Internet-Based Delivery of Cognitive Behaviour Therapy Compared to Monitoring, Feedback and Support for Problem Gambling: A Randomised Controlled Trial

Does cognitive-behavioral treatment affect putative mechanisms of change among individuals with problem gambling? A systematic review and exploratory meta-analysis

OBJECTIVE

The current study was a systematic review and meta-analysis of cognitive behavioral treatment (CBT) for problem gambling and gambling disorder and whether it produced different outcomes than minimal or no treatment controls on three putative change mechanisms: 1) gambling cognitions, 2) coping, and 3) self-efficacy.

METHOD

Studies were identified from five bibliographic databases (i.e., Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, PsycINFO, and PubMed). Included studies were randomized controlled trials of CBT that included posttreatment data on putative mechanisms. Between-group Hedges's g effect sizes were calculated to examine outcomes of CBT relative to minimal or no treatment control on gambling cognitions, coping, and self-efficacy at posttreatment. Risk of bias was determined using the Cochrane Risk of Bias tool.

RESULTS

Fifteen studies, representing 1,536 participants, were eligible for analysis. Participants in CBT had more favorable gambling cognitions (g = -0.41), coping behaviors (g = 0.27), and self-efficacy (g = 1.12) at posttreatment than minimal or no treatment control.

CONCLUSIONS

Results of the current study provided preliminary support for the effectiveness of CBT on three putative mechanisms of change among individuals experiencing problem gambling and gambling disorder. Although the results were promising, there was significant heterogeneity in the magnitude of effect sizes for all three outcomes, and outcomes were not consistently assessed with psychometrically established assessment tools.

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.

A Systematic Review on Intervention Treatment in Pathological Gambling

Over the last century, there has been a growing interest in researching pathological gambling, particularly in industrialized nations. Historically, gambling was widely perceived as morally questionable, condemned by religious groups. However, contemporary concerns have shifted towards the health repercussions of gambling disorders and broader societal impacts like increased crime and money laundering. Governments, aiming to mitigate social harm, often regulate or directly oversee gambling activities. The global surge in legal gambling has resulted in a substantial rise in its prevalence, popularity, and accessibility in the last two decades. This paper provides a comprehensive overview of global research on interventions for pathological gambling. Through a systematic search on platforms such as EBSCO, PubMed, and Web of Science, 13 relevant records were identified. The revised findings indicate a heightened occurrence of behavioral addictions, linking them to the early onset of gambling issues and their severe consequences. The research emphasizes the active role that clients play in the process of self-directed change and therapy. Therapists recognizing clients as both catalysts for change and potential obstacles can enhance their effectiveness. A common source of resistance arises when clients and therapists are in different stages of the change process, underlining the importance of therapists aligning with clients' readiness for change. Recognizing the urgent need for a better understanding of this problem in adolescents, this study emphasizes the necessity to tailor prevention and treatment plans based on gender and age-specific requirements.

Internet-delivered therapist-assisted cognitive behavioral therapy for gambling disorder: a randomized controlled trial

Objectives

Cognitive behavioral therapy (CBT) is the most promising treatment for gambling disorder (GD) but only 21% of those with problematic gambling seek treatment. CBT over the Internet might be one way to reach a larger population. The aim of this study was to assess the effectiveness of Internet-delivered CBT with therapist guidance compared to an active control treatment.

Methods

Using a single-blinded design, 71 treatment-seeking gamblers (18-75 years) diagnosed with GD were randomized to 8 weeks of Internet-delivered CBT guided by telephone support, or 8 weeks of Internet-delivered motivational enhancement paired with motivational interviewing via telephone (IMI). The primary outcome was gambling symptoms measured at a first face-to-face assessment, baseline (treatment start), every 2 weeks, post-treatment, and 6-month follow-up. Gambling expenditures, time spent gambling, depression, anxiety, cognitive distortions, and quality of life were assessed as secondary outcomes. Analysis was performed on the full analysis sample (n = 60), with intention-to-treat sensitivity analyses (n = 69).

Results

In the CBT group, 80% stayed in treatment until the final week, compared to 67% in IMI. Post-treatment and at 6-month follow-up, no differences were found between CBT and IMI for any outcome measure. An exploratory analysis of the total sample (n = 60) showed a significant effect of time during treatment on gambling symptoms (d, [95% CI] 0.52, [-1.15, 2.02]) and all secondary outcomes except the gambling diary (depression (0.89, [-1.07-2.65]); anxiety (0.69, [-1.20-2.38])); cognitive distortions (0.84, [-0.73-2.29]); quality of life (0.60, [-0.61-1.70])). Post-treatment, there were no clinical gambling symptoms in either group. Some deterioration was seen between post-treatment and 6-month follow-up on gambling symptoms (0.42, [-1.74-2.43]), depression (0.59, [-0.82-1.86]), and anxiety (0.30, [-0.99-1.48]). Additionally, it was observed that the largest reduction in gambling symptoms was between the first assessment and baseline.

Conclusion

Both treatments offered in this study were effective at reducing gambling symptoms. It is also possible that the process of change started before treatment, which gives promise to low-intensity interventions for GD. Additional research is needed as this approach could be both cost-effective and has the potential to reach more patients in need of treatment than is currently possible.

Clinical trial registration

https://www.isrctn.com/, identifier ISRCTN38692394.

Validation of a Spanish Adaptation of the Gambling Symptom Assessment Scale (G-SAS) in Persons with Recent History of Gambling

Gambling is becoming increasingly frequent and problematic, especially due to the explosion of online alternatives. Evaluating the severity of gambling symptomatology is therefore more important than ever. However, innovations in the gambling field have generally focused on its treatment rather than its evaluation. The Gambling Symptom Assessment Scale (G-SAS) is a well-established measure of gambling-related symptomatology (e.g., gambling urges, gambling-related thoughts and behaviours, and interpersonal functioning). The aim of this study is to validate a Spanish adaptation of the G-SAS so that individual differences in gambling symptomatology can be assessed by clinicians and researchers. The internal structure of the G-SAS was investigated using an exploratory factor analysis with a sample of 364 individuals from the general population in Spain (mean age = 28.84 years, SD = 11.73; 54% males). A four-factor structure was preferred considering fit indices (Chi-square = 22.62, p = .162, RMSEA = 0.030, CFI = 0.998, TLI = 0.995) and internal consistency estimates (0.67 ≤ α ≤ 0.89). The factors were labelled gambling-related symptoms, control of gambling urges/thoughts, interference, and arousal. Regarding construct validity, the four factors of the G-SAS were positively and significantly (all p < .001) correlated with measures of problematic gambling severity (0.40 ≤ r ≤ .73), problematic gambling diagnostic (0.40 ≤ r ≤ .67), gambling cognitions (0.48 ≤ r ≤ .57), impulsivity (0.26 ≤ r ≤ .42), anxiety (0.22 ≤ r ≤ .38), and depression (0.16 ≤ r ≤ .42), and negatively with quality of life (-0.24 ≤ r≤-.42). In sum, this study provides Spanish clinicians and researchers with a tool that serves to assess the status of individuals in relation to gambling symptomatology, which can be used to screen for at-risk profiles and evaluate treatment response.

Effect of cognitive-behavioral techniques for problem gambling and gambling disorder: A systematic review and meta-analysis

AIMS

To measure the effect of cognitive-behavioral techniques (CBTs) on gambling disorder severity and gambling behavior at post-treatment and follow-up.

