A preliminary, qualitative exploration of the influences associated with drop-out from cognitive-behavioural therapy for problem gambling: an Australian perspective

Exploring the psychosocial characteristics of women with gambling disorder through a qualitative study

Introduction

Gambling disorder is a behavioral addiction that has been primarily male, but in the last few years, the age of onset has been equated between the sexes. The profile of female gamblers could be different from that of men. Consequently, this study analyzes the testimonies of women with gambling disorder to determine their specific characteristics (gambling motives, gambling preferences, and associated pathologies).

Method

The sample comprises 18 women with gambling disorder aged between 30 and 68. Three discussion groups were held, and a "blind" inductive process was carried out to extract categories. The Atlas.Ti 22.0 program was used to recode and analyze the data.

Results

Results show that women may start gambling due to abuse suffered in childhood, and often family members initiate women into gambling. Likewise, the onset of gambling could be a maladaptive way to manage negative emotions. Also highlighted is the predominance of feelings of social stigmatization, which can be reflected in women's choice of games where they are not visible. Comorbidity with other disorders such as depression, anxiety, bipolar disorder, personality disorders, and the use of other substances are noteworthy.

Discussion

The factors explaining why female gamblers do not seek treatment compared to male gamblers are analyzed. More studies on women's experience with gambling are needed to address the specific characteristics of gambling disorder in women.

"I was Treated by the Program, the Therapist, and Myself": Feasibility of an Internet-Based Treatment Program for Gambling Disorder

The majority of people with problematic gambling behavior never seek or receive professional help. Internet-based treatment approaches have been shown to help patients overcome practical and psychological barriers associated with face-to-face therapy. In this uncontrolled pilot study, we explored the feasibility of the eight-module therapist-guided internet-based treatment program SpilleFri ("Free from Gambling") for patients with gambling disorder (GD). We included 24 patients seeking treatment at a Danish hospital-based treatment clinic. The focus of the feasibility study was evaluation of recruitment and retention rates, data completion rates, treatment response, satisfaction, and program utility. In addition, a series of semi-structured interviews were conducted to explore patient-perceived acceptability and potential barriers to treatment completion and positive outcome. Treatment acceptability among therapists was examined in a focus group interview. Sixteen of the included patients completed the program, yielding an acceptable treatment dropout rate (29.17%), and 82.35% of treatment completers provided full data at all assessment points. Overall, patients were satisfied with the treatment received, and patient interviews highlighted multiple psychological as well as practical benefits associated with the treatment form and content. Patients with more severe gambling symptoms at baseline might be more likely to drop out before treatment completion than patients with less severe symptoms. The results suggest that SpilleFri may be a feasible alternative to face-to-face treatment for GD. However, the uncontrolled design and small sample size of the study limit the robustness of the findings. In the future, the effect of SpilleFri treatment should be examined in a randomized controlled trial.Clinical trial registrations: The study protocol was prospectively registered at clinicaltrials.gov (TRN: NCT05051085; registration date: September 21, 2021).

Gambling disorder duration and cognitive behavioural therapy outcome considering gambling preference and sex

Gambling Disorder (GD) is a behavioural addiction that leads to high level of clinical distress and, in general, it is characterized by enduring symptomatology that presents high rates of chronicity. However, there is high variability of illness duration among patients who seek treatment for GD. Previous studies reported mixed results about the relevance of illness duration in GD treatment outcome. However, there are different profiles of patients who are diagnosed with GD. For this reason, this study aimed to evaluate the effect of illness duration in the treatment outcome of different profiles of GD patients according to their gambling preference and sex. The sample were 1699 patients diagnosed with GD. All patients received cognitive-behavioural therapy in a group format. Treatment outcome was evaluated in terms of relapsing to gambling behaviours and dropout from treatment. Results showed higher probability of poor outcome in the first years of the disorder for strategic gambling compared to non-strategic or mixed forms of gambling. Moreover, women also showed higher probability of poor outcomes than men since the first stages of the disorder. This study draws attention to the relevance of illness duration in the treatment outcome of specific profiles of GD patients. In particular, patients who presented a preference for strategic forms of gambling and women who are diagnosed with GD would have a higher risk of poor treatment outcomes since the first stages of the disorder. These results highlight the importance of an early intervention in these patients in order to prevent the chronicity of the disorder.

