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Problem Gambling and evidence based responses

Problem Gambling and evidence based responses. Dr. Neil Smith BSc (Hons), D.Clin.Psy, C.Psychol Principal Clinical Psychologist & Service Manager National Problem Gambling Clinic. Types of gambling. Sports: Horses, Dogs, football FOBT: Fixed Odds Betting Terminals, Roulette +

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Problem Gambling and evidence based responses

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  1. Problem Gambling and evidence based responses Dr. Neil Smith BSc (Hons), D.Clin.Psy, C.Psychol Principal Clinical Psychologist & Service Manager National Problem Gambling Clinic

  2. Types of gambling • Sports: • Horses, Dogs, football • FOBT: • Fixed Odds Betting Terminals, Roulette + • Internet: • Online poker, or on-phone • Casino: • replacing clubs as late-night drinking option • Fruit machines: • can be found on FOBT • Socially acceptable gambling • Lottery, Shares

  3. Diagnostic terminology:A compulsive and pathological problem disorder • Pathological Gambling: • Impulse control disorder as defined by DSM-IV and ICD-10 • Compulsive gambling • Original term, used by GA, descriptive term • Problem gambling • Broad title to describe problem gambling behaviours • Can be problematic without being pathological • Disordered gambling • Possible new DSM-V term

  4. Diagnosis • DSM-IV Pathological Gambling – 5 or more of: • Preoccupation with gambling activities • Gambling with increasingly larger amounts of money • Repeated unsuccessful attempts to stop or cut down, and being restless or irritable with trying to reduce the behaviour • Gambling to take away these feelings • Gambling to escape from problems or lift mood • ‘Chasing’ losses – returning to try to win back money lost • Lying to family, friends or others about the extent of gambling • Relying on others to provide money to relieve a desperate financial situation caused by gambling • Committing illegal acts to finance gambling • Jeopardising social/occupational opportunities • Making unsuccessful attempts to limit or stop gambling

  5. Difference to substance misuse • Not much • Substances and alcohol achieve much of their effect using endogenous substances • Cerny and Cerny (1992) • Case studies of dependence on carrots • Paper queried what substance in carrots caused dependence • Popular misconception • Behaviours and substances act on same systems

  6. Assessment and screening • Consensus is there is no consensus • Banff consensus (2006) • Standardised gambling measures • SOGS, MAGS, GAMTOMS • Problem Gambling Severity Index (PGSI) • Brief screening • ‘Lie-Bet’ question • Have you lied about gambling • Have you ever felt the need to bet more and more money • Brief Biosocial gambling screen (BBGS; Gebauer et al, 2010) • Validated against DSM-IV criteria (5+)

  7. Prevalence: Gambling • British Gambling Prevalence Survey 2010 • 73% of population gambled last year (56% less lottery) • Up from 68% and 48% respectively in 2007 • Sport in bookmakers 3-9%; online 3-5%; FOBT 3-4% • Gambling highest amongst: • Male, white-British, married, with qualifications, working in ‘lower-supervisory technical’ areas, with higher income

  8. Prevalence: Problem gambling • British Gambling Prevalence Survey 2010 • Using DSM-IV criteria 0.9% of population (CI: 0.7-1.2%) • Up from 0.6% 2007 (p=.049) • PGSI suggest no significant increase 0.5% - 0.7% • Estimated 342,000 – 593,000 16+ • Odds of being a problem gambler increased from 2007-2010 by 1.5 times • 64 problem gamblers out of 7756 respondents • Prevalence of PG highest amongst pub/club poker players, online and FOBT

  9. Treatment seeking population: ‘What is problematic?’

  10. Associated problems • Debt • Depression • Suicidality • Relationship breakdown • Social isolation • Pressure on families and carers • Loss of employment • Crime • Health – Morasco et al, 2006

  11. Co-occurring MH difficulties • Substance use in PG 25-63% (Crockford & el-Guebaly, 1998) • PG in substance misuse 9-30% (Lesieur et al, 1986) • Rate of PG increases with no. of substances used • 76% meet criteria for Major Depression (McCormick et al, 1984) • PG precedes depression in 86% of cases • 20% of 162 GA members attempted suicide (Moran, 1969) • 76% had thought about it • 93% of treatment seekers meet criteria for PD (Blaszczynski & Steel, 1998) • ASPD possibly most likely, although link obscured by presence of poly-substance • PG more likely to meet criteria for ADHD (Specker et al, 1995)

  12. Types of gambler • Pathways Model (Blaszczynski and Nower, 2002) • 1. Behaviourally conditioned • May be chance entry, no significant co-morbidity • Low end of PG continuum, prey to conditioning effects • 2. Emotionally vulnerable • Negative family backgrounds, life events, developmental • Low self-esteem and emotional escape though gambling • 3. Anti-social/Impulsive • Wider range of behavioural problems, negative emotions interpersonal difficulties, poly-drug, criminality

  13. Evidence based treatment • Psychological • CBT • MI / Brief • Innovations • Pharmacological • Opioid • Anti-depressants • Dopaminergic

