2018 and 2020, 166 participants were recruited into this study. At 6-month follow-up 87 participants (52.4%) provided data. Participants’ knowledge about gambling and gambling problems, confidence, desire for social distance and intentions to help a person experiencing problem gambling significantly improved from pre-course to post-course, and from pre-course to 6-month follow-up. The quality of some actions taken to support a person they knew who was experiencing problem gambling also improved from pre-course to 6-month follow-up, in line with the teachings of the course. Participants perceived the course to be highly acceptable.

Conclusions

The results of this initial evaluation of Mental Health First Aid Australia’s Conversations About Gambling course suggest that it is an effective and acceptable educational intervention for those who wish to support a person experiencing problem gambling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00785-w.

Filling the GAP: Integrating a gambling addiction program into a shelter setting for people experiencing poverty and homelessness

The burden of harm from problem gambling weighs heavily on those experiencing poverty and homelessness, yet most problem gambling prevention and treatment services are not designed to address the complex needs and challenges of this population. To redress this service gap, a multi-service agency within a shelter setting in a large urban centre developed and implemented a population-tailored, person-centred, evidence-informed gambling addiction program for its clients. The purpose of this article is to report on qualitative findings from an early evaluation of the program, the first designed to address problem gambling for people experiencing poverty and/or homelessness and delivered within a shelter service agency. Three themes emerged which were related to three program outcome categories. These included increasing awareness of gambling harms and reducing gambling behaviour; reorienting relationships with money; and, seeking, securing, and stabilizing shelter. The data suggest that problem gambling treatment within the context of poverty and homelessness benefits from an approach and setting that meets the unique needs of this community. The introduction of gambling treatment into this multi-service delivery model addressed the complex needs of the service users through integrated and person-centered approaches to care that responded to client needs, fostered therapeutic relationships, reduced experiences of discrimination and stigma, and enhanced recovery. In developing the Gambling Addiction Program, the agency drew on evidence-based approaches to problem gambling treatment and extensive experience working with the target population. Within a short timeframe, the program supported participants in the process of recovery, enhancing their understanding and control of their gambling selves, behaviours, and harms. This project demonstrates that gambling within the context of poverty requires a unique treatment space and approach.

Making Change: Attempts to Reduce or Stop Gambling in a General Population Sample of People Who Gamble

OBJECTIVE

This study examined past year attempts to reduce or quit gambling among people who gamble generally and those with gambling problems specifically.

METHODS

Regular gamblers recruited from an online panel (N = 10,054) completed a survey of gambling, mental health and substance use comorbidity and attempts to reduce or quit gambling. The sample was weighted to match the gambling and demographic profile for the same subsample (i.e., past month gamblers) in a recent Canadian national survey.

RESULTS

5.7% reported that they tried to cutback or stop gambling in the past year. As predicted, individuals making a change attempt had greater levels of problem gambling severity and were more likely to have a gambling problem. Of individuals with problem gambling, 59.8% made a change attempt. Of those, 90.2% indicated that they did this primarily on their own, and 7.7% accessed formal or informal treatment. Most people attempting self- change indicated that this was a personal preference (55%) but about a third reported feeling too ashamed to seek help. Over a third (31%) reported that their attempt was successful. Of the small group of people accessing treatment, 39% described it as helpful.

CONCLUSIONS

Whereas gambling treatment-seeking rates are low, rates of self-change attempts are high. The public health challenge is to promote self-change efforts among people beginning to experience gambling problems, facilitate success at self-change by providing accessible support for use of successful strategies, and provide seamless bridges to a range of other treatments when desired or required.

Treatment for problem gambling and counselors' perception of their clinical competence: a national web survey in Sweden

BACKGROUND

Despite their crucial role in bridging science and practice, not much is known about counselors offering treatment for Problem Gambling (PG). This study maps current treatment, the type of change techniques that are prioritized in treatment and how counselors perceive their clinical competence in their work with PG clients.

METHODS

A sample of PG counselors from the healthcare and social services (N = 188, mean age: 49 years, 67% women) completed an online survey. A principal component analysis was conducted to map prioritized types of change techniques, and a multiple regression analysis was carried out to analyze predictors of counselors' role adequacy in their clinical work.