Reasons for dropping out of internet-based problem gambling treatment, and the process of recovery – a qualitative assessment

Problem gambling (PG) is a condition affecting the economy, mental health, and relationships of both the individuals with gambling problems, and concerned significant others (CSOs). While PG is treatable, few individuals with gambling problems seek treatment, and many drop out of treatment. This qualitative study aims to investigate a) the reasons for individuals with gambling problems to drop-out from Internet-based PG treatment, and b) what individuals with gambling problems and CSOs find helpful and unhelpful processes in PG recovery. A total of 16 participants (8 individuals with gambling problems and 8 CSOs) who had participated in an Internet-based PG treatment were interviewed over the telephone in a semi-structured interview. The interviews were analyzed using thematic analysis. Drop-out from treatment was one aspect of an overarching theme identified as unstable path to recovery, where alternating periods of progress and setbacks delineate several aspects of PG. Relapses, negative emotions, and changing life circumstances were identified to separately, and in combination, contribute to drop-out. Drop-outs were also explained by participants’ experiences of a reduced need for treatment. Openness and a support from CSOs and peers were identified as themes important for recovery. The results suggest that PG treatments should consider the emotional state, and comorbidities of the patients, in order to reduce drop-out and improve chances of recovery.

Predictors of Dropout in Disordered Gamblers in UK Residential Treatment

Within the cohort of individuals who seek treatment for disordered gambling, over half fail to complete treatment. The current study sought to identify predictors of treatment dropout in a sample of gamblers attending a residential treatment facility for disordered gamblers in the UK and to report differences in voluntary and enforced dropout. Data on 658 gamblers seeking residential treatment with the Gordon Moody Association (GMA) was analysed, collected between 2000 and 2015. Measurements included demographic data, self-reported gambling behavior, (including the Problem Gambling Severity Index), mental and physical health status, and a risk assessment. Binary logistic regression models were used to examine predictors of treatment termination. Results confirm a high percentage of treatment dropout among disordered gamblers (51.3%). Significant predictors of treatment dropout included older age of the client, higher levels of education, higher levels of debt, online gambling, gambling on poker, shorter duration of treatment, higher depression, experience of previous treatment programmes and medication, and adverse childhood experiences. Within non-completers, significant predictors of enforced dropout included lifetime homelessness, less debt, sports gambling, depression and lifetime smoking. Those who were on a longer treatment programme and had previously received gambling treatment or support were less likely to be asked to leave. Clinicians working in inpatient support need to be aware of the increased psychopathogical and psychosocial problems in those who are at risk of termination and make attempts to retain them in treatment and increase patient compliance.

Response trajectories of gambling severity after cognitive behavioral therapy in young-adult pathological gamblers

BACKGROUND AND AIMS

The significant increase in the prevalence of gambling disorder (GD) among young adults in recent years has attracted interest in determining therapeutic efficiency in this sector of the population. The aim of this work was to estimate the response trajectories of gambling severity during the six-month follow-up after a cognitive behavioral therapy (CBT) program in young adult patients and to identify the main variables associated with each trajectory.

METHODS

The sample included n = 192 patients, aged 19-35 years old, seeking treatment for GD. Response trajectories were identified through latent class growth analysis.

RESULTS

Three trajectories emerged: T1 (n = 118, 61.5%), composed of patients with severe GD at pre-treatment and good evolution to recovery; T2 (n = 62, 32.3%), with patients with moderate-high GD affectation at baseline and good evolution to recovery; and T3 (n = 12, 6.3%), with participants with severe baseline GD severity and poor evolution after CBT (Abbott, 2019). The highest risk of poor therapeutic outcomes was related to lower social index positions, high emotional distress, high scores in harm avoidance and low scores in self-directedness.

DISCUSSION AND CONCLUSIONS

Differences in the response trajectories at short-term follow-up after CBT reveal heterogeneity in the samples including young and young-adult GD patients. Patients' phenotype at baseline should be considered when developing efficient, person-centered intervention programs, which should comprise strategies aimed at increasing emotional regulation capacities, self-esteem and self-efficacy, with the aim of avoiding relapses in the medium-long term after therapy.

