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This article briefly describes the major pharmacologic and psychological treatment modalities for problem gambling and establishes their relative efficacy. We emphasize controlled research for gambling treatment, consistent with the American Psychological Association recommendations regarding empirically validated treatments (EVT; 1,2). These criteria define the conditions that should be met when deciding whether a treatment has been empirically validated. They require that interventions be tested in randomized clinical trials and shown efficacious in at least 2 studies by 2 independent research teams. We refer readers to Walker (3), Lopez-Viets and Miller (4), and Blaszczynski and Silove (5) for excellent reviews of the gambling-treatment literature in general and to Toneatto and Ladouceur (6) for a recent critical review of the controlled-treatment literature. Prior to reviewing the treatment literature, however, this article summarizes both recent advances in the assessment of problem gambling and developments in the psychological and biological understanding of problem gambling. Finally, we suggest guidelines for future gambling-treatment research. Recent Developments in the Assessment of Problem GamblingThe increasing development of assessment instruments specific to gambling pathology aids accurate identification of disordered gambling. Available tools focus primarily on diagnostic factors (that is, the degree of involvement and consequences associated with gaming behaviour) with the goal of classifying gamblers along a continuum of severity or assessment tools that tap gambling-related attitudes and beliefs. We offer a brief overview of several currently available assessment instruments chosen for their psychometric properties. Diagnostic Tools The South Oaks Gambling Screen (SOGS; 10) is arguably the best-known self-report screening tool for gambling pathology. The SOGS was developed in the mid-1980s for use with clinical populations; it has subsequently been used worldwide. According to Stinchfield, use of the SOGS in the past 10 years has extended to nonclinical populations and prevalence surveys, which raises questions about its psychometric properties and classification accuracy under these conditions (11). Further, development of the SOGS items was based on DSM-III and DSM-III-R criteria, and item content does not well reflect current changes to the now-updated DSM-IV criteria (8). The Canadian Problem Gambling Index (CPGI) attempts to address concerns about the SOGS and to develop a more appropriate measure of problem gambling for use in the general population by offering a more “holistic view of gambling” within a social context (12). The CPGI has 3 main sections: gambling involvement, problem gambling assessment, and correlates of problem gambling (including familial history of gambling). It yields 5 categories of gambling behaviour, ranging from nongambling to problem gambling. Initial studies indicate that the CPGI demonstrates good reliability and validity. The DSM-IV diagnostic criteria for pathological gambling have recently been put into practice in a 10-item self-report measure (13). In 2000, Fisher constructed the DSM-IV- Multiple Response (DSM-IV-MR) following successful use of this format in a youth population (14). Although a cut-off score of 5 is traditionally required to meet the DSM criteria, Fisher adopted a continuum approach and classified respondents who scored 3 or 4 as “problem gamblers.” Those who endorsed 5 or more items were classified as “severe problem gamblers.” For clinicians and researchers interested in a very brief self-report instrument using DSM-IV criteria, Johnson and colleagues have constructed the Lie/Bet questionnaire (15,16). This questionnaire contains only 2 items: “Have you ever felt the need to bet more and more money?” and “Have you ever had to lie to people important to you about how much you gambled?” Two separate investigations indicate that the measure has good predictive validity and is appropriate for use with both clinical and community populations. Attitude and Belief Measures Recent Developments in the Psychological Understanding of Problem GamblingRecent efforts to increase our understanding of the psychology of problem gambling have focused on several areas, including the role of negative affect (that is, depression and anxiety), personality factors (such as sensation seeking, impulsivity, boredom proneness, extroversion, locus of control, narcissism, and antisociality), concurrent disorders (that is, the overlap between gambling pathology and mood disorders, substance misuse, and attention-deficit hyperactivity disorder [ADHD]), sex differences, and the role of cognitions (including metacognition). This section highlights some of the relevant research; readers interested in a thorough review of the literature are referred to Raylu and Oei (23). The Role of Negative Affect Anxiety and (or) Obsessive–Compulsiveness. Similarities between problem gambling and obsessive–compulsive disorders have been noted, specifically, preoccupation with