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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
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
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
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
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
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
Co Occurring Disorders
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
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
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
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
Co-occurring Mental Health
Disorders and Problem Gambling
are a World Wide Phenomena
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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
Problem Gambling
is Associated with
Multiple Mental Health Disorders
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Substance use disorders,
especially alcohol dependence
Antisocial personality disorder
Affective disorders
Anxiety disorders
Personality disorders as a group
Mania
Other impulse control disorders
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
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
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
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
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
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
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 cooccurring 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
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
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
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.
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
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 cooccurrence with a broad range of
substance use disorders (Petry, Stinson & Grant,
2005; Potenza M, 2006; Petry NM, 2006; Westphal &
Johnson, 2007).
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).
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
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 nonsubstance 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
Candidates for Addiction-Like
Behavioral Disorders
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Computer and online gaming
Exercise
Gambling
Internet use
Shopping
Skin picking
Sexual behaviors
Video game playing, Pinball
Television Watching
Work
Westphal, 2007
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
World wide, Across Treatment
Modalities
Problem gamblers drop out of
treatment
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
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
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
Gambling Treatment Attrition
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Attrition in gambling treatment is
prevalent and substantial
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Attrition may affect the majority of
patients in some types of gambling
treatment.
Problem Gambling Treatment
Why Worry About Evidence?
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
Why?
• Slow dissemination of new evidence
based treatments into practice
• slow extinguishment of practices whose
utility has been disproved
Westphal, 2007
Brief History of Gambling
Treatment Structured Reviews
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Oakley-Browne, Adams & Mobberley, 2000
Toneatto & Ladoceur, 2003
Pallesen, Mitsem, Kvale et al., 2005
Pallesen, Molde, Arnestad et al., 2007
Gooding & Tarrier, 2009
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 shortterm (relative risk 0.44, 95% confidence interval (CI)
0.24-0.81).
Oakley-Browne, Adams & Mobberley, 2000
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
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
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
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
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
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
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
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
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
Gambling Treatment Effect Sizes
Only studies 6, 14 and 15 had CTAM scores > 65
Effect sizes from .2 to .43 (small to medium)
CBT Treatment Effect Sizes
• A recent meta analysis of CBT among adult
patients with depression found that effect sizes
were systematically over estimated.
• Their estimate for the effect size for CBT for
adult depression was .42 (small to medium
range).
Cuijpers P, Smit F, Bohlmeijer E, Hollon SD & Andersson G,
2010
Why is Drop Out a Problem?
Treatment Dose Response
Relationship
• Increasing amounts of treatment are
associated with better outcomes and
• Conversely, lower amounts of treatment
are associated with poorer outcomes.
Shaffer et al. 2005; Petry et al. 2006;
Gooding & Tarrier, 2009
Is there a Specific Treatment
for Problem Gambling?
Is there an effect of problem gambling
treatment beyond the effect of paying
attention to the problem?
Placebo Response among
Pathological Gamblers
• The average rate of placebo response
among pathological gamblers in
pharmacological clinical trials is 42%.
• Duration of the response ranges from 6-8
weeks to 9 months.
• This response is defined as the nonspecific response to treatment, equivalent
to paying attention to and observing the
problem or behavior
Placebo Response Among
Pharmacological Clinical Trials
Study
Hollander
Kim
Kim
Blanco
Grant
Saiz-Ruiz
Hollander
Grant
Year
1998
2001
2002
2002
2003
2005
2005
2006
Placebo %
41.7%
24%
23.8 %
59%
49%
72%
25%
34%
Evidence Based Recovery
Processes
• Provision of support, goal direction, and
monitoring;
• Engagement in rewarding activities other
than substance use,
• Exposure to abstinence-oriented norms
and models,
• Attempts to build self-efficacy and coping
skills.
Moos, 2007
Trends
• Treatment studies of gambling and other comorbid conditions (Korman, Collins, LittmanSharp et al., 2008; Toneatto, Brands & Selby,
2009).
• Focused pharmacology treatment studies
(Grant, Kim & Hartman, 2008; Blanco C et al,
2009)
• Unbundling studies (Petry, Litt, Kadden et al.,
2007)
Naltrexone as a Treatment for Concurrent
Alcohol Use Disorder and PG
• Randomized, double-blind, placebo-controlled trial.
• Fifty-two, mostly male, subjects were recruited from
the community and received 11 weeks of medication
during which CBT was also provided.