METHOD

Seven databases and two clinical trial registries were searched to identify peer-reviewed studies and unpublished studies of randomized controlled trials. The Cochrane Risk of Bias tool assessed risk of bias in the included studies. A random effect meta-analysis with robust variance estimation was conducted to measure the effect of CBTs relative to minimally treated or no treatment control groups.

RESULTS

Twenty-nine studies representing 3991 participants were identified. CBTs significantly reduced gambling disorder severity (g = -1.14, 95% CI = -1.68, -0.60, 95% prediction interval [PI] = -2.97, 0.69), gambling frequency (g = -0.54, 95% CI = -0.80, -0.27, 95% PI = -1.48, 0.40) and gambling intensity (g = -0.32, 95% CI = -0.51, -0.13, 95% PI = -0.76, 0.12) at post-treatment relative to control. CBTs had no significant effect on follow-up outcomes. Analyses supported the presence of publication bias and high heterogeneity in effect size estimates.

CONCLUSIONS

Cognitive-behavioral techniques are a promising treatment for reducing gambling disorder and gambling behavior; however, the effect of cognitive-behavioral techniques on gambling disorder severity and gambling frequency and intensity at post-treatment is overestimated, and cognitive-behavioral techniques may not be reliably efficacious for all individuals seeking treatment for problem gambling and gambling disorder.

The evaluation of a brief ICBT program with therapist support for individuals with gambling problems in the context of a gambling helpline: a randomized pilot trial

BACKGROUND AND AIMS

Gambling helplines are a natural way of first contact for individuals with gambling problems. However, few studies have evaluated the feasibility and effectiveness of brief interventions in a gambling helpline. To reduce this knowledge gap, this study evaluated the feasibility of an online cognitive behavioral therapy (ICBT) program in the context of a gambling helpline as a first step towards a full-scale RCT.

DESIGN

This is a two-group parallel randomized controlled pilot trial where the participants were randomized to either a brief four-module ICBT program (n = 22) or a control group (n = 21). Participants were followed up weekly during the intervention, post intervention, and 6 weeks upon completion of intervention.

PARTICIPANTS

A total of 43 self-identified individuals with gambling problems (scoring 3 or more on the Problem Gambling Severity Index) were recruited via the Swedish national gambling helpline, 59% females, mean age 43.7 years.

MEASUREMENTS

Feasibility of the procedure and intervention (i.e., recruitment pace, attrition, program engagement, and satisfaction) were the primary outcomes; treatment effect (net gambling losses) was the secondary outcome.

RESULTS

Approximately 2 participants per week were randomized, and retention was low, with 47% lost to follow-up at the 6-week follow-up time-point. Most participants engaged in the online modules (86%) and rated their overall satisfaction with the program as high (7.5 out of 10). Both groups decreased their weekly gambling losses at both follow-up time-points, but the between-group comparisons were inconclusive.

CONCLUSION

It is not advisable to conduct a full-scale RCT based on the results from this pilot study. Future studies in a gambling helpline should consider interventions that are more suited to be incorporated in a gambling helpline and identify ways to increase participant engagement.

TRIAL REGISTRATION

The study was retrospectively registered on ClinicalTrials.gov (ID: NCT04609007 , 29/10/2020).

Efficacy of cognitive-behavioral therapy in improving the quality of life of people with compulsive gambling, a systematic review

FUNDAMENTALS

Cognitive-behavioral therapy can reduce gambling behavior and other symptoms of pathological gambling.

AIM

To synthesize and analyze the evidence on the efficacy of cognitive-behavioral interventions to improve the quality of life of people with pathological gambling.

METHODOLOGY

Systematic review with a narrative synthesis of clinical trials published in English and Spanish in Medline, Scopus, Web of Science, CINAHL, The Cochrane Library Plus, PsycoInfo, and ProQuest of articles until January 2020 that will analyze this phenomenon. The PRISMA Declaration was followed and the quality of the articles was analyzed with the Jadad scale.

RESULTS

1233 articles were found, including nine in the review. Two studies confirmed the efficacy of cognitive behavioral therapy-based interventions for improving the quality of life in people with pathological gambling. In addition, these interventions improved depression, anxiety, the amount of money played, and reduced alcohol consumption and the gambling diagnosis score, which had an impact on improving the quality of life. Cognitive behavioral interventions were more effective when it was supported by a manual or when were combined with Mindfulness or Player Anonymous sessions. Having better long-term results in these cases.

CONCLUSIONS

Cognitive behavioral-based interventions can improve the quality of life of people with pathological gambling and other psychological variables without being its immediate effect. Future research should analyze whether they are more efficacy online or in person, individually, or in groups, and the number of sessions required for their effects to last over time.

Internet-based interventions for behavioral addictions: A systematic review

BACKGROUND AND AIMS

Behavioral addictions are a public health problem that causes harm to both individuals and society. Internet-based interventions offer potential benefits over face-to-face therapy for the treatment of behavioral addictions, including their accessibility, perceived anonymity, and low costs. We systematically reviewed the characteristics and effectiveness of these interventions.

METHODS

A systematic literature search was conducted in: PubMed, PsycINFO, Embase, and the Cochrane Central Register of Controlled Trials. A standardized methodological quality assessment was performed on all identified studies via the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool.

RESULTS

Twenty-nine studies were assessed in this systematic review. Between them, considerable heterogeneity was noted in various study characteristics, including screening tools, inclusion criteria, and outcome measures. Attrition rates also ranged widely (9-89%), as did study quality, with three of the 29 studies rated strong, 12 moderate, and 14 weak methodologically. Twenty-two studies focused on gambling disorder, most revealing significant within-group effects for the assessed intervention on gambling-related symptoms and four of these studies identified significant between-group effects. Behavioral addictions studied in the remaining studies included gaming disorder, internet use disorder, hoarding disorder, and pornography use disorder, revealing generally-promising, albeit limited results.

CONCLUSIONS

Internet-based interventions seem promising at reducing gambling problems, but too few studies have been published, to date, for conclusions to be drawn for other behavioral addictions. Internet-based interventions targeting other behavioral addictions - like gaming disorder, internet use disorder, hoarding disorder, and pornography use disorder - remain under-examined, warranting considerable additional research to assess their effectiveness.

Latent Classes for the Treatment Outcomes in Women with Gambling Disorder and Buying/Shopping Disorder

BACKGROUND

The risk for behavioral addictions is rising among women within the general population and in clinical settings. However, few studies have assessed treatment effectiveness in females. The aim of this work was to explore latent empirical classes of women with gambling disorder (GD) and buying/shopping disorder (BSD) based on the treatment outcome, as well as to identify predictors of the different empirical groups considering the sociodemographic and clinical profiles at baseline.

METHOD

A clinical sample of n = 318 women seeking treatment for GD (n = 221) or BSD (n = 97) participated. Age was between 21 to 77 years.

RESULTS

The four latent-classes solution was the optimal classification in the study. Latent class 1 (LT1, good progression to recovery) grouped patients with the best CBT outcomes (lowest risk of dropout and relapses), and it was characterized by the healthiest psychological state at baseline, the lowest scores in harm avoidance and self-transcendence, and the highest scores in reward dependence, persistence, self-directedness and cooperativeness. Latent classes 3 (LT3, bad progression to drop-out) and 4 (LT4, bad progression to relapse) grouped women with the youngest mean age, earliest onset of the addictive behaviors, and worst psychological functioning.

