Stages of change in treatment-seeking pathological gamblers

Stages of psychological change among patients with non-alcoholic fatty liver disease in China: a national cross-sectional study

OBJECTIVES

Non-alcoholic fatty liver disease (NAFLD) is becoming the leading cause of chronic liver disease worldwide. However, treatment of NAFLD is potentially influenced by psychological conditions. Using the simplified version of the University of Rhode Island Change Assessment (URICA-SV) scale, this study aimed to evaluate the stage of psychological change as a prerequisite to refining implementation strategies for psychological change.

DESIGN

A multicentre cross-sectional survey.

SETTING

Ninety hospitals in China.

PARTICIPANTS

5181 patients with NAFLD were included in this study.

OUTCOME MEASURES

All patients completed the URICA-SV questionnaire and were assigned to one of the three stages of change (precontemplation, contemplation or action) according to their readiness scores. A stepwise multivariate logistic regression analysis was used to identify independent factors associated with the stage of psychological change.

RESULTS

A total of 4832 (93.3%) patients were included in the precontemplation stage and only 349 (6.7%) considered making a change or preparing to make one. There were significant differences in gender (Cohen's d=0.039, p=0.005), age (Cohen's d=-0.327, p<0.001), waist circumference (Cohen's d=0.143, p=0.003), alanine transaminase (Cohen's d=0.347, p=0.001), triglyceride (Cohen's d=0.351, p=0.002), body mass index (BMI; Cohen's d=0.056, p<0.001), proportion of hyperlipidaemia (Cohen's d=0.068, p<0.001) and cardiovascular disease (Cohen's d=0.032, p=0.029), therapeutic regimen (Cohen's d=0.136, p<0.001), and Chronic Liver Disease Questionnaire-Non-Alcoholic Fatty Liver Disease overall score (Cohen's d=-0.420, p<0.001) between patients with NAFLD in the precontemplation stage and those in the contemplation/action stage. Logistic regression identified BMI (HR 0.659, 95% CI 0.469 to 0.928, p=0.017), cardiovascular disease (HR 2.161, 95% CI 1.089 to 4.287, p=0.027) and triglyceride (HR 0.751, 95% CI 0.591 to 0.955, p=0.020) as independent factors predicting psychological change.

CONCLUSIONS

The results demonstrated that very few patients with NAFLD presented psychological condition in the stage of action. Psychological condition was found to be significantly related to BMI, cardiovascular disease and triglyceride factors. Integrated diversity considerations for evaluating psychological change are necessary.

The role of cultural worldviews in predicating gambling risk perception and behavior in a Chinese sample

OBJECTIVES

We investigated the relationships between cultural worldviews, gambling risk perception, and gambling behavior with a sample of tourists in Macao.

METHODS

Participants were enrolled at famous landmarks and casinos in Macao, China. Data were collected using several instruments to assess an individual's cultural worldviews, gambling risk perceptions, and gambling intentions.

RESULTS

We found that the three-dimensional solution was valid for the Chinese version of the gambling expectancy scale. Correlational and mediational analyses revealed that the relationship between an individualistic worldview and gambling intention was fully mediated by gambling risk perception. Respondents with an egalitarian worldview perceived greater risk associated with gambling than those with other worldviews.

CONCLUSION

These findings demonstrated the important influence of cultural variables on perceived risk and behavior in gambling. Moreover, understanding gamblers' worldviews could be beneficial for problem gambling interventions. Future research directions and the limitations of the findings were discussed.

Direct Marketing Experiences Among Individuals With Current and Lifetime Gambling Disorder

Gambling providers use varied and complex marketing techniques, including marketing that targets the individual directly. Previous research indicates that individuals with gambling disorder are disproportionately influenced by gambling marketing, however, very few studies have examined gamblers' experiences with direct marketing. The current exploratory interview study examined experiences with direct gambling marketing among 12 individuals with either current (n = 5) or lifetime (n = 7) gambling disorder. A broad research question was employed encompassing experiences with different types of direct marketing and corresponding attitudes, influences, and interactions. The interview data were analyzed with thematic analysis using an inductive approach, and the participants reported extensive and varied experiences with direct marketing. Two overarching themes, with two and four subthemes, respectively, were identified. The overarching themes showed that marketing experiences were intimately connected with participants' gambling behaviors and their relationships to their own problems. Overall, direct marketing was experienced as an interactive form of marketing with individually tailored promotions such as free gambling credits, bonuses, and special gifts. Some promotions were experienced as personal, while others were experienced as mass produced. Direct marketing was in some cases experienced as predatory and was reported to hamper the participants' ability to cope with their gambling disorder. Participants' attitudes toward direct marketing varied as a function of the participants' engagement in gambling. During periods of active gambling, direct marketing was experienced as beneficial and positive as the participants took advantage of the offers or actively manipulated how the offers were made. In contrast, when attempting to reduce/abstain from gambling, the participants experienced direct marketing as aggressive, and they reported making considerable efforts to try to limit it. Direct marketing was experienced as a trigger for gambling urges and was reported to induce a conflict between gambling and abstinence. Directly marketed promotions are discussed in relation to ecological factors of access and availability that form a basis for the development of gambling disorder, and variations in experiences are related to stages of change in gambling disorder. Implications for treatment are discussed where the current findings suggest that coping with marketing should be addressed in treatment.

