A Smartphone-Delivered Ecological Momentary Intervention for Problem Gambling (GamblingLess: Curb Your Urge): Single-Arm Acceptability and Feasibility Trial

A Self-Applied Psychological Treatment for Gambling-Related Problems via The Internet: A Pilot, Feasibility Study

The main purpose of this study was to evaluate the feasibility of an online psychological intervention for individuals with gambling-related problems, supported by ecological momentary assessments and interventions (EMAs and EMIs), along with weekly phone-calls, before conducting a randomized controlled trial. Participants were required to complete 3 of the 8 modules of the program based on cognitive-behavioral therapy (CBT) and extensions and innovations of CBT. The study measured the outcomes of feasibility (i.e., reach, appropriateness, technology literacy and technology usability, fidelity, and adherence). In terms of reach, 19.8% (n = 11) of the initial population met the inclusion criteria and completed the three modules (mean age = 41; 90.9% men). The perceived appropriateness and the technology usability after the first use were both excellent, fidelity and adherence to the online treatment (73.3%) were adequate. Adherence to the EMAs and the weekly phone calls were more modest (54.51% and 66.67%, respectively). The results of the present study show that an online treatment for gambling problems enhanced by EMA and EMI might be feasible but challenges were noted in terms of reach and adherence to these assessments and calls. These challenges are important to consider for future trials and the scalability of treatments for individuals with gambling disorders.

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.

Applying the Just-In-Time Adaptive Intervention Framework to the Development of Gambling Interventions

Just-In-Time Adaptive Interventions (JITAIs) are emerging "push" mHealth interventions that provide the right type, timing, and amount of support to address the dynamically-changing needs for each individual. Although JITAIs are well-suited to the delivery of interventions for the addictions, few are available to support gambling behaviour change. We therefore developed GamblingLess: In-The-Moment and Gambling Habit Hacker, two smartphone-delivered JITAIs that differ with respect to their target populations, theoretical underpinnings, and decision rules. We aim to describe the decisions, methods, and tools we used to design these two treatments, with a view to providing guidance to addiction researchers who wish to develop JITAIs in the future. Specifically, we describe how we applied a comprehensive, organising scientific framework to define the problem, define just-in-time in the context of the identified problem, and formulate the adaptation strategies. While JITAIs appear to be a promising design in addiction intervention science, we describe several key challenges that arose during development, particularly in relation to applying micro-randomised trials to their evaluation, and offer recommendations for future research. Issues including evaluation considerations, integrating on-demand intervention content, intervention optimisation, combining active and passive assessments, incorporating human facilitation, adding cost-effectiveness evaluations, and redevelopment as transdiagnostic interventions are discussed.

Chatbot-assisted therapy for patients with methamphetamine use disorder: a preliminary randomized controlled trial

Background

Methamphetamine (MA) use disorder is associated with a large public health burden. Despite the therapeutic effects of psychosocial interventions based on current evidence, finding an approach to retain patients in treatment remains a real-world challenge. The rapid development of mobile health (mHealth) systems suggests the potential to provide real-time personalized care at any time and from any location, minimize barriers to treatment, maximize use, and promote the dissemination of accessible therapeutic tools in at-risk populations. Our study aimed to investigate the feasibility and effectiveness of chatbots for the treatment of MA use disorder.

Method

The inclusion criteria were (a) a diagnosis of MA use disorder as defined by the DSM-5, (b) age between 18 and 65 years, (c) no acute exacerbation of severe mental illness during the initial assessment, such as schizophrenia or bipolar I disorder, (d) willingness to participate in standard outpatient treatment for ≥ 6 months, and (e) an Android phone. Participants were randomly allocated to either a chatbot-assisted therapy via smartphone (CAT) group or a control group following simple randomization procedures (computerized random numbers) without blinding. All participants were followed up for 6 months. Treatment retention and monthly urine test results were analyzed as outcome measures. Participants' satisfaction with CAT was also assessed.

Results

In total, 50 and 49 participants were allocated to the CAT and control groups, respectively. There were no significant differences in retention time between the two treatment groups (df = 1, p = 0.099). The CAT group had fewer MA-positive urine samples than the control group (19.5% vs. 29.6%, F = 9.116, p = 0.003). The proportion of MA-positive urine samples was positively correlated with the frequency of MA use (r = 0.323, p = 0.001), severity of MA use disorder (r = 0.364, p < 0.001), and polysubstance use (r = 0.212, p = 0.035), and negatively correlated with readiness to change (r = -0.330, p = 0.001). Totally 55 participants completed the study at the 6-month follow-up and 60% reported relative satisfaction.