gambling and the enormous amount of time spent developing gambling strategies and planning gaming behaviour (29). Blaszczynski found that pathological gamblers scored significantly higher on measures of obsessive–compulsiveness than did research control subjects, especially with regard to excessive preoccupation with intrusive gambling-related thoughts (30). Frost and others examined obsessive–compulsive factors in lottery and scratch-ticket gamblers (31). Results of this study confirmed Blaszczynski’s findings that patho- logical gamblers endorse more symptoms of obsessive– compulsiveness when compared with recreational gamblers (30). Personality Factors Impulsivity. The hypothesis of an association between impulsivity and disordered gambling follows naturally from the inclusion of pathological gambling in the impulse disorders section of the DSM-IV. Some research has demonstrated that pathological gamblers score higher on indices of impulsivity, compared with research control subjects (33,34). Petry has suggested that impulsivity could be conceptualized and measured as a multidimensional construct that includes such behaviours as orientation to the present, diminished ability to delay gratification, behavioural disinhibition, risk taking, sensation seeking, boredom proneness, reward sensitivity, hedonism, and poor planning abilities (35). Concurrent Disorders. Significant research identifies comorbidity between gambling pathology and mental health problems, especially substance use disorders, mood disorders, ADHD, and personality disorders. Specker and others compared pathological gamblers in treatment with control subjects from the community (36). Findings revealed that 54% of pathological gamblers had an Axis I disorder (most frequently, affective, substance abuse, and anxiety disorders). Further, 25% of subjects displayed Axis II personality disorders (most frequently, avoidant personality disorder). Additionally, Petry found that subjects who abused substances and had a gambling problem reported increased levels of somatization, obsessive–compulsiveness, interpersonal sensitivity, and paranoia (37). A more recent study by Ladd and Petry found that gamblers with a history of treatment for substance abuse reported more depression, hallucinations, suicidal ideation and attempts, and difficulty controlling violent behaviour over their lifetime, compared with gamblers who had not been previously treated for substance abuse (38). Sex Differences. A small body of work examines sex differences in motivations for gambling. According to a study by Grant and Kim, women are more triggered to gamble by feelings of loneliness and dysphoria, compared with men (39). Further, women’s motivations for gambling include escape from personal or family problems, whereas men gamble more for excitement and to win money (23). A more recent study by Scannell and others confirmed that women employ more emotion-focused coping strategies, such as avoidance and self-blame, which in turn lead to reduced control over gambling behaviour (40). Cognitive Variables Recent Developments in the Biological Understanding of Problem GamblingOnly within the past decade has investigation begun into biological factors associated with the development and maintenance of problem gambling. Although this research is in its infancy, several significant and encouraging findings have emerged with respect to genetic factors, brain activity or functioning, and neurotransmitter performance. Genetic Factors Brain Activity or Functioning Neurotransmitter Performance Research into the role of dopamine dysfunction in pathological gambling has found, at least in men, reduced cerebrospinal fluid levels of dopamine and increased metabolites, compared with control subjects (60). A more recent study investigated sensory motor gating as a measure of endogenous brain dopamine activity in subjects suffering from pathological gambling (61). This study found increased dopaminergic transmission in pathological gambling. The researchers caution, however, that their findings only support indirect evidence of dopamine dysfunction and that more research is needed to confirm the finding. Additional support for neurotransmitter dysfunction exists in the literature reviewing the efficacy of pharmacologic agents in the treatment of pathological gambling. Grant and others comprehensively discuss pharmacologic treatments for disordered gambling (62), and Raylu and Oei offer a more detailed review of neurotransmitter dysfunction in gambling pathology (23). Recent Developments in the Treatment of Problem GamblingPsychological Treatments Behaviourally Oriented Treatment Studies. McConaghy and colleagues have conducted several controlled studies of imaginal desensitization and compared it with various alternative treatments (for example, electric aversion therapy and imaginal relaxation) (63,64). Key findings showed that imaginal desensitization is more effective than electric aversion therapy, but not superior to imaginal relaxation, in attaining abstinence or a marked reduction of gambling and gambling-related urges. Cognitive-Behaviourally