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Gambling Harm Minimisation

ABACUS Feedback to the Ministry of Health
regarding
Emerging Trends in National & International Literature.

This summary of research has relevance to the clinical workforce,
it forms part of a regular six monthly report provided by ABACUS to the Ministry.

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Emerging Trends in National & International Literature

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Literature:

A naturalistic study of recovering gamblers: what gets better and when they get better Authors: D. Rossini-Dib, D Fuentes, H Tavares (2015) Psychiatry Research Vol 227, 17-26

Findings:

  • The focus of this paper was the ‘less obvious features’ of problem gambling behaviour, instead of the gambling behaviour and its consequences. Instead, the authors focused upon negative affectivity, gambling cognitive distortions, impulsivity, cognitive flexibility, planning, inhibitory control, and decision-making.
  • The aim was to ascertain the relationship between these factors and if they were related to gambling recovery.
  • N=113 patients attending an outpatient gambling treatment facility at a public university hospital in Brazil were assigned to psycho-education and treatment, with a subset also assigned to CBT therapy (12 sessions). N=72 patients were reassessed six months after the commencement of treatment. It was found that recovered and non-recovered problem gamblers did not differ in their pre-treatment characteristics (demographics, their gambling or their psychiatric issues).
  • Common distortions held by problem gamblers were that personal luck was not due to chance, and that random events were able to be predicted and controlled, and these distortions led to greater involvement in gambling.
  • Three outcome variables were strongly related with recovery from problem gambling. These were negative affectivity, cognitive distortions, and improved decision-making, with the latter two being the strongest predictors of recovery regardless of type of treatment.
  • The authors concluded that in addition to usual problem gambling outcome measures, increased sensitivity to loss as well as decreased positive expectancies towards gambling are important key targets when addressing problem gambling.

Comment:

  • Problem gamblers fell within the moderate to severe range despite having to meet all the criteria of DSM-IV-TR. Some 60% of the samples were smokers of tobacco, a similar finding to other studies of presenting problem gamblers. More than half of the gamblers met criteria for ADHD compared with the usual finding of one in four or five. There were the expected high rates of depression (43%), anxiety (35%), alcohol disorder (22%), and past suicide attempts (25%) and those at current risk (30%) were also high. These findings confirmed the high psychiatric severity of problem gamblers.
  • Focusing upon emotion, fantasising less about winning, and being more rational about chances of winning may result in better decisions and may improve outcomes in therapy. Current therapy may focus upon gambling behaviours, its consequences, and impulsivity control, yet in the view of the authors, may not be the core aspect of problem gambling. The confirmed high co-existing mental health disorders may support this focus.
  • The study confirms the NZ approach to identify all coexisting issues and integrate these into a formulation. With the anxiety and depression levels identified, and addressing emotions and lifting depression as well as ensuring decisions are rational rather than those based upon skewed perceptions may be a more effective approach to treatment.
  • This research suggests that the NZ problem gambling treatment workforce may benefit from use of CBT approaches in its delivery of therapy. This paper does not, however, compare other therapies with CBT, and psycho-education was the only alternative. However, these conclusions were independent of either therapy and are a core approach of CBT (correcting distortions, providing coping skills, relapse prevention).

Literature:

Predictors of outcome among pathological gamblers receiving cognitive behavioural therapy Authors: Jimenez-Murcia S, Granero R, Fernandez-Aranda F et al (2015) Eur Addiction Research Vol 21, 169-178

Findings:

  • This study addressed post-treatment outcomes following Spanish patients diagnosed with Gambling Disorder and receiving group therapy based upon CBT therapy.
  • N=440 attended 16 outpatient group therapy sessions with a 3-month follow-up.
  • Patients showed significant improvements in both their mental health and gambling severity following the group therapy. However, involvement of a partner in the therapy was a negative factor in recovery and likelihood of relapse, while being of younger age and having lower education was correlated with drop-out from treatment
  • The authors concluded that strategies which improved self-control and emotional regulation were important for treatment of problem gambling; however, other techniques that addressed individual characteristics of each patient were also important, and this may be difficult when in group therapy when the same treatment was applied to several clients simultaneously. The authors also warned against the involvement of family members without careful management, which resulted in poorer outcomes for the treatment.