CONCLUSIONS

GD and BSD are complex conditions with multiple interactive causes and impacts, which need wide and flexible treatment plans. Specific interventions should be designed according to the specific profiles of women for achieving early inclusion, retention and well-maintained long-term effects.

Psychological online interventions for problem gambling and gambling disorder - A meta-analytic approach

OBJECTIVE

The Covid-19 pandemic has reignited discussions about the prevalence of and treatment options for problem gambling and gambling disorder (PGGD). Since affected persons seldom seek professional help, online interventions can improve accessibility. Thus, this study aimed to investigate the effectiveness of psychological online interventions on PGGD.

METHODS

We conducted a systematic review and meta-analysis and searched in PubMed, PsycINFO, and Google Scholar for peer-reviewed experimental and quasi-experimental research published between 2010 and 2021. We calculated two meta-anlyses, one for treatment control comparisons (TCC), and one for pre-post-comparisons (PCC).

RESULTS

We included six studies (ten TCC and n = 2076) in meta-analysis 1 and five studies (six PCC and n = 781) in meta-analysis 2. Online interventions turned out to be effective in both analyses with Hedges g = 0.41, 95% confidence interval = [0.22 to 0.60], p < .001, for meta-anaylsis 1 and Hegdes g = 1.28, 95% confidence interval = [0.85 to 1.71], p < .001, for meta-analysis 2.

CONCLUSIONS

We identified significant effects of online interventions on PGGD in both analyses, indicating the potential of online applications. We discuss methodological aspects and further research directions.

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

Emerging Gambling Problems and Suggested Interventions: A Systematic Review of Empirical Research

The goal of the present systematic review is to identify emerging gambling problems and the harm minimization strategies proposed to address them. Our interdisciplinary research team conducted this systematic literature review in 5 nations between which there is significant gambling research exchange. A keyword search of the Scopus and Web of Science databases followed by filtering using inclusion criteria identified 1292 empirical gambling studies from peer-reviewed journals. The data obtained from the articles were analyzed using the content analysis technique. We then used a unique approach to identify relationships between harm minimization strategies and gambling problems. The findings reveal that the most frequently reported gambling problems are related to young gamblers, online gambling, electronic gaming machines, and children and adolescents (underage gamblers). Harm minimization strategies to address these included creating educational and awareness programs, further restrictions on gambling advertising, developing an intervention mechanism for online gambling, and remote gambling-related help (i.e., online counseling, online treatment).

Client's Experiences Using a Location-Based Technology ICT System during Gambling Treatments' Crucial Components: A Qualitative Study

Cognitive Behavioral Therapy is the treatment of choice for Gambling Disorder (GD), with stimulus control (SC) and exposure with response prevention (ERP) being its two core components. Despite their efficacy, SC and ERP are not easy to deliver, so it is important to explore new ways to enhance patient compliance regarding SC and ERP. The aim of this study is to describe and assess the opinion of two patients diagnosed with problem gambling and GD that used the Symptoms app, a location-based ICT system, during SC and ERP. A consensual qualitative research study was conducted. We used a semi-structured interview, developed ad-hoc based on the Expectation and Satisfaction Scale and System Usability Scale. A total of 20 categories were identified within six domains: usefulness, improvements, recommendation to other people, safety, usability, and opinion regarding the use of the app after completing the intervention. The patients considered the app to be useful during the SC and ERP components and emphasized that feeling observed and supported at any given time helped them avoid lapses. This work can offer a starting point that opens up new research paths regarding psychological interventions for gambling disorder, such as assessing whether location-based ICT tools enhance commitment rates.

Effect of Engagement With Digital Interventions on Mental Health Outcomes: A Systematic Review and Meta-Analysis

Digital mental health interventions (DMHIs) present a promising way to address gaps in mental health service provision. However, the relationship between user engagement and outcomes in the context of these interventions has not been established. This study addressed the current state of evidence on the relationship between engagement with DMHIs and mental health outcomes. MEDLINE, PsycINFO, and EmBASE databases were searched from inception to August 1, 2021. Original or secondary analyses of randomized controlled trials (RCTs) were included if they examined the relationship between DMHI engagement and post-intervention outcome(s). Thirty-five studies were eligible for inclusion in the narrative review and 25 studies had sufficient data for meta-analysis. Random-effects meta-analyses indicated that greater engagement was significantly associated with post-intervention mental health improvements, regardless of whether this relationship was explored using correlational [r = 0.24, 95% CI (0.17, 0.32), Z = 6.29, p < 0.001] or between-groups designs [Hedges' g = 0.40, 95% CI (0.097, 0.705), p = 0.010]. This association was also consistent regardless of intervention type (unguided/guided), diagnostic status, or mental health condition targeted. This is the first review providing empirical evidence that engagement with DMHIs is associated with therapeutic gains. Implications and future directions are discussed.

Systematic Review Registration: PROSPERO, identifier: CRD 42020184706.

Efficacy of an internet-based psychological intervention for problem gambling and gambling disorder: Study protocol for a randomized controlled trial

Gambling Disorder is a prevalent non-substance use disorder, which contrasts with the low number of people requesting treatment. Information and Communication Technologies (ICT) could help to enhance the dissemination of evidence-based treatments and considerably reduce the costs. The current study seeks to assess the efficacy of an online psychological intervention for people suffering from gambling problems in Spain. The proposed study will be a two-arm, parallel-group, randomized controlled trial. A total of 134 participants (problem and pathological gamblers) will be randomly allocated to a waiting list control group (N = 67) or an intervention group (N = 67). The intervention program includes 8 modules, and it is based on motivational interviewing, cognitive-behavioral therapy (CBT), and extensions and innovations of CBT. It includes several complementary tools that are present throughout the entire intervention. Therapeutic support will be provided once a week through a phone call with a maximum length of 10 min. The primary outcome measure will be gambling severity and gambling-related cognitions, and secondary outcome measures will be readiness to change, and gambling self-efficacy. Other variables that will be considered are depression and anxiety symptoms, positive and negative affect, difficulties in emotion regulation strategies, impulsivity, and quality of life. Individuals will be assessed at baseline, post-treatment, and 3-, 6-, and 12-month follow-ups. During the treatment, participants will also respond to a daily Ecological Momentary Intervention (EMI) in order to evaluate urges to gamble, self-efficacy to cope with gambling urges, gambling urge frequency, and whether gambling behaviour occurs. The EMI includes immediate automatic feedback depending on the participant's responses. Treatment acceptance and satisfaction will also be assessed. The data will be analysed both per protocol and by Intention-to-treat. As far as we know, this is the first randomized controlled trial of an online psychological intervention for gambling disorder in Spain. It will expand our knowledge about treatments delivered via the Internet and contribute to improving treatment dissemination, reaching people suffering from this problem who otherwise would not receive help.

TRIAL REGISTRATION

Clinicaltrials.gov as NCT04074681. Registered 22 July 2019.

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.