RESULTS

There was a large variation in the type of treatments offered for PG (mean 3.6). Cognitive Behavioral Therapy (CBT) and Motivational Interviewing were the most common treatments offered and motivation was rated as the most important type of change technique prioritized in the treatment of PG. A principal component analysis identified four components reflecting different types of change techniques prioritized by the counselors: (1) standard CBT, e.g., gambling cognitions, craving management, and finding alternative activities, (2) assessment of PG, (3) family orientation, i.e., involvement of concerned significant others in treatment, and (4) focus on exposure strategies. Counseling more clients monthly was associated with higher levels of willingness, adequacy and legitimacy in their clinical work with clients with PG. Additionally, offering CBT was a predictor for higher role adequacy and providing counseling on the origins of and consequences of PG.

CONCLUSION

There was a large heterogeneity among the treatments offered and what change techniques that were prioritized among the PG counselors. Clinical experience is of importance for developing competence in treating clients with PG. This finding suggests there could be benefits to establishing specialized, more visible treatment units where PG counselors could gain adequate clinical experience, thus increasing clinical competence for treating PG.

A Normative Feedback Intervention on Gambling Behavior-A Longitudinal Study of Post-Intervention Gambling Practices in At-Risk Gamblers

BACKGROUND

In problem gambling, normative personalized feedback interventions have demonstrated promising effects. Given the widespread increase in online gambling in recent years, internet-delivered normative feedback may serve as a promising intervention. This study aimed to examine whether such an intervention, delivered by a gambling operator and aiming to help problem gamblers decrease their gambling, may in fact be associated with lower gambling practices post-intervention.

METHODS

Online questions on norms and beliefs about one's own and peers' gambling habits, derived from the Gambling Quantity and Perceived Norms Scale, were followed by personalized feedback, delivered online by the Swedish state-owned gambling operator. A total of 1,453 gamblers consented to participate in a pre-post measure of wagering levels.

RESULTS

Wagering decreased significantly post-intervention (28 days) compared to pre-intervention (28 days prior). The decrease was significantly more pronounced in younger and online casino gamblers. In an 84-day follow-up, the decrease remained significant, although less pronounced.

CONCLUSIONS

An online normative intervention delivered by a state-owned gambling operator, addressing norms and beliefs about gambling levels, may lower risky gambling in the short term. Implications and further research needs are discussed.

Differences in Perceived and Experienced Stigma Between Problematic Gamblers and Non-gamblers in a General Population Survey

We consider a sample of about 700 people, interviewed on the streets, who are sorted into two groups by a self-report, screening questionnaire: namely, non-problematic gamblers/non-gamblers and problematic gamblers. Within each group, we compare both social (perceived) stigma and self-perceived (experienced) stigma, measured by means of other two self-report questionnaires, and we seek for relations between stigma and socio-demographic variables that can help targeting possible interventions to reduce gambling-related stigma. We, then, compare stigma between the two groups of non-(problematic) gamblers and problematic ones, and we also check the hypothesis that higher social stigma is related to higher self-perceived stigma, as well as higher stigma is related to lesser help-seeking. The latter hypothesis is of utmost importance, given that stigma is recognised to be one of the major causes for hindering help-seeking by problematic gamblers. The research is carried out in Italy, one of the first countries in the world for the money spent per capita in gambling activity every year.

Digital Therapeutic Alliance With Fully Automated Mental Health Smartphone Apps: A Narrative Review