Oriented Treatment Studies. Echeburua and others found that subjects exposed to 3 active treatments (specifically, exposure and response prevention, group cognitive restructuring, and combined treatment) achieved higher rates of abstinence at 6 months posttreatment, compared with a waiting list control group (65). The individually administered response-prevention treatment was found to be superior to the group or combined treatment at 1-year follow-up, with no group differences between the active treatments for any of the other dependent variables (for example, frequency of gambling). In a more recent study, Echeburua and others treated subjects who gambled on slot machines with stimulus control and in vivo exposure followed by response prevention until they were abstinent (66). Subjects were subsequently randomly assigned to 1 of 3 relapse-prevention (RP) modalities: individual RP, group RP, and no RP control. Significant differences in abstinence rates between the 2 RP groups and the no-treatment control group emerged at 3 months post- treatment and were maintained throughout the 12 month follow-up. Milton and others enhanced a cognitive-behavioural intervention with interventions designed to increase treatment compliance (67). Subjects who received the compliance enhancements (for example, follow-up letters, positive reinforcement, and increased self-efficacy) completed the 8-session program at a higher rate (65%), compared with those randomly assigned to the standard cognitive- behavioural therapy (CBT) (35%). However, there were no group differences on measures of improvement (for example, the SOGS or measures of percentage of net monthly income gambled away in the past month). Similarly, no group differences on a measure of clinically significant change were evident at 9-month follow-up. Cognitively Oriented Treatment Studies. Sylvain and others found gamblers treated with cognitively oriented therapy to be superior to a waiting list control group on measures of gambling behaviour (for example, frequency and hours spent gambling) and on measures of clinically significant change (68). Cognitively treated subjects maintained gains up to 12 months posttreatment. Ladouceur and others found that subjects given individual cognitive therapy at posttest were superior to the waiting list control group on measures of diagnostic symptoms, desire to gamble, perceived self-efficacy, and gambling frequency (46). On measures of clinically significant change, virtually all the treated sample and none of the waiting list control group improved (a finding similar to that of Sylvain and others’ study, reviewed earlier; 68). At 1-year follow-up, significant differences between pretest and follow-up were found for the key dependent variables. Recently, Ladouceur and others evaluated group cognitive treatment in a randomized controlled trial with a waiting list control group (45). Results at posttreatment were very similar to those found earlier by these researchers, with almost 9/10 cognitively treated gamblers no longer classifiable as pathological gamblers, compared with 2/10 gamblers in the control group (68). Gains were maintained at 2-year follow-up. Self-Help Approaches. Dickerson and others evaluated a minimal intervention for gamblers by comparing a self-help manual mailed to subjects with the manual plus telephone and postal contact only (69). The manual-only group reduced their weekly gambling sessions and weekly dollars wagered for the 6 months following the manual’s mailing, whereas the manual-plus-interview group showed this reduction for only 3 months postinterview. Hodgins and others compared a waiting list control group with groups receiving 2 versions of a cognitive-behaviourally based self-help manual (that is, they either simply mailed the self-help manual or preceded the mailing with a telephone motivational interview reviewing the assessment information and enhancing commitment to change) (70). They randomly assigned 102 subjects to 3 groups with follow-up of up to 12 months. Significant reduction in gambling behaviour was reported by 84% of subjects over the 1-year follow-up period. At the early follow-ups, an initial superior outcome was demonstrated by the group receiving motivational intervention plus the manual, compared with the manual-only group (for example, 42% vs 19%, respectively, at 3 months); this was not evident at 12 months, except for gamblers with less severe problems. Pharmacologic Treatments. Recent years have witnessed proliferating research evaluating the efficacy of a wide variety of medications used to treat problem gambling, although to date no medication has been approved for treatment of this disorder. Grant and others have recently reviewed the evidence of pharmacotherapy for problem gambling and summarized the key issues in this area of research (71). Below, we summarize the few studies that have employed double-blind, placebo-controlled, and randomization methodology. Hollander and others conducted a double-blind crossover trial of fluvoxamine in which 13 gamblers were randomly assigned either to receive fluvoxamine for 