Conclusion

Participants in this study had favorable acceptance and generally positive outcomes, which indicates that chatbot is feasible for treating people who use MA.

Smartphone Apps for Problem Gambling: A Review of Content and Quality

Purpose of review

Problem gambling can have profound consequences for affected individuals, yet only a small proportion of people with problem gambling seek treatment. Mobile phone applications (apps) may provide an effective and scalable therapeutic option. The purpose of this study was to evaluate publicly available mobile apps aimed at improving problematic gambling behavior.

Recent findings

To date, there are no published studies that have evaluated the quality of publicly available smartphone apps for problem gambling in the US. There is thus a significant gap in knowledge of existing apps for addressing problem gambling.

Summary

This study included a review of 14 problem-gambling-specific apps. Apps that incorporated cognitive-behavioral therapy concepts and in-app communities were associated with better aesthetics and information quality scores. Additionally, in-app communities were associated with better engagement scores. Our results highlight the importance of evidence-based and engaging features in apps designed to help people with problem gambling.

Co-created Technological Solutions for Caregivers in Health Care: Systematic Review

BACKGROUND

Support interventions for caregivers can reduce their stress, possibly improving the quality of patients' care while reducing care costs. Technological solutions have been designed to cover their needs, but there are some challenges in making them truly functional for end users. Co-design approaches present important opportunities for engaging diverse populations to help ensure that technological solutions are inclusive and accessible.

OBJECTIVE

This study aimed to identify co-created technological solutions, as well as the process followed for their co-creation, in the field of health for caregivers.

METHODS

The literature review was conducted in the Medline, Web of Science, Scopus, Science Direct, Scielo, and IEEE Xplore databases. The inclusion criteria were studies written in English or Spanish and with a publication date until May 2021. The content had to specify that the caregivers actively participated in the co-creation process, which covered until the development phase of the technological solution (prototype). The level of evidence and the methodological quality were analyzed when possible, using the Scottish Intercollegiate Guidelines Network criteria and the Mixed Methods Appraisal Tool, version 2018, respectively.

RESULTS

In total, 410 papers were identified, and 11 met the eligibility criteria. The most predominant articles were mixed methods studies and qualitative studies. The technology used in the analyzed articles were mobile or web applications (9 studies) and specific devices such as sensors, cameras, or alarm systems (2 studies) to support the health and social aspects of caregivers and improve their education in care. The most common patient profile was older people (7 studies); 6 studies used co-creation in the requirements phase, 6 studies detailed the design phase. In 9 studies, the prototype was iteratively refined in the development phase, and the validation phase was performed in 5 of the reviewed studies.

CONCLUSIONS

This systematic review suggests that existing co-created technological solutions in the field of health for caregivers are mostly mobile or web applications to support caregivers' social health and well-being and improve their health knowledge when delivering care to patients, especially older people. As for the co-creation process, caregivers are particularly involved during development and in the design. The scarce literature found indicates that further research with higher methodological quality is needed.

Update on Gambling Disorder

Gambling disorder (GD) is estimated to be experienced by about 0.5% of the adult population in the United States. The etiology of GD is complex and includes genetic and environmental factors. Specific populations appear particularly vulnerable to GD. GD often goes unrecognized and untreated. GD often co-occurs with other conditions, particularly psychiatric disorders. Behavioral interventions are supported in the treatment of GD. No medications have a formal indication for the GD, although clinical trials suggest some may be helpful. Noninvasive neuromodulation is being explored as a possible treatment. Improved identification, prevention, and treatment of GD are warranted.

Telehealth treatment for gambling disorder in the COVID-19 era: seismic shifts and silver linings

PURPOSE OF REVIEW

Gambling disorder is a serious mental health condition and the only behavioral addiction currently recognized by the American Psychiatric Association. Though prevalence and treatment seeking for gambling disorder have been stable for decades, the global COVID-19 pandemic has created a seismic shift in societal factors that influence gambling disorder and treatment availability. At the same time, the increasing availability of telehealth therapy for gambling disorder offers a new way to provide specialized treatment nationwide.

