1
|
Johannessen DA, Overå S, Arnevik EA. The role of contextual factors in avenues to recover from gambling disorder: a scoping review. Front Psychol 2024; 15:1247152. [PMID: 38410405 PMCID: PMC10894926 DOI: 10.3389/fpsyg.2024.1247152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 01/17/2024] [Indexed: 02/28/2024] Open
Abstract
Introduction Recovery from complex conditions such as gambling disorders (GD) often entail considerable change and require a range of adaptable interventions in the health care system. Outcomes from such avenues to change are influenced by multifarious contextual factors, which are less frequently considered in treatment outcome studies. Accordingly, this scoping review aims to map the level of evidence and explore how contextual factors influence the provision and outcomes of GD interventions. Methods A systematic search in selected health and social science research databases yielded a total of 2.464 unique references. The results were screened in three selection steps-titles (n = 2.464), abstracts (n = 284) and full-text (n = 104). The scoping approach was applied to provide a narrative account of the final included references (n = 34). Results and discussion Findings suggest that the research on GD treatment is in the early stages of development. Additionally, studies on GD interventions are characterized by cultural biases (Region and ethnicity and Gender perspectives), while three key elements are described as successful avenues to recover from GD (Competence, Perception and Utilization). In line with these findings, proposals for future research and treatment designs are made.
Collapse
Affiliation(s)
- Dagny Adriaenssen Johannessen
- Department of Social Work, Child Welfare and Social Policy, OsloMet—Oslo Metropolitan University, Oslo, Norway
- Blue Cross East, Oslo, Norway
| | - Stian Overå
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brumunddal, Norway
| | - Espen Ajo Arnevik
- Section for Clinical Addiction Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
2
|
Snippe L, Boffo M, Galvin H, Willemen R, Pronk T, Dom G, Wiers RW. How We Lost 90% of Participants on a Bad Bet: Results from a Pilot Randomized Controlled Trial on Cognitive Bias Modification in Problem Gamblers. J Gambl Stud 2023:10.1007/s10899-023-10263-6. [PMID: 38006537 DOI: 10.1007/s10899-023-10263-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 11/27/2023]
Abstract
Whilst opportunities to participate in gambling have increased, access to support for problem gamblers is lacking behind. This lack of balance calls for improved and accessible intervention methods. The present double-blind randomized controlled trial (RCT) explored the effectiveness of two interventions targeting automatic cognitive processes, known as Attentional Bias Modification (AtBM) and Approach Bias Modification (ApBM). It was hypothesized these interventions would reduce gambling behavior and reduce or reverse targeted biases. Participants (N = 331) were community-recruited Flemish (35%) and Dutch (65%) adult problem gamblers motivated to reduce or stop their gambling who received either six sessions of active training (AtBM or ApBM) or of the corresponding sham-training (sham-AtBM or sham-ApBM). Due to high attrition rates (90.1% up to the intervention phase) the study was terminated before completion, since it would greatly limit the validity of any results. A post hoc qualitative study was performed on a subset of participants to gain insight into contributing factors for the high attrition rate. Issues negatively impacting participants' motivation to complete the program were identified, as well as elements of the program that received approval. The results from this study provide a first insight into the potential of the use of online cognitive bias modification (CBM) interventions in problem gambling (PG). Suggestions and directions for future studies are discussed.
Collapse
Affiliation(s)
- Leroy Snippe
- Addiction Development and Psychopathology (ADAPT) Lab, Department of Psychology, University of Amsterdam, Nieuwe Achtergracht 129, 1018 WS, Amsterdam, The Netherlands.
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp (UAntwerp), Wilrijk, Belgium.
