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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:

Central Queensland University & Auckland University of Technology. 2017. Measuring the burden of gambling harm in NZ. Wellington: Ministry of Health

Findings:

  • Aim was to develop a framework and methodology for understanding and measuring gambling-related harm in the NZ population.
  • Different levels of gambling-related harm were applied to measure of the burden of harm of gambling. This was the first NZ burden of harm by gambling study, but only the second in the world, and used a standard methodology approved by the WHO to compare gambling to other well-researched health issues.
  • The total burden of harm was greater than many common health conditions such as diabetes and arthritis, and the total level is almost as high as anxiety and depressive disorders.
  • This gambling harm is largely attributable to relationship damage, emotional and psychological distress, disruptions to work and/or study, and financial impact
  • When the burden was applied through years of life lost in NZ, almost 162,000 years were lost as a result of gambling harms (in year 2012), broken down into almost 68,000 years lost by gamblers, and almost 95,000 years lost by those affected by another’s gambling.
  • Harm affected mainly six areas: decreased health, emotional or psychological health, financial harm, reduced performance at work/education, relationship disruption, conflict/breakdown, and criminal activity.
  • These years lost only apply to the analysed year (2012) and do not include loss of years in later years by the 2012 harm. The authors therefore concluded this sum of years lost was likely to be conservative for gambling harm.
  • The loss of years/burden of harm mainly impacts upon those who may not themselves be gambling.
  • The authors noted that there were more low risk gamblers than those experiencing problems with gambling in NZ, however, when impact of harm was categorised, 48% of the harm was attributable to low-risk gambling, 34% of the harm to moderate risk gambling, and just 18% of gambling harm attributable to high risk gambling. They concluded that ‘although low-risk gamblers are harmed comparatively less than ‘problem’ gamblers, they contribute much more to the total harm to the community’.
  • The authors noted that a significant amount of gambling harm arises from those who may not meet a gambling disorder psychiatric definition, with low and moderate risk gamblers accounting for 80%, and 20% from ‘serious problem gamblers’. Because harms are not all equal, those at low risk might manage the effects but these will impact upon their enjoyment of life (e.g. unmanageable credit card debt, having less money to spend upon essential expenses).
  • The authors identified that ‘gambling causes over twice as much harm than chronic conditions such as osteoarthritis (2.1x) and diabetes (2.5x), and three times the amount of harm from drug use disorders’ but less than anxiety and depression (0.63x) and hazardous alcohol drinking (0.77x).
  • Because of the high impact of gambling harm (primarily damaged relationships, emotional and psychological distress, disruptions to work/study, and financial impacts), the authors stated that focusing only upon reducing the incidence of problem gambling was insufficient, and ‘rather, the focus should be on minimising gambling-related harm across the entire spectrum of problematic gambling behaviour’. \

Comment:

  • Past estimates for the number of significant others has often varied but has been estimated to be generally between 7-17 for each person experiencing gambling harm, while an estimated 89,000 (one in 40) people were affected in NZ by the gambling of others (NZ Health Survey 2012), particularly Maori and Pasifika people.
  • The finding of a higher impact overall of gambling harm resting upon those not themselves gambling, (68,000 years lost by those gambling and 95,000 years by those affected by others’ problem gambling in 2012), provides an important focus on resource allocation, especially when treatment access for family and others may not exceed one-third of the numbers of gamblers seeking help.
  • This report provides awareness that the harm from gambling may exceed other common health conditions that may have a higher profile (e.g. diabetes, drug use disorders, osteoarthritis and arthritis) and therefore more public understanding of gambling harm may be needed to assist in reducing the level of such harm.

Literature:

Auckland University of Technology. 2017. Problem gambling and family violence in help-seeking populations: co-occurrence, impact and coping. Wellington: Ministry of Health

Findings:

