Pathological Gamblers in Singapore: Treatment Response at 3 Months

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.

Diverse predictors of treatment response to active medication and placebo in gambling disorder

Gambling disorder creates a significant public health burden. Despite decades of clinical trials, there are no licensed pharmacological treatments for gambling disorder. Contributing factors to this are the high placebo response rates seen in clinical trials, the heterogeneity of the disorder and high rates of psychiatric comorbidities. Indeed, a number of demographic and clinical variables have previously been associated with altered responses to pharmacotherapy, psychotherapy and placebo. Which variables are likely to predict response to one modality over another remains uncertain. We carried out multiple linear regression analyses in a pooled dataset from six treatment studies in gambling disorder with the aim of identifying predictors of treatment response. Potential predictors were identified a priori through hypothesis and entered into models including all patients, and subsequently for those randomized to active medication or placebo separately. We found that baseline severity of gambling symptoms and number of weeks completed in a trial were predictors of active medication response, while decreased baseline symptoms of anxiety, increased baseline symptoms of depression, and non-Caucasian ethnicity were associated with placebo response. Sensitivity analyses showed that these associations were robust to choices made during the analysis. Further research is required to understand whether controlling for these variables, or using enriched samples, improves assay sensitivity in placebo-controlled clinical trials for gambling disorder.

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.

Quality of life instruments used in problem gambling studies: A systematic review and a meta-analysis

The purpose of this systematic review was to identify the instruments used in original articles to measure quality of life (QOL) or health-related QOL (HRQOL) in gambling-disorder patients and to assess their suitability. The systematic literature search to identify QOL/HRQOL instruments used among gambling-disorder patients was performed in PubMed, Embase and PsycINFO databases up to November 2018. A meta-analysis was performed to study the effect size of the QOL/HRQOL instruments and gambling outcomes after an intervention. Thirty-five studies were included. Seven types of instruments aiming at measuring QOL/HRQOL were identified. These instruments explored twenty-six domains. The instruments used were not properly validated in the studies. Most of the clinical trials reported a significant difference in QOL/HRQOL between pre- and post-intervention. These results were concordant with gambling outcomes but had a smaller effect size than gambling outcomes. The currently used general instruments are efficient to measure a significant change after an intervention but might not evaluate specific areas of health related QOL impacted by gambling disorders.

Online Gambling among Treatment-Seeking Patients in Singapore: A Cross-Sectional Study

Given that technology has greatly facilitated easier access to gambling in previous years, it is timely to look in-depth into online gambling activities and behaviors. There have been several studies that examined online gambling. However, most of the current studies to date have focused on determining the prevalence and the epidemiology of problem gambling arising from online gambling in Western cohorts. There remains a paucity of research looking at the problem of online gambling among Asian individuals. The objectives of the current study are to elucidate the characteristics of online gambling among an Asian cohort and to explore the harm associated with online gambling and the potential mechanisms by which harm associated with online gambling could be minimized. It is hoped that the findings of the current paper will bridge the existing gaps in the research literature. A cross-sectional study design was utilized to recruit 100 participants who were attending outpatient services at the National Addictions Management Service (NAMS) from March 2014 to October 2015. The majority of the participants were male, of Chinese ethnicity and under the age of 30 years old (48%). Mobile phones and smartphones were the most commonly utilized platforms for gambling online. The median largest ever debt incurred as a result of online gambling ($20,000) was significantly more than that due to offline gambling ($500) (Z = −4.17, p < 0.001). As for the biggest ever loss, participants had incurred a significantly larger median loss from online gambling ($7000) (Z = −2.73, p < 0.01) compared to offline gambling ($2000). A total of 18.4% of participants had waited between 1 to 2 years from their first online gambling experience to seek treatment and 17.3% had waited for more than 10 years. This is perhaps one of the first Asian studies to investigate the serious harm involved in online gambling. The findings from our study are intended to guide further interventions in the treatment of online gambling related disorders; and would be of interest to governmental organizations in their planning of regulations for online gambling.