| | - Marilisa Boffo
- Department of Psychology, Education and Child Studies (DPECS), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Harriet Galvin
- Addiction Development and Psychopathology (ADAPT) Lab, Department of Psychology, University of Amsterdam, Nieuwe Achtergracht 129, 1018 WS, Amsterdam, The Netherlands
- Department of Psychology, Education and Child Studies (DPECS), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Thomas Pronk
- Addiction Development and Psychopathology (ADAPT) Lab, Department of Psychology, University of Amsterdam, Nieuwe Achtergracht 129, 1018 WS, Amsterdam, The Netherlands
| | - Geert Dom
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp (UAntwerp), Wilrijk, Belgium
| | - Reinout W Wiers
- Addiction Development and Psychopathology (ADAPT) Lab, Department of Psychology, University of Amsterdam, Nieuwe Achtergracht 129, 1018 WS, Amsterdam, The Netherlands
- Centre for Urban Mental Health, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Zhang D, Zhou S, Zheng H, Guo L, Zhai J, Liu Z, Du Z, Dong P, Zhao M, Du J. How general functioning of family affects gambling-related beliefs: the mediating role of communication and the moderating role of impulsivity trait. Front Psychiatry 2023; 14:1165053. [PMID: 37520239 PMCID: PMC10373064 DOI: 10.3389/fpsyt.2023.1165053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/19/2023] [Indexed: 08/01/2023] Open
Abstract
Background Gambling behaviors can be exhibited by individuals raised in families with impaired parent-child communication and individuals with more impulsive traits. However, it remains unclear how gambling-related beliefs are modulated by impulsivity traits and parent-child communication styles. Methods A total of 95 adult patients (age ≥ 18 years) diagnosed via DSM-5 criteria with gambling disorder (GD) completed our questionnaire. Participants filled out pen-and-paper questionnaires that included basic demographic information, the Family Assessment Device (FAD), Parent-Adolescent Communication Scale (PACS), Gambling Attitude and Belief Survey (GABS), and Barratt Impulsiveness Scale (BIS). We used a moderation mediation model to explore the relationship between variables. The study results were considered statistically significant if p < 0.05, or the 95% confidence interval did not contain zero. Results The scores of the problems in communication with mother subscale (PCMS) of PACS were significantly positively correlated with the scores of GABS and the general functioning 12-item subscale (GF12) of FAD. The relationship between the scores of GF12 and GABS was completely mediated [β = 4.83, (1.12, 10.02)] by PCMS scores, and the BIS scores moderated this relationship: the predictive path between GF12 and PCMS scores [index of moderated was β = -0.25, (-0.60, -0.04)], and the indirect predictive front path between the scores of GF12 and GABS were significant only in subjects with low BIS scores. Conclusion These findings suggest that poor general functioning of the family may increase gambling-related beliefs as a result of communication problems with mothers, and this result is only significant for individuals with low impulsivity. When treating patients with GD, more treatment of mother-child communication issues and individual impulsivity may be more conducive to their recovery.
Collapse
Affiliation(s)
- Dapeng Zhang
- The Third People's Hospital of Fuyang, Fuyang, China
- Shanghai Mental Health Center, Shanghai, China
| | - Shuang Zhou
- Shanghai Mental Health Center, Shanghai, China
| | - Hui Zheng
- Shanghai Mental Health Center, Shanghai, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Guo
- Shanghai Mental Health Center, Shanghai, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Zhai
- Shanghai Mental Health Center, Shanghai, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ziqi Liu
- Shanghai Mental Health Center, Shanghai, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zheyi Du
- Shanghai Mental Health Center, Shanghai, China
| | - Ping Dong
- Shanghai Mental Health Center, Shanghai, China
| | - Min Zhao
- Shanghai Mental Health Center, Shanghai, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
| | - Jiang Du
- Shanghai Mental Health Center, Shanghai, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
4
|
Mestre-Bach G, Potenza MN. Features Linked to Treatment Outcomes in Behavioral Addictions and Related Disorders. Int J Environ Res Public Health 2023; 20:2873. [PMID: 36833569 PMCID: PMC9957199 DOI: 10.3390/ijerph20042873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/28/2023] [Accepted: 02/04/2023] [Indexed: 06/18/2023]
Abstract
Behavioral addictions are incompletely understood with respect to their underlying etiologies. This incomplete understanding may contribute to the frequent relapse and dropout rate often observed with behavioral addictions. The present state-of-the-art review aimed to review the literature that explored sociodemographic and clinical factors that link to poor treatment responses. Despite multiple studies, the definitions and evaluations of relapse and dropout are heterogeneous, complicating comparisons across studies. A scientific consensus on the conceptualization of both terms would help to better understand psychological features linked to treatment outcomes in behavioral addictions.