  • This research was conducted by AUT Gambling and Addictions Research Centre and Interdisciplinary Trauma Research Centre, and three gambling treatment providers.
  • A survey of 370 gamblers and 84 affected others (partners, other family and friends, whanau; ‘family’) were surveyed between 2013 and 2015 using a wide definition of family violence (physical, coercion, psychological and emotional abuse, and sexual abuse).
  • Of the 454 participants, 208 comprising 166 gamblers and 42 affected others participated in a more detailed survey with a researcher.
  • Over half of those participating reported being victims of abuse in the previous 12 months, although frequency of this abuse was not sought
  • Of the 50% who identified being the victims of violence in the pervious 12 months, 41% were impacted by being screamed and/or cursed at, 40% by insults or being talked down to, 12% by threats of physical harm, 9% by physical harm, and 4% by sexual abuse. Increased risk factors for being a victim of such violence, were their having children at home, and their experiencing severe harm resulting from the person’s gambling.
  • A high proportion of the participants (44%) also reported being perpetrators of such violence. Of these, 37% admitted to screaming/cursing victims, insulting or talking down to them (34%), threatening physical harm (9%), and inflicting physical harm (7%), although none disclosed perpetrating sexual abuse. A risk factor for being a perpetrator of violence was having a family member with mental health issues.
  • Three quarters of violence was towards or from a current or ex-partner, with others affected being sons/daughters, and other family members.
  • In the second, intensive survey, affected others largely attributed the violence to the gambling (this contrasted with gamblers’ perspectives of cause).
  • Financial abuse was a strong factor, with gamblers more likely to commit financial abuse, while affected others were more likely to be the victims of financial abuse (financial abuse included being concerned about money, valuables/property going missing, money taken without permission, foced to sign papers about money, or to gamble for another person).
  • Gamblers tended to under-estimate the negative impacts of their gambling upon family, the children, and home life. These impacts also included financial problems, relationship damage, health effects, emotional impacts, social deprivation and neglect.
  • Victims of violence used a range of strategies to cope with the family member’s gambling, including emotionally responding to the gambler, explaining their feelings, helping to sort out the financial problems, trying to pretend that they were not impacted, and trying to prioritise the interests of other family members over those of the gambler.
  • The authors concluded that amongst those seeking help for their own or for the impact of another’s gambling, violence and abuse is commonplace.
  • A brief screen, the HITS, was found to be a simple and practical tool for non-experts in family violence. They concluded that if this tool was included with existing procedures to identify family violence, outcomes for those affected by family violence could be improved.
  • The authors also concluded that this would be subject to appropriate family violence/abuse training for screening, assessment, and support (for those disclosing violence/serious risk to self/others) being provided for.

Comment:

  • The high level of violence identified when gambling harm occurs has followed a range, albeit somewhat limited, of previous findings.
  • The use of a broad definition of violence follows international definitions and the strong impacts that non-physical violence can have over time.
  • Family violence has been an under-rated impact that may previoulsy been under-reported or assessed for in treatment, but with recent legislation (e.g. Vulnerable Children Act 2014), this has come to the forefront as an important factor to be identified in gambling treatment.
  • The high levels of violence identified is similar to findings in other populations overseas, while the identification of perpetration of family violence as addressed in this research has shown that clients will disclose some of the violence even with the consequences of disclosure (stigma, legal), although discloure of physical and sexual violence was lower, as might be expected.
  • The use of the HITS screen modified to include a perpetration section as well as a sexual coercion question (as used in the study), provides a brief tool that has now been shown to have some validity.
  • Integration of these findings into treatment planning by routinely providing screening for family violence, will help to address this important issue in New Zealand. Broadening the definition of violence also aligns well with the Vulnerable Children Act, and it will be important to ensure that these important findings are not left to a discretionary treatment approach to what has been in the past, a somewhat hidden problem, and an uncomfortable topic to raise.

Literature:

Dark flow, depression and multiline play (2017). Authors: Dixon M, Stange M, Graydon C, Fugelsang J, Harrigan K. Journal of Gambling Studies, 2017 June 6. Doi: 10.1007/s10899-017-9695-1

Findings:

  • The authors had noted that multiline electronic gambling machines (EGMs) allowed for spin outcomes that showed wins that were less than the wager, as a win; these were described as ‘a loss disguised as a win’ or LDW.
  • They noted that these outcomes altered the gambler’s play experience, in that the number of wins experienced could remain high, despite losing either regularly or overall, with an ‘overall win experience’.
  • The authors noted that research showed that players responded to these LDW ‘wins’ as if they were wins, and not losses, and created what they described as a ‘dark flow’, a highly absorbing, flow-like state, and that research has indicated that there may be a relationship between dark flow and problem gambling, as well as between dark flow, depression, and gamblers’ expectations when gambling.
  • To expand on these understandings, the authors investigated whether single line play as opposed to multiline play was similarly influenced by the LDW wins.
  • Using a pressure measure of arousal, the authors identified whether the pressure used on the spin button changed over different outcomes.
  • The authors identified that arousal following LDW simulated wins were similar to actual small wins.
  • The researchers identified that EGM players overwhelmingly preferred multiline games, and experienced more positive mood than single-line playing.
  • The authors also identified that players with higher PGSI scores were related to the dark flow effect, with the stronger effect found in these players using a multiline game.
  • They found that dark flow and depression were correlated, especially for the multiline game, with a significant correlation between depression and the gambler’s expectation of winning, and that dark flow and expectancy were also related.