RECENT FINDINGS

The present review discusses the seismic shifts in underlying risk factors, gambling availability, and reduced access to treatment. It also covers the emergence of telehealth treatment for gambling disorder, including its benefits and pitfalls.

SUMMARY

In separate commentaries, several experts hypothesized that the pandemic was likely to increase mental health risk factors in society such as social isolation, job loss, and stress. In addition, access to online gambling also increased, while countries that locked down more strictly (like Singapore) saw a reduction in terrestrial gambling, countries that did not lock down strictly (like Sweden) did not see changes in gambling behavior. Telehealth was almost universally recommended as a good option for treatment in the studies we reviewed, though proper training and staffing are needed for telehealth to prove effective. Gambling disorder was only included in nationwide addiction telehealth programs in two countries.

State impulsivity amplifies urges without diminishing self-control

A disproportionate amount of research on impulsivity has focused on trait-related aspects rather than state fluctuations. As a result, the relationship between state impulsivity and moment-to-moment behaviour is unclear. Impulsivity is assumed to negatively affect self-control, but an alternative explanation, yet to be tested, could be that changes in state impulsivity and its homeostatic drivers influence the intensity of urges. We tested whether state impulsivity and hunger affected behaviour through a dual-process model, affecting both the experience of various urges, and self-control, using a smartphone-based experience sampling approach. We found that state impulsivity is associated with stronger urges, but we found no evidence of an association with diminished self-control. Being hungry amplifies urges across different types of urges, and both hunger and late hours are negatively related to the likelihood of controlling urges. These findings imply that the influence of hunger is not limited to the food domain, and provide new insight into the role of state impulsivity in daily life.

GAMBLINGLESS IN-THE-MOMENT: Protocol for a micro-randomised trial of a gambling Just-In-Time Adaptive Intervention (Preprint)

Background

The presence of discrete but fluctuating precipitants, in combination with the dynamic nature of gambling episodes, calls for the development of tailored interventions delivered in real time, such as just-in-time adaptive interventions (JITAIs). JITAIs leverage mobile and wireless technologies to address dynamically changing individual needs by providing the type and amount of support required at the right time and only when needed. They have the added benefit of reaching underserved populations by providing accessible, convenient, and low-burden support. Despite these benefits, few JITAIs targeting gambling behavior are available.

Objective

This study aims to redress this gap in service provision by developing and evaluating a theoretically informed and evidence-based JITAI for people who want to reduce their gambling. Delivered via a smartphone app, GamblingLess: In-The-Moment provides tailored cognitive-behavioral and third-wave interventions targeting cognitive processes explicated by the relapse prevention model (cravings, self-efficacy, and positive outcome expectancies). It aims to reduce gambling symptom severity (distal outcome) through short-term reductions in the likelihood of gambling episodes (primary proximal outcome) by improving craving intensity, self-efficacy, or expectancies (secondary proximal outcomes). The primary aim is to explore the degree to which the delivery of a tailored intervention at a time of cognitive vulnerability reduces the probability of a subsequent gambling episode.

Methods

GamblingLess: In-The-Moment interventions are delivered to gamblers who are in a state of receptivity (available for treatment) and report a state of cognitive vulnerability via ecological momentary assessments 3 times a day. The JITAI will tailor the type, timing, and amount of support for individual needs. Using a microrandomized trial, a form of sequential factorial design, each eligible participant will be randomized to a tailored intervention condition or no intervention control condition at each ecological momentary assessment across a 28-day period. The microrandomized trial will be supplemented by a 6-month within-group follow-up evaluation to explore long-term effects on primary (gambling symptom severity) and secondary (gambling behavior, craving severity, self-efficacy, and expectancies) outcomes and an acceptability evaluation via postintervention surveys, app use and engagement indices, and semistructured interviews. In all, 200 participants will be recruited from Australia and New Zealand.

Results

The project was funded in June 2019, with approval from the Deakin University Human Research Ethics Committee (2020-304). Stakeholder user testing revealed high acceptability scores. The trial began on March 29, 2022, and 84 participants have been recruited (as of June 24, 2022). Results are expected to be published mid-2024.

