Reviewing the Evidence Base for Problem Gambling Treatment

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. Co Occurring Disorders

8. 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

9. 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

10. 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

11. 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

12. 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

13. Problem Gambling is 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

14. Pathological 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

15. Pathological 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

16. Pathological 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

17. Canadian Study • 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

18. Canadian Study (2) • 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

19. Interaction of Pathological Gambling and Alcohol Use • 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

20. Interaction of Substance Dependency and Other Disorders • 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

21. Interaction of Substance Dependency and Other Disorders • 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

22. Interaction of Substance Dependency and Other Disorders (2) • 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

23. Summary • 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.

24. Addiction Syndrome • 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

25. Evidence Supporting Addiction 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).

26. Evidence Supporting Addiction 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).

27. Evidence Supporting Addiction 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

28. DSM 5 Proposals • 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

29. Candidates for Addiction-Like Behavioral Disorders • Computer and online gaming • Exercise • Gambling • Internet use • Shopping • Skin picking • Sexual behaviors • Video game playing, Pinball • Television Watching • Work Westphal, 2007

30. DSM 5 Changes for Pathological Gambling • 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

31. World wide, Across Treatment Modalities Problem gamblers drop out of treatment

32. 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

33. Attrition rates • 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

34. Attrition Rates with Confidence Intervals • 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

35. Gambling Treatment Attrition • Attrition in gambling treatment is prevalent and substantial • Attrition may affect the majority of patients in some types of gambling treatment.

36. Problem Gambling Treatment Why Worry About Evidence?

37. 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

38. Why? • Slow dissemination of new evidence based treatments into practice • slow extinguishment of practices whose utility has been disproved Westphal, 2007

39. Brief History of Gambling Treatment Structured Reviews • Oakley-Browne, Adams & Mobberley, 2000 • Toneatto & Ladoceur, 2003 • Pallesen, Mitsem, Kvale et al., 2005 • Pallesen, Molde, Arnestad et al., 2007 • Gooding & Tarrier, 2009

40. 2000 • 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

41. 2000 (2) • 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

42. 2003 • 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

43. 2005 • 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

44. 2005 (2) • 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

45. 2007 • 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

46. 2007 (2) • 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

47. 2009 • 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

48. 2009 (2) • 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

49. 2009 (3) • 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

50. Only studies 6, 14 and 15 had CTAM scores > 65Effect sizes from .2 to .43 (small to medium) Gambling Treatment Effect Sizes