Collapse
Affiliation(s)
- Gemma Mestre-Bach
- Facultad de Ciencias de la Salud, Universidad Internacional de La Rioja, 26006 La Rioja, Spain
| | - Marc N. Potenza
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06510, USA
- Connecticut Mental Health Center, New Haven, CT 06519, USA
- Connecticut Council on Problem Gambling, Wethersfield, CT 06109, USA
- Wu Tsai Institute, Yale University, New Haven, CT 06510, USA
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT 06510, USA
- Department of Neuroscience, Yale University School of Medicine, New Haven, CT 06510, USA
| |
Collapse
|
5
|
Gooding NB, Kim HS, Williams RJ, Williams JN. Individual differences and predictors of general awareness in problem gambling. Addict Behav 2023; 136:107505. [PMID: 36183686 DOI: 10.1016/j.addbeh.2022.107505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/09/2022] [Accepted: 09/20/2022] [Indexed: 02/03/2023]
Abstract
In Canada, up to 3% of individuals have or are at risk of gambling disorder. Among these individuals, a lack of awareness of their problem gambling is a common barrier to treatment and negatively affects treatment adherence. A secondary analysis was conducted on data from 1346 individuals (mean age = 43.4, SD = 14.4; 54.3 % male) with problem gambling who did and did not perceive having a problem with their gambling as assessed by the fifth item of the Problem Gambling Severity Index, "In the past twelve months, how often have you felt that you might have a problem with gambling?" Additionally, we investigated predictors of increased general awareness at 12-month follow-up. At baseline, individuals who perceived a problem with their gambling experienced more gambling-related harms (OR = 1.714), had greater total gambling losses (OR = 1.067), were more likely to have a family history of problem gambling (OR = 2.143), experienced a greater loss of control (OR = 1.313) and more often gambled alone than with others (OR = 0.879), accounting for 26.6 % of the variance in general awareness. Baseline problem awareness was positively associated with attempts to cut down or control gambling at follow-up (χ2=11.350,p<.001), but negatively associated with remission (χ2=18.392,p<.001). Increases in awareness were related to an increase in the number of gambling-related harms, gambling involvement, impaired control, and lower educational attainment, explaining 35.5% of the variance in increased general awareness. The results indicate that experiencing more gambling-related harms increases the salience and awareness of problem gambling, and that awareness is also associated with an individual's gambling context, their loss of control, and their level of gambling involvement. The findings highlight the importance of gambling harms as they pertain to general awareness and suggest that improving the recognition of gambling harms could be beneficial for the prevention and intervention of gambling disorder.
Collapse
|
6
|
Mena-Moreno T, Munguía L, Granero R, Lucas I, Fernández-Aranda F, Gómez-Peña M, Moragas L, Verdejo-García A, Menchón JM, Jiménez-Murcia S. e-Estesia: A Serious Game for Reducing Arousal, Improving Emotional Regulation and Increasing Wellbeing in Individuals with Gambling Disorder. J Clin Med 2022; 11. [PMID: 36431275 DOI: 10.3390/jcm11226798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/09/2022] [Indexed: 11/19/2022] Open
Abstract
Gambling disorder (GD) is associated with deficits in emotion regulation and impulsivity-related personality traits. In recent years there has been an increase in the use of serious games (SG) to address these factors with positive results. The aim of this study was to analyze the efficacy of the intervention with a new SG (e-Estesia), as an adjunct to a CBT intervention for GD. The sample comprised two groups (experimental group (n = 40) and control group (n = 64)) of patients with GD diagnosis. Both groups received 16 weekly CBT sessions and, concurrently, only the experimental group received 15 additional sessions with e-Estesia. Pre-post treatment with e-Estesia administered in both groups were: DSM-5 Criteria, South Oaks Gambling Screen, Symptom Checklist-Revised and measure of relapses, dropout and compliance of treatment. As regards the experimental group were also administered: Difficulties in Emotion Regulation Scale, Emotion Regulation Questionnaire, and Impulsive Behavior Scale. No statistically significant differences in the general psychopathological state, emotion regulation or impulsivity were found when comparing the groups. However, patients enrolled in the e-Estesia intervention had significantly less relapses and better indicators of treatment compliance than the control group. Considering these results, the use of complementary tools such as SG are useful for addressing GD.
