Measuring treatment outcomes in gambling disorders: a systematic review

STAT: schema therapy for addiction treatment, a proposal for the integrative treatment of addictive disorders

The nature and origins of addictions and of their adjunctive behaviors, as well as their chronicity, call for treatments that conceptualize and treat them as the long-term and complex processes that they are. Addictions are often comorbid with personality problems and with trauma histories. Patients suffering from these disorders often show poor engagement with treatment and high rates of relapse, possibly because available treatments have yet to address the patient suffering from addiction in a more integrated or holistic manner. In particular, comprehensive treatment models for addictive disorders - like treatments for personality disorders or trauma - are likely to require the integration of behavioral, cognitive, and emotion-focused interventions within a facilitative therapeutic relationship. However, most current treatment models, including ones which are highly effective in stabilization or behavioral change, lack one or more components of treatment that could sustain longer term recovery, wellness, and health for a higher percentage of patients. In this article, I propose approaching addictions and their treatment from the perspective of schema therapy, an integrative, developmental model with a strong track record of positive outcomes in addressing personality disorder symptoms and long-standing trauma histories, commonly comorbid with addictive disorders. In advancing this proposal, I begin by providing some background tying together addictions, attachment, and personality, suggesting they be treated simultaneously to achieve improved outcomes. Then, after briefly reviewing the leading approaches to the treatment of addictions, I introduce the idea that schema therapy is well-situated - both theoretically and practically - to address many of the shortcomings of existing treatment options. In particular, I note how addictive and co-occurring colluding behaviors are deeply intertwined with both early and continued frustration of core developmental needs. I illustrate how the addictive cycle is perpetuated through the process of schema reinforcement and through the operation of schema modes. I then demonstrate how these key terms (i.e., needs, schemas, and modes) inform the patient's assessment and case formulation, guiding treatment interventions from a strong therapeutic relationship that focuses on integrating recovery behavior change, healing dysfunctional schemas and modes, and preventing relapse.

Definitions and assessments of recovery from gambling disorder: A scoping review

Background and aims

While the concept of recovery is receiving increasing attention in the context of gambling disorder (GD), no consensus has yet been reached regarding its definition. This scoping review aims to map the literature on GD recovery, identify gaps, and provide insights for a more holistic and patient-centred perspective.

Methods

A systematic search of three databases was conducted (PubMed, PsycINFO, and ScienceDirect). Based on the method by which the results of these studies were produced, the studies included were sorted into four categories (quantitative, instrument validation, qualitative, and mixed studies) and subsequently examined using conceptual analysis.

Results

One hundred thirteen articles were included in this research after the screening process. In the quantitative and instrument validation studies, recovery was defined or operationalized in terms of abstinence, the absence of a GD diagnosis, or mild GD severity, or by reference to treatment outcomes or controlled gambling. A meta-synthesis of the results of the qualitative studies revealed four core features of recovery (insight, empowerment and commitment, wellbeing enhancement, and reconsideration of the issue of relapse).

Discussion

Discrepancies in definitions, outcomes, and variables used were evident across studies. Additionally, the quantitative and standardized approaches employed in most studies exhibited severe limitations with regard to defining recovery from the subjective and multidimensional perspectives of people recovering from GD.

Conclusions

This lack of definitional clarity emphasizes the necessity for further qualitative research. This research should encompass multiple stakeholder perspectives to develop a working definition promoting recovery from a holistic, patient-centred, and tailored approach.

The Role of Social Support and Belonging in Predicting Recovery from Problem Gambling

Research indicates a role for both social support and belonging in addiction recovery, however little is known about the role of these constructs in the recovery from problem gambling, and whether they relate to the effectiveness of mutual aid groups such as Gamblers Anonymous. The aim of this study was therefore to explore the relationship between social support and belonging, and to assess the role of demographics (including group membership of GA), social support and/or belongingness in predicting gambling addiction recovery in terms of gambling urges and quality of life. Using a cross sectional design, participants identifying as having problem gambling (n = 60) completed an online questionnaire with two independent variables (Social Support and Belonging), two dependent variables (Gambling Urges and Quality of Life) to assess gambling addiction recovery and measures of GA membership. The results showed no significant association between gender, age, ethnicity, education or employment status and gambling urges or quality of life. Membership to GA, and length of membership were significantly associated with gambling recovery indicating that being a member of GA and longer membership was associated with lower gambling urges and higher quality of life. Further, the results showed a high but not perfect correlation between social support and belonging (r(58) = .81, p =  < .01). A regression analysis showed that although there was a significant correlation between social support and belongingness, they played different roles in gambling addiction recovery. Social support alone predicted higher quality of life, but not a reduction in gambling urges; belonging (along with being a member of GA) predicted a reduction in gambling urges, but not an increase in quality of life. Social support and belonging have a differential impact on aspects of gambling addiction, and should be considered as different constructs. In particular, whilst the process underpinning reduced gambling urges is membership of GA and the sense of belonging it provides its members, social support per se is a better predictor of quality of life. These findings have implications for the development of treatment for problem gamblers in the future.