8 weeks, followed by placebo for 8 weeks, or to receive the reverse order (72). Ten subjects completed at least 12 weeks of treatment. Clinician ratings of improvement showed that both groups improved within 1 or 2 weeks of medication and remained relatively stable thereafter throughout treatment. Blanco and others also evaluated fluvoxamine treatment in a 6-month, double-blind, placebo-controlled study (73). They found no group differences on measures of reduced gambling expenditures and time spent gambling, although evidence for the superiority of fluvoxamine was found in younger gamblers and in male gamblers. Kim and others evaluated naltrexone in a 12-week, double-blind, placebo-controlled randomized study (74). Eligible subjects were first enrolled for a 1-week period in a single- blind placebo lead-in. The naltrexone group reported higher rates of much or very much improvement (75% of sample), compared with 24% of the placebo group, who improved much or very much. Kim and others evaluated paroxetine treatment in an 8-session, double-blind, randomized clinical trial (75). Paroxetine was found to be more effective at the end of treatment, as evaluated by rating scales. There were no significant group differences at the end of treatment in a second study of paroxetine’s efficacy (a 16-week, double-blind, placebo-controlled study), according to investigator ratings of clinical improvement and other measures (71). In a 14-week, single-blind trial evaluating lithium and valproate, 42 subjects who gambled received either medication (76). On self- and investigator ratings of improvement, both medications performed equally well, compared with baseline; however, they did not show any group differences at the end of treatment. Based on the best-conducted research to date, there is no compelling empirical evidence for the efficacy of any medication except for naltrexone (75). However, this finding has yet to be replicated in a double-blind, placebo-controlled study, suggesting that this medication can only be considered possibly efficacious. In many studies, improvement rates appear to favour the medication, but statistical significance is often not attained. Thus, although there is reason for optimism that effective pharmacotherapy for problem gambling will be developed, much additional research is needed. Summary of Treatment EfficacyReview of the best-designed treatment studies indicates that cognitive-behavioural and pharmacologic treatments for gambling are possibly efficacious; in no case has any specific modality been found effective by at least 2 independent research teams. In much of the psychological therapy research, significant findings have been found for CBTs, compared with waiting list control; significant findings have been found less often when CBTs are compared with other viable treatments. The studies by Echeburua and others (65,66), Ladouceur and others (45,46,68), and Hodgins and others (70) appear to be the best-conducted studies to date and suggest that interventions falling within the cognitive- behavioural spectrum, even when delivered via a manual and involving only minimal therapist contact, have the most empirical support, compared with no treatment. Among the medications that have been studied, some limited support for naltrexone seems to be promising. However, it is not possible to determine which specific type of CBT or medication is most effective or whether it is more effective than other approaches to treatment. Implications for Treatment DeliveryWith the prevalence of concurrent addiction and psycho- pathology among gamblers established (for example, 77), appropriate screening for such comorbidity and determination of the primary disorder should assist decisions about treatment (which will most likely be a combination of psychological and pharmacologic therapies). To address the function of gambling properly, treatment for gamblers who suffer from concurrent disorders should take into account the functional relation between gambling and other psychiatric and addiction symptoms. Very little research has investigated the outcomes that followed combination of validated psychological therapies and medications. For gamblers who do not possess a comorbid disorder, the initial intervention should strive to increase the individual’s commitment to treatment and resolve treatment-disrupting ambivalence as much as possible. The relatively high rate of dropout and treatment noncompletion suggests that more effort should be made to strengthen the client’s motivation to change. Interventions consistent with the stage of change model would be appropriate. The available empirical research suggests that CBTs, generally brief and delivered on an outpatient basis, are the most effective treatments to date, because they have strengthened motivation. Concurrent pharmacotherapy (that is, with nalxtrexone and selective serotonin reuptake inhibitors [SSRIs]) is a promising adjunct at the present time. Future DirectionsAlthough all the reviewed treatment studies met the basic criteria of randomization to a control group, all suffered from methodological