Fully automated mental health smartphone apps show strong promise in increasing access to psychological support. Therefore, it is crucial to understand how to make these apps effective. The therapeutic alliance (TA), or the relationship between healthcare professionals and clients, is considered fundamental to successful treatment outcomes in face-to-face therapy. Thus, understanding the TA in the context of fully automated apps would bring us insights into building effective smartphone apps which engage users. However, the concept of a digital therapeutic alliance (DTA) in the context of fully automated mental health smartphone apps is nascent and under-researched, and only a handful of studies have been published in this area. In particular, no published review paper examined the DTA in the context of fully automated apps. The objective of this review was to integrate the extant literature to identify research gaps and future directions in the investigation of DTA in relation to fully automated mental health smartphone apps. Our findings suggest that the DTA in relation to fully automated smartphone apps needs to be conceptualized differently to traditional face-to-face TA. First, the role of bond in the context of fully automated apps is unclear. Second, human components of face-to-face TA, such as empathy, are hard to achieve in the digital context. Third, some users may perceive apps as more non-judgmental and flexible, which may further influence DTA formation. Subdisciplines of computer science, such as affective computing and positive computing, and some human-computer interaction (HCI) theories, such as those of persuasive technology and human-app attachment, can potentially help to foster a sense of empathy, build tasks and goals and develop bond or an attachment between users and apps, which may further contribute to DTA formation in fully automated smartphone apps. Whilst the review produced a relatively limited quantity of literature, this reflects the novelty of the topic and the need for further research.

Online self-exclusion from multiple gambling venues: Stakeholder co-design of a usable and acceptable self-directed website

Gambling self-exclusion programs are under-utilised and barriers to entry include shame and embarrassment with face-to-face registration, and complex and effortful procedures. The current study aimed to facilitate self-exclusion from gambling venues via an online self-directed website. A co-design approach was used to elicit key stakeholders' perspectives on required website features, functionality, and to identify variables potentially impacting on development and implementation. Semi-structured focus groups and interviews were conducted across four stakeholders (N = 25): self-exclusion end users (consumers, n = 5), gambling counsellors (n = 7), venue staff (n = 6), and policy makers (n = 7). Overall, stakeholder perspectives were consistent with content analysis indicating the importance of website user-friendliness, flexibility, supportiveness, and trustworthiness. Importantly, these attributes were linked to target end users': perceived vulnerabilities, diverse backgrounds and individual expectations. Participants believed that the entire self-exclusion process should be conducted online, including identity verification, whilst expecting high-level data security measures to protect their personal privacy. A separate webpage was also suggested containing relevant information and links to additional help services, such as counselling. This study describes an adaptable co-design framework for developing a usable and acceptable self-exclusion website. Future studies should empirically test system usability and acceptability to refine and maximise system uptake upon implementation. Findings may have broader implications for digital health intervention design.

[Gambling and Internet habits in a French population with addictive disorders seeking treatment: a multicentric study]

BACKGROUND

Transversal grouping of addictions under the heading "Substance related and addictive disorders" in the DSM-5 has led to a common policy on addictions and the promotion of addiction services covering all types of addictions, including behavioral addictions.

MATERIAL AND METHODS

The main objective of this study was to describe the prevalence of problem gambling in a population of patients seeking treatment in addictive disorders center. Secondary objectives were: to describe the use of Internet and the prevalence of gaming disorder, sexual addiction and compulsive buying online ; to describe a population of patients consulting in addictive disorders center; to explore associated factors related to problem gambling. A self-questionnaire was built, evaluating the socio-demographic elements, the addiction pathway, problem gambling and Internet use with a focus on video game disorder, sexual addiction and compulsive buying. It was offered to consultants from five addictology centers in Brittany.

RESULTS

252 patients seeking treatment for addictive disorders were included. Problem gambling was present in 9.9 % of patients. Problem gamblers were more likely to have been asked about their gambling by the addictology team than other patients. The rate of identification of gambling habits, whether in addiction or outside, was generally low. Internet use was 83 %. The prevalence of other online behavioral addictions was low.

DISCUSSION AND CONCLUSION

The prevalence of problem gambling is almost 4 times higher among addictology consultants, compared to the general population, probably related to addictive comorbidities. The identification of gambling habits concerned a small proportion of the patients included, whether in specialized care or outside. There is significant room for improvement in the identification of problem gambling, in addictology and beyond. It is important to question gambling habits for any reason for addiction consultation and to repeat this identification over time. As the Internet is widely used by addictology consultants, it can represent a key element in care, both in the identification of behavioral addictions and in follow-up.

