Treatment of pathological gambling: A comparative study between a cognitive behavioural program and

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Treatment of pathological gamblingA comparative
study between a cognitive behavioural program and
a minimal intervention program

• The Bergen Clinics FoundationArvid Skutle Eli
  T. H. Bu
• Financed by The Norwegian Research Councel
• Period 01.07.06 01.07.09.

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The definition of pathological gambling in ICD-10
is

• The disorder consists of frequent, repeated
  episodes of gambling that dominate the patient's
  life to the detriment of social, occupational,
  material, and family values and commitments
• (ICD- 10 World health Organization, 1992).

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Gambling related problems

• The consequences from gambling involvement can be
  severe
• Relationship problems,
• reduced work capacity and
• crime
• are all overrepresented in this group (Raylu
  Oei, 2002).
• A number of mental health problems and a
  relatively high prevalence rate of these problems
  are reported
• suicidal attempts,
• depressive reactions,
• alcohol problems,
• stress and
• somatic symptoms ( Jonsson et al., 2003)

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Prevalence rates

• The prevalence of pathological gamblers in
  Western countries 1-2 (Becona et al., 1996
  Van Es, 2000 Ladouceur, 2002). Shaffer, Hall and
  Vander Bilt (1999) conducted a meta- analysis of
  119 prevalence studies from Canada and USA, and
  found an average lifetime prevalence rate of 1.6
  for adults and 3.9 for adolescents.
• If we include problem gambling, the prevalence
  rate is between 5-10 for the adult population
  and even higher for adolescents (Shaffer, Hall
  and Vander Bilt, 1999).
• In Norway, Lund and Nordlund (2003) found an
  average lifetime prevalence rate of 1, 4 for
  problematic and pathological gambling in the
  Norwegian population, age 15-74 years, and 0,7
  (70.were classified as pathological gamblers at
  present.
• Rossow and Hansen (2003) found the corresponding
  prevalence rate to be 3, 2 (N11000) in a study
  conducted on Norwegian teenagers 13 19 years
  old, and many of these young people were
  contemplating suicide. ( For the adult population
  in Norway, most problem and pathologic gamblers
  develop a problem for slot machines, prior to the
  new sanctions in July 2007 (Lund and Nordlund,
  2003).
• New trends from slot machines to net poker and
  odds, from public space to restricted arenas.

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Cognitive-Behavioural treatments

• Combine interventions based on behavioural and
  cognitive approaches.
• In spite of methodological flaws in some of the
  studies, cognitive-behavioural treatments show
  promising results (Petry and Armentano, 1999
  Ledgerwood Petry, 2005).
• Cognitive-behavioural treatment has had the most
  favourable treatment outcome in the treatment of
  gambling problems (Oakley-Brown et al., 2002
  Viets Miller, 1997 Ladouceur et al., 2001,
  2003 Blaszczynski, 2005).

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Minimal interventions

• Includes a range of brief and less resource
  demanding approaches, including self-help manual,
  with or without therapist contact (Dickerson et
  al., 1990).
• Has developed as a result of the ever increasing
  cost of health services, and of the emergence of
  the ideology of self help.
• The approach has been applied to other areas of
  addictive behaviour, particularly alcohol
  addiction (Anderson, 2002). There is some
  evidence for the efficacy of a gambling self-help
  manual (Dickerson et al., 1990 Hodgins et al.,
  2001, 2004 Ladouceur, 2003).
• Included in the Minimal Intervention approach
  towards gambling is the motivational
  interviewing by Miller and Rollnick (1991),
  where overcoming ambivalence and clarifying goals
  are essential factors.

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Rationale and aims for this study

• The present study will make a comparison between
  standard cognitive behavioural therapy and a
  minimal intervention program.
• The main questions addressed are
• a. What will be the comparative treatment outcome
  of a cognitive behavioural treatment and a
  minimal intervention, based upon a broad range of
  outcome criteria, including the severity of
  gambling addiction and negative gambling-related
  consequences?
• b. Will a minimal intervention, demanding less
  personal resources, be as effective as the more
  comprehensive program?

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Recruitment

• Sixty persons with a gambling addiction,
  according to the DSM-IV diagnostic criteria, will
  be randomized into the two comparative conditions
  - the cognitive behavioural treatment program and
  the minimal intervention condition.
• Gender will be applied as a matching criterion,
  to secure an approximate even gender distribution
  in the two groups.
• Exclusion criteria
• Severe alcohol and substance abuse
• Severe mental disorder

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Study design

• The participants will be assessed by an
  experienced clinician at intake (all the
  instruments), at post-treatment, 3 months and 6
  months follow-up
• A final measure of the DSM-IV diagnostic criteria
  will be taken at the final follow-up.

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The cognitive behavioural treatment program in
the study

• a. assessment, feedback and general information
  about gambling addiction,
• b. information about the gambling industry, the
  players role and their cognitions,
• c. the players misconception, risk situations and
  craving,
• d. motivation, ambivalence, and decisions,
• e. continuous focus on risk situations and coping
  mechanisms, and cue exposure,
• f. self-sabotage and relapse prevention.
• The main components in the program are to define
  a goal, to offer some options to support their
  coping capability, to explore and challenge their
  cognitive misperceptions, their ambivalence and
  their decision making process.

• Half of the sample is offered group treatment at
  an outpatient setting, comprising 7 sessions,
  each two hours.
• The manualized treatment program includes the
  following topics

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Instruments

• DSM-IV diagnostic criteria (Ladouceur et al.,
  2002).
• South Oaks Gambling Screen (SOGS-R). Measures the
  severity of the gambling problem. Both life-time
  prevalence data and data for the last three
  months will be collected
• Gamblers Beliefs Questionnaire. Measures the
  gambler cognitions and misconception in gambling
  situations.
• Gambling Self-Efficacy Questionnaire (GSEQ). The
  experience of self-efficacy in gambling
  situations (risk situations).
• PGBS Gambling behavior last week
• Symptomscale (G-SAS) Symptomskala
  spilleavhengighet
• Klientkartleggingsskjemaet (KKS) demografi,
  psykisk helse og rus
• SCL-90-R (Derogatis, 1992). Assessment of mental
  health symptoms and complaints.
• AUDIT Screening questionnaire for alcohol
  dependence (Saunders Aasland, 1987)

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Patients referrals and recruitment so far

• A total of 60 patients per Jan-08
• Included
• 25 completers of the programs
• 12 are currently attending the treatment
  programs
• 5 at the waiting list
• Excluded
• 18 excluded due to the exclusion criteria
• 22 No-show, mainly due to the prohibition of
  slot machines (July 07)
• 8 No-show Treatment contract signed, were
  assessed, but did not show up
• 10 drop out/partly attendance

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Plans for publication 2008

• Suggested title
• Research in a clinical setting From ideology to
  realities Characteristics of pathological
  gamblers in need for treatment
• demography
• mental health
• alcohol and substance abuse
• severity of pathological gambling