Comment:

  • This study provides further awareness that losses represented as wins (where amount won is less than the amount gambled, but is presented as a win) can have significant influence in a gambler’s perception of their overall financial status in the game, and also that these may be stronger for those who are at risk of, or already experiencing problems with their gambling.
  • The authors’ description of this as ‘dark flow’ appears to suggest and explain why gamblers may persist with their gambling session despite losing and may also dissociate or ‘lose time’ in a positive mood experience, and that this ‘dark flow’ may have even higher attraction for depressed gamblers, resulting in longer sessions and higher losses.
  • The relationship being stronger with those playing multiline games, will result in higher likelihood of these LDW ‘wins’ from a line, when other (losing) lines subtract from any win.
  • The connection between those gamblers who score higher on the PGSI (at-risk or gamblers experiencing harm), and their attraction to a dissociated state that may relieve dysphoria or even depression when playing multiline games, may explain how gambling behaviours leading to harm may escalate quickly, with confusion over the extent of lost money and time, and distorted expections of winning.

Literature:

Internet-based delivery of Cognitive Behaviour Therapy compared to monitoring, feedback and support for problem gambling: a randomised controlled trial (Jan 2017). Authors: Casey L, Oei T, Raylu N, Horrigan K, Day J, Ireland M, Clough B. Journal of Gambling Studies, 2017, doi: 10.1007/s10899-016-9666-y

Findings:

  • The authors sought to investigate the efficiency of an internet-based CBT programme (I-CBT) for the treatment of gambling problems, and compared this with an active internet programme of monitoring, feedback and support (I-MFS) and an inactive waitlist control option, with N=174 clients being randomly allocated to one or other of these.
  • Outcome variables were gambling outcomes and outcomes of measures of related mental health (outcomes relating to gambling urges, cognitions, stress, and life satisfaction).
  • The authors found that the internet I-CBT and I-MFS programmes both resulted in significant improvements in reducing gambling severity. However, the I-CBT programme resulted in stronger gambling improvements as well as improved mental health outcomes. The CBT effects were greater across seven outcome measures (than I-MFS) and participants rated the programme as more satisfactory.
  • Both I-CBT and I-MFS programmes resulted in stable gains at a 12-month follow-up.
  • The authors concluded that the benefits of the CBT programme were due to more than the motivation, feedback and support aspects of I-MFS.
  • The authors also concluded that online treatments for gambling may be a valuable tool in increasing help-seeking and engagement by those affected by gambling problems, and may also provide an addition to a stepped care approach for those impacted by gambling harm.

Comment:

  • On-line programmes can be a cost-effective option once established, and may offer an alternative for those experiencing gambling harm and who may not be motivated to access face to face, or telephone counselling.
  • CBT-based therapy has the advantage of being more structured and can align itself with a self-help process if motivation is present.
  • This research adds to evidence that a CBT approach can be effective for addressing gambling harm, and may provide an earlier stage alternative for harm-affected gamblers.
  • Those affected by their gambling can be reluctant help-seekers, with perceptions of stigma, and avoidance being barriers to help-seeking. The convenience of online help can reduce barriers where gamblers may have difficulties accessing treatment, and can provide a stepped approach to help.
  • A CBT approach may not suit all clients where motivation to complete tasks may be required. Where depression is evident, an internet approach may not be the best or optimal strategy. The MFS alternative did have positive but lesser outcomes, but was not a Motivational Interviewing strategy. However, it is useful to have a range of options for increasing engagement with what is acknowledged as a low help-seeking proportion of those impacted by their gambling.