  14. Psychological:Meta Analyses, Palleson et al, 2005: ‘Outcome of psychological treatments’ 22 studies selected, 1434 subjects 11 studies CBT ‘Eclectic’, 12 step, exposure, MI, relaxation Overall effect size for psychological treatment 2.01; at follow-up 1.59 No differentiation between treatments Lower effect size with formal PG diagnosis Relationship between session N and outcome

  15. Psychological:Meta-Analyses Gooding and Tarrier 2009 Systematic review and meta-analysis of cognitive-behavioural interventions (Gooding and Tarrier, 2009) 25 studies overall - immediate & follow-up 1078 had pre and immediate post scores Effect sizes (ES) for range of outcomes Abstinence, ‘bout duration’, frequency, SOGS 0-3 month ES overall 0.72; 6month 0.56 0-3mnth Abstinence 1.87; more effective with males No difference in mode of delivery

  16. Psychological:Meta-Analyses, Gooding and Tarrier 2009 ‘robust short term effects which do endure’ Significant in spite of study variability ‘Desire to gamble’, not frequency significant at 6 months Only group CBT significant at 6 months, but a trend for greater effectiveness of individual when compared directly with group No effect of session number or length

  17. CBT models • Robert Ladouceur • Earlier RCTs in Canada, strong cognitive correction element • 2001 RCT- up to 20 sessions (avg.11); 2007 self-help workbook • Nancy Petry • Cognitive-behavioural programme, 8 session manualised • Contingency management element, 2006 RCT • Tian Oei • Cognitive-behavioural programme with therapist manual 2010 • RCT 6 x 2hourly sessions; Manual = 10 session with electives,

  18. Models comparison

  19. Motivational treatments • RCTs show Motivational Interviewing or Motivational Enhancement Therapy superior to self-help interventions or wait-list controls • Hodgins et al 2001 and 2009 • MI interventions greater improvements compared with wait-list control • Petry et al 2008 • 1 session MI > 4 session MI+CBT

  20. Brief interventions • Petry et al 2008 • 10 minute check-up > 1 session > 4session MI/CBT • Non-treatment seeking sample • Hodgins et al, 2001 • 30 min telephone MI session + workbook > work book only • Hodgins et al 2009 – ‘More is not necessarily better’ • 30 min telephone MI session + workbook vs. addition of booster phone calls • Both interventions better than wait-list control • No differences between two active interventions

  21. Innovations in psychological treatment • Remote working • Internet and phone support, (Carlbring and Smit, 2008) • ‘Third wave’ • ACT: Mark Dixon, Southern Illinois University research • Mindfulness and problem gambling (Lisle et al, 2011) • Metacognitions: controlling gambling thoughts predict gambling behaviour (Lindberg et al, 2010) • Imagery: early big win memories and the effect on gambling • Implicit learning • Cue exposure/inhibition work in alcohol (e.g. Houben et al, 2011) • Cognitive-bias modification? Promising results in depression

  22. Pharmacological treatment • Research indicates involvement of • Serotonergic, noradrenergic, dopaminergic and opioidergic systems in pathological gambling • Good results for mood stabilisers, anti-depressants and opioid antagnoists (Palleson et al, 2007) • Overall effect size 0.78 • No difference between 3 main classes of pharmacological intervention

  23. Opioid antagonists • Use is based on theory that over-production of opioids contributes to PG • ++B-endorphins = disinhibition of dopamine neurons in ventral tegmentum and nucleus accumbens • Naltrexone blocks endorphins = reduced NA dopamine • RCTs find that opioid antagonists superior to placebo in reducing gambling severity (Kim et al, 2001; Grant et al, 2006; Grant et al 2008)

  24. Anti-depressants • Mixed results with antidepressant trials to reduce problem gambling • SSRIs most frequently examined • Strong results when compared to pretreatment • RCTs show high placebo response rates • Fluvoxamine, Sertraline, Paroxetine, Escitalopram, Buproprion have shown no difference to placebo • Paroxetine > placebo (Kim et al, 2002)

  25. Dopamine treatment? • Agonists known to increase problem gambling (Smith, Kitchenham and Bowden-Jones, 2011) • So antagonist will reduce? • Haloperidol increased motivation to gamble and psychophysiological measures of arousal (Zack and Poulus, 2007) • Unclear picture • Low level antagonists may increase dopamine (Frank & O’Reilly, 2006) • May be role for D2 Agonist • Has role in blocking sensitivity to cost of reward (Dagher, 2012)

  26. ‘Monash’ Guidelines • Extensive review of literature pertaining to screening assessment and treatment of PG; published in conjunction with Monash University/ University of Melbourne with support of State of Victoria • Gave strength of evidence rating A-D • ‘Individual or group CBT’; Motivational Interviewing and Motivational Enhancement Therapy’ given ‘B’ rating (body of evidence can be trusted to guide practice in most situations) • Practitioner delivered over self-help interventions (‘B’) • Naltrexone (‘C’ – ‘some support’); Not to use antidepressants to reduce gambling (‘B’)

  27. Further reading: • Pathological gambling: etiology, comorbidity and treatment. Nancy Petry, 2005 • A cognitive-behavioural therapy programme for problem gambling: Therapist manual. Raylu and Oei, 2010 • Overcoming Your Pathological Gambling. Robert Ladouceur & Stella Lachance. 2007 • Overcoming Compulsive Gambling. Alex Blacszczynski, 1998

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