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Reviewing the Evidence Base for Problem Gambling Treatment . Dr. James Westphal, Clinical Professor of Psychiatry University of Hawaii-Manoa John Burns School of Medicine. April 9, 2010. Objectives. Who are problem gamblers? Co-occurring disorders Addiction syndrome DSM 5

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Reviewing the evidence base for problem gambling treatment l.jpg
Reviewing the Evidence Base for Problem Gambling Treatment

Dr. James Westphal,

Clinical Professor of Psychiatry

University of Hawaii-Manoa

John Burns School of Medicine

April 9, 2010


Objectives l.jpg
Objectives

  • Who are problem gamblers?

    • Co-occurring disorders

  • Addiction syndrome

  • DSM 5

  • General issues with gambling treatment

    • Attrition

    • Placebo/Attention response

  • Current evidence base for gambling treatment efficacy

  • Trends in the evidence base


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Who Develops Problem Gambling?

  • Problem gambling is not randomly distributed through the population

  • Problem gambling tends to concentrate in specific cultural and socio-economic groups that varies by jurisdiction

  • Problem gambling concentrates among people with mental health and substance use problems


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US Ethnic Differences

  • US National Epidemiologic Survey, a large (N=43,093) national survey of adults during 2001-2002.

  • Results: Prevalence rates of disordered gambling among blacks (2.2%) and Native/Asian Americans (2.3%) were higher than that of whites (1.2%).

  • Demographic characteristics and psychiatric comorbidity differed among Hispanic, black, and white disordered gamblers.

  • All racial and ethnic groups evidenced similarities with respect to symptom patterns, time course, and treatment seeking for pathological gambling.

    Alegria AA et al, 2009


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US Ethnic Differences (2)

  • Conclusion: The prevalence of disordered gambling, but not its onset or course of symptoms, varies by racial and ethnic group.

  • These varying prevalence rates may reflect, at least in part, cultural differences in gambling and its acceptability and accessibility.

    Alegria AA et al, 2009


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Pathological Gambling Risk Factor Review

  • Found very few well established risk factors for pathological gambling (i.e. more than two studies to support the conclusions).

  • Well established risk factors included demographic variables (age, gender),

  • Cognitive distortions (erroneous perceptions, illusion of control),

  • Sensory characteristics,

  • Schedules of reinforcement,

  • Comorbid disorders (OCD, drug abuse), and delinquency/illegal acts

    Johansson, Grant, Kim, Odlaug & Götestam, 2009



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US National Co-morbidity Survey Replication (1)

  • Nationally representative face-to-face household survey

  • Conducted between February 2001 and April 2003 using a fully structured diagnostic interview

  • 9282 English-speaking adults

    Kessler RC et al, 2005


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US National Co-morbidity Survey Replication(2)

  • 55% had a single diagnosis

  • 22% had two diagnoses

  • 23% had three or more diagnoses.

  • Highly comorbid patients represent 7% of the population.

    Kessler RC et al, 2005


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National Co-morbidity Survey Replication (3)

  • 12-month cases:

  • 22.3% were classified as serious;

  • 37.3%, moderate; and

  • 40.4%, mild.

    Kessler RC et al, 2005


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National Co-morbidity Survey Replication (4)

  • Although mental disorders are widespread among the US community population,

  • Serious cases are concentrated among a relatively small proportion of cases with high co-morbidity.

    Kessler RC et al, 2005


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Co-occurring Mental Health Disorders and Problem Gambling are a World Wide Phenomena

  • US, Canada and New Zealand community (majority)

  • New Zealand, US and Canada treatment (majority)

  • Australia treatment

  • Germany treatment

  • Israel treatment

  • France treatment

  • Lithuania treatment

  • Spain treatment

    Westphal and Johnson, 2007


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Problem Gambling are a World Wide Phenomenais Associated with Multiple Mental Health Disorders

  • Substance use disorders,

  • especially alcohol dependence

  • Antisocial personality disorder

  • Affective disorders

  • Anxiety disorders

  • Personality disorders as a group

  • Mania

  • Other impulse control disorders


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Pathological are a World Wide Phenomena Gambling and Other Co-occurring Disorders

  • 43,093 US adults participated in face to face interviews in a 2001-2002 survey.