Interventions for comorbid problem gambling and psychiatric disorders: Advancing a developing field of research

Despite significant psychiatric comorbidity in problem gambling, there is little evidence on which to base treatment recommendations for subpopulations of problem gamblers with comorbid psychiatric disorders. This mini-review draws on two separate systematic searches to identify possible interventions for comorbid problem gambling and psychiatric disorders, highlight the gaps in the currently available evidence base, and stimulate further research in this area. In this mini-review, only 21 studies that have conducted post-hoc analyses to explore the influence of psychiatric disorders or problem gambling subtypes on gambling outcomes from different types of treatment were identified. The findings of these studies suggest that most gambling treatments are not contraindicated by psychiatric disorders. Moreover, only 6 randomized studies comparing the efficacy of interventions targeted towards specific comorbidity subgroups with a control/comparison group were identified. The results of these studies provide preliminary evidence for modified dialectical behavior therapy for comorbid substance use, the addition of naltrexone to cognitive-behavioral therapy (CBT) for comorbid alcohol use problems, and the addition of N-acetylcysteine to tobacco support programs and imaginal desensitisation/motivational interviewing for comorbid nicotine dependence. They also suggest that lithium for comorbid bipolar disorder, escitalopram for comorbid anxiety disorders, and the addition of CBT to standard drug treatment for comorbid schizophrenia may be effective. Future research evaluating interventions sequenced according to disorder severity or the functional relationship between the gambling behavior and comorbid symptomatology, identifying psychiatric disorders as moderators of the efficacy of problem gambling interventions, and evaluating interventions matched to client comorbidity could advance this immature field of study.

Strategic Versus Nonstrategic Gambling: Results From a Community Survey

OBJECTIVES

The aims of the current study were to establish the prevalence and correlates of strategic and nonstrategic gambling, using data from an epidemiological survey conducted in 2010 in Singapore.

METHODS

Data were used from a nationwide cross-sectional, nationally representative survey of the resident (citizens and permanent residents) population of Singaporean adults aged 18 years and older (N=6616). All respondents were administered the South Oaks Gambling Screen to determine the gambling activities and screen for pathological gambling. The diagnosis of mental disorders was established using the Composite International Diagnostic Interview, and relevant sociodemographic data were collected using a structured questionnaire. In the analysis, 1835 adults who had gambled at least once in their lives were included.

RESULTS

The prevalence of strategic gamblers only, both strategic and nonstrategic gamblers, and nonstrategic gamblers was 12.9%, 30%, and 57.1%, respectively. As compared with nonstrategic gamblers, strategic gamblers were more likely to be males, and economically inactive (vs employed). They were less likely to be of Indian ethnicity and were currently married and divorced/separated. The prevalence of pathological gambling was significantly higher among strategic gamblers only, and both strategic and nonstrategic gamblers than nonstrategic gamblers (7.1% and 7.3% vs 2.1%; P = 0.001).

CONCLUSIONS

This study on gambling preferences in a multiethnic community sample has reiterated some of the findings from previous studies, whereas others are unique to this population.

Gambling in Singapore: an overview of history, research, treatment and policy

AIMS

This paper describes the current situation regarding gambling in Singapore in relation to its historical and cultural context.

METHODS

A computerized search was performed of two databases (PubMed and PsychINFO) and the reference lists from the papers searched manually to identify relevant studies. The findings were synthesized and their implications assessed.

RESULTS

In addition to state lotteries and much informal gambling, Singapore has two large resort casinos, which rank third after Las Vegas and Macau in terms of gross revenues. The major ethnic subgroups in Singapore have different cultural connections to gambling, including the active involvement of the Chinese and religious prohibition among the Malay. A range of secondary prevention and treatment services has been developed to attempt to minimize potential negative impacts. Overall, the prevalence of pathological gambling and problem gambling has decreased in recent years: an estimated 0.2% are classified as probable pathological gamblers compared with 1.4% in 2011, 1.2% in 2008 and 2.1% in 2005.

CONCLUSIONS

Singapore has experienced a reduction in problem gambling prevalence which may reflect the influence of multiple initiatives.