Literature:

Increased urge to gamble following near-miss outcomes may drive purchasing behaviour in scratch card gambling. Authors: Stange M, Graydon C, Dixon M. Journal of Gambling Studies, Dec 2016 doi: 10.1007/s10899-016-9662-2

Findings:

  • The authors noted that previous research had highlighted that in scratch cards, near misses have been associated with high levels of arousal (physiological and subjective), and in negative emotional evaluations, including frustration.
  • The authors wanted to extend the research to ascertain if near misses increased gambling urge and the purchase of additional scratch cards.
  • Players rated their urges after using two cards, one group experiencing a near miss, the other a regular loss. Following an initial phase, players could use their winnings to purchase additional cards.
  • Findings were that there was a significant urge to continue gambling following a near miss, as compared with the regular losses group. In addition, those in the near-loss group who purchaed additional cards reported stronger or higher urges to gamble, than those in the near-loss who did not purchase more cards. Those in the solely losing group reported lower urge levels whether or not they purchased more cards.
  • The authors concluded that despite losing money, the near-loss group described higher urges to gamble, indicating a possible connection between a near-loss and urge to gamble.

Comment:

  • This research provided further information around the impact of the perception of near-loss as an expectation, and therefore increased urge to gamble.
  • Increased frustration from a near-miss may be alleviated by participating in a future chance to win, and this may be continued with a further near miss.
  • Although identification of self-talk to support this possibility was not available, this simple experiment does add to knowledge through statistical evidence of increased gambling behaviour following a near loss outcome.

Literature:

Gambling problems among patients in primary care: a cross-sectional study of general practices (2017). Authors: Cowlishaw S, Gale L, Gregory A, McCambridge J, Kessler D. British Journal of General Practice, 67(657), pp e274-e279

Findings:

  • The authors sought to establish the extent of gambling problems amongst general medical practices and to identify groups with heightened risk.
  • Eleven practices in Bristol recruited n=1058 patients from waiting rooms by completing anonymous questionnaires for mental health, addictive behaviours, and the PGSI, and a single question family problem gambling screen.
  • 0.9% of patients scored five or more on the PGSI and 4.3% scored low to moderate (PGSI 1-4).
  • 7% of patients reported gambling problems among family members.
  • Any gambling problem (one or more on PGSI) was higher among males and young adults, and among students. Higher gambling risk was also found amongst those with higher (risky) alcohol use, drug use, and depression.
  • The authors concluded there was a need to improve primary care service understanding of problem gambling, screening, early intervention and improved care.

Comment:

  • The finding of 7% of patients affected by another’s gambling substantially exceeds the general population NZ Health Survey finding of 1:40 (2.5%).
  • The problem gambling prevalence together with the family prevalence suggests that this study has identified an issue sufficient to warrant concern by primary care providers.
  • The recommendations by the authors suggests that further interest will be likely by GPs in the identification and intervention in gambling harm issues for their patients

Literature:

Gambling Disorder: association between duration of illness, clinical and neurocognitive variables. Authors: Medeiros G, Redden S, Chamberlain S, Grant J. Behavioral Addiction, 2017, Jun 1, 6 (2), pp194-202

Findings:

  • The authors noted that Gambling Disorder (GD) can occur at most ages ranging from adolescent to adult, and also that help-seeking can also occur at different times of life.
  • Because of these variables (development of GD and help-seeking age) clients may present at treatment services at any stage during the period of being affected by gambling harm. The authors noted that the duration of illness at the time of help-seeking was an under-studied variable, yet an important one in understanding influences upon treatment outcomes.
  • The authors analysed clinical and neurocognitive characteristics at varying duration of GD at the time of help-seeking.
  • N=448 clients diagnosed with GD participated, with all assessments being completed prior to treatment commencing.
  • The authors identified four main effects. The first was that there was a negative correlation between the length of time of the presence of GD prior to help-seeking and the initial onset of the GD following first gambling. In other words, when GD developed soon after first starting to gamble, the time before help-seeking was longer.
  • Second, the existence of concurrent alcohol use disorder is associated with a longer duration of GD (i.e. a correlation between the two conditions).
  • Third, the presence of a first-degree relative with a history of alcohol use disorders is positively associated with extended period of GD.
  • Fourth, (as might be expected), there is a negative correlation between the duration of the GD to help-seeking with quality of life.
  • The authors concluded that there are important treatment variables that occur that may be related to the time lapse that occurs between the age that GD occurs and the age at which help-seeking commences.
  • The authors concluded that these important findings may be used to optimise treatment seeking behaviour, that psychological interventions could be customised to address these variables, and when treatment planning also includes management of alcohol use disorders, this may indicate more chronic presentation of gambling disorder.