  • 73.2% of pathological gamblers had an alcohol use disorder

  • 38.1% had a drug use disorder

  • 60.4% had nicotine dependence

  • 49.6% had a mood disorder

  • 41.3% had an anxiety disorder

  • 60.8% had a personality disorder

    Petry, Stinson & Grant, 2005


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Pathological are a World Wide Phenomena Gambling and Other Co-occurring Disorders (2)

  • Onset and persistence of PG were predicted by a variety of prior DSM-IV anxiety, mood, impulse-control and substance use disorders.

  • PG also predicted the subsequent onset of generalized anxiety disorder, post-traumatic stress disorder (PTSD) and substance dependence.

  • Although none of the NCS-R respondents with PG ever received treatment for gambling problems, 49.0% were treated at some time for other mental disorders.

    Kessler RC et al, 2008


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Pathological are a World Wide Phenomena Gambling and Other Co-occurring Disorders (3)

  • CONCLUSIONS: DSM-IV PG is a comparatively rare, seriously impairing, and undertreated disorder whose symptoms typically start during early adulthood and is frequently secondary to other mental or substance disorders that are associated with both PG onset and persistence.

    Kessler RC et al, 2008


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Canadian Study are a World Wide Phenomena

  • DESIGN: Cross-sectional national survey (Canadian Community Health Survey-Mental Health and Well-Being) data collected through a multi-stage stratified cluster design.

  • SETTING: Population-based household survey.

  • PARTICIPANTS: 36 885 participants

  • MAIN OUTCOME MEASURES: The prevalence and severity of PG were measured using the Canadian Problem Gambling Index.

    Rush, Bassani, Urbanoski, Castel, 2008


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Canadian Study (2) are a World Wide Phenomena

  • Prevalence of MD (mood and anxiety disorders) and SUD were defined according to the World Mental Health Survey Initiative Composite International Diagnostic Interview

  • CONCLUSIONS: Prevalence of all levels of PG increased with SUD severity, but the pattern did not appear to be affected by MD co-occurrence.

  • Results suggest particular attention be given to SUD in treatment-seeking clients with co-occurring disorders.

    Rush, Bassani, Urbanoski, Castel, 2008


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Interaction of Pathological Gambling and Alcohol Use are a World Wide Phenomena

  • Random sample of 2638 U.S. adults

  • Current alcohol use and current gambling behavior

  • Found an unusually strong relationship between current alcohol dependence and current pathological gambling.

  • The odds ratio (23.1)

  • Found a positive interaction in current drinking and gambling. As the amount of drinking per day increased in the sample, the amount and severity of the gambling also increased

    Welte et al, 2001


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Interaction of Substance Dependency and Other Disorders are a World Wide Phenomena

  • A national US study

  • The relationship of substance use and mental health disorders

  • Found a strong association with a co-occurring mental health disorder and any drug dependency.

  • Multiple drug dependencies increased the strength of the association, especially if the drug was an illegal substance

    Kandel, Huang & Davies, 2001


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Interaction of Substance Dependency and Other Disorders are a World Wide Phenomena

  • Similar Patterns Across Cultures

  • A cross-national and cross cultural study

  • Co-occurring substance use, anxiety and mood disorders

  • Netherlands, Canada, Mexico, Brazil, Germany and the Latino population of Fresno, California


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Interaction of Substance Dependency and Other Disorders (2) are a World Wide Phenomena

  • Similar relationships occurred at all sites.

  • As the number of co-occurring disorders increased, the association with a dependency diagnosis became stronger.

  • Conversely, as the severity of the substance use increased from use to abuse to dependence, so did the number of co-occurring disorders.

    Merikangas et al, 1998


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Summary are a World Wide Phenomena

  • Pathological gambling is highly comorbid with substance use, mood, anxiety, and personality disorders.