Gambling Disorder: Exploring Pre-treatment and In-treatment Dropout Predictors. A UK Study

The aim of this study was to identify predictors of treatment dropout in a sample of gamblers attending a specialist clinic for gambling disorder. We analysed data on 846 treatment-seeking pathological gamblers. Firstly, we investigated differences in socio-demographic and clinical variables between treatment completers and pre-treatment dropouts, as well as between treatment completers and during-treatment dropouts. Subsequently, variables were entered into a multinomial logistic regression model to identify significant predictors of pre-treatment and in-treatment dropout. Overall, 44.8% of clients did not complete the treatment: 27.4% dropped out before starting it, while 17.4% dropped out during the treatment. Younger age and use of drugs were associated with pre-treatment dropout, while family history of gambling disorder, a lower PGSI score, and being a smoker were related with in-treatment dropout. Our findings suggest that pre-treatment dropouts differ from in-treatment dropouts, and, thus, further research will benefit from considering these groups separately. In addition, this newly gained knowledge will also be helpful in increasing treatment retention in specific subgroups of problem gamblers.

Experiences of Playscan: Interviews with users of a responsible gambling tool

Online gambling, encompassing a wide variety of activities and around-the-clock access, can be a potential risk factor for gamblers who tend to gamble excessively. Yet, the advent of online gambling has enabled responsible gambling (RG) features that may help individuals to limit their gambling behaviour. One of these features is RG tools that track gamblers' behaviour, performs risk assessments and provides advice to gamblers. This study investigated users' views and experiences of the RG tool Playscan from a qualitative perspective using a semi-structured interview. The tool performs a risk assessment on a three-step scale (low, medium and high risk). Users from every risk category were included. Twenty interviews were carried out and analysed using thematic analysis. Two main themes with associated sub-themes were identified: "Usage of Playscan and the gambling site" and "Experiences of Playscan". Important experiences in the sub-themes were lack of feedback from the tool and confusion when signing up to use Playscan. These experiences counteracted positive attitudes that should have promoted usage of the tool. Providing more feedback directly to users is a suggested solution to increase usage of the RG tool.

Effects of added involvement from concerned significant others in internet-delivered CBT treatments for problem gambling: study protocol for a randomised controlled trial

INTRODUCTION

Problem gambling is a public health concern affecting ∼2.3% of the Swedish population. Problem gambling also severely affects concerned significant others (CSOs). Several studies have investigated the effect of individual treatments based on cognitive-behavioural therapy (CBT), but less is known of the effect of involving CSOs in treatment. This study aims to compare an intervention based on behavioural couples therapy (BCT), involving a CSO, with an individual CBT treatment to determine their relative efficacy. BCT has shown promising results in working with substance abuse, but this is the first time it is used as an intervention for problem gambling. Both interventions will be internet-delivered, and participants will receive written support and telephone support.

METHODS AND ANALYSIS

A sample of 120 couples will be randomised to either the BCT condition, involving the gambler and the CSO, or the CBT condition, involving the gambler alone. Measures will be conducted weekly and at 3, 6 and 12 months follow-up. The primary outcome measure is gambling behaviour, as measured by Timeline Followback for Gambling. This article describes the outline of the research methods, interventions and outcome measures used to evaluate gambling behaviour, mechanisms of change and relationship satisfaction. This study will be the first study on BCT for problem gambling.

ETHICS AND DISSEMINATION

This study has been given ethical approval from the regional ethics board of Stockholm, Sweden. It will add to the body of knowledge as to how to treat problem gambling and how to involve CSOs in treatment. The findings of this study will be published in peer-reviewed journals and published at international and national conferences.

TRIAL REGISTRATION NUMBER

NCT02543372; Pre-results.

[To take into account addicted patients' motivation to seek treatment. About a case report of a disordered gambler]

Only few subjects with addictive disorders seek treatment. Early identification and intervention are capital. Compliance for addictions' treatment remains low. Motivation enhancement promotes alliance and therapeutic compliance. Therapeutic goals should be discussed with the patient. It is important to diagnose the psychiatric and addictive comorbid disorders, which are frequent.

Treatment Outcome in Male Gambling Disorder Patients Associated with Alcohol Use

Aims: The primary objective of this study was to analyze the association between alcohol consumption and short-term response to treatment (post intervention) in male patients with gambling disorder enrolled in a group cognitive behavioral therapy (CBT) program.

Methods: The sample consisted of 111 male individuals with a diagnosis of Gambling Disorder, with a mean age of 45 years (SD = 12.2). All participants were evaluated by a comprehensive assessment battery and assigned to CBT groups of 10–14 patients attending 16 weekly outpatient sessions lasting 90 min each.