Collapse
|
7
|
Mestre-Bach G, Granero R, Mora-Maltas B, Valenciano-Mendoza E, Munguía L, Potenza MN, Derevensky JL, Richard J, Fernández-Aranda F, Menchón JM, Jiménez-Murcia S. Sports-betting-related gambling disorder: Clinical features and correlates of cognitive behavioral therapy outcomes. Addict Behav 2022; 133:107371. [PMID: 35691124 DOI: 10.1016/j.addbeh.2022.107371] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS The number of patients with gambling disorder (GD) whose gambling preference is sports betting is increasing. However, their clinical profile and their responses to psychological treatments -compared to patients with other forms of gambling- have not been thoroughly studied. Therefore, the aims of this study were: (1) to compare the clinical characteristics of GD patients whose primary gambling activity was sports betting (SB+; n = 113) with GD patients with other primary gambling activities (SB-; n = 1,135); (2) to compare treatment outcomes (dropout and relapses) between SB + and SB- patients; and (3) to explore relationships between specific variables (GD severity, psychological distress and personality features) and treatment outcome in SB + and SB- GD patients, through correlation models and path-analysis. METHODS The cognitive behavioral treatment consisted of 16 weekly sessions. Personality features, psychopathology, and sociodemographic and clinical factors were assessed. RESULTS The SB + group included higher proportions of younger patients who were single and had higher educational levels, older ages of GD onset, and greater GD severities. Regarding treatment outcomes, the dropout rate was lower in the SB + group, and no between-group differences were found regarding relapse. Dropout within the SB + group was related to being unemployed, and relapse was related to being unmarried and experiencing more psychological distress. DISCUSSION AND CONCLUSION The differences between SB + and SB- GD patients suggest that GD patients with sports-betting problems may benefit from tailored therapeutic approaches.
Collapse
Affiliation(s)
| | - Roser Granero
- Departament de Psicobiologia i Metodologia de les Ciències de la Salut, Universitat Autònoma de Barcelona, Barcelona, Spain; Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain; Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain.
| | - Bernat Mora-Maltas
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain; Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain.
| | - Eduardo Valenciano-Mendoza
- Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain; Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain; Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain.
| | - Lucero Munguía
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain.
| | - Marc N Potenza
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; Child Study Center, Yale University School of Medicine, New Haven, CT, USA; Connecticut Mental Health Center, New Haven, CT, USA; Connecticut Council on Problem Gambling, Wethersfield, CT, USA; Department of Neuroscience, Yale University, New Haven, CT, USA.
| | - Jeffrey L Derevensky
- Department of Educational and Counselling Psychology, McGill University, Montreal, Québec, Canada.
| | - Jérémie Richard
- Department of Educational and Counselling Psychology, McGill University, Montreal, Québec, Canada.
| | - Fernando Fernández-Aranda
- Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain; Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain; Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain.
| | - José M Menchón
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; CIBER Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain; Psychiatry and Mental Health Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain.
| | - Susana Jiménez-Murcia
- Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain; Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain; Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain.
| |
Collapse
|
8
|
Mena-Moreno T, Testa G, Mestre-Bach G, Miranda-Olivos R, Granero R, Fernández-Aranda F, Menchón JM, Jiménez-Murcia S. Delay Discounting in Gambling Disorder: Implications in Treatment Outcome. J Clin Med 2022; 11:1611. [PMID: 35329937 DOI: 10.3390/jcm11061611] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/21/2022] [Accepted: 03/12/2022] [Indexed: 02/04/2023] Open
Abstract
Impulsive choice, measured by delay discounting (DD) tasks, has been shown in patients with gambling disorders (GD). However, the impact of DD and treatment outcome has been scarcely explored in GD patients. The aims of this study were: (1) to examine the baseline association between DD and clinical variables in GD patients depending on their age and gambling preferences (strategic vs. non-strategic); and (2) to estimate the predictive role of DD on poorer outcomes of cognitive-behavioral therapy (CBT) when considering also the effect of other clinical variables. 133 treatment-seeking male GD patients were evaluated at baseline with a DD task and measures of GD severity, personality traits and psychopathology. Treatment outcome was measured in terms of dropout from CBT and relapses. Results showed baseline associations between DD and GD severity (correlation coefficient R = 0.408 among strategic gamblers and R = 0.279 among mixed gamblers) and between DD and positive/negative urgency (R = 0.330 for the youngest patients, R = 0.244 for middle age, and around R = 0.35 for gamblers who reported preferences for strategic games). Other personality traits such as high harm avoidance and low cooperativeness were also related to DD at baseline (R = 0.606 among strategic gamblers). Regarding treatment outcome, a steeper discount rate predicted a higher risk of relapses in strategic gamblers (odds ratio OR = 3.01) and middle-age ones (OR = 1.59), and a higher risk of dropout in younger gamblers (OR = 1.89), non-strategic gamblers (OR = 1.70) and mixed gamblers (R = 4.74). GD severity mediated the associations between age, DD, personality traits and poor CBT outcome. In conclusion, impulsive choice affects treatment response in individuals with GD and may interfere with it to a significant extent. Considering DD in GD, patients seeking treatment could help control its impact on treatment adherence and relapses.