Conclusions

GamblingLess: In-The-Moment forms part of a suite of theoretically informed and evidence-based web-based and mobile gambling interventions. This trial will provide important empirical data that can be used to facilitate the JITAI’s optimization to make it a more effective, efficient, and scalable tailored intervention.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12622000490774; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380757&isClinicalTrial=False

International Registered Report Identifier (IRRID)

PRR1-10.2196/38958

Gambling Habit Hacker: Protocol for a micro-randomised trial of planning interventions delivered via a Just-In-Time Adaptive Intervention for adult gamblers (Preprint)

Background

People with gambling problems frequently report repeated unsuccessful attempts to change their behavior. Although many behavior change techniques are available to individuals to reduce gambling harm, they can be challenging to implement or maintain. The provision of implementation support tailored for immediate, real-time, individualized circumstances may improve attempts at behavior change.

Objective

We aimed to develop and evaluate a Just-In-Time Adaptive Intervention (JITAI) for individuals who require support to adhere to their gambling limits. JITAI development is based on the principles of the Health Action Process Approach with delivery, in alignment with the principles of self-determination theory. The primary objective was to determine the effect of action- and coping planning compared with no intervention on the goal of subsequently adhering to gambling expenditure limits.

Methods

Gambling Habit Hacker is delivered as a JITAI providing in-the-moment support for adhering to gambling expenditure limits (primary proximal outcome). Delivered via a smartphone app, this JITAI delivers tailored behavior change techniques related to goal setting, action planning, coping planning, and self-monitoring. The Gambling Habit Hacker app will be evaluated using a 28-day microrandomized trial. Up to 200 individuals seeking support for their own gambling from Australia and New Zealand will set a gambling expenditure limit (ie, goal). They will then be asked to complete 3 time-based ecological momentary assessments (EMAs) per day over a 28-day period. EMAs will assess real-time adherence to gambling limits, strength of intention to adhere to goals, goal self-efficacy, urge self-efficacy, and being in high-risk situations. On the basis of the responses to each EMA, participants will be randomized to the control (a set of 25 self-enactable strategies containing names only and no implementation information) or intervention (self-enactable strategy implementation information with facilitated action- and coping planning) conditions. This microrandomized trial will be supplemented with a 6-month within-group follow-up that explores the long-term impact of the app on gambling expenditure (primary distal outcome) and a range of secondary outcomes, as well as an evaluation of the acceptability of the JITAI via postintervention surveys, app use and engagement indices, and semistructured interviews. This trial has been approved by the Deakin University Human Research Ethics Committee (2020-304).

Results

The intervention has been subject to expert user testing, with high acceptability scores. The results will inform a more nuanced version of the Gambling Habit Hacker app for wider use.

Conclusions

Gambling Habit Hacker is part of a suite of interventions for addictive behaviors that deliver implementation support grounded in lived experience. This study may inform the usefulness of delivering implementation intentions in real time and in real-world settings. It potentially offers people with gambling problems new support to set their gambling intentions and adhere to their limits.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12622000497707; www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383568

International Registered Report Identifier (IRRID)

DERR1-10.2196/38919

Client's Experiences Using a Location-Based Technology ICT System during Gambling Treatments' Crucial Components: A Qualitative Study

Cognitive Behavioral Therapy is the treatment of choice for Gambling Disorder (GD), with stimulus control (SC) and exposure with response prevention (ERP) being its two core components. Despite their efficacy, SC and ERP are not easy to deliver, so it is important to explore new ways to enhance patient compliance regarding SC and ERP. The aim of this study is to describe and assess the opinion of two patients diagnosed with problem gambling and GD that used the Symptoms app, a location-based ICT system, during SC and ERP. A consensual qualitative research study was conducted. We used a semi-structured interview, developed ad-hoc based on the Expectation and Satisfaction Scale and System Usability Scale. A total of 20 categories were identified within six domains: usefulness, improvements, recommendation to other people, safety, usability, and opinion regarding the use of the app after completing the intervention. The patients considered the app to be useful during the SC and ERP components and emphasized that feeling observed and supported at any given time helped them avoid lapses. This work can offer a starting point that opens up new research paths regarding psychological interventions for gambling disorder, such as assessing whether location-based ICT tools enhance commitment rates.