• No significant group differences were found on any
alcohol or gambling variable (ie, frequency, quantity,
expenditures) at post-treatment or at the one year
follow-up.
• However, a strong time effect was found suggesting
that treatment, in general, was effective.
• The use of naltrexone to treat concurrent alcohol use
and gambling problems was not supported.
Toneatto, Brands & Selby, 2009
Integrated Therapy for Comorbid Anger and
Gambling
• This study evaluated an integrated treatment for
comorbid problem gambling, anger, and
substance use.
• Problem gamblers with comorbid anger
problems (N=42), half of whom also had
substance use disorders, were randomized to
either a 14-week integrated treatment targeting
anger and addictions (i.e., both gambling and
substance use) or a specialized treatment-asusual (TAU) for gambling and substance use.
Korman, Collins, Littman-Sharp et al., 2008
Integrated Therapy for Comorbid Anger
and Gambling (2)
• Relative to the TAU, participants in the
integrated anger and addictions treatment
reported significantly less gambling at T2 and
T3 and less trait anger and substance use at
T3.
• Findings suggest that it is important to screen
gambling clients for the presence of comorbid
anger and substance use problems and that,
when present, these problems need to be
addressed concurrently in gambling treatment
in order to optimize treatment outcomes.
Korman, Collins, Littman-Sharp et al., 2008
Naltrexone in the Treatment of Pathological
Gambling Urges
• An 18-week, double-blind, placebo-controlled
trial
• evaluate the safety and efficacy of 3 doses of
oral naltrexone for PG.
• Seventy-seven individuals with DSM-IV-TR PG
were randomly assigned to naltrexone (50
mg/day, 100 mg/day, or 150 mg/day) or
placebo.
Grant, Kim & Hartman, 2008
Naltrexone in the Treatment of
Pathological Gambling Urges (2)
• CONCLUSION: Subjects assigned to
naltrexone demonstrated statistically
significant reductions in gambling urges and
behavior in PG.
• Low-dose naltrexone (50 mg/day) appeared
as efficacious as higher doses (100 mg/day
and 150 mg/day), and all doses were well
tolerated.
Grant, Kim & Hartman, 2008
Impulsivity
• Study examined the relationship between gambling
severity, impulsivity and obsessionality/compulsivity in
38 pathological gamblers
• Representing the complete Minnesota sample of a
randomized, placebo-controlled clinical trial of
paroxetine for the treatment of pathological gambling
• Changes in PG-YBOCS scores after treatment
correlated with changes in Impulsiveness scores.
• These changes appeared independent of paroxetine
treatment.
• The results suggest that, although PG exhibits
features of both obsessionality/compulsivity and
impulsivity and elements of both decrease with
treatment, impulsivity predominates and changes in
gambling severity are most associated with changes in
impulsivity. (Blanco C et al, 2009)
Do coping sills mediate the relationship between
cognitive –behavioral therapy and reductions in
gambling in pathological gamblers?
• This study examined whether coping skills
acquisition mediated the effects of CBT on
decreasing gambling in pathological gamblers.
• DESIGN: Participants were assigned randomly
to CBT plus referral to Gamblers Anonymous
(GA) or to GA referral alone.
• Setting Out-patient clinic.
• PARTICIPANTS: A total of 127 pathological
gamblers.
Petry, Litt, Kadden et al., 2007
Coping Skills (2)
• MEASUREMENTS: Participants completed the
Coping Strategies Scale (CSS) before treatment and 2
months later; indices of gambling behavior and
problems were administered pretreatment and at
months 2 and 12.
• FINDINGS: Overall, CSS scores increased for
participants in both conditions, but those receiving
CBT evidenced larger increases than those in the GA
condition (P < 0.05), and they also reduced gambling
more substantially between pretreatment and month 2.
• Changes in CSS scores mediated the relationship
between treatment assignment and gambling
outcomes from pretreatment to month 2, but little
evidence of mediation occurred for the long-term
follow-ups.
Petry, Litt, Kadden et al., 2007
Objectives
• Co-occurring disorders predominate, SUD’s are a
likely driver and consequence of PG
• DSM 5 is considering adapting the addiction syndrome
• Gambling treatment has significant attrition and
response to attention
• Current evidence base for gambling treatment efficacy
supports CBT interventions as a whole, (but likely to
over estimate effects) and naltrexone
• Trends in the evidence base: focused pharmacology,
integrated treatment for co occurring disorders and
unbundling (causal factors) studies.
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Black DW, Monahan PO, Temkit M, Shaw M.
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