Comment:

  • As a follow-up to the above findings, these researchers identified that CBT based group therapy was an effective intervention through a focus upon self-control and emotional regulation. These findings similarly address the importance of emotional dysregulation similar to the study above using a group therapy approach.
  • The added finding of the need to include individual needs and manage partner impact suggests a combination of group and individual therapy using a CBT approach may be an effective focus for therapy. In addition, it also highlights the impact of problem gambling on the partner and the importance of inclusion of the partner in addressing their own needs with therapy. Skills that are required in a couples approach when addressing problem gambling are additional skills required of workforce therapists.

Literature:

Cognitive behavioural group treatment for Chinese problem gamblers in Hong Kong Authors: D Wong, C Chung, J Wu, J Tang, P Lau (2014) J Gambling Studies, April

Findings:

  • The authors noted that Chinese people may be impacted more by gambling than other cultures and yet therapy approaches were not well addressed for this culture. CBT has been effective in Western cultures in addressing problem gambling.
  • N=38 were randomly allocated to experimental (CBT and individual counselling services) or control groups (individual counselling services only) over a 10 week period. CBT was delivered in group therapy sessions.
  • There were significant decreases in gambling severity and frequency of gambling with the CBT group. In addition, there were improvements in cognitions of the CBT group with urge reduction, which also found that gambling severity reduction resulted in reduced depression.
  • The authors concluded that the culturally attuned programme using CBT was an effective approach in addressing problem gambling in a Chinese population affected by gambling.

Comment:

  • This study has been included as a further evidence of the effectiveness of CBT in the treatment of problem gambling. This was a relatively brief therapy term (10 weeks) and with a culture that appeared to benefit from the precise, concrete approach of CBT.
  • The inclusion of both CBT therapy groups and individual CBT (see above) may be an approach beneficial to NZ therapists addressing problem gambling issues.
  • Similar findings with CBT approaches in this population were found in other studies (Guo, Manning et al 2014) and the combination of CBT and pharmacological approaches for problem gambling for Chinese problem gamblers (Raylu, Loo & Oei, 2013).

Literature:

Co-morbidity between gambling problems and depressive symptoms: a longitudinal perspective of risk and protective factors Authors: Dussault F, Brendgen M, Vitaro F et al (2015) J Gambling Studies, May 21

Findings:

  • The authors drew data from an ongoing long-term longitudinal study of N=1162 participants in Montreal, commencing in 1984. Data was collected from N=878 initially kindergarten boys from an economically disadvantaged area in Canada who had been asked at ages 17, 23 and 28 years about their gambling and/or depression issues.
  • Three percent identified with having chronic gambling problems, similar to the population prevalence of 1-3% of adults. The majority (73%) of those with significant gambling problems were also suffering from depression problems that had become more severe over time. The authors concluded that gambling problems should be treated together with depression.
  • The authors concluded that mental health problems such as depression should be treated as the norm and should be expected. Impulsiveness was a strong indicator for gambling problems and depression. Although they considered that a strong parent-child family relationship usually countered the development of depression, this may not occur for those youth with the risk of gambling tendencies. Rather, early (in life) prevention programmes were recommended.

Comment:

  • As has been identified in other studies (Rossini-Dib et al 2015, above), depression and gambling problems commonly coexist. This study provides evidence that problem gambling can overwhelm protective factors such as family relationships unless addressed early in life. The authors note that other issues that may arise because of economic disadvantages tend to reduce after adolescence for many, but that gambling problems may continue and affect mood, and be difficult to remove because they are similar to substance-related addictions.
  • Impulsivity or impulse control was a predictor of four different pathways to problem gambling and depression, with poor child-parent relationship more likely to result in depression. Although the age group of the study was at the last data selection, just 28 years, there was no indication of moderation in severity of depression or gambling - an expectation in other adolescent issues, but a likelihood of greater severity for these in the future.
  • Although this may be a cohort of increased risk for problem gambling (economic disadvantage) the finding of 3% at 28 years of age is considerably above the estimation of DSM5 of 0.2%-0.3% ie. 10x the prevalence, and may suggest that the difficulties of population estimates are resulting in considerable under-estimation of problem gambling. This, associated with high levels of depression, which untreated, will increase in severity alongside gambling problems, supports the addressing of both issues in an integrated approach.