Efficacy of an internet-based psychological intervention for problem gambling and gambling disorder: Study protocol for a randomized controlled trial

Gambling Disorder is a prevalent non-substance use disorder, which contrasts with the low number of people requesting treatment. Information and Communication Technologies (ICT) could help to enhance the dissemination of evidence-based treatments and considerably reduce the costs. The current study seeks to assess the efficacy of an online psychological intervention for people suffering from gambling problems in Spain. The proposed study will be a two-arm, parallel-group, randomized controlled trial. A total of 134 participants (problem and pathological gamblers) will be randomly allocated to a waiting list control group (N = 67) or an intervention group (N = 67). The intervention program includes 8 modules, and it is based on motivational interviewing, cognitive-behavioral therapy (CBT), and extensions and innovations of CBT. It includes several complementary tools that are present throughout the entire intervention. Therapeutic support will be provided once a week through a phone call with a maximum length of 10 min. The primary outcome measure will be gambling severity and gambling-related cognitions, and secondary outcome measures will be readiness to change, and gambling self-efficacy. Other variables that will be considered are depression and anxiety symptoms, positive and negative affect, difficulties in emotion regulation strategies, impulsivity, and quality of life. Individuals will be assessed at baseline, post-treatment, and 3-, 6-, and 12-month follow-ups. During the treatment, participants will also respond to a daily Ecological Momentary Intervention (EMI) in order to evaluate urges to gamble, self-efficacy to cope with gambling urges, gambling urge frequency, and whether gambling behaviour occurs. The EMI includes immediate automatic feedback depending on the participant's responses. Treatment acceptance and satisfaction will also be assessed. The data will be analysed both per protocol and by Intention-to-treat. As far as we know, this is the first randomized controlled trial of an online psychological intervention for gambling disorder in Spain. It will expand our knowledge about treatments delivered via the Internet and contribute to improving treatment dissemination, reaching people suffering from this problem who otherwise would not receive help.

TRIAL REGISTRATION

Clinicaltrials.gov as NCT04074681. Registered 22 July 2019.

GamblingLess: A Randomised Trial Comparing Guided and Unguided Internet-Based Gambling Interventions

There is little evidence relating to the effects of adding guidance to internet-based gambling interventions. The primary aim was to compare the effectiveness of an online self-directed cognitive-behavioural gambling program (GamblingLess) with and without therapist-delivered guidance. It was hypothesised that, compared to the unguided intervention, the guided intervention would result in superior improvements in gambling symptom severity, urges, frequency, expenditure, psychological distress, quality of life and help-seeking. A two-arm, parallel-group, randomised trial with pragmatic features and three post-baseline evaluations (8 weeks, 12 weeks, 24 months) was conducted with 206 gamblers (106 unguided; 101 guided). Participants in both conditions reported significant improvements in gambling symptom severity, urges, frequency, expenditure, and psychological distress across the evaluation period, even after using intention-to-treat analyses and controlling for other low- and high-intensity help-seeking, as well as clinically significant changes in gambling symptom severity (69% recovered/improved). The guided intervention resulted in additional improvements to urges and frequency, within-group change in quality of life, and somewhat higher rates of clinically significant change (77% cf. 61%). These findings, which support the delivery of this intervention, suggest that guidance may offer some advantages but further research is required to establish when and for whom human support adds value.

Ecological Momentary Assessment of the Relationship between Positive Outcome Expectancies and Gambling Behaviour

Relapse prevention models suggest that positive outcome expectancies can constitute situational determinants of relapse episodes that interact with other factors to determine the likelihood of relapse. The primary aims were to examine reciprocal relationships between situational positive gambling outcome expectancies and gambling behaviour and moderators of these relationships. An online survey and a 28 day Ecological Momentary Assessment (EMA) were administered to 109 past-month gamblers (84% with gambling problems). EMA measures included outcome expectancies (enjoyment/arousal, self-enhancement, money), self-efficacy, craving, negative emotional state, interpersonal conflict, social pressure, positive emotional state, financial pressures, and gambling behaviour (episodes, expenditure). Pre-EMA measures included problem gambling severity, motives, psychological distress, coping strategies, and outcome expectancies. No reciprocal relationships between EMA outcome expectancies and gambling behaviour (episodes, expenditure) were identified. Moderations predicting gambling episodes revealed: (1) cravings and problem gambling exacerbated effects of enjoyment/arousal expectancies; (2) positive emotional state and positive reframing coping exacerbated effects of self-enhancement expectancies; and (3) instrumental social support buffered effects of money expectancies. Positive outcome expectancies therefore constitute situational determinants of gambling behaviour, but only when they interact with other factors. All pre-EMA expectancies predicted problem gambling severity (OR = 1.61-3.25). Real-time interventions addressing gambling outcome expectancies tailored to vulnerable gamblers are required.