The Effectiveness of a Motivational Interviewing Treatment for Help-Seeking Problem Gamblers in a Community Organization

Motivational Interviewing (MI) has been used as an approach to enhance readiness for change and behavior modification in a range of addiction and substance use disorders. Large meta-analyses comparing MI with non-MI interventions point to mixed conclusions about the short-term and long-term effectiveness of MI, with participant, outcome, and delivery factors being important moderators. The current study aimed to assess the immediate (1-2 weeks) and long-term (18 months) effectiveness of MI when delivered at the first point of client contact at a community gambling help counselling service and to investigate whether practitioners' MI adherent and non-adherent behaviors were significant predictors of change in client outcomes. There were 146 individuals presenting for gambling help counselling at an Australian not-for-profit organization who participated in this research. From the overall sample, 55% completed the 18 months follow-up assessment. Multilevel modelling showed a significant reduction in participants' problem gambling severity and psychological distress, which was a small effect size change in the short-term and large effect size change by the 18 months follow-up. While MI adherent practitioner behaviors were not found to be significant predictors of improvement in participants' problem gambling severity and psychological distress, MI non-adherent practitioner behaviors were significant predictors of deterioration in participants' problem gambling severity and psychological distress. This study highlights the importance of excluding MI non-adherent (confront and persuade) practitioner behaviors in order to prevent deterioration in client outcomes.

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.

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 systematic review and meta-analysis of psychological interventions to improve mental wellbeing

Our current understanding of the efficacy of psychological interventions in improving mental states of wellbeing is incomplete. This study aimed to overcome limitations of previous reviews by examining the efficacy of distinct types of psychological interventions, irrespective of their theoretical underpinning, and the impact of various moderators, in a unified systematic review and meta-analysis. Four-hundred-and-nineteen randomized controlled trials from clinical and non-clinical populations (n = 53,288) were identified for inclusion. Mindfulness-based and multi-component positive psychological interventions demonstrated the greatest efficacy in both clinical and non-clinical populations. Meta-analyses also found that singular positive psychological interventions, cognitive and behavioural therapy-based, acceptance and commitment therapy-based, and reminiscence interventions were impactful. Effect sizes were moderate at best, but differed according to target population and moderator, most notably intervention intensity. The evidence quality was generally low to moderate. While the evidence requires further advancement, the review provides insight into how psychological interventions can be designed to improve mental wellbeing.

Exploring the public's perception of gambling addiction on Twitter during the COVID-19 pandemic: Topic modelling and sentiment analysis

The present study explored the topics and sentiment associated with gambling addiction during the COVID-19 pandemic, using topic modeling and sentiment analysis on tweets in English posted between 17-24^th April 2020. The study was exploratory in nature, with its main objective consisting of inductively identifying topics embedded in user-generated content. We found that a five-topic model was the best in representing the data corpus, including: (i) the public's perception of gambling addiction amid the COVID-19 outbreak, (ii) risks and support available for those who stay at home, (iii) the users' interpretation of gambling addiction, (iv) forms of gambling during the pandemic, and (v) gambling advertising and impact on families. Sentiment analysis showed a prevalence of underlying fear, trust, sadness, and anger, across the corpus. Users viewed the pandemic as a driver of problematic gambling behaviors, possibly exposing unprepared individuals and communities to forms of online gambling, with potential long-term consequences and a significant impact on health systems. Despite the limitations of the study, we hypothesize that enhancing the presence of mental health operators and practitioners treating problem gambling on social media might positively impact public mental health and help prevent health services from being overwhelmed, in times when healthcare resources are limited.

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.

Non-pharmacological treatment of gambling disorder: a systematic review of randomized controlled trials

BACKGROUND

The main focus of the non-pharmacological treatment of Gambling Disorder (GD) is the behaviour, cognition and motivation of the patient, addressing the psychological determinants of gambling. Although there is not a gold standard non-pharmacological treatment yet, many studies already had promising results, and the outcomes were even better when pharmacotherapies were combined with psychotherapies. This review intended to synthesise the efficacy of various available non-pharmacological therapies for GD evaluated in randomized controlled trials.

METHODS

A systematic search was conducted in PubMed and in Cochrane Library for randomized controlled trials. Studies were included if participants had GD as their primary diagnosis and excluded if patients had other comorbidities.

RESULTS

From 320 records identified, 22 studies were included in the critical appraisal. They included a total of 1694 patients, with a mean age of 42.94 years, and a 62.31% of males. Seven trials revealed the efficacy of cognitive behaviour therapy in improving significantly the outcomes. Three studies assessing cognitive therapy showed significant improvements in gambling symptoms, while one study showed improvements in gambling behaviour using exposure therapy. Combined or separate motivational interviewing and imaginal desensitization had significant results in 4 trials. Four other studies also showed efficacy for: couples therapy, node-link mapping therapy, 12-step facilitated and personalized feedback intervention. Physical exercise had promising results but did not reach significance.

CONCLUSION

The literature included in this review showed the heterogeneity of available psychotherapies. The majority of studies supported the efficacy of the tested therapies, while some of them, due to limitations such as small sample sizes or inadequate control groups, failed to reach significance.

Identification of Behavior Change Techniques From Successful Web-Based Interventions Targeting Alcohol Consumption, Binge Eating, and Gambling: Systematic Review

BACKGROUND

Web-based interventions are thought to overcome barriers to treatment, such as accessibility and geographical location, which can undermine the effectiveness of traditional face-to-face interventions. Owing to these features, researchers are increasingly testing the efficacy of web-based interventions as ways to reduce alcohol misuse, binge eating, and gambling. However, many web-based interventions have poorly defined mechanisms of action; therefore, it is often uncertain how they propose to bring about behavior change.

OBJECTIVE

This systematic review aims to identify effective behavior change techniques (BCTs) present in web-based interventions aimed at reducing alcohol consumption, binge eating, or gambling.

METHODS

This systematic review covered research conducted in the last 20 years. Inclusion criteria for interventions were web-based administration; targeting alcohol use, binge eating, and/or gambling; and reporting on baseline and postintervention measures of behavior. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. We coded intervention effectiveness, study quality, and BCTs present in the interventions.

RESULTS

Following removal of 4152 ineligible articles, 45 were included in the review: 32 (71%) targeted alcohol misuse, 6 (13%) targeted binge eating, and 7 (16%) targeted gambling. In total, 5 frequency counts were performed to identify the most commonly used BCTs: all studies, effective interventions, high-quality studies at 2 thresholds, and both high quality and effective studies. The results obtained from this were integrated to identify 7 BCTs. These 7 BCTs were problem solving, feedback on behavior, self-monitoring of behavior, self-monitoring of outcomes, instruction on how to perform a behavior, information about social and health consequences, and social comparison. A total of 4 BCTs were found in all frequency counts: feedback on behavior, self-monitoring of behavior, instruction on how to perform a behavior, and social comparison. Self-monitoring of outcomes of behavior was found in 3 of the 5 frequency counts, problem solving was found in 2 frequency counts, and information about social and health consequences was found in 1 frequency count.

CONCLUSIONS

This systematic review identified 7 of the most frequently used BCTs used in web-based interventions focused on alcohol misuse, binge eating, and gambling. These results can inform the development of evidence-based eHealth interventions that have the potential to lead to effective, positive behavior changes in all 3 areas.