Internet-based cognitive behavior therapy for problem gambling in routine care: protocol for a non-randomized pilot and feasibility trial

Background

Problem gambling and gambling disorder are major public health concerns worldwide, and awareness of associated negative consequences is rising. In parallel, treatment demand has increased, and Internet interventions offer a promising alternative for providing evidence-based treatment at scale to a low cost.

Method

We developed a novel Internet-delivered cognitive behavioral treatment for gambling, based on qualitative interviews with treatment-seeking gamblers, behavioral research on gambling behavior, and the pathway model for problem gambling. This research protocol describes a non-randomized pilot and feasibility trial conducted in routine addiction care with adult treatment-seeking patients (max N = 25) with problem gambling. The primary aim is to ensure acceptability and safety, measured by satisfaction, credibility, working alliance, and possible negative effects. Secondary aims are feasibility of study procedures in terms of recruitment and measurement procedures as well as potential effectiveness measured weekly by gambling symptoms as primary outcome and gambling behavior, quality of life, symptoms of depression and anxiety, alcohol, and drug use as secondary outcomes. Potential mediators measured weekly are loss of control, verbal rules, and well-being.

Discussion

This study is innovative in several respects, regarding both treatment development and implementation. The results of the study will guide a future randomized controlled trial, as well as the development of the intervention and intervention implementation within ordinary addiction care.

Trial registration

Clinical trials.gov, NCT ID: NCT03946098. Registered 10 May 2019

Correlation between precontemplation and alpha activity in gambling disorder

PURPOSE

Gambling disorder is a psychiatric condition characterized by persistent and recurrent maladaptive gambling. In the present study, we evaluated the characteristics of resting-state electroencephalogram (EEG) recordings in patients with gambling disorder. In addition, we explored the association between the EEG characteristics of the patients and the stages of change in a transtheoretical model.

METHODS

All participants were men who visited a gambling disorder clinic in Seoul, Korea. At the assessment, questionnaires, including the Readiness to Change Questionnaire (RCQ), were administered and resting-state EEGs were carried out. Participants were grouped based on Ward's method for cluster analysis. Independent sample t-tests were used to evaluate group differences. To assess the relationship between the clinical data and the EEG recordings, we used Pearson's partial correlation analysis.

RESULTS

Overall, 63 male participants were enrolled. Cluster analysis of the alpha activity revealed two clusters. No significant differences were observed in the demographic or clinical data between the two groups except for the Beck Depression Inventory (BDI). We found that the precontemplation score of the RCQ was positively correlated with the z-score of the relative alpha power in almost all cortical regions.

CONCLUSION

This study suggests that EEG parameters, particularly alpha activity, could inform us about the subtypes or stages of change in gambling disorder. Alpha power is the predominant EEG rhythm in a relaxed, alert person; thus, alpha power serves as an index of relaxation. We expect that the level of alpha activity could be utilized as an additional parameter to help clinicians assess and treat patients with gambling disorder.

Gender Differences in Self-Conscious Emotions and Motivation to Quit Gambling

Considerable gender differences have been previously noted in the prevalence, etiology, and clinical features of problem gambling. While differences in affective states between men and women in particular, may explain differential experiences in the process of gambling, the role of affect in motivations for quitting gambling and recovery has not been thoroughly explored. The aim of this study was to examine gender differences within a sample of problem gamblers motivated to quit with or without formal treatment, and further, to explore the interactions between gender, shame and guilt-proneness, and autonomous versus controlled reasons for change. Motivation for change and self-conscious emotional traits were analyzed for 207 adult problem gamblers with an interest in quitting or reducing their gambling (96.6 % not receiving treatment). Overall, gender differences were not observed in clinical and demographic characteristics. However, women exhibited greater shame [F(1,204) = 12.11, p = 0.001] and guilt proneness [F(1,204) = 14.16, p < 0.001] compared to men, whereas men scored higher on trait detachment [F(1,204) = 7.08, p = 0.008]. Controlling for demographic and clinical characteristics, general linear models revealed that autonomous motivation for change was associated with higher guilt-proneness, greater problem gambling severity, and the preparation stage of change; whereas controlled forms of motivation were significantly associated with higher shame-proneness and greater problem gambling severity. No gender effects were observed for either motivation for change. These findings suggest that the process of change can be different for shame-prone and guilt-prone problem gamblers, which may impact behavioral outcomes.