Treatment of harmful gambling: a scoping review of United Kingdom-based intervention research

BACKGROUND

Understanding and treating the harm caused by gambling is a growing international psychiatric and public health challenge. Treatment of gambling harm may involve psychological and pharmacological intervention, in conjunction with peer support. This scoping review was conducted to identify, for the first time, the characteristics and extent of United Kingdom (UK) based gambling treatment research. We reviewed studies conducted among people seeking treatment for disordered or harmful gambling in the UK, the settings, research designs, and outcome measures used, and to identify any treatment research gaps.

METHODS

Systematic searches of PsycInfo, PsycArticles, Scopus, PubMed, and Web of Science databases were carried out for gambling treatment research or evaluation studies conducted in the UK. Studies were included if they evaluated the effectiveness of an intervention or treatment designed to improve symptoms of harmful or problematic gambling, reported outcomes of interventions on treatment adherence, gambling symptoms, or behaviours using standardised measures, were conducted in the UK, and were published since 2000.

RESULTS

Eight studies met the inclusion criteria. Four were retrospective chart reviews, two were single-participant case reports, one described a retrospective case series, and one employed a cross-sectional design. None used an experimental design.

CONCLUSION

The limited number of studies included in this review highlights a relative paucity of gambling treatment research conducted in UK settings. Further work should seek to identify potential barriers and obstacles to conducting gambling treatment research in the UK.

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.

Effects of cognitive behavioral techniques for gambling on recovery defined by gambling, psychological functioning, and quality of life: A systematic review and meta-analysis

OBJECTIVE

Individuals who experience gambling harms report that sustained recovery involves changing both gambling behaviors and psychological symptoms, as well as building a meaningful life. However, there is limited understanding about the effect of cognitive behavioral (CB) techniques on psychological symptoms and quality of life. The purpose of the present study was to examine the effect of CB techniques for gambling-related harms on broader recovery outcomes such as psychological symptoms and quality of life.

METHOD

A systematic article search was conducted to identify randomized controlled trials of CB techniques with nonactive and minimal treatment control groups that assessed psychological symptoms or quality of life as outcomes. Random-effects meta-analysis was used to examine the effect of CB techniques relative to nonactive and minimal treatment control groups.

RESULTS

A total of nine studies representing 658 participants were included. Eight studies reported outcomes on depression and anxiety, three on substance use, and six on quality of life. CB techniques significantly reduced anxiety (g = -0.44) and depression (g = -0.35) at posttreatment, but not substance use. CB techniques also significantly increased quality of life at posttreatment (g = 0.40). There was a large amount of heterogeneity suggesting the magnitude of effects could vary significantly in future randomized trials.

CONCLUSIONS

Future studies should examine the longitudinal associations between gambling harms, psychological symptoms, and quality of life and to assess whether changes in gambling harms throughout treatment precede or are a consequence of changes in psychological symptoms and quality of life. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Betting on Non-Invasive Brain Stimulation to Treat Gambling Disorder: A Systematic Review and Meta-Analysis

Gambling disorder (GD) is a behavioral addiction that severely impacts individuals' functioning, leading to high socioeconomic costs. Non-invasive brain stimulation (NiBS) has received attention for treating psychiatric and neurological conditions in recent decades, but there is no recommendation for its use for GD. Therefore, this study aimed to systematically review and analyze the available literature to determine the effectiveness of NiBS in treating GD. Following the PRISMA guidelines, we screened four electronic databases up to July 2022 and selected relevant English-written original articles. We included ten papers in the systematic review and seven in the meta-analysis. As only two studies employed a sham-controlled design, the pre-post standardized mean change (SMCC) was computed as effect size only for real stimulation. The results showed a significant effect of NiBS in reducing craving scores (SMCC = -0.69; 95% CI = [-1.2, -0.2], p = 0.010). Moreover, considering the GD's frequent comorbidity with mood disorders, we ran an exploratory analysis of the effects of NiBS on depressive symptoms, which showed significant decreases in post-treatment scores (SMCC = -0.71; 95% CI = [-1.1, -0.3], p < 0.001). These results provide initial evidence for developing NiBS as a feasible therapy for GD symptoms but further comprehensive research is needed to validate these findings. The limitations of the available literature are critically discussed.

Features Linked to Treatment Outcomes in Behavioral Addictions and Related Disorders

Behavioral addictions are incompletely understood with respect to their underlying etiologies. This incomplete understanding may contribute to the frequent relapse and dropout rate often observed with behavioral addictions. The present state-of-the-art review aimed to review the literature that explored sociodemographic and clinical factors that link to poor treatment responses. Despite multiple studies, the definitions and evaluations of relapse and dropout are heterogeneous, complicating comparisons across studies. A scientific consensus on the conceptualization of both terms would help to better understand psychological features linked to treatment outcomes in behavioral addictions.