  • Gambling disorders may not be independent, but rather add to the disease burden of patients with multiple disorders.

  • There are significant implications; both for the care of individual patients and systems of care.


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Addiction Syndrome are a World Wide Phenomena

  • Shaffer recently proposed that addiction is a “syndrome” based on non specific biological risk factors across substance use disorders.

  • A syndrome is a cluster of signs and symptoms related to an abnormal underlying condition.

  • Not all signs and symptoms are present in every expression of the syndrome.

  • Some manifestations of the syndrome have unique signs and symptoms.

    Shaffer, LaPlante, LaBrie, Kidman, Doanto, Stanton, 2004


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Evidence Supporting are a World Wide PhenomenaAddiction Syndrome

  • The association of disorders with each other or co-occurrence is one of the types of evidence supporting addiction models.

  • Pathological gambling has strong co-occurrence with a broad range of substance use disorders(Petry, Stinson & Grant, 2005; Potenza M, 2006; Petry NM, 2006; Westphal & Johnson, 2007).


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Evidence Supporting are a World Wide PhenomenaAddiction Syndrome (2)

  • Genetic studies also find an association of pathological gambling and substance use disorders (Black, Monahan, Temkit & Shaw, 2006)

  • Neuroscientists hypothesize that an under functioning dopamine reward system or reward deficiency is a vulnerability for development of both substance use disorders and disorders of excessive behavior (Blum et al., 2000).


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Evidence Supporting are a World Wide PhenomenaAddiction Syndrome (3)

  • Multiple studies with patients with pathological gambling demonstrate shared psychological and social risk factors with substance use disorders (Shaffer & Korn, 2002).

  • A non specific response to treatment among patients with substance dependence and disorders of excessive behavior has also been recognized

    Shaffer, LaPlante, LaBrie, Kidman, Doanto, Stanton, 2004; Westphal & Abbott, 2006


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DSM 5 Proposals are a World Wide Phenomena

  • The Substance-Related Disorders  work group has proposed to tentatively re-title the category, Addiction and Related Disorders, the diagnostic category will include both substance use disorders and non-substance addictions.

  • Gambling disorder has been moved into this category and there are other addiction-like behavioral disorders such as “Internet addiction” that will be considered as potential additions to this category as research data accumulate. 

  • The work group had extensive discussions on the use of the word “addiction.” 

    http://www.dsm5.org/ProposedRevisions/Pages/Substance-RelatedDisorders.aspx


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Candidates for Addiction-Like Behavioral Disorders are a World Wide Phenomena

  • Computer and online gaming

  • Exercise

  • Gambling

  • Internet use

  • Shopping

  • Skin picking

  • Sexual behaviors

  • Video game playing, Pinball

  • Television Watching

  • Work

    Westphal, 2007


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DSM 5 Changes for Pathological Gambling are a World Wide Phenomena

  • Include Pathological (Disordered) Gambling within Addiction and Related Disorders

  • Lower Threshold for Pathological (Disordered) Gambling Diagnosis

  • Eliminate Illegal Act Criterion for Pathological (Disordered) Gambling

    http://www.dsm5.org/ProposedRevisions/Pages/Substance-RelatedDisorders.aspx


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World wide, Across Treatment Modalities are a World Wide Phenomena

Problem gamblers drop out of treatment


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Dropout from Psychological Treatments for Pathological Gambling

  • 12 studies from five countries.

  • Dropout ranged from 14% to 50%, with a median of dropout 26%.

  • Overall, 31% of the participants dropped out of treatment.

  • Few studies distinguish between dropouts at different stages of participation.

  • The evidence on specific variables that predict dropout is limited or inconsistent, and is characterised by a lack of a coherent, gambling-specific model and by methodological problems.

    Melville, Casey & Kavanagh, 2007


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Attrition rates Gambling

  • Short term pharmacological treatment ranged from 11.3% to 40%.

  • Long term pharmacological treatment ranged from 48.3% to 59.4%.