Motivation to quit or reduce gambling: Associations between Self-Determination Theory and the Transtheoretical Model of Change

Motivation for change and recovery from addiction has been commonly assessed using the Transtheoretical Model's stages of change. Analogous to readiness for change, this measure of motivation may not recognize other elements of motivation relevant to successful change. The aim of this study was to examine the relationship between stages of change and reasons for change according to the Self-Determination Theory among problem gamblers motivated to quit. Motivations for change were examined for 200 adult problem gamblers with intent to quit in the next 6 months (contemplation stage) or 30 days (preparation stage). Analyses revealed that higher autonomous motivation for quitting gambling predicted greater likelihood of being in the preparation stage, whereas those with higher external motivation for change were less likely to be farther along the stage of change continuum. The findings suggest that autonomous motivations relate to readiness for quitting gambling, and may predict successful resolution from problem gambling.

Predictors of outcomes of psychological treatments for disordered gambling: A systematic review

This systematic review aimed to synthesise the evidence relating to pre-treatment predictors of gambling outcomes following psychological treatment for disordered gambling across multiple time-points (i.e., post-treatment, short-term, medium-term, and long-term). A systematic search from 1990 to 2016 identified 50 articles, from which 11 socio-demographic, 16 gambling-related, 21 psychological/psychosocial, 12 treatment, and no therapist-related variables, were identified. Male gender and low depression levels were the most consistent predictors of successful treatment outcomes across multiple time-points. Likely predictors of successful treatment outcomes also included older age, lower gambling symptom severity, lower levels of gambling behaviours and alcohol use, and higher treatment session attendance. Significant associations, at a minimum of one time-point, were identified between successful treatment outcomes and being employed, ethnicity, no gambling debt, personality traits and being in the action stage of change. Mixed results were identified for treatment goal, while education, income, preferred gambling activity, problem gambling duration, anxiety, any psychiatric comorbidity, psychological distress, substance use, prior gambling treatment and medication use were not significantly associated with treatment outcomes at any time-point. Further research involving consistent treatment outcome frameworks, examination of treatment and therapist predictor variables, and evaluation of predictors across long-term follow-ups is warranted to advance this developing field of research.

Subtyping based on readiness and confidence: the identification of help-seeking profiles for gamblers accessing web-based counselling

BACKGROUND AND AIMS

Problem gamblers are not a homogeneous group and recent data suggest that subtyping can improve treatment outcomes. This study administered three readiness rulers and aimed to identify subtypes of gamblers accessing a national web-based counselling service based on these rulers.

METHODS

Participants were 1204 gamblers (99.4% problem gamblers) who accessed a single session of web-based counselling in Australia. Measures included three readiness rulers (importance, readiness and confidence to resist an urge to gamble), demographics and the Problem Gambling Severity Index (PGSI).

RESULTS

Gamblers reported high importance of change [mean = 9.2, standard deviation (SD) = 1.51] and readiness to change (mean = 8.86, SD = 1.84), but lower confidence to resist an urge to gamble (mean = 3.93, SD = 2.44) compared with importance and readiness. The statistical fit indices of a latent class analysis identified a four-class model. Subtype 1 was characterized by a very high readiness to change and very low confidence to resist an urge to gamble (n = 662, 55.0%) and subtype 2 reported high readiness and low confidence (n = 358, 29.7%). Subtype 3 reported moderate ratings on all three rulers (n = 139, 11.6%) and subtype 4 reported high importance of change but low readiness and confidence (n = 45, 3.7%). A multinomial logistic regression indicated that subtypes differed by gender (P < 0.001), age (P = 0.01), gambling activity (P < 0.05), preferred mode of gambling (P < 0.001) and PGSI score (P < 0.001).

CONCLUSIONS

Problem gamblers in Australia who seek web-based counselling comprise four distinct subgroups based on self-reported levels of readiness to change, confidence to resist the urge to gamble and importance of change.

Pathological gambling: understanding relapses and dropouts

There is little available information on the factors that influence relapses and dropouts during therapy for pathological gambling (PG). The aim of this study was to determine socio-demographic, clinical, personality, and psychopathological predictors of relapse and dropout in a sample of pathological gamblers seeking treatment. A total of 566 consecutive outpatients diagnosed with PG according to DSM-IV-TR criteria were included. All patients underwent an individualized cognitive-behavioral treatment program. We analyzed predictors of relapse during 6months of treatment and during the subsequent 6months of follow-up, and predictors of dropout over the entire therapeutic program. Eighty patients (14.1%) experienced at least one relapse during the entire follow-up of the study: 50 (8.8%) within the treatment period and 12 (2.1%) during the subsequent 6-month follow-up period. The main predictors of relapse were single marital status, spending less than 100euros/week on gambling, active gambling behavior at treatment inclusion, and high scores on the TCI-R Harm Avoidance personality dimension. One hundred fifty-seven patients (27.8%) missed 3 or more therapeutic sessions over the entire therapeutic program. The main predictors of dropout were single marital status, younger age, and high scores on the TCI-R Novelty Seeking personality dimension. The presence of these factors at inclusion should be taken into account by physicians dealing with PG patients.

