Latest Developments in Treatment for Disordered Gambling: Review and Critical Evaluation of Outcome Studies

Congruence couple therapy for alcohol use and gambling disorders with comorbidities (part I): Outcomes from a randomized controlled trial

A nonblinded randomized trial was conducted at two Canadian provincial outpatient addiction clinics that tested the effectiveness of a systemic congruence couple therapy (CCT) versus individual-based treatment-as-usual (TAU) on nine clinical outcomes: (1) primary outcomes-alcohol use and gambling, psychiatric symptoms, and couple adjustment; (2) secondary outcomes-emotion regulation, substance use, depression, post-traumatic stress symptoms, and life stress. Data of primary clients and partners (N = 46) were analyzed longitudinally across baseline, posttreatment (5 months), and follow-up (8 months). Alcohol use disorder (95%) and gambling disorder (5%) were in the severe range at baseline, and co-addiction was 27%. Psychiatric comorbidity was 100%, and 18% of couples were jointly addicted. Between-group comparison favored CCT in primary outcomes with medium-to-large effect sizes (Cohen's h = 0.74-1.44). Secondary outcomes were also significantly stronger for CCT (Cohen's h = 0.27-1.53). Within-group, for all primary outcomes, a significant proportion of symptomatic CCT clients and partners improved, converging with ANOVA results of large effect sizes (0.14-0.29). All secondary outcomes improved significantly in CCT with large effect sizes (0.14-0.50). TAU showed significant within-group improvement in alcohol use, other substance use, and life stress with large effect sizes (0.16-0.40). Primary clients and partners made largely equivalent improvement within CCT and within TAU. Results were triangulated with clients' satisfaction ratings and counselors' reports. Overall, significant within-group effects were detected for CCT both clinically and statistically and between-group difference favored CCT. Future trials are required to validate these promising findings.

e-Estesia: A Serious Game for Reducing Arousal, Improving Emotional Regulation and Increasing Wellbeing in Individuals with Gambling Disorder

Gambling disorder (GD) is associated with deficits in emotion regulation and impulsivity-related personality traits. In recent years there has been an increase in the use of serious games (SG) to address these factors with positive results. The aim of this study was to analyze the efficacy of the intervention with a new SG (e-Estesia), as an adjunct to a CBT intervention for GD. The sample comprised two groups (experimental group (n = 40) and control group (n = 64)) of patients with GD diagnosis. Both groups received 16 weekly CBT sessions and, concurrently, only the experimental group received 15 additional sessions with e-Estesia. Pre-post treatment with e-Estesia administered in both groups were: DSM-5 Criteria, South Oaks Gambling Screen, Symptom Checklist-Revised and measure of relapses, dropout and compliance of treatment. As regards the experimental group were also administered: Difficulties in Emotion Regulation Scale, Emotion Regulation Questionnaire, and Impulsive Behavior Scale. No statistically significant differences in the general psychopathological state, emotion regulation or impulsivity were found when comparing the groups. However, patients enrolled in the e-Estesia intervention had significantly less relapses and better indicators of treatment compliance than the control group. Considering these results, the use of complementary tools such as SG are useful for addressing GD.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSIONS

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

Reasons for dropping out of internet-based problem gambling treatment, and the process of recovery – a qualitative assessment

Problem gambling (PG) is a condition affecting the economy, mental health, and relationships of both the individuals with gambling problems, and concerned significant others (CSOs). While PG is treatable, few individuals with gambling problems seek treatment, and many drop out of treatment. This qualitative study aims to investigate a) the reasons for individuals with gambling problems to drop-out from Internet-based PG treatment, and b) what individuals with gambling problems and CSOs find helpful and unhelpful processes in PG recovery. A total of 16 participants (8 individuals with gambling problems and 8 CSOs) who had participated in an Internet-based PG treatment were interviewed over the telephone in a semi-structured interview. The interviews were analyzed using thematic analysis. Drop-out from treatment was one aspect of an overarching theme identified as unstable path to recovery, where alternating periods of progress and setbacks delineate several aspects of PG. Relapses, negative emotions, and changing life circumstances were identified to separately, and in combination, contribute to drop-out. Drop-outs were also explained by participants’ experiences of a reduced need for treatment. Openness and a support from CSOs and peers were identified as themes important for recovery. The results suggest that PG treatments should consider the emotional state, and comorbidities of the patients, in order to reduce drop-out and improve chances of recovery.

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.