Gambling disorder duration and cognitive behavioural therapy outcome considering gambling preference and sex

Gambling Disorder (GD) is a behavioural addiction that leads to high level of clinical distress and, in general, it is characterized by enduring symptomatology that presents high rates of chronicity. However, there is high variability of illness duration among patients who seek treatment for GD. Previous studies reported mixed results about the relevance of illness duration in GD treatment outcome. However, there are different profiles of patients who are diagnosed with GD. For this reason, this study aimed to evaluate the effect of illness duration in the treatment outcome of different profiles of GD patients according to their gambling preference and sex. The sample were 1699 patients diagnosed with GD. All patients received cognitive-behavioural therapy in a group format. Treatment outcome was evaluated in terms of relapsing to gambling behaviours and dropout from treatment. Results showed higher probability of poor outcome in the first years of the disorder for strategic gambling compared to non-strategic or mixed forms of gambling. Moreover, women also showed higher probability of poor outcomes than men since the first stages of the disorder. This study draws attention to the relevance of illness duration in the treatment outcome of specific profiles of GD patients. In particular, patients who presented a preference for strategic forms of gambling and women who are diagnosed with GD would have a higher risk of poor treatment outcomes since the first stages of the disorder. These results highlight the importance of an early intervention in these patients in order to prevent the chronicity of the disorder.

Development and Psychometric Properties of a New Patient-Reported Outcome Instrument of Health-Related Quality of Life Specific to Patients with Gambling Disorder: The Gambling Quality of Life Scale (GQoLS)

BACKGROUND

Impairment or distress caused by gambling disorder can be subjectively assessed via quality of life. The aim of this study was to develop a new patient-reported outcome instrument to explore the health-related quality of life (HRQoL) in gambling disorders, the Gambling quality-of-life scale (GQoLS), and to document its psychometric properties.

METHODS

A previous qualitative study had been conducted using focus groups of problem gamblers to identify areas of HRQoL impacted by gambling. The seven domains identified served as the basis for the hypothetical structure of GQoLS. Draft items were generated from the patient's speeches to illustrate each of these domains. Cognitive debriefing interviews were realized to obtain a final hypothetical GQoLS. A validation study was then carried out to determine the final version of GQoLS and its psychometric properties (structural validity, construct validity, internal consistency).

RESULTS

The final GQoLS was composed of 21 items, with a total mean score of 38.3 (±13.6). Structural validity found a major dimension and four other minor dimensions. The five dimensions were: "emotion", "lifestyle", "loneliness", "taboo" and "preoccupation". GQoLS was moderately to strongly correlated with PGSI and EQ-5D visual analogic scale. Cronbach's alpha coefficient was 0.92.

CONCLUSION

GQoLS is the first HRQoL instrument specific to patients with a gambling disorder and developed from the patient's perspective. GQoLS presents good psychometric properties. GQoLS can be used in clinical research to demonstrate the effectiveness of an intervention on outcomes that are relevant from the patient's perspective.

Sports-betting-related gambling disorder: Clinical features and correlates of cognitive behavioral therapy outcomes

BACKGROUND AND AIMS

The number of patients with gambling disorder (GD) whose gambling preference is sports betting is increasing. However, their clinical profile and their responses to psychological treatments -compared to patients with other forms of gambling- have not been thoroughly studied. Therefore, the aims of this study were: (1) to compare the clinical characteristics of GD patients whose primary gambling activity was sports betting (SB+; n = 113) with GD patients with other primary gambling activities (SB-; n = 1,135); (2) to compare treatment outcomes (dropout and relapses) between SB + and SB- patients; and (3) to explore relationships between specific variables (GD severity, psychological distress and personality features) and treatment outcome in SB + and SB- GD patients, through correlation models and path-analysis.

METHODS

The cognitive behavioral treatment consisted of 16 weekly sessions. Personality features, psychopathology, and sociodemographic and clinical factors were assessed.

RESULTS

The SB + group included higher proportions of younger patients who were single and had higher educational levels, older ages of GD onset, and greater GD severities. Regarding treatment outcomes, the dropout rate was lower in the SB + group, and no between-group differences were found regarding relapse. Dropout within the SB + group was related to being unemployed, and relapse was related to being unmarried and experiencing more psychological distress.

DISCUSSION AND CONCLUSION

The differences between SB + and SB- GD patients suggest that GD patients with sports-betting problems may benefit from tailored therapeutic approaches.

Emotion regulation-enhanced group treatment for gambling disorder: a non-randomized pilot trial

BACKGROUND

Despite the association of Gambling Disorder (GD) with poor mental health, treatment options generally lack components targeting emotional difficulties. This study investigated the feasibility and acceptability of adding strategies of emotion regulation to an eight-session weekly group treatment.

METHOD

This non-randomized pilot study recruited 21 treatment-seeking adults with GD, (mean age = 36.3, 19% females) from addiction care. In a mixed methods design, measures of within-group changes in self-reported symptoms of GD were complemented with thematic analysis of post-treatment interviews regarding the feasibility of the treatment.

RESULTS

Within-group scores on the Gambling Symptoms Assessment Scale (G-SAS) showed a 47% decrease (β: -0.1599, 95% CI: - 0.2526 to - 0.0500) from pre-treatment to 12-month follow-up, with Hedges' g = 1.07 (CI: 0.57-1.60). The number of GD-symptoms according to the Structured Clinical Interview for Gambling Disorder (SCI-GD) decreased from 7.0 (SD = 1.60) at pre-treatment to 2.1 (SD = 2.36) at 12-month follow-up. Participants completed an average of 6.3 sessions and rated the intervention high in satisfaction and acceptability. Feasibility interviews showed no noticeable negative effects or ethical issues. Furthermore, helpful components in the treatment were: increased awareness of emotional processes and strategies to deal with difficult emotions.