Evaluation of a Brief Online Self-help Program for Concerned Gamblers

The purpose of this study was to evaluate the feasibility and module content of a brief online self-help program for concerned gamblers, i.e., gamblers who perceived a need to change their gambling habits, in the context of a gambling helpline. The program consisted of four modules based on Motivational Interviewing (MI) and Cognitive Behavioral Therapy (CBT), covering motivation to change, logging gambling behaviors, planning and implementing gambling-free activities, and managing risk situations. Gambling expenditures were also logged in the program, and their development over time were analyzed as longitudinal data using marginalized two-part models. Out of 4655 gamblers recruited via the helpline's webpage, 92% completed content in at least one module, and 23% were active in all four modules. Attrition was in general high, with only 10% retention in the gambling log for longer than 14 days. Gambling expenditures decreased for those who logged them for a shorter time period, whereas it increased for those who logged expenditures for a longer time period. This study shows that it is relatively easy to recruit participants to an online program for concerned gamblers in the context of a gambling helpline. However, since few users logged in to the program more than once, we suggest future online programs to have open modules with all content accessible at once.

Internet-based treatment of gambling problems: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

The effect of internet-based psychological treatment for gambling problems has not been previously investigated by meta-analysis. The present study is therefore a quantitative synthesis of studies on the effects of internet-based treatment for gambling problems. Given that effects may vary according to the presence of therapist support and control conditions, it was presumed that subgroup analyses would elucidate such effects.

METHODS

A systematic search with no time constraints was conducted in PsycINFO, MEDLINE, Web of Science, and the Cochrane Library. Two authors independently extracted data using a predefined form, including study quality assessment based on the Cochrane risk of bias tool. Effect sizes were calculated using random-effects models. Heterogeneity was indexed by Cochran's Q and the I 2 statistics. Publication bias was investigated using trim and fill.

RESULTS

Thirteen studies were included in the analysis. Random effects models at post-treatment showed significant effects for general gambling symptoms (g = 0.73; 95% CI = 0.43-1.03), gambling frequency (g = 0.29; 95% CI = 0.14-0.45), and amount of money lost gambling (g = 0.19; 95% CI = 0.11-0.27). The corresponding findings at follow-up were g = 1.20 (95% CI = 0.79-1.61), g = 0.36 (95% CI = 0.12-0.60), and g = 0.20 (95% CI = 0.12-0.29) respectively. Subgroup analyses showed that for general gambling symptoms, studies with therapist support yield larger effects than studies without, both post-treatment and at follow-up. Additionally, on general gambling symptoms and gambling frequency, there were lower effect sizes for studies with a control group compared to studies without a control group at follow-up. Studies with higher baseline severity of gambling problems were associated with larger effect sizes at both posttreatment and follow-up than studies with more lenient inclusion criteria concerning gambling problems.

DISCUSSION AND CONCLUSIONS

Internet-based treatment has the potential to reach a large proportion of persons with gambling problems. Results of the meta-analysis suggest that such treatments hold promise as an effective approach. Future studies are encouraged to examine moderators of treatment outcomes, validate treatment effects cross-culturally, and investigate the effects of novel developments such as ecological momentary interventions.

Psychiatric Drug Prescription and Temporal Associations with a First Diagnosis of Gambling Disorder—Results from a National Register Study

Psychiatric comorbidity is common in gambling disorder (GD), but there are few studies on larger nationwide samples of treatment-seeking patients. Also, temporal associations between GD and other psychiatric disorders are often difficult to study. To address the prevalence and the temporal associations of prescriptions for psychiatric disorders — both in specialized care and primary care — in patients with a GD diagnosis (ICD-10 F63.0). Data was derived from national health registers in Sweden. All patients who were diagnosed with GD in specialized health care in 2005–2016 were included and run against the nationwide database on prescription of pharmaceuticals aimed for psychiatric disorders (n = 2018). Prevalence of psychiatric drug prescription was used as a proxy for psychiatric comorbidity and studied for two 2-year periods (period 1 and 2) prior to GD and one 2-year period (period 3) after the diagnosis. Controlling for gender, age, and time periods, for eight drug categories (anti- epileptics, anti-psychotics, benzodiazepine derivatives, anxiolytics, hypnotics, anti- depressants and drugs used in addictive disorders), significant increases in drug prescription were seen. For central stimulants, a significant increase was seen upon receiving the GD diagnosis (from period 2 to 3), and for benzodiazepines, an increase was seen prior to the GD diagnosis (from period 1 to 2), but not upon diagnosis (from period 2 to 3). Psychiatric comorbidity in GD is common. Drug prescription for psychiatric problems increased markedly in the years temporarily associated with a first diagnosis of GD. The findings may call for early screening for problem gambling in patients with treatment contacts for increasingly poor mental health.