Perspective of Internet Poker Players on Harm-Reduction Strategies: A Cross-Sectional Study

Background: Internet gambling may increase rates of gambling harm. This current study aimed to assess Internet poker players’ views on various harm-reduction (HR) strategies. It also examined differences in these views according to the games played (poker only vs. poker plus other gambling activities), indebtedness, and problem gambling severity. Methods: Internet poker players (n = 311; 94.2% Male) recruited online between 2012 and 2014 were included in the analyses and completed a survey on indebtedness, problem gambling severity index, and ten statements regarding HR features. Results: Among the whole sample, the most frequently endorsed HR strategy was setting money limits, specialized online help, and peer support forums. People who play poker only (70%) are less prone to endorse the utility of information on excessive gambling and specialized healthcare centers. No differences were found between those people with debt versus those without regarding HR assessment. Participants with severe problem gambling were more skeptical about HR strategies based on information on specialized healthcare centers. Conclusion: Setting money limits, online help, and peer support forums are the most commonly endorsed strategies. Future research is needed to evaluate the effectiveness of online harm reduction strategies.

Effectiveness of a voluntary casino self-exclusion online self-management program

Despite evidence for effectiveness, only a small proportion of individuals with gambling disorder ever access treatment and support resources for their problem. Voluntary self-exclusion (VSE) programs are an ideal circumstance to engage individuals who are reluctant or have not yet sought formal treatment, given that individuals are already electing to prevent themselves from gambling through self-exclusion. The present study was a randomized controlled trial of a novel, online VSE self-management intervention. Individuals who chose to self-exclude at gambling venues (N = 201) were randomly assigned to participate in an online self-management program combined with VSE or to an in-person self-awareness educational workshop combined with VSE comparison group. Following a baseline assessment, participants were followed up at three, six, and twelve months via telephone interviews. Measured outcomes were gambling frequency and expenditure, problem gambling scores, problem drinking scores, type of goal set for gambling behaviour, quality of life, and treatment-seeking. The 12-month follow-up rate was 71% (n = 143). Participants in both VSE groups gambled less, spent less money gambling, and reported decreased need for formal treatment. However, there were no significant group differences on any of the primary or secondary outcomes. Only 30-35% of the participants completed their assigned workshop, depending on the group. Results from the online program satisfaction survey revealed that participants generally liked the program and rated the quality of the content highly, but thought there could be improvement regarding interactivity, variety, stimulation and greater clarity around registration steps and program objectives. The online VSE program is an effective alternative to the face-to-face VSE program. Although the outcomes between the two programs were not significantly different, the online program is easier to administer, able to reach more individuals since it only requires access to a computer and is based on motivational evidence-based principles of psychotherapy for gambling disorder.

Developing and testing the effectiveness of a novel online integrated treatment for problem gambling and tobacco smoking: a protocol for an open-label randomized controlled trial

BACKGROUND

Gambling and tobacco smoking are highly comorbid among North American adults. However, there is a paucity of treatment options that are integrated (i.e. targeting both gambling and tobacco smoking simultaneously), accessible, and evidence based.

METHODS

The aim of this two-arm open-label randomized controlled trial is to examine the effectiveness of an online, self-guided integrated treatment for problem gambling and tobacco smoking. A target sample of 214 participants will be recruited and be randomized into either an 8-week integrated or gambling only control condition. Both conditions will consist of seven online modules following cognitive behavioural therapy and motivational interviewing principles. Our three primary outcomes are (1) the number of days gambled, (2) money spent on gambling activities, and (3) time spent in gambling activities. Secondary outcomes include gambling disorder symptoms, cigarette use, and nicotine dependence symptoms. Assessments will be completed at baseline, at completion (i.e. 8 weeks from baseline), and at follow-up (i.e. 24 weeks from baseline). Generalized linear mixed modelling will be used to evaluate our primary and secondary outcomes. We expect that participants receiving online integrated treatment will show larger reductions in gambling relative to those receiving a control gambling only intervention. We further hypothesize that reductions in smoking will mediate these group differences.

DISCUSSION

The rates of problem gambling and tobacco smoking are high in North America; yet, the treatment options for both are limited, with no integrated treatments available. If supported, our pilot study will be a cost-effective and accessible way to improve treatments for co-occurring problem gambling and tobacco use.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03614884 . Registered on August 3, 2019.

Feasibility, Acceptance, and Safety of Metacognitive Training for Problem and Pathological Gamblers (Gambling-MCT): A Pilot Study

Approximately 90% of problem and pathological gamblers remain untreated. This treatment gap may be diminished by the implementation of low-threshold treatment programs. As cognitive distortions play a crucial role in the development and maintenance of gambling problems, interventions targeting gambling-related biases may be particularly effective. The aim of the present study was to examine the feasibility, acceptance, and safety of a novel metacognitive training for individuals with gambling problems (Gambling-MCT). Twenty-five participants were included in an uncontrolled pilot trial with two assessment points (intervention). The intervention comprised eight training modules targeting gambling-specific cognitive distortions. At baseline and post assessment, symptom severity, as measured with the PG-YBOCS, and gambling-related cognitive distortions, as measured with the GABS, were assessed. In addition, interim assessments measuring session-specific changes were conducted. Subjective appraisal was examined after each module and also post treatment. On average, participants took part in 4.16 (SD = 2.84) training sessions. Both intent-to-treat and per protocol analyses showed significant improvements on the PG-YBOCS and the GABS (d_z = 0.37–1.37). After Bonferroni correction for multiple testing, linear mixed models for the analysis of session-specific changes showed no deterioration in participants’ mental state after any of the modules. Subjective appraisal of Gambling-MCT was good. The present pilot study provides first evidence for the feasibility, acceptance, and safety of Gambling-MCT. Recruitment of participants remains challenging, emphasizing the importance of overcoming patient-related treatment barriers. Future studies need to investigate the efficacy of Gambling-MCT in randomized controlled trials.

Coping Strategies, Creativity, Social Self-Efficacy, and Hypercompetitiveness in Gambling Behaviors: A Study on Male Adolescent Regular Gamblers

The purpose of this research was to explore the cognitive and personality characteristics of male adolescent gamblers. Participants were 273 teenage males (M = 18.04, SD = 2.10) attending betting centers in Sicily, who completed self-report questionnaires on gambling, creativity, perceived social self-efficacy, hypercompetitiveness, and coping strategies. Pathological gamblers reported higher levels of avoidant coping strategies than occasional gamblers. They also scored higher on hypercompetitiveness than both occasional and problem gamblers. Further, problem gamblers scored higher than occasional gamblers on the complexity domain of creative personality. Finally, poor perceived social self-efficacy, higher levels of avoidant coping, and hypercompetitiveness predicted pathological gambling. Theoretical, psycho-educational, and clinical implications are discussed.

Behavioral couples therapy versus cognitive behavioral therapy for problem gambling: a randomized controlled trial

Background and aims

There is evidence that cognitive behavioral therapy (CBT) is effective for treating problem gambling (PG). Some research points to the possible benefits of involving concerned significant others (CSOs) in treatment. This study compared the efficacy of behavioral couples therapy (BCT) and CBT for both the gambler and the CSO.

Design

Two parallel‐group randomized controlled study comparing two different internet‐based treatments for PG. Follow‐up measures were conducted at treatment finish, and at 3‐, 6‐ and 12‐month post‐treatment.

Setting

Stockholm, Sweden.

Participants

A total of 136 problem gamblers and 136 CSOs were included in the study: 68 gamblers and 68 CSOs for each treatment condition. The gamblers were on average 35.6 years old and 18.4% were female. CSOs were on average 45.3 years old and 75.7% were women.