CONCLUSIONS

Adding emotion regulation strategies in the treatment of GD is feasible and acceptable and warrants further investigation in a controlled trial.

TRIAL REGISTRATION

This study was registered with ClinicalTrials.gov (Identifier NCT03725735 ).

Clustering Treatment Outcomes in Women with Gambling Disorder

The rising prevalence of gambling disorder (GD) among women has awakened considerable interest in the study of therapeutic outcomes in females. This study aimed to explore profiles of women seeking treatment for GD based on a set of indicators including sociodemographic features, personality traits, clinical state at baseline, and cognitive behavioral therapy (CBT) outcomes. Two-step clustering, an agglomerative hierarchical classification system, was applied to a sample of n = 163 women of ages ranging from 20 to 73 years-old, consecutively attended to by a clinical unit specialized in the treatment of G. Three mutually exclusive clusters were identified. Cluster C1 (n = 67, 41.1%) included the highest proportion of married, occupationally active patients within the highest social status index. This cluster was characterized by medium GD severity levels, the best psychopathological functioning, and the highest mean in the self-directedness trait. C1 registered 0% dropouts and only 14.9% relapse. Cluster C2 (n = 63; 38.7%) was characterized by the lowest GD severity, medium scores for psychopathological measures and a high risk of dropout during CBT. Cluster C3 (n = 33; 20.2%) registered the highest GD severity, the worst psychopathological state, the lowest self-directedness level and the highest harm-avoidance level, as well as the highest risk of relapse. These results provide new evidence regarding the heterogeneity of women diagnosed with GD and treated with CBT, based on the profile at pre- and post-treatment. Person-centered treatments should include specific strategies aimed at increasing self-esteem, emotional regulation capacities and self-control of GD women.

Women and gambling disorder: Assessing dropouts and relapses in cognitive behavioral group therapy

BACKGROUND

Gender-specific literature focused on gambling disorder (GD) is scarce, and women with GD have been understudied. Therefore, the aim of this study was to estimate the short-term effectiveness in women with GD (n = 214) of a group standardized cognitive-behavioral therapy (CBT) and to identify the most relevant predictors of the primary therapy outcomes (dropout and relapse).

METHODS

The manualized CBT consisted of 16 weekly outpatient group sessions. Women were provided with resources to obtain a better understanding of the GD, to improve self-control and to manage risk situations.

RESULTS

The dropout risk was higher for women with lower GD severity and higher psychopathological distress. Among other factors, lower education levels were a significant predictor of the relapse risk and and the frequency of relapses was higher for divorced women with a preference for non-strategic gambling and with substances consumption.

CONCLUSIONS

Our findings evidence women-specific predictors of the primary therapy outcomes. The results highlight the need to design psychological interventions that address dropout and relapse risk factors in women.

Study protocol for an online randomised controlled trial among non-treatment seeking problem gamblers: training inhibition in online problem gambling (TRAIN-online) trial

INTRODUCTION

Development of fully internet-based programs could provide a new avenue to improve access to healthcare for problem gamblers. In this project, we aim to assess the efficacy of a web-based cognitive intervention targeting inhibitory control among problem gamblers, using a randomised controlled design. As impaired inhibitory control is involved in self-regulation difficulties in behavioural addictions, it represents a particularly relevant cognitive process to target for an online psychological intervention.

METHODS AND ANALYSIS

This will be a single-blinded, randomised, comparative therapeutic web-based, controlled trial. Up to 200 non-treatment seeking adult problem gamblers with a Problem Gambling Severity Index-recent (PGSI-recent) score ≥5 will be included. The intervention will be a computerised cognitive training program targeting inhibitory skills. The comparator, an active control, will be a computerised neutral sensorial program. Both programs will be carried out under similar conditions: biweekly online training for 6 weeks and optional telephone support will be offered to patients for debriefing. The main objective of the study is to assess the clinical efficacy of the online cognitive training program at 6 weeks, measured with the PGSI-recent. The secondary objectives are to assess the efficacy on the gambling behaviour assessed by the account-based gambling data, on the self-reported gambling practice, and on the inhibition performance at the neuropsychological level at 6, 14 and 52 weeks. We will also assess the acceptability of this program and the preferred level of guidance. Data analysis will be in intention-to-treat.

ETHICS AND DISSEMINATION

This randomized controlled trial will be executed in compliance with the Helsinki Declaration, and was approved by the local ethics boards (Comité de Protection des Personnes) in October 2017. The findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03673800.

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.

A scoping review of hard systems and tools that restrict money and cash for gambling

BACKGROUND

Gamblers engage in a range of "soft" financial options to limit access to money or cash for gambling (e.g., family looks after cash). Such barriers are easily overturned, resulting in a demand for financial systems and tools that offer "hard" restrictions on access to money and cash in a gambling context. The aim of this scoping review was to determine the attitudes and preferences of gamblers and their families on systems or tools to restrict access to money and cash, as well as the effectiveness of systems and tools that can be used to accomplish that goal.

METHODS

A systematic search of articles related to financial restrictions and gambling was conducted. Eligibility criteria included samples of gamblers or affected others and interventions targeted at money or cash restrictions in a gambling context. Soft financial barriers such as family involvement were excluded, as were limit-setting systems which focused on gambling expenditure in gambling venues.