Collapse
|
9
|
Kim J, Amaev A, Quilty LC, Selby P, Shah P, Caravaggio F, Ueno F, Pollock BG, Graff-Guerrero A, Gerretsen P. A Measure to Assess Illness Awareness in Problem Gambling: Gambling Awareness and Insight Scale (GAS). J Gambl Stud 2021; 38:1029-1043. [PMID: 34169396 DOI: 10.1007/s10899-021-10037-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2021] [Indexed: 11/25/2022]
Abstract
Impaired subjective awareness of problem gambling may act as a barrier to help-seeking and treatment adherence. However, the impact of impaired problem gambling awareness on clinical and social outcomes has received little empirical study. The aim of this study was to develop and investigate the psychometric properties of a novel scale that measures impaired illness awareness in individuals with problem gambling. We developed the Gambling Awareness and Insight Scale (GAS), a self-report measure that assesses the core theoretical constructs of illness awareness in problem gambling, namely General Disorder or Problem Awareness, Accurate Symptom Attribution, Awareness of Need for Treatment and the Negative Consequences attributable to problem gambling ( www.illnessawarenessscales.com ). Data were acquired from an online survey platform, Dynata, to evaluate the psychometric properties of the GAS. A total of 100 participants aged 18 years or older with problem gambling defined by a score of 4 or more on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Pathological Gambling Diagnostic Form were included. The GAS demonstrated good convergent (r = 0.57, p < 0.001) and discriminant validity (r = - 0.18, p = 0.080). It also demonstrated good internal consistency (Cronbach's α = 0.80) and one-month test-retest reliability (intra-class correlation = 0.86). An exploratory factor analysis suggested retention of two components. The GAS is a novel psychometric tool designed to evaluate impaired subjective illness awareness in problem gambling. Initial evidence suggests that the GAS can be used in research and clinical settings to evaluate the impact of impaired problem gambling awareness on adherence to treatment programs, clinical and psychosocial outcomes. Replication in applied settings is needed.
Collapse
Affiliation(s)
- Julia Kim
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Aron Amaev
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, ON, Canada
| | - Lena C Quilty
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Campbell Institute Research Program, CAMH, University of Toronto, Toronto, ON, Canada
| | - Peter Selby
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Campbell Institute Research Program, CAMH, University of Toronto, Toronto, ON, Canada
| | - Parita Shah
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, ON, Canada
| | - Fernando Caravaggio
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Fumihiko Ueno
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, ON, Canada
| | - Bruce G Pollock
- Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, ON, Canada
- Campbell Institute Research Program, CAMH, University of Toronto, Toronto, ON, Canada
| | - Ariel Graff-Guerrero
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, ON, Canada
- Campbell Institute Research Program, CAMH, University of Toronto, Toronto, ON, Canada
| | - Philip Gerretsen
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, ON, Canada.
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
- Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, ON, Canada.
- Campbell Institute Research Program, CAMH, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
10
|
Cassú-Ponsatí D, Pedrero-Pérez EJ, Morales-Alonso S, Ruiz-Sánchez de León JM. Impulsivity-Compulsivity Axis: Evidence of Its Clinical Validity to Individually Classify Subjects on the Use/Abuse of Information and Communication Technologies. Front Psychol 2021; 12:647682. [PMID: 33889117 PMCID: PMC8056074 DOI: 10.3389/fpsyg.2021.647682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
The compulsive habit model proposed by Everitt and Robbins has accumulated important empirical evidence. One of their proposals is the existence of an axis, on which each a person with a particular addiction can be located depending on the evolutionary moment of his/her addictive process. The objective of the present study is to contribute in addressing the identification of such axis, as few studies related to it have been published to date. To do so, the use/abuse of Information and Communication Technologies (ICT) was quantified on an initial sample of 807 subjects. Questionnaires were also delivered to measure impulsivity, compulsivity and symptoms of prefrontal dysfunction. Evidence of the existence of the proposed axis was obtained by means of Machine Learning techniques, thus allowing the classification of each subject along the continuum. The present study provides preliminary evidence of the existence of the Impulsivity-Compulsivity axis, as well as an IT tool so that each patient that starts getting treatment for an addiction can be statistically classified as “impulsive” or “compulsive.” This would allow the matching of each person with the most appropriate treatment depending on his/her moment in the addiction/abuse process, thus facilitating the individualized design of each therapeutic process and a possible improvement of the results of the treatment.
