How Well are We Helping Problem Gamblers? An Update to the Evidence Base Supporting Problem Gambling Treatment

When Does Premature Treatment Termination Occur? Examining Session-by-Session Dropout Among Clients with Gambling Disorder

Premature termination challenges the successful outcomes of psychological treatments for gambling disorder. To date, research has primarily identified clients who are at particular risk for dropping out of treatment. A smaller but growing body of literature has investigated when dropout occurs. Typically, those studies have not considered improvement in psychological distress within their operationalizations of dropout and therefore may have misrepresented when dropout occurs. The current study examined when dropout occurs using an operationalization based on the criteria of attaining reliable change in a naturalistic sample of clients with gambling disorder, and the classification rates yielded from that operationalization were compared to the rates from a more common operationalization. Participants (n = 334) were clients meeting diagnostic criteria for gambling disorder at an outpatient private practice who completed a measure of psychological distress at baseline and prior to each subsequent treatment session. A survival analysis was conducted to determine temporal patterns of treatment dropout (i.e., clients who discontinued treatment before realizing reliable changes in psychological distress) and completion (i.e., clients who discontinued treatment after realizing reliable changes in distress) at each treatment session. Forty-nine percent of clients were classified as dropouts, and the majority of those clients did so in the first few sessions. The more common operationalization of dropout classified clients as dropouts when they had improved in their distress and clients as completers when they had not improved in their distress. Discussion centers on the implications of dropout occurring at various stages of treatment and future directions.

Mindfulness and problem gambling: a review of the literature

This article reviews the literature with respect to mindfulness and its potential for reducing the severity of problem gambling behaviour. Interest in the role of mindfulness as a treatment for problem gambling has gained the attention of researchers across Australia, the United States, and Canada. However, the literature is limited and current studies have severe methodological limitations. Despite this issue, investigations have revealed that dispositional mindfulness is related to less severe problem gambling outcomes and that psychological distress, overconfidence and risk willingness, myopic focus on reward and ego involvement may act as mediators in this relationship. Moreover, the literature indicates that the inverse relationship between dispositional mindfulness and psychological distress may be mediated by factors such as values clarification; emotional, cognitive, and behavioural flexibility; non-attachment; emotion dysregulation/distress intolerance; thought suppression; and rumination. This article discusses the theoretical and clinical implications of these relationships with respect to mindfulness-based interventions for problem gambling. It is recommended that the approach be considered with cautious optimism.

Psychological therapies for pathological and problem gambling

BACKGROUND

Various psychological therapies for pathological and problem gambling have been evaluated in randomised trials. A synthesis of best-quality evidence is required.

OBJECTIVES

The objective was to synthesise evidence from randomised trials of psychological therapies for pathological and problem gambling (cognitive-behaviour therapy (CBT), motivational interviewing therapy, integrative therapy, other psychological therapy), in order to indicate the efficacy of therapies and durability of therapy effects, relative to control conditions.

SEARCH METHODS

We conducted a search of the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR), which includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (The Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also carried out complementary searches of MEDLINE, EMBASE, PsycINFO, LILACS and CENTRAL for studies published between January 1980 and October 2011. We examined the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov and also conducted manual searches of selected journals and reference lists of included studies.

SELECTION CRITERIA

Included studies were clinical trials using random allocation to groups, considering pathological or problem gamblers, and evaluating a psychological therapy for pathological or problem gambling. Control conditions included 'no treatment' controls, referral to Gamblers Anonymous and non-specific treatment component controls.

DATA COLLECTION AND ANALYSIS

We systematically extracted data on the characteristics and results of studies. Primary outcomes were measures of gambling symptom severity, financial loss from gambling and frequency of gambling. Secondary outcomes were occurrence of pathological gambling diagnoses and depression and anxiety symptoms. Treatment effects were defined by comparisons between therapy and control conditions at post-treatment assessments (conducted from 0 to 3 months following completion of treatment) and follow-up assessments (conducted from 9 to 12 months following completion of treatment), respectively, using the standardised mean difference (SMD) or risk ratio (RR). We synthesised results through random-effects meta-analysis.