RESULTS

Nine studies met the eligibility criteria, with three focused on financial systems (e.g., ban on credit betting) and six focused on removal of cash machines from gambling venues. The included literature was generally of low quality, with just two pre-post studies and seven cross-sectional or qualitative ones.

CONCLUSIONS

The included studies provided strong support for financial mechanisms to support gamblers and their families. Future studies need to involve multiple stakeholders to provide this type of support as well as to evaluate the holistic impact that such hard barriers can have on gambling and gambling-related harms.

Changes in secondary outcomes associated with brief interventions for problem gambling in methadone patients

BACKGROUND

Patients in methadone maintenance treatment (MMT) with problem gambling (PG) experience worse psychosocial outcomes than their non-PG counterparts. Interventions targeting PG in MMT may enhance psychosocial functioning beyond gambling reduction and abstinence. The present study was a secondary data analysis that examined the trajectories of non-gambling outcomes of three brief PG interventions (i.e., brief psychoeducation, brief advice, motivational enhancement therapy plus cognitive-behavioral therapy [MET + CBT]) among MMT patients.

METHODS

Participants (N = 109) were engaged in substance use disorder treatment, met criteria for PG, and had a current or lifetime history of MMT. Latent growth curve models examined outcome trajectories of psychiatric, medical, legal, employment, and social problems, as well as psychological distress and quality of life. Follow-up analyses examined clinically significant change.

RESULTS

MET + CBT patients reported lower medical problems at baseline and over time than the brief interventions. There was no evidence of differences between interventions on the other outcomes. Psychiatric problems and psychological distress decreased over time for the entire sample, regardless of the PG intervention. About 24% and 13% of the sample demonstrated clinically significant improvements in psychological distress from baseline to 5 months, and 5 months to 12 months, respectively. Nearly 21% of the sample showed clinically significant improvements in psychiatric problems from 5 months to 12 months. Among all patients, men and those with more severe opioid dependence symptoms demonstrated the greatest psychological improvements.

CONCLUSIONS

Many patients in MMT with PG experience improvements in psychological problems, including long-term improvement, regardless of the PG intervention offered.

Pharmacological and Psychosocial Treatment of Adults With Gambling Disorder: A Meta-Review

BACKGROUND AND OBJECTIVES

Gambling disorder (GD) leads to impaired socioeconomical functioning and increased social costs. Although the research on GD has been rising over the years, approved treatment guidelines are currently not available. The aim of this study was to systematically review the literature on the pharmacological and psychosocial treatment of adults with GD, and to identify possible agreed-upon standards of care.

METHODS

MEDLINE, PubMed, Cochrane, Web of Science, Embase, and CINAHL electronic databases were searched up to April 2019 for systematic reviews on pharmacological, psychosocial, and combined treatment of adults with GD. Twenty-six studies were eventually included in this meta-review.

RESULTS

Studies reported promising results of opioid antagonists and mood stabilizers in reducing GD-related symptomatology. Lithium was particularly effective in subjects with comorbid bipolar disorders. Cognitive behavioral therapy (CBT) was the most commonly used psychological intervention and reduced global severity, gambling frequency, and financial loss. Motivational interviewing (MI) seemed to improve several GD domains, alone or in combination with CBT. Self-help interventions (SHIs) showed some efficacy in promoting treatment-seeking, and in combination with other treatments.

CONCLUSIONS

We found moderate evidence of effect for CBT, but weaker evidence for pharmacotherapy and SHIs. Results suggested some efficacy for MI in the short but not in the long term. It is likely that certain interventions might be more effective than others on specific features of GD. Further studies are needed to compare the efficacy and acceptability of individual and combined psychosocial and pharmacological interventions, to deliver patient-tailored treatments.

Development of the Gambling Disorder Identification Test: Results from an international Delphi and consensus process

OBJECTIVES

Diverse instruments are used to measure problem gambling and Gambling Disorder intervention outcomes. The 2004 Banff consensus agreement proposed necessary features for reporting gambling treatment efficacy. To address the challenge of including these features in a single instrument, a process was initiated to develop the Gambling Disorder Identification Test (GDIT), as an instrument analogous to the Alcohol Use Disorders Identification Test and the Drug Use Disorders Identification Test.

METHODS

Gambling experts from 10 countries participated in an international two-round Delphi (n = 61; n = 30), rating 30 items proposed for inclusion in the GDIT. Gambling researchers and clinicians from several countries participated in three consensus meetings (n = 10; n = 4; n = 3). User feedback was obtained from individuals with experience of problem gambling (n = 12) and from treatment-seekers with Gambling Disorder (n = 8).

RESULTS

Ten items fulfilled Delphi consensus criteria for inclusion in the GDIT (M ≥ 7 on a scale of 1-9 in the second round). Item-related issues were addressed, and four more items were added to conform to the Banff agreement recommendations, yielding a final draft version of the GDIT with 14 items in three domains: gambling behavior, gambling symptoms and negative consequences.

CONCLUSIONS

This study established preliminary construct and face validity for the GDIT.

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.

Is there a health inequality in gambling related harms? A systematic review

Background

Here we present a systematic review of the existing research into gambling harms, in order to determine whether there are differences in the presentation of these across demographic groups such as age, gender, culture, and socioeconomic status, or gambling behaviour categories such as risk severity and participation frequency.