Collapse
Affiliation(s)
| | | | - Sara Morales-Alonso
- Department of Experimental Psychology, Cognitive Processes and Speech Therapy, Faculty of Psychology, Complutense University of Madrid, Madrid, Spain
| | - José María Ruiz-Sánchez de León
- Department of Experimental Psychology, Cognitive Processes and Speech Therapy, Faculty of Psychology, Complutense University of Madrid, Madrid, Spain
| |
Collapse
|
11
|
Martínez-Loredo V, Macipe V, Errasti Pérez JM, Al-Halabí S. Clinical symptoms and personality traits predict subpopulations of treatment-seeking substance users. J Subst Abuse Treat 2021; 125:108314. [PMID: 34016301 DOI: 10.1016/j.jsat.2021.108314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/09/2020] [Accepted: 01/25/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The heterogeneity of treatment-seeking substance users represents a challenge, as most studies include participants having problems with specific substances or merge polysubstance users into the same category without considering differences between profiles. Considering the inconsistent literature on predictors of treatment outcomes, this study aimed to identify subpopulations of individuals with substance use disorders (SUDs) and analyze the association among class membership, previous relapses, and treatment retention. METHODS The study recruited a total of 159 participants (mean age = 40.60, SD = 8.70; 85.5% males) from two treatment facilities (outpatient daycare and inpatient residential centers). The baseline assessment gathered lifetime and current substance use, and personality and psychopathology measures. The study performed a latent class analysis to identify subpopulations of substance users and explored predictors of class membership using a multinomial regression analysis. RESULTS The study found six different classes of substance users based on their diagnosis and pattern of substance use: class 1 (6.92% of participants): individuals with cannabis as primary substance, alcohol/cocaine as secondary substance and additional use of stimulants or other drugs; class 2 (30.82%): cocaine as primary substance, alcohol as secondary and additional cannabis use; class 3 (20.13%): alcohol as primary substance, cocaine as secondary and additional cannabis use; class 4 (17.61%): cocaine as primary substance, cannabis as secondary and additional alcohol/other drugs use; class 5 (16.35%): alcohol as primary and cannabis as secondary substance; class 6 (8.18%): heroin as primary substance, cocaine as secondary and additional alcohol use. Several traits and clinical symptoms predicted distinct class memberships. Participants pertaining to class 6 presented the highest number of relapses (M = 2.54, SD = 1.56). CONCLUSIONS These results have several clinical implications. Belonging to class 6 was associated with a greater number of previous relapses. Also, specific psychopathological symptoms and personality traits may impact SUD treatment response, which may help clinicians to guide initial assessment and treatment allocation.
Collapse
Affiliation(s)
- V Martínez-Loredo
- Department of Psychology, University of Oviedo, Oviedo, Asturias, Spain; Department of Psychology and Sociology, University of Zaragoza, Teruel, Aragón, Spain.
| | - V Macipe
- Department of Psychology, University of Oviedo, Oviedo, Asturias, Spain
| | - J M Errasti Pérez
- Department of Psychology, University of Oviedo, Oviedo, Asturias, Spain
| | - S Al-Halabí
- Department of Psychology, University of Oviedo, Oviedo, Asturias, Spain
| |
Collapse
|
12
|
Abstract
Gamblers are a heterogenous group in terms of the presence of comorbid psychopathology, maladaptive personality traits, and motivation to gamble. The Pathways Model, the most promising comprehensive framework to explain this heterogeneity, classifies gamblers into three subtypes. The aim of this review was to determine whether or not subtyping of gamblers based on the Pathways Model of problem and disordered gambling is valid. A literature review was conducted using the following online databases: Academic Search Complete, PubMed, Web of Science, and PsychINFO. Studies were selected or excluded based on meeting predetermined criteria. Fourteen studies examining subtyping of gamblers based on the Pathways Model were reviewed and evaluated. Results suggest that in the adult population there are three subtypes of gamblers that largely coincide with the subtypes defined in the Pathways Model. Of these, the emotionally vulnerable subtype is the most problematic and inconsistent. In contrast, for adolescents, at least four gambler subtypes have been identified. The extant literature on subtyping of gamblers suffers from some severe limitations. Further research is required to fully validate the Pathways Model.
Collapse
Affiliation(s)
- Adam Kurilla
- Psychology Department, College of Humanities and Sciences, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA, 23284-2018, USA.