Negative Recovery Capital in Gambling Disorder: A Conceptual Model of Barriers to Recovery

Recovery from any addiction, including gambling, involves continuous efforts to improve wellness despite the obstacles and challenges. The recovery capital (RC) model is a holistic conceptual framework operationalized along a continuum ranging from positive internal and external RC resources that enhance recovery to negative recovery capital (NRC) which are defined as obstacles that impede individuals from coping with their addiction. Although previous studies have conceptualized the positive side of the RC model, no study has systematically explored NRC. This study develops a model that maps and conceptualizes the elements that impede recovery from gambling disorder (GD). In the current study, 133 individuals with a lifetime GD were interviewed about the factors that have hindered their recovery. A content analysis identified 14 NRC categories that were classified into four domains: Human NRC (urges and uncontrolled urges, cognitive distortions, inaction, sensation seeking, stressful life events, negative emotions, ability to conceal, a lack of motivation to recover), Social NRC (lack of social or familial networks, conflictual or dangerous social networks), Community NRC (an environment that encourages gambling, money lenders), and Financial NRC (financial distress and debt, money as a risk factor). The discussion centers on a holistic perspective of the elements that hinder recovery from GD, and calls for intervention methods that aim to minimize NRC to provide more holistic solutions to GD and possibly other addictions.

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.

Locating gambling problems across a continuum of severity: Rasch analysis of the Quinte Longitudinal Study (QLS)

Addressing gambling problems across a continuum requires understanding of low severity problems, as well as severe levels of problem gambling or disorder. The aims of this study were thus to derive a map of how problematic gambling behaviours and harms are situated across a continuum, and identify the best available indicators of low severity problems to inform assessment and secondary prevention. This involved the Rasch analyses of baseline data from the Quinte Longitudinal Study (QLS); a community-based survey involving random-digit dialling of numbers around Belleville, Canada. Participants were n = 1305 adults with non-zero scores across 26-items from: the Problem Gambling Severity Index (PGSI); the NORC DSM Screen for Gambling Problems (NODS); and the Problem and Pathological Gambling Measure (PPGM). Results indicated that item-level measures except chasing losses provided fit to the Rasch model, and most were clustered within a narrow region of the continuum which resembled addictive disorders. At the most severe end were mainly items about harms, while there were few items representing low severity levels (feeling guilty, betting more than one can afford, attempts to reduce gambling, gambling more than intended). There was Differential Item Functioning (DIF) for several indicators of low severity problems. The findings suggest that measures remain closely aligned with psychiatric models and are suited for discriminating across severe levels of problem gambling or addictive disorder. Although cognitive-affective and behavioural indicators comprise the best available indicators of low severity symptoms, there is an urgent need for improvements in conceptualisation and measurement.

Randomized controlled trial of an Internet intervention for problem gambling provided with or without access to an Internet intervention for co-occurring mental health distress

BACKGROUND AND AIMS

The current randomized controlled trial tested whether there was benefit to providing an online gambling intervention and a separate self-help mental health intervention for anxiety and depression (i.e. MoodGYM) (G + MH), compared to only a gambling intervention (G only) among people with co-occurring gambling problems and mental health distress. The primary outcome of interest was improvement in gambling outcomes. Secondary analyses also tested for the impact of the combined intervention on depression and anxiety outcomes.

METHODS

Participants who were concerned about their gambling were recruited to help evaluate an online intervention for gamblers. Those who met criteria for problem gambling were randomized to receive either the G only or the G + MH intervention. Participants were also assessed for current mental health distress at baseline, with three quarters (n = 214) reporting significant current distress and form the sample for this study. Participants were followed-up at 3- and 6-months to assess changes in gambling status, and improvements in depression and anxiety.

RESULTS

Follow-up rates were poor (47% completed at least one follow-up). While there were significant reductions in gambling outcomes, as well as on measures of current depression and anxiety, there was no significant difference in outcomes between participants receiving the G only versus the G + MH intervention.

DISCUSSION AND CONCLUSION

There does not appear to be a benefit to providing access to an additional online mental health intervention to our online gambling intervention, at least among participants who are concerned about their gambling.Trial registration: ClinicalTrials.govNCT02800096; Registration date: June 14, 2016.

Who Are the Anonymous? Involvement and Predictors of Gamblers Anonymous Attendance Among Disordered Gamblers Presenting for Treatment

Gamblers Anonymous is the most widely available form of support for disordered gambling. Although chapters exist worldwide, knowledge of how attendees interact with the program is limited. The present study aimed to investigate involvement in Gamblers Anonymous among attendees, motives for attendance, and overall satisfaction with the program. Furthermore, potential gambling-related predictors of attendance versus deciding not to attend Gamblers Anonymous were investigated. A treatment-seeking sample of disordered gamblers (N = 512) from São Paulo, Brazil completed a series of self-report measures including an author-compiled Gamblers Anonymous survey. From the sample, 141 gamblers reported attending Gamblers Anonymous over the previous 30 days. An examination of involvement, satisfaction, and motives for attending Gamblers Anonymous was conducted, followed by regression analyses to assess predictors of attendance and satisfaction with the program. The majority of attendees (80%) reported some satisfaction with the program. The most common motive for attending Gamblers Anonymous was related to relapse prevention. Regression analyses revealed that greater gambling severity and number of days gambled were associated with not attending Gamblers Anonymous while giving testimonials was strongly related (OR = 6.18) to satisfaction with the program. The findings of this study contribute to the literature on Gamblers Anonymous. In particular, that members derive great satisfaction from the program and see it as a way to strengthen their abstinence goals. However, despite high satisfaction, the results also suggest that most members were passively involved in the program. More research that assesses the effectiveness of Gamblers Anonymous as either a stand-alone or adjunct treatment is needed.