  • Psychosocial treatment ranged between 32% and 55.4% attrition.

  • Community multimodal treatment ranged between 29% and 83%,

  • GA studies ranged from 50% to 69.4% attrition.

    Westphal, 2007


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Attrition Rates with Confidence Intervals Gambling

  • Short term pharmacological treatment (23.5%, CI: 17.5% to 29.5%)

  • Psychosocial (42%, CI: 37% to 47%),

  • Long term pharmacological treatment (50.4%, CI: 47.4% to 53.4%),

  • GA (67.5%, CI: 61.6% to 73.4%)

  • Community multi-modal (75%, CI: 73.8% to 76.2%).

    Westphal, 2007


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Gambling Treatment Attrition Gambling

  • Attrition in gambling treatment is prevalent and substantial

  • Attrition may affect the majority of patients in some types of gambling treatment.


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Problem Gambling Treatment Gambling

Why Worry About Evidence?


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Multiple Worldwide Studies of Both Mental and Physical Health Services

  • Ineffective services are routinely provided

  • Effective services are misapplied to inappropriate patient populations

  • Effective services are incorrectly delivered

  • Effective services are delivered to small proportions of patients who would benefit

    Westphal, 2007


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Why? Health Services

  • Slow dissemination of new evidence based treatments into practice

  • slow extinguishment of practices whose utility has been disproved

    Westphal, 2007


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Brief History of Gambling Treatment Structured Reviews Health Services

  • Oakley-Browne, Adams & Mobberley, 2000

  • Toneatto & Ladoceur, 2003

  • Pallesen, Mitsem, Kvale et al., 2005

  • Pallesen, Molde, Arnestad et al., 2007

  • Gooding & Tarrier, 2009


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2000 Health Services

  • Only four RCTs of psychological treatments were identified.

  • The RCTs were heterogeneous in terms of design, interventions, outcome measurement and follow-up periods.

  • All had small numbers of participants.

  • The studies had poor methodological quality features.

  • The experimental interventions, behavioural or cognitive-behavioural therapy (BT/CBT), were more efficacious than the control interventions in the short-term (relative risk 0.44, 95% confidence interval (CI) 0.24-0.81).

    Oakley-Browne, Adams & Mobberley, 2000


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2000 (2) Health Services

  • CONCLUSIONS: This systematic review revealed a paucity of evidence for effective treatment of pathological gambling. As gambling is becoming more accessible in many countries and there is epidemiological evidence of increasing rates of pathological gambling, more rigorous RCTs are required.

    Oakley-Browne, Adams & Mobberley, 2000


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2003 Health Services

  • This critical review includes only controlled treatment studies.

  • The primary inclusion criterion was randomization of participants to an experimental group and to at least 1 control group.

  • Eleven studies were identified and evaluated.

  • Key findings showed that cognitive-behavioral studies received the best empirical support.

  • Recommendations to improve gambling treatment research include better validated psychometric measures, inclusion of process measures, better definition of outcomes, and more precise definition of treatments.

    Toneatto & Ladoceur, 2003


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2005 Health Services

  • A total of 37 outcome studies, published or reported between 1968 and 2004, were identified.

  • Of these 15 were excluded, thus 22 studies were included, involving 1434 subjects

  • Effect sizes represent the difference between the mean score in a treatment condition and a control condition or the difference between mean scores at separated points in time for one group, expressed in terms of standard deviation units.

  • At post-treatment the analysis indicated that psychological treatments were more effective than no treatment, yielding an overall effect size of 2.01 (Large effect).

    Pallesen, Mitsem, Kvale et al, 2005


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2005 (2) Health Services

  • At follow-up (averaging 17.0 months) the corresponding effect size was 1.59 (Large effect).

  • A multiple regression analysis showed that the magnitude of effect sizes at post-treatment were lower in studies including patients with a formal diagnosis of pathological gambling only,

  • positively related to number of therapy sessions.