Results: The highest mean pre- and post-therapy differences were recorded for the alcohol risk/dependence group on the obsessive/compulsive and anxiety dimensions of the SCL-90-R. As regards the presence of relapses and dropouts over the course of the CBT sessions, the results show a significant association with moderate effect size: patients with risk consumption or alcohol dependence were more likely to present poor treatment outcomes.

Conclusions: Alcohol abuse was frequent in GD, especially in patients with low family income and high accumulated debts. High levels of somatization and high overall psychopathology (measured by the SCL-90-R) were associated with increased risk of alcohol abuse. Alcohol abuse was also associated with poor response to treatment.

The Efficacy of Three Modalities of Internet-Based Psychotherapy for Non-Treatment-Seeking Online Problem Gamblers: A Randomized Controlled Trial

Background

Internet-based interventions targeted at the most at-risk gamblers could reduce the treatment gap for addictive disorders. Currently, no clinical trial has included non–treatment-seeking patients who have been recruited directly in their gambling environment. This study was the first exclusively Internet-based randomized controlled trial among non–help-seeking problem gamblers with naturalistic recruitment in their gambling environment.

Objective

The aim of this study was to assess the efficacy of three modalities of Internet-based psychotherapies with or without guidance, compared to a control condition, among problem gamblers who play online poker.

Methods

All active poker gamblers on the Winamax website were systematically offered screening. All problem poker gamblers identified with a Problem Gambling Severity Index (PGSI) score of ≥5 were eligible to be included in the trial. Problem gamblers were randomized into four groups: (1) waiting list (control group), (2) personalized normalized feedback on their gambling status by email, (3) an email containing a self-help book to be downloaded with a Cognitive Behavioral Therapy (CBT) program without guidance, and (4) the same CBT program emailed weekly by a trained psychologist with personalized guidance. Efficacy was assessed based on the change in PGSI between baseline and 6 weeks (end of treatment) or 12 weeks (maintenance) and supported by player account-based gambling data automatically collected at the three time points.

Results

All groups met high attrition rates (83%), but the group with guidance had a significantly higher dropout rate than the other three groups, including the control group. Although all groups showed some improvement, with a mean decrease of 1.35 on the PGSI, no significant difference in efficacy between the groups was observed. One-third of the problem gamblers fell below the problem gambling threshold at 6 weeks.

Conclusions

Guidance could have aversively affected problem gamblers who had not sought help. Despite the lack of significant difference in efficacy between groups, this naturalistic trial provides a basis for the development of future Internet-based trials in individuals with gambling disorders. Comorbidities, natural course of illness, and intrinsic motivation seem to be critical issues to consider in future designs.

Trial Registration

ANSM 2013-A00794-41

Pathological gambling: understanding relapses and dropouts

There is little available information on the factors that influence relapses and dropouts during therapy for pathological gambling (PG). The aim of this study was to determine socio-demographic, clinical, personality, and psychopathological predictors of relapse and dropout in a sample of pathological gamblers seeking treatment. A total of 566 consecutive outpatients diagnosed with PG according to DSM-IV-TR criteria were included. All patients underwent an individualized cognitive-behavioral treatment program. We analyzed predictors of relapse during 6months of treatment and during the subsequent 6months of follow-up, and predictors of dropout over the entire therapeutic program. Eighty patients (14.1%) experienced at least one relapse during the entire follow-up of the study: 50 (8.8%) within the treatment period and 12 (2.1%) during the subsequent 6-month follow-up period. The main predictors of relapse were single marital status, spending less than 100euros/week on gambling, active gambling behavior at treatment inclusion, and high scores on the TCI-R Harm Avoidance personality dimension. One hundred fifty-seven patients (27.8%) missed 3 or more therapeutic sessions over the entire therapeutic program. The main predictors of dropout were single marital status, younger age, and high scores on the TCI-R Novelty Seeking personality dimension. The presence of these factors at inclusion should be taken into account by physicians dealing with PG patients.

Predictors of Outcome among Pathological Gamblers Receiving Cognitive Behavioral Group Therapy

AIMS

The aim of this study was to evaluate posttreatment changes of individuals with a diagnosis of gambling disorder (GD) treated with group cognitive behavioral therapy (CBT), to assess the potential moderator effect of sex on CBT outcome, and to explore the best predictors of posttreatment changes, relapse, and dropout rates.

METHODS

A cohort design was applied with a prospective follow-up. The sample comprised 440 patients and the CBT intervention consisted of 16 weekly outpatient group sessions and a 3-month follow-up period.