Examining Change in Self-Reported Gambling Measures Over Time as Related to Socially Desirable Responding Bias

Socially desirable responding is a response bias that can affect the accuracy of self-reports. It is especially likely when questions address sensitive topics, such as gambling attitudes, problems and behaviours. A sample of 321 participants were recruited from Amazon's mTurk crowdsourcing platform for a randomized controlled trial investigating an online gambling intervention. Data from this study was used to examine the influence of socially desirable responding on gambling self-report measures over time. At baseline, self-deception (SD), a factor of socially desirable responding, was significantly higher among males than females and among those with household incomes greater than $20,000 per year. Controlling for demographic variability, mixed effects models examining the relationship between socially desirable responding factors [SD and impression management (IM)] and time were conducted. Among males, there were significant interactions between IM with the NORC DSM-IV screen for gambling problems (NODS) and the gambling symptom assessment scale (G-SAS) scores respectively, over time. In other words, males with higher IM scores, demonstrated less change in NODS and G-SAS scores from baseline to 6-month follow-up compared to males with lower IM scores. There were no significant interactions in any models among females or among the full sample. Controlling the well-documented effect of socially desirable responding on self-reported measures in addictions research should be considered as a method to help reduce error and improve validity. Future research should continue to examine the effect of this bias on gambling measures over time and in each gender.Trial registration: https://ClinicalTrials.gov/NCT03124589 , registered 19 January 2017.

Self-Exclusion from Gambling-A Measure of COVID-19 Impact on Gambling in a Highly Online-Based Gambling Market?

The COVID-19 pandemic, and related changes of the gambling market, have been suspected to affect the risk of problem gambling. Despite media attention and political concern with this risk, study findings hitherto have been mixed. Voluntary self-exclusion from gambling was introduced on a national level in Sweden as a harm reduction tool in 2019, and this self-exclusion service in Sweden is a rare example of such an official, nationwide, multi-operator system. The present study aimed to evaluate whether short-term self-exclusion patterns were affected by different phases of COVID-19-related impacts on gambling markets in 2020. During the lock-down of sports in the spring months of 2020, three-month self-exclusion was unaffected, and one-month self-exclusion appeared to increase, though not more than in a recent period prior to COVID-19. Despite large differences in sports betting practices between women and men, self-exclusion patterns during COVID-19 were not apparently gender-specific. Altogether, self-exclusion from gambling, to date, does not appear to be affected by COVID-19-related changes in society, in contrast with beliefs about such changes producing greater help-seeking behavior in gamblers. Limitations are discussed, including the fact that in a recently introduced system, seasonality aspects and the autocorrelated nature of the data made substantial statistical measures unfeasible.

A randomized controlled trial on a self-guided Internet-based intervention for gambling problems

The majority of individuals with problematic and pathological gambling remain untreated, and treatment barriers are high. Internet-based interventions can help to address existing barriers, and first studies suggest their potential for this target group. Within a randomized controlled trial (N = 150) with two assessment times (baseline and post-intervention), we aimed to investigate the feasibility, acceptance, and effectiveness of a self-guided Internet-based intervention targeted at gambling problems. We expected a significant reduction in gambling symptoms (primary outcome) and depressive symptoms as well gambling-specific dysfunctional thoughts (secondary outcomes) in the intervention group (IG) compared to a wait-list control group with access to treatment-as-usual (control group, CG) after the intervention period of 8 weeks. Results of the complete cases, per protocol, intention-to-treat (ITT), and frequent user analyses showed significant improvements in both groups for primary and secondary outcomes but no significant between-group differences (ITT primary outcome, F(1,147) = .11, p = .739, ηp2 < .001). Moderation analyses indicated that individuals in the IG with higher gambling and depressive symptoms, older age, and comorbid anxiety symptoms showed significant improvement relative to the CG. The intervention was positively evaluated (e.g., 96.5% rated the program as useful). Possible reasons for the nonsignificant between-group differences are discussed. Future studies should include follow-up assessments and larger samples to address limitations of the present study.