Primary and secondary outcome measures

Inclusion criteria were: 1) focus on gambling harms; 2) focus on harms to the gambler rather than affected others; 3) discussion of specific listed harms and not just harms in general terms. Exclusion criteria were: 1) research of non-human subjects; 2) not written in English; 3) not an empirical study; 4) not available as a full article.

Methods

We conducted a systematic search using the Web of Science and Scopus databases in August 2020. Assessment of quality took place using Standard Quality Assessment Criteria.

Results

A total of 59 studies published between 1994 and 2020 met the inclusion criteria. These were categorised into thematic groups for comparison and discussion. There were replicated differences found in groups defined by age, socioeconomic status, education level, ethnicity and culture, risk severity, and gambling behaviours.

Conclusion

Harms appear to be dependent on specific social, demographic and environmental conditions that suggests there is a health inequality in gambling related harms. Further investigation is required to develop standardised measurement tools and to understand confounding variables and co-morbidities. With a robust understanding of harms distribution in the population, Primary Care Workers will be better equipped to identify those who are at risk, or who are showing signs of Gambling Disorder, and to target prevention and intervention programmes appropriately.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10337-3.

Gambling Disorder Symptoms, Suicidal Ideation, and Suicide Attempts

OBJECTIVE

Gambling disorder (GD) patients have a higher suicide risk compared to the general population. The present study investigates the suicide-related risk factors of GD patients by analyzing GD diagnosis-related symptoms and suicide-related behaviors of subjects.

METHODS

This study investigated which symptoms among GD diagnosis criteria are related to suicide risk in 142 patients diagnosed with GD. To analyze the relationship between GD symptoms and suicidal ideation and suicide attempt, the odds ratio (OR) was determined through multivariate logistic regression.

RESULTS

The number of symptoms was significantly higher in the subjects who had suicidal ideation group and attempt group. In the cases of past suicide attempts, responses to withdrawal and escape questions were significantly higher; in the cases of ongoing suicidal ideation, responses to negative consequences and bailout questions were significantly higher. When depression was corrected, the 'bailout' item was, indicating that 'bailout' increased suicidal ideation (OR=4.937, 95% CI=1.009-24.164). In the suicide attempt group, 'relieve' item may increase suicide attempt (OR=6.978, 95% CI=1.300-35.562).

CONCLUSION

Past suicide attempts in GD patients correlated with withdrawal symptoms, and financial problem correlated with suicidal ideation. This suggests that evaluating suicide risk is important when evaluating GD patients, and evaluation of financial problems is important for GD patients with suicide risks.

Current pharmacotherapy for gambling disorder: a systematic review

Introduction: Gambling disorder is classified as an addictive disorder and is associated with significant distress and impairment in personal, social, occupational or other important areas of functioning. Although no pharmacotherapy has a formal indication for gambling disorder, data suggest potential benefits of specific medications.Area covered: This systematic review evaluated findings from 19 randomized controlled trials testing pharmacotherapies for the treatment of gambling disorder.Expert opinion: Few randomized controlled trials have studied pharmacotherapies for gambling disorder. Though results are limited, opioid antagonists like naltrexone showed promise in the pharmacological treatment of gambling disorder. Pharmacotherapy combined with psychotherapy treatments for gambling disorder may provide better rates of patient retention in comparison to pharmacology-only treatments, though further research is needed in this area. Future studies should address gaps relating to considerations of racial, ethnic, gender and other individual differences in clinical studies. Because gambling disorder often co-occurs with other psychiatric disorders, additional research is needed to test treatments for dually diagnosed patients.

Treating gambling disorder with as needed administration of intranasal naloxone: a pilot study to evaluate acceptability, feasibility and outcomes

BACKGROUND AND AIM

There is growing interest in the use of medication-assisted treatments for gambling disorder (GD). Opioid receptor antagonists are hypothesised to blunt the craving associated with gambling. This study was designed to assess the feasibility of using an intranasal naloxone spray to treat GD.

DESIGN

An 8-week, open-label, uncontrolled pilot study.

SETTING

A single study site in the capital region of Finland.

SUBJECTS

Twenty problem gamblers (nine men) were randomised into two groups. Group A (n=10) took one dose into one nostril (2 mg naloxone), as needed, with a maximum of 4 doses/day (max. 8 mg/day). Group B (n=10) took one dose into each nostril (4 mg naloxone) as needed, with a maximum of 4 doses/day (max. 16 mg/day).

INTERVENTION

Naloxone hydrochloride nasal spray.

MEASURES

Acceptability and feasibility of the intervention were assessed. Use of study medication, adverse events, gambling frequency and gambling expenditure were recorded in a mobile diary. Problem gambling: South Oaks Gambling Screen (SOGS), depressive symptoms: Beck Depression Inventory (BDI) and alcohol use: Alcohol Use Disorders Identification Test were recorded.

RESULTS

Study completion rate was 90%. Acceptability and feasibility scores were high. Group B used intranasal naloxone more frequently than group A, and consequently used more naloxone. No serious adverse events were reported. The postintervention SOGS scores were lower (median=4 (IQR=3.75) versus preintervention scores (median=12 (IQR=4.75)). Depressive symptoms were reduced during the trial (preintervention BDI median=9, IQR=9 vs postintervention BDI median=6, IQR=6).