Using Roadside Billboard Posters to Increase Admission Rates to Problem Gambling Services: Reflections on Failure

Based on the stimulus-response model of advertising, this study sought to increase admission rates to a local problem gambling service (PGS) in Windsor, Ontario, Canada, by adding a series of locally based 10 foot by 20 foot roadside billboard posters to PGS's existing communications tools for a 24-week period. Using proof of performance reports, a pre-post survey of new callers to PGS, a website visit counter, and a media awareness survey, the findings showed that at least some individuals were influenced by billboard exposure, but admission rates continued to decline during the billboard campaign period. While one possible explanation for the communications failure was that the whole PGS communications campaign was below the minimal threshold for communications perception, another possible explanation is that the stimulus-response model of advertising used may not have been appropriate for such advertising that targets behavior change. Reflections on using an information-processing model instead of a stimulus-response model, and considerations of a two-step flow of communication, are provided. Recommendations are made regarding matching communications messages to stages of behavior change, use of online promotion, and strategies for future research.

Problem gambling subtypes based on psychological distress, alcohol abuse and impulsivity

The notion of comorbidities within problem gambling populations has important clinical implications, particularly for appropriate treatment matching. The comorbidities most commonly cited in problem gambling literature include depression, anxiety, alcohol abuse and impulsivity. Previous research shows evidence of patterns in multiple co-occurring comorbidities and that there may be different subtypes of gamblers based on these patterns. To further the current understanding of gambling subtypes, the aim of our study was to identify subtypes of gamblers currently in treatment. Hierarchical Cluster Analysis yielded four mutually exclusive groups of 202 gamblers: (1) gamblers with comorbid psychological problems (35%); (2) 'pure' gamblers without other comorbidities (27%); (3) gamblers with comorbid alcohol abuse (25%); and (4) 'multimorbid' gamblers (13%). The four groups differed on demographic information, drug use and gambling behaviours including gambling activity and problem gambling severity. Gamblers with comorbid psychological problems were more likely to be older women on low income, more likely to report a family history of psychological problems and were more often electronic gaming machine players. As expected, 'pure' gamblers had lower problem gambling severity and were more likely to report current abstinence. Gamblers with comorbid alcohol abuse were more likely to be young men who used stimulant drugs, endorsed a higher quality of life and worked full-time. 'Multimorbid' gamblers were elevated on all comorbidities, had general problems related to their health and wellbeing and reported high rates of hostility and aggression. These groups combine elements of existing conceptual models of gambling subtypes and may require different treatments.

Who goes to treatment? Predictors of treatment initiation among gambling help-line callers

BACKGROUND AND OBJECTIVES

Although the consequences of problem gambling can be severe, few ever seek treatment for this disorder. Problem gambling help-lines represent a crucial point of entry into the treatment system. Through brief telephone counseling, help-lines have the potential of enhancing callers' motivations to engage in longer-term treatment. We prospectively examined treatment initiation and its predictors among individuals calling a state help-line.

METHODS

Participants (n = 143) were assessed shortly after their initial call and re-contacted at least two months later.

RESULTS

Overall 67% of the re-contacted help-line callers had attended at least one treatment session at the time of the follow-up interview (92.7% formal treatment and 28.1% peer-support meetings). Multivariate analysis revealed that gambling-related financial difficulties and past treatment for problem gambling (but not for mental health or substance abuse) predicted treatment initiation.

CONCLUSIONS AND SIGNIFICANCE

Enhanced counseling focusing on motivational factors may result in better treatment engagement for some problem gamblers.

Predictors of treatment outcome among Asian pathological gamblers (PGs): clinical, behavioural, demographic, and treatment process factors