Literature:

Suicidal events among pathological gamblers: the role of comorbidity of axis 1 and axis II disorders Authors: Bishof A, Meyer C, Bishof G, Ulrich J et al (2015) Psychiatry Research 225, 413-419

Findings:

  • The authors noted that risk for suicidal ideation and attempts are high amongst pathological gamblers when compared with the general population, but that little was known about the presence and ‘interplay’ of coexisting axis 1 and axis II disorders with pathological gambling.
  • N=442 participants were enlisted from the general German population, from gambling venues, a telephone hotline and in-patient problem gambling services.
  • Research has identified that suicidal ideation with problem gamblers to be high (cited 27%-32%) with suicide attempts also very high (cited 9.7%-27%) although information as to influencing factors was considered to be rarely identified. General population suicide surveys (as opposed to pathological gamblers) have found risk factors to be substance use disorders, mood disorders, anxiety disorders, personality disorders, being young, being female, as well as accessing intensive pathological treatment services more often, to be high risk factors for both suicidal ideation and attempts. Gambling problems have been found to be another risk factor independent of others, although the authors questioned this research, and referred to co-morbidity studies (gambling and an axis 1 disorder/s), although the research appeared to be restricted only to those problem gamblers in treatment for their gambling, and therefore more likely to be severely affected by their gambling.
  • There was an association between suicidal ideation and the coexistence of mood disorders, substance use disorders, and with early onset (in life) of the gambling problem. Suicide attempts were associated with being a female, having a mood disorder/s, and cluster B personality disorders.
  • Some 30.1% were identified with suicidal ideation (no attempts) and 18.6% had attempted suicide. Psychiatric disorders (during lifetime) were high amongst the three groups (non-ideation, ideation only, ideation and attempts) of problem gamblers. Gamblers with suicidal ideation had an increased rate for a mood disorder of 6 times over the general population, and twice as likely as the non-ideation gamblers to have a substance use disorder. Those gamblers attempting suicide increased their risk for a mood disorder by 12 times, with a 2.5% increased risk for cluster B personality disorders of 2.5 times over the non-ideation gamblers.
  • The authors concluded that mood disorders were the most important risk factors for suicide, and that although anxiety disorders were common, there was no association with suicide. They also concluded that their identification of cluster B personality disorders with problem gambling and suicide was the first research that has identified this finding and that these disorders were strongly identified with suicide.
  • The finding that treatment for problem gambling was an identified risk factor was explained through the late stage help seeking (with coexisting disorders as well as severity of all disorders for these help-seekers).

Comment:

  • This is an important study in that it not only confirms the high levels of suicide attempts with pathological gamblers, but also that the majority of problem gamblers will be affected by thoughts of suicide. The ideation and attempt rates were at the higher range of previous findings with half of the participants meeting these risk factors, emphasising the importance for screening and checking for suicide risk throughout therapy. With the higher severity previously found with problem gamblers presenting for treatment, and the current finding that presentation for problem gambling therapy is itself a risk factor, the prevalence with clients in treatment may well be higher than this finding (participants were not only treatment clients).
  • Personality disorders (PDs) have been found to coexist with many problem gamblers, and particularly those meeting cluster B PDs. These comprise Antisocial PD, Borderline PD, Histrionic PD and Narcissistic PD. The presence of such PDs does result in a client with complex needs and requires insight to identify and modify treatment to take such perspectives into account. That these also raise the risk factor for suicide is an important factor in that clients with PDs can be complex to engage and may disconnect from treatment more readily. Training of the workforce to identify, address and maintain treatment with such clients is important, as therapists may find such clients to be difficult, seemingly unmotivated, or confusing in their responses if not identified. Those who had attempted suicide had higher levels of personality disorders (over half (52.4%) met criteria for PD; 39% cluster B) while those with only ideation had levels of over one-third (35.4% met PD; 18.5% cluster B).
  • The highest risk for suicide is mood disorders, a common finding. This highlights the need to screen for depression as well as other disorders with mood symptoms. Post-traumatic Stress Disorder was identified in over one-third of problem gambling suicide attempters and one in six of those with ideation only. Almost all attempters (92.7%) were affected by mood disorders and 70% of those with suicidal ideation only; even 28% of those gamblers without ideation were affected by mood disorders.
  • The importance of treating the mood disorders in an integrated approach with the gambling problems, formulated in keeping with the personality disorder, is an important factor in both addressing suicide risk, problem gambling issues, and also maintaining engagement with clients who, as this research explains, are more likely to have a higher risk for suicide through the fact of being a presenting client.
  • Training of the problem gambling workforce should include identification and addressing mood disorders, substance use disorders, PDs, and also anxiety issues, and these finding should inform the formulation of a treatment plan.

