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 +
 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
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
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
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
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+)
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
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
50.0
Treatment seeking population:
‘What is problematic?’
47.0
45.0
40.0
37.1
28.8
30.0
25.0
20.0
13.6
Private
Skill
0.8 0.8 1.5
Gen.Spread
Fin.Spread
Gaming machines
Sport
2.3 2.3
Dogs
Bingo
Bookmakers
2.3
FOBT
3.0
Casino table
TV
Mobile
Internet
0.0
0.8
Telephone
5.0 3.1
6.8 6.9 6.8
Sp.Spread
6.8
Casino machine
10.0
10.7
9.1
Horses
15.0
Lottery
Percentage
35.0
Associated problems
 Debt
 Depression
 Suicidality
 Relationship breakdown
 Social isolation
 Pressure on families and carers
 Loss of employment
 Crime
 Health – Morasco et al, 2006
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)
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
Evidence based treatment
 Psychological
– CBT
– MI / Brief
– Innovations
 Pharmacological
– Opioid
– Anti-depressants
– Dopaminergic
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
Psychological:
Meta-Analyses Gooding and Tarrier 2009
 Systematic review and meta-analysis of cognitivebehavioural 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
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
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,
Models comparison
Ladouceur
Petry
Oei
Relapse prevention
X
X
X
Stimulus control
X
X
X
Motivational work
X
X
Alternative activities
X
Reinforcement
X
Extended cognition work
X
X
X
Debt
X
X
Assertiveness
X
X
Family issues
X
Imaginal exposure
X
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
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
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
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
Bupropion vs pretreatment
1.71
Black, 2004
Fluvoxamine vs placebo
0.56
Blanco et al, 2002
Topirte vs pretreatment
0.69
Dannon et al, 2005
Fluvoxamine vs pretreatment
0.27
Topirate vs fluvoxamine*
0.45
Bupropion vs pretreatment
0.82
Naltrexone vs pretreatment
0.63
Bupropion vs naltrexone*
0.08
Paroxetine vs placebo
0.05
Grant et al, 2003
Nalmefene (25 mg) vs placebo
0.57
Grant et al, 2006
Nalmefene (50 mg) vs placebo
0.6
Nalmefene (100 mg) vs placebo
0.28
Escitalopram vs pretreatment
1.2
Grant and Potenza, 2006
Fluvoxamine vs placebo
0.48
Hollander et al, 2000
Lithium carbonate vs placebo
0.58
Hollander et al, 2005
Naltrexone vs pretreatment
1.79
Kim & Grant, 2001
Naltrexone vs placebo
1.55
Kim et al, 2001
Paroxetine vs placebo
1.24
Kim et al, 2002
Nefazodone vs pretreatment
1.07
Pallanti et al, 2002
Lithium carbonate vs pretreatment
1.8
Pallanti et al, 2002
Valproate vs pretreatment
1.88
Valproate vs lithium carbonate*
0.2
Sertraline vs placebo
0.11
Sa´iz-Ruiz et al, 2005
Citalopram vs pretreatment
2.48
Zimmerman et al, 2002
Dannon et al, 2005
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)
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)
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)
‘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’)
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