Interventions

A treatment based on BCT was compared with a CBT intervention. Both treatments were internet‐based, with 10 therapist‐guided self‐help modules accompanied by weekly telephone and e‐mail support from a therapist. CSOs were given treatment in the BCT condition, but not in the CBT condition.

Measurements

The primary outcome measures were time‐line follow‐back for gambling (TLFB‐G) and the NORC Diagnostic Screen for Gambling Problems (NODS) for problem gamblers, corresponding to DSM‐IV criteria for pathological gambling. Secondary outcomes measures were the Patient Health Questionnaire‐9 (PHQ‐9), the Generalized Anxiety Disorder seven‐item scale (GAD‐7), the Relation Assessment Scale Generic (RAS‐G), the Alcohol Use Disorders Identification Test (AUDIT), the Inventory of Consequences of Gambling for the Gambler and CSO (ICS) and adherence to treatment for both the problem gambler and the CSO.

Findings

The outcomes of both gambler groups improved, and differences between the groups were not statistically significant: TLFB‐G: multiplicative effect = 1.13, 95% confidence interval (CI) = 0.30;4.31); NODS: multiplicative effect = 0.80, 95%, 95% CI = 0.24;2.36. BCT gamblers began treatment to a higher proportion than CBT gamblers: P = 0.002.

Conclusions

Differences in the efficacy of internet‐based behavioral couples therapy and cognitive behavioral therapy for treatment of problem gambling were not significant, but more gamblers commenced treatment in the behavioral couples therapy group.

Manaaki - a cognitive behavioral therapy mobile health app to support people experiencing gambling problems: a randomized control trial protocol

Background

The low utilisation of current treatment services by people with gambling problems highlights the need to explore new modalities of delivering treatment interventions. This protocol presents the design of a pragmatic randomized control trial aimed at assessing the effectiveness and acceptability of cognitive behavioral therapy (CBT) delivered via a mobile app for people with self-reported gambling problems.

Methods

An innovative CBT mobile app, based on Deakin University’s GamblingLess online program, has been adapted with end-users (Manaaki). Six intervention modules have been created. These are interwoven with visual themes to represent a journey of recovery and include attributes such as avatars, videos, and animations to support end-user engagement. An audio facility is used throughout the app to cater for different learning styles. Personalizing the app has been accomplished by using greetings in the participant’s language and their name (e.g. Kia ora Tāne) and by creating personalized feedback.

A pragmatic, randomized control two-arm single-blind trial, will be conducted in New Zealand. We aim to recruit 284 individuals. Eligible participants are ≥18 years old, seeking help for their gambling, have access to a smartphone capable of downloading an app, able to understand the English language and are willing to provide follow-up information at scheduled time points. Allocation is 1:1, stratified by ethnicity, gender, and gambling symptom severity based on the Gambling Symptom Assessment Scale (G-SAS). The intervention group will receive the full mobile cognitive behavioural programme and the waitlist group will receive a simple app that counts down the time left before they have access to the full app and the links to the data collection tools. Data collection for both groups are: baseline, 4-, 8-, and 12-weeks post-randomisation. The primary outcome is a change in G-SAS scores. Secondary measures include changes in gambling urges, frequency, expenditure, and readiness to change. Indices of app engagement, utilisation and acceptability will be collected throughout the delivery of the intervention.

Discussion

If effective, this study will contribute to the improvement of health outcomes for people experiencing gambling problems and have great potential to reach population groups who do not readily engage with current treatment services.

Ethics approval

NZ Health and Disability Ethics Committee (Ref: 19/STH/204)

Trial registration

Australian New Zealand Clinical Trial Registry (ANZCTRN 12619001605189) Registered 1 November 2019.

La santé à l’ère du numérique

Les technologies de l’information et de la communication ont profondément marqué le champ de la santé. De nouvelles pratiques médicales utilisant ces technologies tentent de promouvoir une meilleure égalité d’accès aux soins, en particulier dans le champ de la santé mentale et des addictions où le recours aux professionnels de santé demeure faible. L’addiction aux jeux de hasard et d’argent en ligne, que nous désignerons sous le terme de jeu problématique, semble représenter un modèle pertinent de mesures de prévention et de soin fondé sur l’exploitation des données numériques issues du Big data et sur l’utilisation des nouvelles technologies. Ens effet, les données issues des comptes des joueurs offrent la possibilité d’une lecture directe de leur comportement de jeu. Parallèlement, le recours à l’internet offre un cadre de soin auquel les joueurs en ligne pourraient être particulièrement sensibles.

Web-Based Intervention and Email-Counseling for Problem Gamblers: Results of a Randomized Controlled Trial

Web-based interventions have the potential to reduce the treatment gap for problem gambling. In the past years, several web-based help options were made available to the public. However, only few studies were conducted to test their effects. This study investigated the efficacy of two interventions for problem gamblers provided online by the German Federal Center for Health Education (BZgA). The first intervention is the guided program “Check Out” (CO), the second is email counselling (EC). A web-based randomized controlled trial with follow-up surveys after 3, 6 and 12 months was conducted. Participants were allocated to CO, to EC or to a waitlist (WL). Outcomes were the degree of problem gambling according to the Problem Gambling Severity Index, the number of days gambled in past 30 days, the highest stake during the past 30 days and the subjective well-being (WHO-5). 167 individuals were included in the trial. In comparison to the WL at the 3 months follow-up, participants of CO showed significant improvements with moderate to strong effect sizes in all outcomes. Strongest effects were found in the problem gambling severity (d = 0.91; p = 0.023), followed by the well-being (d = 0.70; p = 0.011), the gambling days (d = 0.59; p = 0.001) and the highest stake (d = 0.55; p = 0.012). Improvements were sustained until last follow-up. Compared to the WL, users of EC had beneficiary results in the problem gambling severity (d = 0.74; p = 0.022). No significant effect differences were found between CO and EC. However, according to process evaluation, users of CO reported a significantly stronger working alliance than users of EC (d = 0.70; p = 0.019) and used the intervention considerably longer (d = 0.84; p = 0.004). CO helps treatment-seeking individuals to sustainably reduce their gambling behavior and to increase their general well-being. Compared to EC, CO seems a better support option, since its effects include a wider range of outcomes. Possible reasons are the more engaging program structure and elements of CO, as well as the closer interaction between client and counselor.

Online Self-Directed Interventions for Gambling Disorder: Randomized Controlled Trial

Self-directed treatments for gambling disorder have been developed to attract individuals who are reluctant to seek formal treatment. Self-directed treatments provide individuals with information and support to initiate a recovery program without attending formal treatment. In this study, an online version of a previously evaluated telephone-based intervention package is compared to a brief online normative feedback intervention called Check Your Gambling. In a randomized controlled trial design, participants with gambling problems who were not interested in formal treatment (N = 181) were recruited through media announcements. After a baseline telephone assessment, participants were assigned to have access to either the brief Check Your Gambling, or the extended self-management tools intervention. Follow-up assessments were conducted at 3, 6, and 12 months post baseline by blinded interviewers. Participant nominated collaterals were contacted to validate self-reported gambling involvement. The follow-up rate at 12 months was 78%. Participants in both conditions showed significant reductions in days of gambling and problem severity but no differences between conditions were found, contrary to the primary hypothesis. Lack of previous treatment for gambling and higher baseline self-efficacy predicted fewer days of gambling in both conditions. Self-efficacy increased over time but did not appear to mediate changes in gambling. Participants who were most engaged in the extended online program showed better outcomes. Those with low engagement showed a slower trajectory of change but equivalent improvements by 12 months. The extended online intervention was not associated with better outcomes than the brief Check Your Gambling intervention. Future research needs to explore the attractiveness, uptake, and effectiveness of online interventions with and without therapist support to understand their potential role in gambling disorder treatment systems.Trial Registration ISRCTN06220098.