  • CONCLUSION: Psychological interventions for pathological gamble seem to be yield very favourable short- and long-term outcomes.

    Pallesen, Mitsem, Kvale et al, 2005


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2007 Health Services

  • 130 studies were identified; 16 met the criteria.

  • 597 subjects were included, mean age was 43.3 years, males (62.8%).

  • Analysis showed that the pharmacological interventions were more effective than no treatment/placebo, yielding an overall effect size of 0.78 (Large effect).

  • A multiple regression analysis showed that the magnitude of effect sizes at post treatment was lower in studies using a placebo-control condition compared with studies using a predesign/postdesign without any control condition.

    Pallesen, Molde, Arnestad et al., 2007


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2007 (2) Health Services

  • Effect sizes were also negatively related to the proportion of male participants in the included studies.

  • No differences in outcome between the 3 main classes of pharmacological interventions (antidepressants, opiate antagonists, mood stabilizers) were detected.

  • CONCLUSION: Pharmacological interventions for pathological gambling may be an adequate treatment alternative in pathological gambling.

    Pallesen, Molde, Arnestad et al., 2007


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2009 Health Services

  • Twenty-five studies met the inclusion criteria.

  • Highly significant effect of CBT in reducing gambling behaviours within the first three months of therapy cessation regardless of the type of gambling behaviour practiced.

  • Effect sizes were also significant at six, twelve and twenty-four month follow-up periods.

  • Sub-group analysis suggested that both individual and group therapies were equally as effective in the 3 month time window, however this equivalence was not clear at follow-up.

    Gooding & Tarrier, 2009


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2009 (2) Health Services

  • All variants of CBT (cognitive therapy, motivational interviewing and imaginal desensitization) were significant, although there was tentative evidence that when different types of therapy were compared cognitive therapy had an added advantage.

  • Meta-regression analyses showed that the quality of the studies influenced the effect sizes, with those of poorer quality having greater effect sizes.

    Gooding & Tarrier, 2009


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2009 (3) Health Services

  • These results give an optimistic message that CBT, in various forms, is effective in reducing gambling behaviours.

  • However, caution is warranted because of the heterogeneity of the studies.

  • Evaluation of treatment for problem gambling lags behind other fields and this needs to be redressed in the future.

    Gooding & Tarrier, 2009


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Only studies 6, 14 and 15 had CTAM scores > 65 Health Services Effect sizes from .2 to .43 (small to medium)

Gambling Treatment Effect Sizes


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CBT Treatment Effect Sizes Health Services

  • A recent meta analysis of CBT among adult patients with depression found that effect sizes were systematically over estimated.

  • Their estimate for the effect size for CBT for adult depression was .42 (small to medium range).

    Cuijpers P, Smit F, Bohlmeijer E, Hollon SD & Andersson G, 2010



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Treatment Dose Response Relationship Health Services

  • Increasing amounts of treatment are

    associated with better outcomes and

  • Conversely, lower amounts of treatment are associated with poorer outcomes.

    Shaffer et al. 2005; Petry et al. 2006; Gooding & Tarrier, 2009


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Is there a Specific Treatment for Problem Gambling? Health Services

Is there an effect of problem gambling treatment beyond the effect of paying attention to the problem?


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Placebo Response among Pathological Gamblers Health Services

  • The average rate of placebo response among pathological gamblers in pharmacological clinical trials is 42%.

  • Duration of the response ranges from 6-8 weeks to 9 months.

  • This response is defined as the non-specific response to treatment, equivalent to paying attention to and observing the problem or behavior


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Placebo Response Among Pharmacological Clinical Trials Health Services

Study Year Placebo %

Hollander 1998 41.7%

Kim 2001 24%

Kim 2002 23.8 %

Blanco 2002 59%

Grant 2003 49%

Saiz-Ruiz 2005 72%

Hollander 2005 25%

Grant 2006 34%


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Evidence Based Recovery Processes Health Services

  • Provision of support, goal direction, and monitoring;

  • Engagement in rewarding activities other than substance use,

  • Exposure to abstinence-oriented norms and models,

  • Attempts to build self-efficacy and coping skills.