CONCLUSIONS

The acceptability and feasibility of using intranasal naloxone were high, and no serious adverse events were reported. Preliminary results suggest mixed results in terms of gambling behaviour (ie, reduced frequency but not expenditure) and decreased depressive symptoms.

TRIAL REGISTRATION NUMBER

EudraCT2016-001828-56.

Gambling disorder

Gambling disorder is characterized by a persistent, recurrent pattern of gambling that is associated with substantial distress or impairment. The prevalence of gambling disorder has been estimated at 0.5% of the adult population in the United States, with comparable or slightly higher estimates in other countries. The aetiology of gambling disorder is complex, with implicated genetic and environmental factors. Neurobiological studies have implicated cortico-striato-limbic structures and circuits in the pathophysiology of this disorder. Individuals with gambling disorder often go unrecognized and untreated, including within clinical settings. Gambling disorder frequently co-occurs with other conditions, particularly other psychiatric disorders. Behavioural interventions, particularly cognitive-behavioural therapy but also motivational interviewing and Gamblers Anonymous, are supported in the treatment of gambling disorder. No pharmacological therapy has a formal indication for the treatment of gambling disorder, although placebo-controlled trials suggest that some medications, such as opioid-receptor antagonists, may be helpful. Given the associations with poor quality of life and suicide, improved identification, prevention, policy and treatment efforts are needed to help people with gambling disorder.

Pharmacological Treatments for Disordered Gambling: A Meta-analysis

Disordered gambling is a public health concern associated with detrimental consequences for affected individuals and social costs. Currently, opioid antagonists are considered the first-line treatments to reduce symptoms of uncontrolled gambling. Only recently, glutamatergic agents and combined pharmacological and psychological treatments have been examined appearing promising options for the management of gambling disorder. A multilevel literature search yielded 34 studies including open-label and placebo-controlled trials totaling 1340 participants to provide a comprehensive evaluation of the short- and long-term efficacies of pharmacological and combined treatments. Pharmacological treatments were associated with large and medium pre-post reductions in global severity, frequency, and financial loss (Hedges's g: 1.35, 1.22, 0.80, respectively). The controlled effect sizes for the outcome variables were significantly smaller (Hedges's g: 0.41, 0.11, 0.22), but robust for the reduction of global severity at short-term. In general, medication classes yielded comparable effect sizes independent of predictors of treatment outcome. Of the placebo controlled studies, results showed that opioid antagonists and mood stabilizers, particularly the glutamatergic agent topiramate combined with a cognitive intervention and lithium for gamblers with bipolar disorders demonstrated promising results. However, more rigorously designed, large-scale randomized controlled trials with extended placebo lead-in periods are necessary. Moreover, future studies need to monitor concurrent psychosocial treatments, the type of comorbidity, use equivalent measurement tools, include outcome variables according to the Banff, Alberta Consensus, and provide follow-up data in order to broaden the knowledge about the efficacy of pharmacological treatments for this disabling condition.

Developmental trajectories of gambling severity after cognitive-behavioral therapy

AIMS

To estimate trajectories of the gambling disorder (GD) severity for 12 months following a manualized cognitive-behavior-therapy (CBT) program, and to identify the main variables associated with each trajectory.

METHODS

Latent Class Growth Analysis examined the longitudinal changes of n = 603 treatment-seeking patients with GD.

RESULTS

Five separate empirical trajectories were identified: T1 (n = 383, 63.5%) was characterized by the most highest baseline gambling severity levels and positive progress to recovery during the follow-up period; T2 (n = 154, 25.5%) featured participants with high baseline gambling severity and good progress to recovery; T3 (n = 30, 5.0%) was made up of patients with high gambling baseline severity and slow progress to recovery; T4 (n = 13, 2.2%) and T5 (n = 23, 3.8%) contained participants with high baseline gambling severity and moderate (T4) and poor (T5) progress in GD severity during the follow-up. Psychopathological state and personality traits discriminated between trajectories. Poor compliance with the therapy guidelines and the presence of relapses also differed between the trajectories.

CONCLUSIONS

Our findings show that patients seeking treatment for GD are heterogeneous and that trends in progress following treatment can be identified considering sociodemographic features, psychopathological state and personality traits. These results could be useful in developing more efficient interventions for GD patients.

Giving room to subjectivity in understanding and assessing problem gambling: A patient-centered approach focused on quality of life

BACKGROUND AND AIMS

Problem gambling is characterized by high stigma and self-stigma, making relevant measurement of the burden of the disorder complex. The aim of our qualitative study was to describe health-related quality of life (HRQOL) impacted by problem gambling from the patients' perspective.

METHODS

We conducted 6 focus groups with 25 current or lifetime at-risk problem gamblers to identify key domains of quality of life impacted by problem gambling. A content analysis from the focus groups data was conducted using Alceste^© software, using descendant hierarchical classification analysis, to obtain stable classes and the significant presences of reduced forms. The class of interest, detailing the core of impacted quality of life, was described using a cluster analysis.