limitations. To improve future treatment research, sample sizes need to be larger to increase the chance of detecting significant differences. This is particularly important for medication research, where sample sizes have been very small (62). Continued attention should be paid to developing validated measures of gambling behaviour and related constructs (for example, urges and cognitions). Gambling-treatment research has long been plagued by poorly constructed and insufficiently validated assessment scales. Many studies—especially the medication-research studies—have also relied on clinician ratings and measures of gambling-related constructs and have tended to neglect direct measures of gambling behaviour. Perhaps owing to its relative novelty, the gambling-treatment literature has tended to combine diverse types of gambling behaviours and avoided the specifying treatments for different gambling subtypes. Combining different gambling subtypes in a single treatment study may introduce a source of variance that interacts with the delivered treatment (whether psychological or pharmaco- therapeutic). Researchers are encouraged to define their gambling samples better to reduce such hetereogeneity. Attention to the role of process (and not just outcomes) in treatment studies is important, since this will allow us to understand the effects of treatment across seemingly different treatment types. For example, if different treatments all show that increased coping with urges is a key correlate of outcome, specific treatments for urges can be developed. In the area of medication research, validation of the pathway by which medications produce their effects is also important. It is assumed that SSRIs modify gambling behaviour through their action on the serotonergic system; however, this has to be validated. The presence of comorbid psychiatric disorders and their implication for treatment have been generally neglected. Most studies do not appear to screen for psychiatric symptoms, much less to factor comorbid psychiatric symptoms into treatment plans. Since comorbidity seems to be prevalent (for example, 35,36,77) future research should develop treatments that take concurrent disorders into account. Finally, more attention should be paid to establishing both better baseline and longer-term follow-up (this is especially true of medication research) and better characterization of gambling behaviour along such key variables as frequency and gambling-related expenditures. Daughters and others reviewed the available treatment literature and suggested that gambling-treatment outcomes can be improved by addressing the factors contributing to treatment failure (78). These researchers identify several predictors of poor treatment outcome and suggest that clinical research focused on them may influence the success of gambling treatment. These predictors include gambling-related cognitive distortions and beliefs about randomness, impulsivity or sensation seeking, biological vulnerabilities, and negative affect or mood symptoms. The conclusions of Daughters and others are consistent with the direction that future gambling-treatment research should take to improve the clinical outcomes achieved thus far (78). Conceptually, the pathways model of problem gambling (79) synthesizes the role of the multiple determinants of problem gambling identified above and may be a useful guide to treatment. The pathways model identifies 3 main subgroups of problem gamblers: those whose gambling is controlled by conditioning, cognitive variables, and poor judgement (behaviourally conditioned problem gamblers); those who also suffer from premorbid psychiatric pathology, usually depression and anxiety, and who exhibit generally poor coping skills and disturbed personal histories (emotionally vulnerable problem gamblers); and those who demonstrate features of impulsivity and character disorders (especially antisocial personality disorder and other neurologic or biochemical disturbances (antisocial impulsivist problem gamblers). 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Lithium and valproate treatment of pathological gambling: a randomized single-blind study. J Clin Psychiatry 2002;63:559–64. 77. Petry NM. How treatments for pathological gambling can be informed by treatments for substance use disorders. Exp Clin Psychopharmacol 2002;10:184–92. 78. Daughters SB, Lejuez CW, Lesieur HR, Strong DR, Zvolensky MJ. Towards a better understanding of gambling treatment failure: implications of translational research. Clin Psychol Rev 2003;23:573–86. 79. Blaszczynski A, Nower L. A pathways model of problem and pathological gambling. Addiction 2002;97:487–99. Author(s)Manuscript received and accepted February 2003. 1. Scientist, Centre for Addiction and Mental Health, Toronto, Ontario. 2. Postdoctoral Fellow, Centre for Addiction and Mental Health, Toronto, Ontario. Address for correspondence: Dr T Toneatto, Clinical Research Department, Center for Addiction and Mental Health, 33 Russell Street, Toronto, ON M5S 2S1 e-mail: tony_toneatto@camh.net
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