Research on predictors of treatment outcome among pathological gamblers (PGs) is inconclusive and dominated by studies from Western countries. Using a prospective longitudinal design, the current study examined demographic, clinical, behavioural and treatment programme predictors of gambling frequency at 3, 6 and 12-months, among PGs treated at an addiction clinic in Singapore. Measures included the Hospital anxiety and depression scale, gambling symptom assessment scale (GSAS), personal well-being index (PWI), treatment perception questionnaire and gambling readiness to change scale. Treatment response in relation to changes in symptom severity, personal wellbeing and abstinence were also assessed. Abstinence rates were 38.6, 46.0 and 44.4 % at 3, 6 and 12-months respectively. Significant reductions in gambling frequency, GSAS, and improvement in PWI were reported between baseline and subsequent outcome assessments, with the greatest change occurring in the initial three months. No demographic, clinical, behavioural or treatment programme variable consistently predicted outcome at all three assessments, though treatment satisfaction was the most frequent significant predictor. However, being unemployed, having larger than average debts, poor treatment satisfaction and attending fewer sessions at the later stages of treatment were associated with significantly poorer outcomes, up to 1-year after initiating treatment. These findings show promise for the effectiveness of a CBT-based treatment approach for the treatment of predominantly Chinese PGs. Clinical implications and suggestions for future research are discussed. Taken together, the findings suggest early treatment satisfaction is paramount in improving short-term outcomes, with baseline gambling behaviour and treatment intensity playing a more significant role in the longer term.

The use of clinical trials in comparative effectiveness research on mental health

OBJECTIVES

A large body of comparative effectiveness research (CER) focuses on the use of observational and quasi-experimental approaches. We sought to examine the use of clinical trials as a tool for CER, particularly in mental health.

STUDY DESIGN AND SETTING

Examination of three ongoing randomized clinical trials in psychiatry addressing issues that would pose difficulties for nonexperimental CER methods.

RESULTS

Existing statistical approaches to nonexperimental data appear insufficient to compensate for biases that may arise when the pattern of missing data cannot be properly modeled such as when there are no standards for treatment, when affected populations have limited access to treatment, or when there are high rates of treatment dropout.

CONCLUSION

Clinical trials should retain an important role in CER, particularly in cases of high disorder prevalence, large expected effect sizes, difficult-to-reach populations, or when examining sequential treatments or stepped-care algorithms. Progress in CER on mental health will require careful consideration of appropriate selection between clinical trials and nonexperimental designs and on allocation of research resources to optimally inform key treatment decisions for each patient.

Internet-based CBT intervention for gamblers in Finland: experiences from the field

From September 2007 to May 2011 a total of 471 participants (325 males and 146 females) signed up for an 8-week Internet-based cognitive behavioral therapy offered for gamblers in Finland. Sixty-four percent of the participants were pathological gamblers (PGs) (NODS 5> points), 14% were problem gamblers (NODS 3-4 points) and 10% were at risk of gambling problems (NODS 1-2 points). Two hundred and twenty four participants completed the treatment and after the treatment period significant changes were found in the following variables: gambling related problems (NODS), gambling urge, impaired control of gambling, alcohol consumption (AUDIT-C), social consequences, gambling-related cognitive erroneous thoughts and depression (MARD-S). In this sample co-morbid alcohol consumption was stronger among males. The main finding of this study was that the onset age of gambling was associated with a greater amount of gambling-related cognitive erroneous thoughts.

A preliminary, qualitative exploration of the influences associated with drop-out from cognitive-behavioural therapy for problem gambling: an Australian perspective

It has been estimated that 80% of Australians engage in some form of gambling, with approximately 115,000 Australians experiencing severe problems (Productivity Commission 2010). Very few people with problem gambling seek help and, of those who do, large numbers drop-out of therapy before completing their program. To gain insights into these problems, participants who had either completed or withdrawn prematurely from an individual CBT-based problem gambling treatment program were interviewed to examine factors predictive of premature withdrawal from therapy as well as people's 'readiness' for change. The results indicated that there might be some early indicators of risk for early withdrawal. These included: gambling for pleasure or social interaction; non-compliance with homework tasks; gambling as a strategy to avoid personal issues or dysphoric mood; high levels of guilt and shame; and a lack of readiness for change. The study further showed that application of the term 'drop-out' to some clients may be an unnecessarily negative label in that a number appear to have been able to reduce their gambling urges even after a short exposure to therapy.

Brief motivational feedback and cognitive behavioral interventions for prevention of disordered gambling: a randomized clinical trial

AIMS

The purpose of the current study was to evaluate feasibility and efficacy of two promising approaches to indicated prevention of disordered gambling in a college population.

DESIGN

Randomized clinical trial with assignment to a personalized feedback intervention (PFI), cognitive-behavioral intervention (CBI) or assessment-only control (AOC). PFI was delivered individually in a single session and included feedback regarding gambling behavior, norms, consequences and risk-reduction tips, delivered in a motivational interviewing style. CBI was delivered in small groups over four to six sessions and included functional analysis and brief cognitive correction, as well as identification of and alternatives for responding to gambling triggers.

SETTING

College campus.

PARTICIPANTS

At-risk or probable pathological gamblers (n = 147; 65.3% male; group assignment: PFI, n = 52; CBI, n = 44; AOC, n = 51).

MEASUREMENTS

Self-reported gambling quantity, frequency, consequences, psychopathology, normative perceptions and beliefs.