    Moos, 2007


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Trends Health Services

  • Treatment studies of gambling and other co-morbid conditions (Korman, Collins, Littman-Sharp et al., 2008; Toneatto, Brands & Selby, 2009).

  • Focused pharmacology treatment studies

    (Grant, Kim & Hartman, 2008; Blanco C et al, 2009)

  • Unbundling studies (Petry, Litt, Kadden et al., 2007)


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Naltrexone as a Treatment for Concurrent Alcohol Use Disorder and PG

  • Randomized, double-blind, placebo-controlled trial.

  • Fifty-two, mostly male, subjects were recruited from the community and received 11 weeks of medication during which CBT was also provided.

  • No significant group differences were found on any alcohol or gambling variable (ie, frequency, quantity, expenditures) at post-treatment or at the one year follow-up.

  • However, a strong time effect was found suggesting that treatment, in general, was effective.

  • The use of naltrexone to treat concurrent alcohol use and gambling problems was not supported.

    Toneatto, Brands & Selby, 2009


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Integrated Therapy for Comorbid Anger and Gambling Disorder and PG

  • This study evaluated an integrated treatment for comorbid problem gambling, anger, and substance use.

  • Problem gamblers with comorbid anger problems (N=42), half of whom also had substance use disorders, were randomized to either a 14-week integrated treatment targeting anger and addictions (i.e., both gambling and substance use) or a specialized treatment-as-usual (TAU) for gambling and substance use.

    Korman, Collins, Littman-Sharp et al., 2008


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Integrated Therapy for Comorbid Anger and Gambling (2) Disorder and PG

  • Relative to the TAU, participants in the integrated anger and addictions treatment reported significantly less gambling at T2 and T3 and less trait anger and substance use at T3.

  • Findings suggest that it is important to screen gambling clients for the presence of comorbid anger and substance use problems and that, when present, these problems need to be addressed concurrently in gambling treatment in order to optimize treatment outcomes.

    Korman, Collins, Littman-Sharp et al., 2008


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Naltrexone in the Treatment of Pathological Gambling Urges Disorder and PG

  • An 18-week, double-blind, placebo-controlled trial

  • evaluate the safety and efficacy of 3 doses of oral naltrexone for PG.

  • Seventy-seven individuals with DSM-IV-TR PG were randomly assigned to naltrexone (50 mg/day, 100 mg/day, or 150 mg/day) or placebo.

    Grant, Kim & Hartman, 2008


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Naltrexone in the Treatment of Pathological Gambling Urges (2)

  • CONCLUSION: Subjects assigned to naltrexone demonstrated statistically significant reductions in gambling urges and behavior in PG.

  • Low-dose naltrexone (50 mg/day) appeared as efficacious as higher doses (100 mg/day and 150 mg/day), and all doses were well tolerated.

    Grant, Kim & Hartman, 2008


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Impulsivity (2)

  • Study examined the relationship between gambling severity, impulsivity and obsessionality/compulsivity in 38 pathological gamblers

  • Representing the complete Minnesota sample of a randomized, placebo-controlled clinical trial of paroxetine for the treatment of pathological gambling

  • Changes in PG-YBOCS scores after treatment correlated with changes in Impulsiveness scores.

  • These changes appeared independent of paroxetine treatment.

  • The results suggest that, although PG exhibits features of both obsessionality/compulsivity and impulsivity and elements of both decrease with treatment, impulsivity predominates and changes in gambling severity are most associated with changes in impulsivity. (Blanco C et al, 2009)


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Do coping sills mediate the relationship between cognitive –behavioral therapy and reductions in gambling in pathological gamblers?

  • This study examined whether coping skills acquisition mediated the effects of CBT on decreasing gambling in pathological gamblers.

  • DESIGN: Participants were assigned randomly to CBT plus referral to Gamblers Anonymous (GA) or to GA referral alone.

  • Setting Out-patient clinic.