Comment:

  • There is good evidence available that certain forms of gambling (i.e. continuous) can result in briefer periods between first gambling and the development of GD, as well as higher proportions of GD for that gambling mode (e.g. EGMs). Other factors that may accelerate the risk of GD are early wins, coexisting disorders, and accessibility.
  • The length of time between commencement of gambling and presence of GD was addressed in the Australian Productivity report in 1999, also noting that help-seeking was longer for those seeking help for racing when compared with EGMs.
  • This research notes further important information, albeit some appears to be counter-intuitive (e.g. that insight into harm may be less when there is a faster onset of GD, when changes may be more sudden).
  • Evidence that alcohol problems should be identified and included in treatment are already addressed in NZ treatment by PG services, however, this is further information of the importance of an integrated approach (screening all clients, addressing alcohol impact through awareness and concurrent strategies).
  • There is evidence also that the course of GD (chronic in nature) and that a customised approach, rather than one more focused upon gambling, may have better outcomes.
  • This information may also be useful in a public health awareness strategy focusing upon reducing the period of time between the development of GD and help-seeking, as well as brief, accessible options for help (e.g. GP screening, online self-help strategies, awareness raising in advertising).

Literature:

Effects of alcohol, initial gambling outcomes, impulsivity, and gambling cognitions on gambling behaviour using a video poker task. Authors: Corbin W, Cronce J. Exp Clinical Psychopharmacology, 2017, Jun, 25(3), pp175-185

Findings:

  • The authors noted that gambling and alcohol consumption commonly co-occur, and that this may result in more harm for some gamblers.
  • The authors sought to identify the impact of alcohol effects, gambling outcomes for the session, impulsivity, and gambling cognitions, with the expectations that average bets, perception of wins reoccuring, and gambling persistence would be higher when alcohol use co-occurred.
  • N=162 participants were randomly assigned to alcohol use (to a pre-determined level) and gambling, or not, and to one of three initial outcomes (win, breakeven, loss), followed by a progressive loss schedule.
  • Primary expectations were not supported with those impacted by alcohol placing smaller wagers (although this was not so for at-risk gamblers (n=41)).
  • The authors noted that these findings contradicted prior research that alcohol effects may change depending upon gambling type, and that alcohol will always disinhibit gambling (and raise risk for harmful gambling).

Comment:

  • The authors acknowledged that alcohol impacts were more complex in regard to gambling outcomes than expected, and that primary expectations weren’t supported.
  • Those impacted by alcohol (.08g%) did not increase their wagering or persistence in the experimental task overall, however, those clients already at risk for gambling problems were impacted by alcohol.
  • This research nevertheless provides evidence that for those already at risk for gambling problems, alcohol use can be a harmful variable, and can have an immediate influence upon gambling for those without an existing risk.

Literature:

Gambling frequency and symptoms of attention-deficit hyperactivity disorder in relation to problem gambling among Swedish adolescents: a population-based study. Authors: Hellstrom, C, Wagner P, Nilsson K, Leppert J, Aslund C. Ups J Med Sci, Jun 2017, 122(2), pp119-126

Findings:

  • The authors hypothesised that adolescents with ADHD symptoms would have a higher frequency of gambling when compared with those with fewer ADHD symptoms.
  • N=1412 adolescents (15-18 yrs) with gambling experience were surveyed.
  • Lower risk for gambling problems were associated with decreased ADHD symptoms, lower frequency of gambling, and being younger.
  • However, although ADHD symptoms and frequency of gambling did increase risk for gambling problems, the degree of harm/problems did not change, depending upon the ADHD symptom level in those adolescents already at risk for gambling problems.
  • The authors concluded that although adolescents with ADHD symptoms are more susceptible to gambling problems, once they do become impacted by gambling harm, their frequency of gambling is similar to that of other gamblers already impacted by gambling harm.

Comment:

  • This research supports the increased risk for gambling participation, and therefore gambling harm, by those with ADHD symptoms.
  • Unexpectedly, ADHD does not appear to influence the number of gambling sessions that they participate in once a problem has been established.
  • This may be relevant in treatment as the resolution of ADHD symptoms in those clients seeking help for gambling harm may have less impact on the overall outcome of their treatment as may have been expected.

Literature:

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Findings:

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Comment:

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