Towards Scalable, Integrative Assessment of Children's Self-Regulatory Capabilities: New Applications of Digital Technology

The assessment of self-regulation in children is of significant interest to researchers within education, clinical and developmental psychology, and clinical neuroscience, given its importance to adaptive functioning across a wide range of social, educational, interpersonal, educational and health domains. Because self-regulation is a complex, multidimensional construct, a range of assessment approaches have been developed to assess its various components including behavioural, cognitive and emotional domains. In recent years, digital technology has been increasingly used to enhance or supplement existing measurement approaches; however, developments have predominantly focused on translating traditional testing paradigms into digital formats. There is a need for more innovation in digital psychological assessments that harness modern mechanisms such as game-based design and interactivity. Such approaches have potential for the development of scalable, adaptable universal approaches to screening and assessment of children's self-regulatory capabilities, to facilitate early identification of difficulties in individuals and also guide planning and decision-making at a population level. We highlight a novel, innovative digital assessment tool for children called Rumble's Quest, a new measure of children's socio-emotional functioning that shows promise as an integrative assessment of well-being and self-regulation, and which incorporates both self-report and direct assessment of cognitive self-regulation. This tool is scalable, can be integrated into normal classroom activities, and forms part of a comprehensive prevention support system that can be used to guide stakeholders' decision-making regarding early intervention and support at the individual, classroom, school and community level. We finish by discussing other innovative possibilities for psychological assessment with children, using new and emerging technologies and assessment approaches.

Participants' Experiences of a Workplace-Oriented Problem Gambling Prevention Program for Managers and HR Officers: A Qualitative Study

Workplace health promotion programs (WHPPs) refer to a set of health promotion and protection strategies implemented at a worksite and designed to meet the health and safety needs of employees. One important question for WHPPs is how middle management experience their participation in a WHPP. This study aims to explore this question further by applying a qualitative content analysis to interviews with thirteen managers and ten human resource officers participating in a WHPP focusing on problem gambling. The WHPP consisted of two components: policy implementation and skills-development training. The participants were interviewed about their experiences of these two components and the implementation process. The qualitative content analysis resulted in six themes: (1) Expectations of the skills-development training, (2) Experiences of and prior beliefs about problem gambling, (3) A good foundation, (4) The difficult conversation, (5) Appreciated aspects of the training sessions, and (6) Remaining obstacles. The results suggest that the presentation of cases, facts, and general knowledge was appreciated by most participants. However, participants also expressed that they would benefit from tailored interventions, more support in the policy implementation process, and following up on the results.

Professionally delivered interventions for gambling disorder

PURPOSE OF REVIEW

To assess recent developments in professionally delivered interventions for gambling disorder.

RECENT FINDINGS

During the past 24 months a number of reviews and individual studies have been published. Collectively they assess the efficacy and effectiveness of a range of interventions and identify methodological and other shortcomings. These studies advance knowledge with respect to pharmacological and psychological treatments including brief interventions delivered face-to-face and in other ways. Increased attention has been given to patient diversity, comorbidity, relapse, and nongambling outcomes. A variety of novel interventions have been developed and assessed.

SUMMARY

CBT and brief interventions remain well supported and appear to be similarly effective across varied patient groups. A range of promising new and combination treatments have been developed that require further evaluation. Larger, more robust pragmatic trials are required with diverse populations. Increased attention needs to be given to mechanisms of change, therapy mediators, patient retention, comorbidities, long-term treatment outcome, and relapse prevention.

Pilot randomized controlled trial of an online intervention for problem gamblers

INTRODUCTION

This pilot randomized controlled trial sought to evaluate whether an online intervention for problem gambling could lead to improved gambling outcomes compared to a no intervention control. Participants were recruited through a crowdsourcing platform.

METHODS

Participants were recruited to complete an online survey about their gambling through the Mechanical Turk platform. Those who scored 5 or more on the Problem Gambling Severity Index and were thinking about quitting or reducing their gambling were invited to complete 6-week and 6-month follow-ups. Each potential participant who agreed was sent a unique password. Participants who used their password to log onto the study portal were randomized to either access an online intervention for gambling or to a no intervention control.

RESULTS

A total of 321 participants were recruited, of which 87% and 88% were followed-up at 6 weeks and 6 months, respectively. Outcome analyses revealed that, while there were reductions in gambling from baseline to follow-ups, there was no significant observable impact of the online gambling intervention, as compared to a no intervention control condition.

CONCLUSIONS

While the current trial observed no impact of the intervention, replication is merited with a larger sample size, and with participants who are not recruited through a crowdsourcing platform.Trial registration: ClinicalTrials.govNCT03124589.

The use of self-management strategies for problem gambling: a scoping review

Background

Problem gambling (PG) is a serious public health concern that disproportionately affects people experiencing poverty, homelessness, and multimorbidity including mental health and substance use concerns. Little research has focused on self-help and self-management in gambling recovery, despite evidence that a substantial number of people do not seek formal treatment. This study explored the literature on PG self-management strategies. Self-management was defined as the capacity to manage symptoms, the intervention, health consequences and altered lifestyle that accompanies a chronic health concern.

Methods

We searched 10 databases to identity interdisciplinary articles from the social sciences, allied health professions, nursing and psychology, between 2000 and June 28, 2017. We reviewed records for eligibility and extracted data from relevant articles. Studies were included in the review if they examined PG self-management strategies used by adults (18+) in at least a subset of the sample, and in which PG was confirmed using a validated diagnostic or screening tool.

Results

We conducted a scoping review of studies from 2000 to 2017, identifying 31 articles that met the criteria for full text review from a search strategy that yielded 2662 potential articles. The majority of studies examined self-exclusion (39%), followed by use of workbooks (35%), and money or time limiting strategies (17%). The remaining 8% focused on cognitive, behavioural and coping strategies, stress management, and mindfulness.

Conclusions

Given that a minority of people with gambling concerns seek treatment, that stigma is an enormous barrier to care, and that PG services are scarce and most do not address multimorbidity, it is important to examine the personal self-management of gambling as an alternative to formalized treatment.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6755-8) contains supplementary material, which is available to authorized users.

Internet-Based Interventions for Problem Gambling: Scoping Review

BACKGROUND

This study seeks to give an overview of academic research on internet-based interventions that are used to address problem gambling. The rate of treatment seeking has been demonstrated to be low across several research environments. This is in part because of the systemic barriers that treatment seekers face to accessing traditional face-to-face treatment. Making treatment resources for problem gambling available through the internet is one way to reduce the impact of those systemic barriers. The use of internet-based resources to address problem gambling has been growing, and a field of research evaluating it has developed as well. However, little has been done to summarize this collection of research.

OBJECTIVE

This study aimed to provide a scoping review of the use of internet-based interventions for problem gambling treatment and prevention to provide an understanding of the current state of the field.