- Center for Treatment of Drug Dependencies, Hranicna 2, 821 05, Bratislava, Slovak Republic.
| |
Collapse
|
13
|
Goudriaan AE. Integrating neurocognition from bench to bedside in gambling disorder: from neurocognitive to translational studies. Curr Opin Behav Sci 2020; 31:83-8. [DOI: 10.1016/j.cobeha.2019.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
14
|
Mestre-Bach G, Steward T, Granero R, Fernández-Aranda F, Mena-Moreno T, Vintró-Alcaraz C, Lozano-Madrid M, Menchón JM, Potenza MN, Jiménez-Murcia S. Dimensions of Impulsivity in Gambling Disorder. Sci Rep 2020; 10:397. [PMID: 31941903 DOI: 10.1038/s41598-019-57117-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 11/24/2019] [Indexed: 01/08/2023] Open
Abstract
Impulsivity is a multidimensional construct. Although gambling disorder (GD) has been associated with high impulsivity, impulsivity across multiple domains has not been thoroughly investigated in this population. We first aimed to examine whether associations between three facets of impulsivity (response impulsivity, choice impulsivity and impulsive tendency) varied between GD patients and healthy controls (HC). We next aimed to evaluate relationships between these three types of impulsivity, as proposed by theoretical models of impulsivity, and their associations with GD severity. The sample included 97 treatment-seeking adult men with GD, diagnosed according to DSM-5 criteria, and 32 male HCs recruited from the general population. Greater impulsivity in all three domains was found in men with GD in comparison to men without GD. Associations between impulsivity facets were found in both groups, with response impulsivity being the only domain associated with GD severity. Our findings confirm that multiple domains of impulsivity are relevant in GD. Future studies should examine the extent to which treatments aimed at targeting specific aspects of impulsivity improve outcomes.
Collapse
|
15
|
López-Torres I, León-Quismondo L, Ibáñez A. Impulsivity, Lack of Premeditation, and Debts in Online Gambling Disorder. Front Psychiatry 2020; 11:618148. [PMID: 33551878 PMCID: PMC7855030 DOI: 10.3389/fpsyt.2020.618148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/22/2020] [Indexed: 12/29/2022] Open
Abstract
Background and Objectives: Gambling disorder (GD) is a recurrent and persistent problematic gambling behavior that impairs multiple areas of an individual's life. GD can persist through two modes: online or offline. This study aims to compare sociodemographic, clinical, and psychological characteristics between treatment-seeking online and offline gamblers and analyze the effect of the gambling mode (online or offline) on anxiety, depression, impulsivity, and debts. Methods: Seventy-nine treatment-seeking gamblers (96.2% males), who were simultaneously receiving treatment at a specialized Pathological Gambling and Behavioral Addictions Unit, participated in this study. The sample was divided into two subsamples: online (n = 29, 100% males) and offline (n = 50, 94% males); the characteristics of these two groups were compared and analyzed using Chi-Square test (χ2), t-Test or Mann-Whitney U-test (p < 0.05). Multiple linear regression analyses were performed to determine the effects of gambling mode on significant variables (lack of premeditation and debts). Results: The online sample with a mean age of 29.4 years mainly chose to engage in sports betting (45%, p < 0.05) and showed a higher lack of premeditation levels (25.8 points, p < 0.05) than the offline sample. In addition, the online sample was younger with respect to their onset to gambling (20.2 years, p < 0.05) and the beginning of their gambling problems (25 years, p < 0.05) compared to the offline sample. Online gambling increased the levels of lack of premeditation by an average of 5.43 points compared to offline gambling (p < 0.05). Accumulated debts of the online sample were lower (€11,000) than those of the offline sample (€12,000). However, the interaction between age and gambling mode revealed that online gamblers increased their debt amounts with age at an average increase of €2,726.33 per year compared to offline gamblers (p < 0.05). No significant influence of gambling mode was found on GD severity, anxiety, and depression levels. Conclusions: Gambling mode has a significant relationship with lack of premeditation-a component of impulsivity-and accumulation of debts in treatment-seeking people with GD; however, no relationship was found with the rest of the variables analyzed. Future research with larger samples is needed to confirm these findings.