  • PARTICIPANTS: A total of 127 pathological gamblers.

    Petry, Litt, Kadden et al., 2007


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Coping Skills (2) –behavioral therapy and reductions in gambling in pathological gamblers?

  • MEASUREMENTS: Participants completed the Coping Strategies Scale (CSS) before treatment and 2 months later; indices of gambling behavior and problems were administered pretreatment and at months 2 and 12.

  • FINDINGS: Overall, CSS scores increased for participants in both conditions, but those receiving CBT evidenced larger increases than those in the GA condition (P < 0.05), and they also reduced gambling more substantially between pretreatment and month 2.

  • Changes in CSS scores mediated the relationship between treatment assignment and gambling outcomes from pretreatment to month 2, but little evidence of mediation occurred for the long-term follow-ups.

    Petry, Litt, Kadden et al., 2007


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Objectives –behavioral therapy and reductions in gambling in pathological gamblers?

  • Co-occurring disorders predominate, SUD’s are a likely driver and consequence of PG

  • DSM 5 is considering adapting the addiction syndrome

  • Gambling treatment has significant attrition and response to attention

  • Current evidence base for gambling treatment efficacy supports CBT interventions as a whole, (but likely to over estimate effects) and naltrexone

  • Trends in the evidence base: focused pharmacology, integrated treatment for co occurring disorders and unbundling (causal factors) studies.


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References –behavioral therapy and reductions in gambling in pathological gamblers?

Alegria AA, Petry NM, Hasin DS, Liu SM, Grant BF, Blanco C. Disordered gambling among racial and ethnic groups in the US: results from the national epidemiologic survey on alcohol and related conditions CNS Spectr. 2009 Mar;14(3):132-42

Black DW, Monahan PO, Temkit M, Shaw M. A family study of pathological gambling. Psychiatry Res. 2006 Mar 30;141(3):295-303. Epub 2006 Feb 24


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References –behavioral therapy and reductions in gambling in pathological gamblers?

Blanco C, Potenza MN, Kim SW, Ibáñez A, Zaninelli R, Saiz-Ruiz J, Grant JE. A pilot study of impulsivity and compulsivity in pathological gambling. Psychiatry Res. 2009 May 15;167(1-2):161-8. Epub 2009 Apr 1.

Blum K, Braverman ER, Holder JM, Lubar JF, Monastra VJ, Miller D, Lubar JO, Chen TJ, Comings DE. Reward deficiency syndrome: a biogenetic model for the diagnosis and treatment of impulsive, addictive and compulsive behaviors. J Psychoactive Drugs. 2000 Nov;32 Suppl:i-iv, 1-112.


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References –behavioral therapy and reductions in gambling in pathological gamblers?

Cuijpers P, Smit F, Bohlmeijer E, Hollon SD, Andersson G. Efficacy of cognitive-behavioural therapy and other psychological treatments for adult depression: meta-analytic study of publication bias. Br J Psychiatry. 2010 Mar;196:173-8.

Gooding P, Tarrier N. A systematic review and meta-analysis of cognitive-behavioral interventions to reduce problem gambling: hedging our bets? Behav Res Ther. 2009 Jul;47(7):592-607. Epub 2009 Apr 17.


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References –behavioral therapy and reductions in gambling in pathological gamblers?

Grant JE, Kim SW, Hartman BK. A double-blind, placebo-controlled study of the opiate antagonist, naltrexone in the treatment of pathological gambling urges. J Clin Psychiatry. 2008 May;69(5):783-9.

Johansson A, Grant JE, Kim SW, Odlaug BL, Götestam KG. Risk factors for problematic gambling: a critical review. J Gambl Stud. 2009 Mar;25(1):67-92.


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References –behavioral therapy and reductions in gambling in pathological gamblers?

Kandel DB, Huang FY, Davies M. Comorbidity between patterns of substance use dependence and psychiatric syndromes. Drug Alcohol Depend. 2001 Oct 1;64(2):233-41.

Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):617-27.


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