METHODS

A scoping review was performed for 6 peer-reviewed research databases (Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Social Science Abstracts, and Scopus) and 3 gray literature databases (MedEdPortal, Proquest: Dissertations, and OpenGrey). Article inclusion criteria were as follows: published over the 10-year period of 2007 to 2017, including an intervention for problem gambling, and involving the use of internet to deliver that intervention.

RESULTS

A total of 27 articles were found that met the review criteria. Studies were found from several different areas, with particularly strong representation for Australia, New Zealand, and Scandinavia. Cognitive behavioral therapy was the most common form of internet-based intervention. Internet-based interventions were generally shown to be effective in reducing problem gambling scores and gambling behaviors. A wide range of interventions that made use of internet resources included text-based interactions with counselors and peers, automated personalized and normative feedback on gambling behaviors, and interactive cognitive behavioral therapies. A lack of diversity in samples, little comparison with face-to-face interventions, and issues of changes in the treatment dynamic are identified as areas that require further investigation.

CONCLUSIONS

Internet-based interventions are a promising direction for treatment and prevention of problem gambling, particularly in reducing barriers to accessing professional help. The state of the current literature is sparse, and more research is needed for directly comparing internet-based interventions and their traditional counterparts.

Effects of a depression-focused internet intervention in slot machine gamblers: A randomized controlled trial

BACKGROUND

Problematic and pathological gambling have been linked to depression. Despite a high demand for treatment and negative financial consequences, only a small fraction of problematic and pathological gamblers seek professional help. The existing treatment gap could be narrowed by providing low-threshold, anonymous internet-based interventions. The aim of the present study was to examine the acceptance and efficacy of an online-intervention for depression ("Deprexis") in a sample of problematic and pathological slot-machine gamblers. We hypothesized that the intervention group would show a greater reduction in both depressive and gambling-related symptoms compared to a wait-list control group.

METHOD

A total of 140 individuals with self-reported gambling and mood problems were randomly allocated either to the intervention group or to a wait-list control group. After 8 weeks, all participants were invited for re-assessment. The Patient Health Questionnaire - 9 (PHQ-9) served as the primary outcome assessment. Problematic gambling was measured with the Pathological Gambling Adaptation of Yale-Brown Obsessive Compulsive Scale (PG-YBOCS) and the South Oaks Gambling Screen (SOGS). The trial is registered with the German Registry for Clinical Studies (DRKS00013888).

RESULTS

ITT analyses showed that the intervention led to a significant reduction in depressive symptoms as well as gambling-related symptoms compared to the control group, with moderate to strong effect sizes. PP analyses failed to yield significant results due to high rates of non-completion and limited statistical power. Moderator analyses indicated that Deprexis was particularly beneficial in reducing problematic gambling for those scoring high on baseline gambling-related symptoms and for those who gamble due to loneliness.

DISCUSSION

Results of the present study suggest that Deprexis might be a useful adjunct to traditional interventions for the treatment of problematic gambling. The potential of internet-based interventions that are more targeted at issues specific to gambling should be evaluated in future studies.

TRIAL REGISTRATION

German Registry for Clinical Studies DRKS00013888.

Behavioral Addictions as Mental Disorders: To Be or Not To Be?

Should excessive and problematic engagement in nonsubstance use behaviors be mental disorders? The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) repositioned gambling disorder in the substance use disorders section and introduced Internet gaming disorder in the research appendix; the International Classification of Diseases (ICD-11) is also considering it. This article outlines pros and cons of considering behavioral addictions as mental disorders and also reviews the DSM-5 decision-making processes. It focuses on three conditions: gambling disorder, Internet gaming disorder (IGD), and Internet addiction (IA). We detail assessment methods and prevalence rates for these conditions and outline psychiatric comorbidities, demographic and biological risk factors, and promising treatment approaches. We also briefly discuss other putative behavioral addictions: eating/food, sex, exercise, shopping, and tanning "addictions." Overall, data are inconclusive, and consistent terminology and methodology are needed to define and evaluate these conditions more fully prior to considering them mental disorders.

An overview of gambling disorder: from treatment approaches to risk factors

Gambling disorder (GD) has been reclassified recently into the "Substance-Related and Addictive Disorders" category of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a landmark occurrence for a behavioral addiction. GD is characterized by recurrent, maladaptive gambling behavior that results in clinically significant distress. Although the number of randomized controlled trials assessing the effectiveness of pharmacological treatments is limited, some pharmacological treatments, notably opiate antagonists, have been employed in the treatment of GD. Patients with GD often present cognitive distortions and specific personality traits, making treatment more difficult. Cognitive behavioral therapy has become the most common psychological intervention for treating gambling problems, and it is effective in reducing gambling behavior. In this brief overview, we provide a report on the state of pharmacological and psychological treatments for gambling disorder. Risk factors and potential future lines of research are addressed.

The Effectiveness of Internet-Based Cognitive Behavioral Therapy in Treatment of Psychiatric Disorders

This review article is an overview of the effectiveness of internet-based cognitive behavioral therapy (ICBT) in the treatment of psychiatric disorders. ICBT’s effectiveness has been investigated in treating and managing conditions like depression, generalized anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), adjustment disorder, bipolar disorder, chronic pain, and phobias. ICBT’s role in the treatment of medical conditions such as diabetes mellitus with comorbid psychiatric illnesses was also explored. Furthermore, this study elaborates on its cost-effectiveness and its impact in rural areas. We conducted a thorough literature search using PubMed and Google Scholar with no restrictions on the date. ICBT's role in treating and controlling psychiatric illnesses has been established in the literature. From the data compiled, we conclude that ICBT is useful in treating mental health and medical illnesses with psychiatric comorbidities. It has also been found to be cost-effective for patients and society. ICBT is a potential tool emerging with modern day technological advancements and is useful in rural and urban settings, across various languages and cultures, and on a global scale. Larger randomized control trials on its use in clinical practice and in reaching rural populations are bound to shed more light on the effectiveness of this tool along with spreading awareness among physician and patient communities.

Efficacy of face-to-face versus self-guided treatments for disordered gambling: A meta-analysis

Background and aims In the light of growing traditional and novel forms of gambling, the treatment of disordered gambling is gaining increasing importance and practical relevance. Most studies have examined face-to-face treatments. Although trials implementing self-guided treatments have recently been conducted, these options have not yet been systematically examined. The primary objective of this meta-analysis, therefore, was to analyze the efficacy of all types of psychological face-to-face and self-guided treatments. Methods A multilevel literature search yielded 27 randomized controlled studies totaling 3,879 participants to provide a comprehensive comparative evaluation of the short- and long-term efficacies of face-to-face and self-guided treatments for disordered gambling. Results As expected, the results revealed significantly higher effect sizes for face-to-face treatments (16 studies with Hedges's g ranging from 0.67 to 1.15) as compared with self-guided treatments (11 studies with Hedges's g ranging from 0.12 to 0.30) regarding the reduction of problematic gambling behavior. The intensity of treatment moderated the therapy effect, particularly for self-guided treatments. Discussion and Conclusions The results of this meta-analysis favor face-to-face treatments over self-guided treatments for the reduction of disordered gambling. Although the findings broaden the scope of knowledge about psychological treatment modalities for disordered gambling, further research is needed to identify the reasons for these differences with the goal to optimize the treatment for this disabling condition.