FINDINGS

Relative to control, results at 6-month follow-up indicated reductions in both interventions for gambling consequences (PFI d = 0.48; CBI d = 0.39) and DSM-IV criteria (PFI d = 0.60; CBI d = 0.48), reductions in frequency for PFI (d = 0.48). CBI was associated with reduced illusions of control, whereas PFI was associated with reduced perceptions of gambling frequency norms. Reductions in perceived gambling frequency norms mediated effects of PFI on gambling frequency.

CONCLUSIONS

A single-session personalized feedback intervention and a multi-session cognitive-behavioral intervention may be helpful in reducing disordered gambling in US college students.

Internet-based treatment of pathological gambling with a three-year follow-up

Effective therapies for pathological gambling exist, but their use is limited to about 10% of the target population. In an attempt to lower the barriers for help, Internet-based cognitive behavioural therapy (ICBT) has been shown to be effective when delivered to anon-depressed sample with pathological gambling. This study sought to extend this finding to a larger, more representative population, and also test a model to predict responder status. Following advertisement, a total of 284 participants started an 8-week ICBT programme with minimal therapist contact via e-mail and weekly telephone calls of less than 15 min. The average time spent on each participant, including telephone conversations, e-mail, and administration, was 4 h. In addition to a mixed effects model to evaluate the effectiveness of the treatment, two logistic regression analyses were performed with the following eight pre-defined response predictor variables: work-life satisfaction, primary gambling activity, debts due to gambling, social support, personal yearly salary, alcohol consumption, stage of change, and dissociative gambling. ICBT resulted in statistically significant reductions in the scores of pathological gambling, anxiety, and depression as well as an increase in quality of life compared to pre-treatment levels. Follow-ups carried out in the treatment group at 6, l8, and 36 months indicated that treatment effects were sustained. Using the eight predictor variable model rendered an acceptable predictive ability to identify responders both at post-test (AUC = .72, p < .01) and at 36-month follow-up (AUC = .70, p < .01). We conclude that ICBT for pathological gamblers, even if depressed, can be effective and that outcome can partly be predicted by pre-treatment characteristics.

A brief self-help toolkit intervention for gambling problems: a randomized multisite trial

Two studies conducted in Massachusetts and Nevada evaluated the efficacy of a self-help toolkit for problem gambling. Individuals concerned about gambling-related problems, in response to public notices and newspaper advertisements, volunteered for a randomized trial of the self-help toolkit, Your First Step to Change: Gambling. Participants were randomly assigned to 1 of 3 conditions: (a) a printed toolkit, (b) the toolkit and a brief guide to the toolkit's content, or (c) assignment to a wait-list condition. Participants, 145 in Massachusetts and 170 in Nevada, reported their gambling behavior, beliefs and attitudes about chance, and recent and planned help seeking at baseline, 88% at 1 month later, and 79% at 3 months later. Findings for the complete and intent-to-treat analyses at both sites indicated that participants significantly improved. At the end of the study period, significantly more toolkit recipients than control group participants reported recently abstaining from gambling. Minimally invasive, self-directed resources like this self-help toolkit can assist remediating gambling-related problems among gamblers who do not engage in formal treatment.

Sex Differences in the Rates of Recovery, Treatment-Seeking, and Natural Recovery in Pathological Gambling: Results From an Australian Community-Based Twin Survey

The aim of this study was to estimate the rates of recovery, treatment-seeking, and natural recovery from pathological gambling (PG) in men and women in a community-based national survey, and to examine the role of gambling problem recognition in recovery from PG. Participants were 4,764 individuals from a community-based Australian national twin registry (104 with a lifetime history of PG) who were administered a structured psychiatric telephone interview. Women were more likely than men to recover from (56% versus 36%; odds ratio = 2.3) and to seek treatment for PG (32% versus 13%; odds ratio = 3.2). Most individuals who recovered from PG did so without treatment (82%), but this was higher among men than among women (92% versus 57%; odds ratio = 5.3). This is the first study to document sex differences in treatment-seeking and recovery from PG. These findings highlight the value in continuing to develop self-help and brief treatments for PG that will appeal to those who are unlikely to seek formal help.

The problem with self-forgiveness: forgiving the self deters readiness to change among gamblers

Self-forgiveness is generally understood to be a mechanism that restores and improves the self. In the current study, we examine the possible deleterious consequences of forgiving the self among gamblers-specifically in regard to gamblers' readiness to change their problematic behavior. At a large Canadian university, 110 young adult gamblers' level of gambling pathology was assessed, along with their readiness to change and self-forgiveness for their gambling. Participants were 33 females and 75 males (2 unspecified) with a mean age of 20.33. Results revealed that level of pathology (at risk vs. problem gamblers) significantly predicted increased readiness to change. Self-forgiveness mediated this relationship, such that level of gambling pathology increased readiness to change to the extent that participants were relatively unforgiving of their gambling. Implications for seeking professional assistance as well as treatment and recovery are discussed.