Literature:

Personality traits of problem gamblers with and without alcohol dependence Authors: Lister J, Milosevic A Ledgerwood D (2015) Addictive Behaviours vol 47, 48-54

Findings:

  • The authors noted that few studies have reviewed the relationship of problem gambling and alcohol dependence. Research indicates that problem gamblers are 5 to 6 times more likely to be affected by alcohol use disorders (AUDs; especially dependence) with three out of four problem gamblers affected by AUDs, and one in two with alcohol dependence. In addition, in half of problem gamblers, the alcohol or drug dependence will precede the problem gambling, while both will result in more severe gambling problems. Both alcohol and gambling problems appear to have similar underlying etiology (impulsiveness, personality traits) and be more likely to also be affected by similar co-existing mental health disorders. This has been highlighted in the co-placement of AUDs and Gambling Disorder in Substance-Related and Addictive Disorders section of DSM5.
  • N=150 from the Canadian community (n=91 answering an advertisement) and university students (n=59) met problem or Gambling Disorder criteria, and from these, 41% were identified as having a current/lifetime alcohol dependence disorder using a diagnostic interview. Personality traits (as opposed to disorders) were analysed.
  • Co-occurring alcohol dependence and problem gambling resulted in greater gambling severity, and higher levels of psychiatric problems. Similar personality factors for the problem gamblers appeared to increase the risk for alcohol dependence, with this being similar for males and females.
  • These gamblers with co-existing alcohol dependence experienced emotions negatively (pessimistic, hopeless, worried about being exploited, little focus upon success) and may use alcohol to excess to improve their emotions through either enhancing positive emotions or mitigating negative emotions. Personality traits may interact to lock these gamblers into an addictive cycle. Low ability to control may interconnect with other identified personality traits for these gamblers (low traditional value for society norms and values, low preference for safe activities) matching those affected by substance use disorders, where high impulsiveness also occurs.
  • The authors recommended that therapists address substance use issues, as drinking before or after gambling may affect gambling and alcohol use control. However, they state that for these alcohol/gambling clients, strategies requiring moderate to high levels of restraint (such as controlled gambling and drinking) may not suit this cohort, as they appear to be hypersensitive to ‘the authoritarian constraints of abstinence-based approaches. Rather, the focus should be upon developing a strong therapeutic alliance with the therapist to retain them in treatment. Motivational Interviewing appears to be particularly suited (non-judgemental, empathic, rolling with resistance, discrepancy-building), as does the cultivating of positive emotions (optimism, hope) and alternative coping behaviours.
  • The authors suggest that the personality traits of those problem gamblers with alcohol dependence (ie a behavioural and substance-based addiction) have personality traits that should be taken into account in treatment. Their lower ability to control, lower connection to authority norms, and having less optimism, may make addictive behaviour rewarding, while making controlling addictive behaviours very difficult, and they may resist treatment directed goals or strategies, and have complications from the substance addiction. Treatment should therefore be tailored to these complicating traits and issues.

Comment:

  • Many problem gambling clients will be also affected by alcohol problems and this study provides a possible insight into why such clients may be less likely to engage in treatment or disconnect from treatment.
  • Motivational Interviewing is a common approach in addiction treatment and this study supports its continued use, especially where the client is dually affected. The emotional control suggested indicates that for these clients, there may be a dysfunctional coping approach in the use of alcohol to raise mood and reduce negative emotions.
  • This study may also contribute to understanding why support groups such as Gamblers Anonymous may be so poorly attended when compared with AA, in that possibly a high proportion of problem gamblers may also be affected by alcohol, and be less attracted to the rules of desiring abstinence such that 12-step groups require.
  • Alternative coping strategies elicited from the client, self-elicited goals and self-awareness about inconsistencies in continued behaviours and attaining these goals may be a more effective approach.