Trial Registration ClinicalTrials.gov (NCT03372226), http://clinicaltrials.gov/ct2/show/NCT03372226, date of registration (13/12/2017).

GamblingLess: A Randomised Trial Comparing Guided and Unguided Internet-Based Gambling Interventions

There is little evidence relating to the effects of adding guidance to internet-based gambling interventions. The primary aim was to compare the effectiveness of an online self-directed cognitive-behavioural gambling program (GamblingLess) with and without therapist-delivered guidance. It was hypothesised that, compared to the unguided intervention, the guided intervention would result in superior improvements in gambling symptom severity, urges, frequency, expenditure, psychological distress, quality of life and help-seeking. A two-arm, parallel-group, randomised trial with pragmatic features and three post-baseline evaluations (8 weeks, 12 weeks, 24 months) was conducted with 206 gamblers (106 unguided; 101 guided). Participants in both conditions reported significant improvements in gambling symptom severity, urges, frequency, expenditure, and psychological distress across the evaluation period, even after using intention-to-treat analyses and controlling for other low- and high-intensity help-seeking, as well as clinically significant changes in gambling symptom severity (69% recovered/improved). The guided intervention resulted in additional improvements to urges and frequency, within-group change in quality of life, and somewhat higher rates of clinically significant change (77% cf. 61%). These findings, which support the delivery of this intervention, suggest that guidance may offer some advantages but further research is required to establish when and for whom human support adds value.

What's in a Name? Evaluating the Public Stigma of Gambling Disorder

Public stigma of gambling disorder has negative effects on the mental health and functioning of affected individuals and impedes treatment-seeking. One factor thought to be implicated in stigma is the label used to describe the condition. The aims of this research were to: (1) evaluate whether different labels for problematic gambling behavior influence public stigma; and (2) compare public stigma of gambling disorder to other health conditions. Separate samples of university student (Study 1) and general population (Study 2) participants were randomly assigned to label conditions and completed questionnaires assessing stigma and attitudes towards the assigned label. In Study 1, the eight conditions included four gambling labels (problem gambling, pathological gambling, gambling disorder, and gambling addiction) and four psychiatric or health comparison labels (depression, obsessive-compulsive disorder, alcohol use disorder, and asthma). In Study 2, compulsive buying disorder was added as a fifth psychiatric comparison for a total of nine conditions. The results indicated that the four gambling label conditions elicited similar attitudes and stigma. Those conditions were also more stigmatized than the depression, obsessive-compulsive disorder, and asthma conditions. The gambling conditions elicited similar stigmatizing attitudes as alcohol use disorder but were slightly more stigmatized than compulsive buying disorder, with these conditions showing both similarities and differences across the stigma-related outcomes. The results were largely consistent across both samples and contribute to knowledge of the nature and origins of gambling-related stigma.

Unguided Chatbot-Delivered Cognitive Behavioural Intervention for Problem Gamblers Through Messaging App: A Randomised Controlled Trial