Motivation to change and pathological gambling: analysis of the relationship with clinical and psychopathological variables

OBJECTIVES. The present study analyses the internal factor structure of the University of Rhode Island Change Assessment (URICA) Scale in pathological gambling (PG). The scale's association with the clinical profile of patients is also evaluated. METHOD. The factor analysis was based on a sample of 531 men with a DSM-IV diagnosis of pathological gambling. The statistical analysis included confirmatory factor analysis and linear correlation. RESULTS. The analyses confirmed the internal structure obtained for the URICA. The internal consistency was satisfactory (Cronbach's alpha between .74 and .85). The association between URICA scores and the socio-demographic and clinical profile of patients ranged between moderate and weak (R coefficients below .30). Lower motivation was present in 28.4% of cases and it was associated with shorter duration of the disorder, lower severity of the PG symptoms, and high psychopathology. Conclusions. The results support the validity and reliability of the URICA in a Spanish clinical population of pathological gamblers.

Thinking about going to the dentist: a Contemplation Ladder to assess dentally-avoidant individuals' readiness to go to a dentist

Background

The Transtheoretical Model suggests that individuals vary according to their readiness to change behavior. Previous work in smoking cessation and other health areas suggests that interventions are more successful when they are tailored to an individual's stage of change with regards to the specific behavior. We report on the performance of a single-item measure ("Ladder") to assess the readiness to change dental-avoidant behavior.

Methods

An existing Contemplation Ladder for assessing stage of change in smoking cessation was modified to assess readiness to go to a dentist. The resulting Ladder was administered to samples of English-speaking adolescents (USA), Spanish-speaking adults (USA), and Norwegian military recruits (Norway) in order to assess construct validity. The Ladder was also administered to a sample of English-speaking avoidant adolescents and young adults who were enrolled in an intervention study (USA) in order to assess criterion validity. All participants also had dental examinations, and completed other questionnaires. Correlations, chi square, t tests and one-way ANOVAs were used to assess relationships between variables.

Results

In two samples, participants who do not go to the dentist had significantly more teeth with caries; in a third sample, participants who do not go to the dentist had significantly worse caries. Ladder scores were not significantly related to age, gender, caries, or dental fear. However, Ladder scores were significantly related to statements of intention to visit a dentist in the future and the importance of oral health. In a preliminary finding, Ladder scores at baseline also predicted whether or not the participants decided to go to a dentist in the intervention sample.

Conclusions

The data provide support for the convergent and divergent construct validity of the Ladder, and preliminary support for its criterion validity. The lack of relationship between dental fear and Ladder scores suggests that avoidant individuals may be helped to decide to go to a dentist using interventions which do not explicitly target their fear.

Motivational interviewing versus cognitive behavioral group therapy in the treatment of problem and pathological gambling: a randomized controlled trial

Pathological gambling is a widespread problem with major implications for society and the individual. There are effective treatments, but little is known about the relative effectiveness of different treatments. The aim of this study was to test the effectiveness of motivational interviewing, cognitive behavioral group therapy, and a no-treatment control (wait-list) in the treatment of pathological gambling. This was done in a randomized controlled trial at an outpatient dependency clinic at Karolinska Institute (Stockholm, Sweden). A total of 150 primarily self-recruited patients with current gambling problems or pathological gambling according to an NORC DSM-IV screen for gambling problems were randomized to four individual sessions of motivational interviewing (MI), eight sessions of cognitive behavioral group therapy (CBGT), or a no-treatment wait-list control. Gambling-related measures derived from timeline follow-back as well as general levels of anxiety and depression were administered at baseline, termination, and 6 and 12 months posttermination. Treatment showed superiority in some areas over the no-treatment control in the short term, including the primary outcome measure. No differences were found between MI and CBGT at any point in time. Instead, both MI and CBGT produced significant within-group decreases on most outcome measures up to the 12-month follow-up. Both forms of intervention are promising treatments, but there is room for improvement in terms of both outcome and compliance.

The Gambling Symptom Assessment Scale (G-SAS): a reliability and validity study

Two hundred seven patients with DSM-IV Pathological Gambling Disorder completed both the Gambling Symptom Assessment Scale (G-SAS) and the Yale-Brown Obsessive-Compulsive Scale--modified for Pathological Gambling (PG-YBOCS) at baseline visit and weekly or biweekly thereafter during the 12-week study period. The week 1 to week 2 visit data were used to assess test-retest reliability. Weekly or biweekly data were used for the G-SAS validity. The PG-YBOCS reliability and validity data have been published previously. We used the PG-YBOCS as the established scale and compared the G-SAS performance with the PG-YBOCS. Test-retest reliability was statistically significant. The correlations between the G-SAS and the PG-YBOCS and Clinical Global Impression rating were excellent. Findings suggest that the G-SAS is reliable and valid in assessing changes in symptoms during a drug treatment study.