RESULTS

Patients showed significant improvements in both the level of psychopathology and the severity of the gambling behavior. High self-transcendence and the involvement of the spouse or partner in the therapy predicted a higher risk of relapse. Younger age and low education predicted a higher risk of dropout.

CONCLUSION

Many patients with GD can be treated with strategies to improve self-control and emotional regulation, but other techniques should be incorporated to address the individual characteristics of each patient. This is particularly important in group therapy, in which the same treatment is applied to several patients simultaneously. The involvement of a family member needs to be carefully considered since it may have a negative effect on the response to treatment if not adequately managed.

Video game addiction in gambling disorder: clinical, psychopathological, and personality correlates

OBJECTIVE

We studied the prevalences of video game use (VGU) and addiction (VGA) in gambling disorder (GD) patients and compared them with subjects with non-video game use (non-VGU) in relation to their gambling behavior, psychopathology, and personality characteristics.

METHOD

A sample of 193 GD patients (121 non-VGU, 43 VGU, and 29 VGA) consecutively admitted to our pathological gambling unit participated in the study. Assessment. Measures included the video game dependency test (VDT), symptom checklist-90-revised, and the temperament and character inventory-revised, as well as a number of other GD indices.

RESULTS

In GD, the observed prevalence of VG (use or addiction) was 37.3% (95% CI :30.7% ÷ 44.3),VGU 22.3% (95% CI :17.0% ÷ 28.7), and VGA 15% (95% CI :10.7% ÷ 20.7). Orthogonal polynomial contrast into logistic regression showed positive linear trends for VG level and GD severity and other measures of general psychopathology. After structural equation modeling, higher VG total scores were associated with younger age, general psychopathology, and specific personality traits, but not with GD severity. Patients' sex and age were involved in the mediational pathways between personality traits and VG impairment.

CONCLUSIONS

GD patients with VG are younger and present more dysfunctional personality traits, and more general psychopathology. The presence of VG did not affect the severity of GD.

Internet-based treatment of pathological gambling with a three-year follow-up

Effective therapies for pathological gambling exist, but their use is limited to about 10% of the target population. In an attempt to lower the barriers for help, Internet-based cognitive behavioural therapy (ICBT) has been shown to be effective when delivered to anon-depressed sample with pathological gambling. This study sought to extend this finding to a larger, more representative population, and also test a model to predict responder status. Following advertisement, a total of 284 participants started an 8-week ICBT programme with minimal therapist contact via e-mail and weekly telephone calls of less than 15 min. The average time spent on each participant, including telephone conversations, e-mail, and administration, was 4 h. In addition to a mixed effects model to evaluate the effectiveness of the treatment, two logistic regression analyses were performed with the following eight pre-defined response predictor variables: work-life satisfaction, primary gambling activity, debts due to gambling, social support, personal yearly salary, alcohol consumption, stage of change, and dissociative gambling. ICBT resulted in statistically significant reductions in the scores of pathological gambling, anxiety, and depression as well as an increase in quality of life compared to pre-treatment levels. Follow-ups carried out in the treatment group at 6, l8, and 36 months indicated that treatment effects were sustained. Using the eight predictor variable model rendered an acceptable predictive ability to identify responders both at post-test (AUC = .72, p < .01) and at 36-month follow-up (AUC = .70, p < .01). We conclude that ICBT for pathological gamblers, even if depressed, can be effective and that outcome can partly be predicted by pre-treatment characteristics.

Cognitive-behavioral therapy for pathological gambling in Parkinson's disease: a pilot controlled study

OBJECTIVES

The main objective of this study was to compare the clinical characteristics and differences in response to treatment of two groups of pathological gamblers: with comorbid Parkinson's disease (PG + PD) and without (PG - PD).

METHODS

Clinical and psychopathological profiles and response to cognitive-behavioral treatment were assessed in 15 PG + PD and 45 PG - PD individuals consulting a specialized hospital Unit.

RESULTS

Statistically significant differences were observed between the two groups on a series of clinical variables. PG + PD patients were older and presented later onset of problematic gambling behaviors, lower alcohol consumption and higher bingo playing than PG - PD patients. No significant differences were noted in psychopathology except for lower measures of hostility in the PG + PD group. No statistical differences were detected between groups in terms of response to treatment.

CONCLUSION

These results may provide guidance for obtaining accurate diagnostic information in pathological gamblers by properly identifying patients with specific needs that may be targeted with treatment.