Measuring treatment outcomes in gambling disorders: a systematic review

BACKGROUND AND AIMS

Considerable variation of outcome variables used to measure recovery in the gambling treatment literature has precluded effective cross-study evaluations and hindered the development of best-practice treatment methodologies. The aim of this systematic review was to describe current diffuse concepts of recovery in the gambling field by mapping the range of outcomes and measurement strategies used to evaluate treatments, and to identify more commonly accepted indices of recovery.

METHODS

A systematic search of six academic databases for studies evaluating treatments (psychological and pharmacological) for gambling disorders with a minimum 6-month follow-up. Data from eligible studies were tabulated and analysis conducted using a narrative approach. Guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were adhered to.

RESULTS

Thirty-four studies were reviewed systematically (RCTs = 17, comparative designs = 17). Sixty-three different outcome measures were identified: 25 (39.7%) assessed gambling-specific constructs, 36 (57.1%) assessed non-gambling specific constructs, and two instruments were used across both categories (3.2%). Self-report instruments ranged from psychometrically validated to ad-hoc author-designed questionnaires. Units of measurement were inconsistent, particularly in the assessment of gambling behaviour. All studies assessed indices of gambling behaviour and/or symptoms of gambling disorder. Almost all studies (n = 30; 88.2%) included secondary measures relating to psychiatric comorbidities, psychological processes linked to treatment approach, or global functioning and wellbeing.

CONCLUSIONS

In research on gambling disorders, the incorporation of broader outcome domains that extend beyond disorder-specific symptoms and behaviours suggests a multi-dimensional conceptualization of recovery. Development of a single comprehensive scale to measure all aspects of gambling recovery could help to facilitate uniform reporting practices across the field.

Experiences of Playscan: Interviews with users of a responsible gambling tool

Online gambling, encompassing a wide variety of activities and around-the-clock access, can be a potential risk factor for gamblers who tend to gamble excessively. Yet, the advent of online gambling has enabled responsible gambling (RG) features that may help individuals to limit their gambling behaviour. One of these features is RG tools that track gamblers' behaviour, performs risk assessments and provides advice to gamblers. This study investigated users' views and experiences of the RG tool Playscan from a qualitative perspective using a semi-structured interview. The tool performs a risk assessment on a three-step scale (low, medium and high risk). Users from every risk category were included. Twenty interviews were carried out and analysed using thematic analysis. Two main themes with associated sub-themes were identified: "Usage of Playscan and the gambling site" and "Experiences of Playscan". Important experiences in the sub-themes were lack of feedback from the tool and confusion when signing up to use Playscan. These experiences counteracted positive attitudes that should have promoted usage of the tool. Providing more feedback directly to users is a suggested solution to increase usage of the RG tool.

Gambling problems among patients in primary care: a cross-sectional study of general practices

BACKGROUND

Primary care is an important context for addressing health-related behaviours, and may provide a setting for identification of gambling problems.

AIM

To indicate the extent of gambling problems among patients attending general practices, and explore settings or patient groups that experience heightened vulnerability.

DESIGN AND SETTING

Cross-sectional study of patients attending 11 general practices in Bristol, South West England.

METHOD

Adult patients (n = 1058) were recruited from waiting rooms of practices that were sampled on the basis of population characteristics. Patients completed anonymous questionnaires comprising measures of mental health problems (for example, depression) and addictive behaviours (for example, risky alcohol use). The Problem Gambling Severity Index (PGSI) measured gambling problems, along with a single-item measure of gambling problems among family members. Estimates of extent and variability according to practice and patient characteristics were produced.

RESULTS

There were 0.9% of all patients exhibiting problem gambling (PGSI ≥5), and 4.3% reporting problems that were low to moderate in severity (PGSI 1-4). Around 7% of patients reported gambling problems among family members. Further analyses indicated that rates of any gambling problems (PGSI ≥1) were higher among males and young adults, and more tentatively, within a student healthcare setting. They were also elevated among patients exhibiting drug use, risky alcohol use, and depression.

CONCLUSION

There is need for improved understanding of the burden of, and responses to, patients with gambling problems in general practices, and new strategies to increase identification to facilitate improved care and early intervention.