A randomized trial of brief interventions for problem and pathological gamblers

Limited research exists regarding methods for reducing problem gambling. Problem gamblers (N = 180) were randomly assigned to assessment only control, 10 min of brief advice, 1 session of motivational enhancement therapy (MET), or 1 session of MET plus 3 sessions of cognitive-behavioral therapy. Gambling was assessed at baseline, at 6 weeks, and at a 9-month follow-up. Relative to assessment only, brief advice was the only condition that significantly decreased gambling between baseline and Week 6, and it was associated with clinically significant reductions in gambling at Month 9. Between Week 6 and Month 9, MET plus cognitive-behavioral therapy evidenced significantly reduced gambling on 1 index compared with the control condition. These results suggest the efficacy of a very brief intervention for reduction of gambling among problem and pathological gamblers who are not actively seeking gambling treatment.

Pre/early adolescent onset of gambling and psychosocial problems in treatment-seeking pathological gamblers

This study examined the association between pre- or early-adolescent onset of gambling and severity of gambling and psychosocial problems in treatment-seeking adult pathological gamblers. A total of 236 pathological gamblers entering outpatient treatment completed the South Oaks Gambling Screen (SOGS) and the Addiction Severity Index (ASI). Using a quartile split procedure, gamblers who began gambling during their pre- or early-adolescent years (mean age of 10.5 years; 1st quartile) were compared to gamblers who began gambling later in life (mean age of 23.0 years; 2nd to 4th quartiles). Compared to later onset gamblers, pre/early adolescent onset gamblers reported increased severity of psychiatric, family/social, and substance abuse problems on the ASI. They were more likely to report cognitive problems (trouble understanding, concentrating, or remembering), suicidal ideation, and a history of inpatient psychiatric treatment, and were less likely to be satisfied with their current living situation. Pre/early adolescent onset gamblers also reported earlier age of initiation of drinking, and were more likely to have received treatment for an alcohol use disorder, and to have used cannabis and cocaine in their lifetimes. Taken together, these data suggest that pre/early adolescent-onset of gambling may be a risk factor for later-life psychiatric, family/social, and substance abuse problems in treatment-seeking pathological gamblers.

University of Rhode Island Change Assessment-Trauma: preliminary psychometric properties in an alcohol-dependent PTSD sample

The co-occurrence of posttraumatic stress disorder with substance use disorders (PTSD-SUD) is common and is associated with poorer treatment outcomes. Attrition represents an ongoing, but poorly understood challenge in PTSD-SUD treatment research. The current study examined the initial psychometric properties of the University of Rhode Island Change Assessment-Trauma (URICA-T), a scale designed to assess attitudes and behaviors related to addressing trauma issues, in a sample of 42 individuals meeting diagnostic criteria for PTSD and alcohol dependence. Results suggest that the URICA-T may have acceptable psychometric properties as a continuous measure of motivational readiness in a PTSD-SUD sample. Preliminary data also suggests higher URICA-T scores are associated with retention of alcohol dependent-PTSD participants in a study utilizing trauma-focused exposure.

Should the scope of addictive behaviors be broadened to include pathological gambling?

AIMS

Pathological gambling is currently considered an impulse control disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This paper considers the prospect of reclassifying and broadening the substance use disorders to include non-pharmacological addictions such as pathological gambling.

METHODS

Literature reviews were conducted on areas relevant to pathological gambling and its classification and similarities to substance use disorders.

RESULTS

The diagnostic criteria for pathological gambling are outlined across the three versions of the DSM since its initial introduction. The paper also describes instruments that have been used to assess the disorder, basic epidemiology and some biological and genetic data, especially in terms of potential overlap with substance use disorders. Similarities and differences with respect to treatments are reviewed as well.

CONCLUSIONS

Both advantages and disadvantages should be considered with respect to expanding the classification system to include pathological gambling within the context of addictive disorders.

Cognitive-behavioral therapy for pathological gamblers

Few studies have evaluated efficacy of psychotherapies for pathological gambling. Pathological gamblers (N = 231) were randomly assigned to (a) referral to Gamblers Anonymous (GA), (b) GA referral plus a cognitive- behavioral (CB) workbook, or (c) GA referral plus 8 sessions of individual CB therapy. Gambling and related problems were assessed at baseline, 1 month later, posttreatment, and at 6- and 12-month follow-ups. CB treatment reduced gambling relative to GA referral alone during the treatment period and resulted in clinically significant improvements, with some effects maintained throughout follow-up ( ps = .05). Individual CB therapy improved some outcomes compared with the CB workbook. Attendance at GA and number of CB therapy sessions or workbook exercises completed were associated with gambling abstinence. These data suggest the efficacy of this CB therapy approach.