MAIN RESULTS

Fourteen studies (n = 1245) met the inclusion criteria. Eleven studies compared CBT with control and comparisons at 0 to 3 months post-treatment showed beneficial effects of therapy that ranged from medium (when defined by financial loss from gambling: SMD -0.52; 95% confidence interval (CI) -0.71 to -0.33, n = 505) to very large (for gambling symptom severity: SMD -1.82; 95% CI -2.61 to -1.02, n = 402). Only one study (n = 147) compared groups at 9 to 12 months follow-up and produced smaller effects that were not significant. Four studies of motivational interviewing therapy were identified and mainly considered samples demonstrating less severe gambling (relative to studies of pathological gamblers). Data suggested reduced financial loss from gambling following motivational interviewing therapy at 0 to 3 months post-treatment (SMD -0.41; 95% CI -0.75 to -0.07, n = 244), although comparisons on other outcomes were not significant. The effect approached zero when defined by gambling symptom severity (SMD -0.03; 95% CI -0.55 to 0.50, n = 163). Studies compared groups at 9 to 12 months follow-up and found a significant effect of motivational interviewing therapy in terms of frequency of gambling (SMD -0.53; 95% CI -1.04 to -0.02, n = 62), with comparisons on other outcomes that were not significant. Two studies of integrative therapies also considered samples demonstrating overall low gambling severity, and found no significant effects of therapy at 0 to 3 months post-treatment. Comparisons at 9 to 12 months follow-up suggested a medium effect from therapy in terms of gambling symptom severity, with no significant differences for other outcomes. One study (n = 18) considered another psychological therapy (i.e.Twelve-Step Facilitated Group Therapy) and suggested beneficial effects in terms of most outcomes at 0 to 3 months post-treatment. The evidence supporting these various classes of therapy ranged from very low to low quality.

AUTHORS' CONCLUSIONS

This review supports the efficacy of CBT in reducing gambling behaviour and other symptoms of pathological and problem gambling immediately following therapy. However, the durability of therapeutic gain is unknown. There is preliminary evidence for some benefits from motivational interviewing therapy in terms of reduced gambling behaviour, although not necessarily other symptoms of pathological and problem gambling. However, the findings are based on few studies and additional research is needed to inform conclusions. There is also evidence suggestive of some possible benefit from integrative therapies, and other psychological therapies for pathological and problem gambling. However, there are too few studies and evidence is insufficient to evaluate these therapies. The majority of studies in this review varied in risk of bias, and much of the evidence comes from studies with multiple limitations. The current data may thus reflect overestimates of treatment efficacy.

Mindfulness-Based Cognitive Therapy for Problem Gambling

This article describes treatment of a female problem gambler using mindfulness-based cognitive therapy (MBCT). The treatment protocol was adapted for problem gamblers from the manualized MBCT intervention developed by Segal, Williams, and Teasdale. Gambling behavior and mindfulness practice were monitored using daily diary entries maintained by the participant. The Beck Anxiety Inventory, Beck Depression Inventory—II, and the Five Facet Mindfulness Questionnaire were administered at pretreatment, posttreatment, 4-week follow-up, and 10-week follow-up phases. The Client Satisfaction Questionnaire was also used to assess acceptability of the intervention. The participant abstained from gambling, and anxiety and depression scores significantly reduced to subclinical levels over the assessment period. Exploration of mindfulness facets revealed that MBCT for problem gambling (MBCT-PG) may be useful in promoting acceptance of distressing thoughts and emotions. However, the participant did not maintain an intensive mindfulness-meditation practice over the follow-up phase of the intervention. The clinical implications of this case study are discussed.

Treatment outcomes and predictors of drop out for problem gamblers in South Australia: a cohort study

OBJECTIVES

Recent prevalence studies in Australia, the USA and Canada have estimated 1-2% of the adult population meet the diagnostic criteria for problem or pathological gambling. The Statewide Gambling Therapy Service (SGTS) provides treatment for problem gamblers in key metropolitan and rural regions in South Australia. The aims of this study were two-fold: to analyse the short and mid-term outcomes following treatment provided by SGTS and to identify factors associated with treatment drop-out.

METHOD

A cohort of treatment seeking problem gamblers was recruited through SGTS in 2008. Repeated outcome measures included problem gambling screening, gambling related cognitions and urge. Treatment drop-out was defined as participants attending three or less treatment sessions, whilst potential predictors of drop-out included perceived social support , anxiety and sensation-seeking traits.

RESULTS

Of 127 problem gamblers who participated in the study, 69 (54%) were males with a mean age of 43.09 years (SD = 12.65 years) and with 65 (52%) reporting a duration of problem gambling greater than 5 years. Follow up time for 50% of participants was greater than 8.9 months and, overall, 41 (32%) participants were classified as treatment drop-outs. Results indicated significant improvement over time on all outcome measures except alcohol use for both treatment completers and drop-outs, although to a lesser extent for the treatment drop-out group. A significant predictor of treatment drop-out was sensation-seeking traits.

CONCLUSION

These results will inform future treatment planning and service delivery, and guide research into problem gambling including aspects of treatment drop-out.