Internet-delivered intervention may be an acceptable alternative for the more than 90% of problem gamblers who are reluctant to seek face-to-face support. Thus, we aimed to (1) develop a low-dropout unguided intervention named GAMBOT integrated with a messaging app; and (2) investigate its effect. The present study was a randomised, quadruple-blind, controlled trial. We set pre-to-post change in the Problem Gambling Severity Index (PGSI) as the primary outcome and pre-to-post change in the Gambling Symptom Assessment Scale (G-SAS) as a secondary outcome. Daily monitoring, personalised feedback, and private messages based on cognitive behavioural theory were offered to participants in the intervention group through a messaging app for 28 days (GAMBOT). Participants in the control group received biweekly messages only for assessments for 28 days (assessments only). A total of 197 problem gamblers were included in the primary analysis. We failed to demonstrate a significant between-group difference in the primary outcome (PGSI - 1.14, 95% CI - 2.75 to 0.47, p = 0.162) but in the secondary outcome (G-SAS - 3.14, 95% CI - 0.24 to - 6.04, p = 0.03). Only 6.7% of the participants dropped out during follow-up and 77% of the GAMBOT group participants (74/96) continued to participate in the intervention throughout the 28-day period. Integrating intervention into a chatbot feature on a frequently used messaging app shows promise in helping to overcome the high dropout rate of unguided internet-delivered interventions. More effective and sophisticated contents delivered by a chatbot should be sought to engage over 90% of problem gamblers who are reluctant to seek face-to-face support.

A Smartphone-Delivered Ecological Momentary Intervention for Problem Gambling (GamblingLess: Curb Your Urge): Single-Arm Acceptability and Feasibility Trial

Background

Low uptake rates of traditional gambling treatments highlight the need for innovative treatment modalities. Smartphone apps can provide unprecedented access to real-time ecological momentary interventions (EMIs) delivered in people’s everyday lives.

Objective

This study aims to examine the acceptability, feasibility, and preliminary effectiveness of GamblingLess: Curb Your Urge, the first smartphone app–delivered EMI that aims to prevent gambling episodes by reducing craving intensity in people seeking help for gambling problems.

Methods

This study was a single-arm, 5-week acceptability and feasibility trial (1-week baseline and 4-week intervention periods) involving ecological momentary assessments (EMAs) delivered 3 times daily. The EMAs measured gambling episodes, cravings, and self-efficacy. Web-based evaluations at baseline, postintervention, and 1-month follow-up measured gambling outcomes (severity, cravings, frequency, expenditure, and self-efficacy) and the intervention’s perceived helpfulness, relevance, burden, satisfaction, and impact in relation to gambling cravings.

Results

A total of 36 participants, of whom 22/36 (61%) were male and 34/36 (94%) were problem gamblers, completed the baseline measures, with 61% (22/36) completing the postintervention evaluation and 58% (21/36) completing the follow-up evaluation. The intervention was considered acceptable, as participants perceived all intervention content to be above average in helpfulness and the EMA to be highly relevant but somewhat burdensome. Participants reported that they were satisfied with the intervention and that the intervention improved their knowledge, attitudes, awareness, behavior change, intention to change, and help-seeking behavior for gambling cravings. Regarding the intervention’s feasibility, compliance rates for the EMA (51%) and EMI (15%) were low; however, the intervention was used 166 times, including 59 uses within 60 minutes of EMA completion and 107 on-demand uses. Regarding the intervention’s preliminary effectiveness, descriptive EMA data showed that, compared with the baseline period, 71% and 72% reductions in the average number of gambling episodes and craving occurrences were reported in the intervention period, respectively. In addition, clustered paired-sample two-tailed t tests revealed a significant 5.4% reduction in real-time craving intensity (P=.01) immediately after intervention use, which increased to 10.5% (P=.01), where use was recommended based on craving occurrence. At the group level, significant medium-to-large reductions were observed in mean gambling symptom severity (P=.01 and .003), cravings (P=.03 and .02), frequency (P=.01 and .004), and expenditure (P=.04 and .003) at postintervention and follow-up; moreover, increased mean gambling self-efficacy and craving self-efficacy (P=.01 and .01) were observed at postintervention and increased gambling self-efficacy (P=.04) was observed at follow-up. At the individual level, over a quarter of participants (6/22, 27% to 10/21, 48%) could be categorized as recovered or improved regarding their gambling symptom severity and cravings.

Conclusions

The results support the acceptability, feasibility, and preliminary effectiveness of this app-delivered EMI for preventing gambling episodes through craving management in people with gambling problems, which has implications for extending the reach of evidence-based treatment to moments of vulnerability in people’s everyday lives.