RESULTS

Thematic content analysis identified three stable classes. Class 1 contained the interviewers' speech. Class 3 was composed of the vocabulary related to gambling practice, games and gambling venues (casino, horse betting, etc.). Class 2 described the core of impact of gambling on quality of life and corresponded to 43% of the analyzed elementary context units. This analysis revealed seven key domains of impact of problem gambling: loneliness, financial pressure, relationships deterioration, feeling of incomprehension, preoccupation with gambling, negative emotions, and avoidance of helping relationships.

CONCLUSIONS

We identified, beyond objective damage, the subjective distress felt by problem gamblers over the course of the disorder and in the helping process, marked in particular by stigma and self-stigma. Four impacted HRQOL areas were new and gambling-specific: loneliness, feeling of incomprehension, avoidance of helping relationships, and preoccupation with gambling. These results support the relevance of developing, in a next step, a specific HRQOL scale in the context of gambling.

Development of the Gambling Disorder Identification Test (G-DIT): Protocol for a Delphi Method Study

Background

Research on the identification and treatment of problem gambling has been characterized by a wide range of outcome measures and instruments. However, a single instrument measuring gambling behavior, severity, and specific deleterious effects is lacking.

Objective

This protocol describes the development of the Gambling Disorder Identification Test (G-DIT), which is a 9- to 12-item multiple-choice scale with three domains: gambling consumption, symptom severity, and negative consequences. The scale is analogous to the widely used Alcohol Use Disorders Identification Test (AUDIT) and the Drug Use Disorders Identification Test (DUDIT).

Methods

The G-DIT is developed in four steps: (1) identification of items eligible for the G-DIT from a pool of existing gambling measures; (2) presentation of items proposed for evaluation by invited expert researchers through an online Delphi process and subsequent consensus meetings; (3) pilot testing of a draft of the 9- to 12-item version in a small group of participants with problem gambling behavior (n=12); and (4) evaluation of the psychometric properties of the final G-DIT measure in relation to the existing instruments and self-reported criteria of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), among individuals with problem gambling and nonproblematic recreational gambling behaviors (n=600). This protocol article summarizes step 1 and describes steps 2 and 3 in detail.

Results

As of October 2018, steps 1-3 are complete, and step 4 is underway.

Conclusions

Implementation of this online Delphi study early in the psychometric development process will contribute to the face and construct validity of the G-DIT. We believe the G-DIT will be useful as a standard outcome measure in the field of problem gambling research and serve as a problem-identification tool in clinical settings.

International Registered Report Identifier (IRRID)

RR1-10.2196/12006

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.

The predictive capacity of DSM-5 symptom severity and impulsivity on response to cognitive-behavioral therapy for gambling disorder: A 2-year longitudinal study

BACKGROUND

DSM-5 proposed a new operational system by using the number of fulfilled criteria as an indicator of gambling disorder severity. This method has proven to be controversial among researchers and clinicians alike, due to the lack of studies indicating whether severity, as measured by these criteria, is clinically relevant in terms of treatment outcome. Additionally, numerous studies have highlighted the associations between gambling disorder and impulsivity, though few have examined the impact of impulsivity on long-term treatment outcomes.

METHODS

In this study, we aimed to assess the predictive value of DSM-5 severity levels on response to cognitive-behavioral therapy (CBT) in a sample of male adults seeking treatment for gambling disorder (n = 398). Furthermore, we explored longitudinal predictors of CBT treatment response at a follow-up, considering UPPS-P impulsivity traits.

RESULTS

Our study failed to identify differences in treatment outcomes between patients categorized by DSM-5 severity levels. Higher baseline scores in negative urgency predicted relapse during CBT treatment, and higher levels of sensation seeking were predictive of drop-out from short-term treatment, as well as of drop-out at 24-months.

CONCLUSIONS

These noteworthy findings raise questions regarding the clinical utility of DSM-5 severity categories and lend support to the implementation of dimensional approaches for gambling disorder.

The crucial role of recovery capital in individuals with a gambling disorder

BACKGROUND AND AIMS

The concept of recovery capital (RC) describes the internal and external resources that individuals draw upon to initiate and sustain the processes of addiction recovery. This concept has been primarily applied to individuals recovering from substance addictions. In this study, the RC concept was applied to individuals with a gambling disorder (GD) to test its associations with the diagnosis and severity of GD and with levels of psychopathology as manifested in depression and anxiety.

METHODS

A sample of 140 individuals who recovered or did not recover from a GD was drawn from lists of former and currently treated individuals in five gambling treatment centers in Israel. The DSM-5 diagnostic criteria for GD, Assessment of Recovery Capital and Brief Assessment of Recovery Capital Scales adapted to Gambling, Generalized Anxiety Disorder Scale, and the Patient Health Questionnaire 9 which measures depression were used.

RESULTS

RC clearly distinguishes between individuals who have recovered from GD and those who have not. A structural equation model showed significant negative associations between RC and GD severity, depression, and generalized anxiety. The associations between GD severity and depression and anxiety were not significant. However, when omitting the path between RC and depression/anxiety, the associations between GD and depression/anxiety became significant.

CONCLUSIONS

RC plays an important role in GD severity and diagnosis, as well as in psychopathology. This study extends the concept of RC to the area of gambling and contributes to the growing body of studies that have found parallels and common denominators between substance addiction and behavioral addictions.

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.