Collapse
Affiliation(s)
- Isabel López-Torres
- Foundation for Biomedical Research, Hospital Universitario Ramón y Cajal (FIBioHRC), Madrid, Spain
| | | | - Angela Ibáñez
- Department of Psychiatry, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Ramón y Cajal Institute for Health Research (IRYCIS), Madrid, Spain.,Network Centre for Biomedical Research in Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Departamento de Medicina y Especialidades Médicas, Universidad de Alcala, Madrid, Spain
| |
Collapse
|
16
|
Ruiz de Lara CM, Navas JF, Perales JC. The paradoxical relationship between emotion regulation and gambling-related cognitive biases. PLoS One 2019; 14:e0220668. [PMID: 31381598 DOI: 10.1371/journal.pone.0220668] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/20/2019] [Indexed: 12/14/2022] Open
Abstract
Background Gambling behavior presents substantial individual variability regarding its severity, manifestations, and psychological correlates. Specifically, differences in emotion regulation, impulsivity, and cognitive distortions have been identified as crucial to describe individual profiles with implications for the prevention, prognosis, and treatment of gambling disorder (GD). Aims and method The aim of the present study was to investigate the associations of gambling-related cognitions (measured according to the GRCS model) with impulsivity (UPPS-P model) and emotion regulation (CERQ model), in a sample of 246 gamblers with different levels of gambling involvement, using mixed-effects modelling to isolate theoretically relevant associations while controlling for the potentially confounding effects of sociodemographic and clinical covariates. Results Affective/motivational dimensions of UPPS-P impulsivity positive urgency and sensation seeking, on the one hand, and CERQ emotion regulation strategies reappraisal, rumination and blaming others, on the other, independently and significantly predicted distorted gambling-related cognitions. Conclusions These results (a) reinforce the ones of previous studies stressing the relevance of emotional and motivational processes in the emergence of gambling-related cognitive distortions; and (b) replicate the seemingly paradoxical finding that gamblers use emotion regulation strategies customarily considered as adaptive (i.e. reappraisal) to strengthen and justify their biased beliefs about gambling outcomes and controllability.
Collapse
|
17
|
Jara-Rizzo MF, Navas JF, Catena A, Perales JC. Types of Emotion Regulation and Their Associations with Gambling: A Cross-Sectional Study with Disordered and Non-problem Ecuadorian Gamblers. J Gambl Stud 2019; 35:997-1013. [DOI: 10.1007/s10899-019-09868-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
18
|
Jiménez-Murcia S, Granero R, Fernández-Aranda F, Stinchfield R, Tremblay J, Steward T, Mestre-Bach G, Lozano-Madrid M, Mena-Moreno T, Mallorquí-Bagué N, Perales JC, Navas JF, Soriano-Mas C, Aymamí N, Gómez-Peña M, Agüera Z, Del Pino-Gutiérrez A, Martín-Romera V, Menchón JM. Phenotypes in Gambling Disorder Using Sociodemographic and Clinical Clustering Analysis: An Unidentified New Subtype? Front Psychiatry 2019; 10:173. [PMID: 30984045 PMCID: PMC6450083 DOI: 10.3389/fpsyt.2019.00173] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 03/08/2019] [Indexed: 12/17/2022] Open
Abstract
Background: Gambling disorder (GD) is a heterogeneous disorder which has clinical manifestations that vary according to variables in each individual. Considering the importance of the application of specific therapeutic interventions, it is essential to obtain clinical classifications based on differentiated phenotypes for patients diagnosed with GD. Objectives: To identify gambling profiles in a large clinical sample of n = 2,570 patients seeking treatment for GD. Methods: An agglomerative hierarchical clustering method defining a combination of the Schwarz Bayesian Information Criterion and log-likelihood was used, considering a large set of variables including sociodemographic, gambling, psychopathological, and personality measures as indicators. Results: Three-mutually-exclusive groups were obtained. Cluster 1 (n = 908 participants, 35.5%), labeled as "high emotional distress," included the oldest patients with the longest illness duration, the highest GD severity, and the most severe levels of psychopathology. Cluster 2 (n = 1,555, 60.5%), labeled as "mild emotional distress," included patients with the lowest levels of GD severity and the lowest levels of psychopathology. Cluster 3 (n = 107, 4.2%), labeled as "moderate emotional distress," included the youngest patients with the shortest illness duration, the highest level of education and moderate levels of psychopathology. Conclusion: In this study, the general psychopathological state obtained the highest importance for clustering.
Collapse
Affiliation(s)
- Susana Jiménez-Murcia
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain.,Ciber Fisiopatologia Obesidad y Nutrición, Instituto Salud Carlos III, Barcelona, Spain.,Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Roser Granero
- Ciber Fisiopatologia Obesidad y Nutrición, Instituto Salud Carlos III, Barcelona, Spain.,Departament de Psicobiologia i Metodologia de les Ciències de la Salut, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Fernando Fernández-Aranda
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain.,Ciber Fisiopatologia Obesidad y Nutrición, Instituto Salud Carlos III, Barcelona, Spain.,Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Randy Stinchfield
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Joel Tremblay
- Département de Psychoéducation, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Trevor Steward
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain.,Ciber Fisiopatologia Obesidad y Nutrición, Instituto Salud Carlos III, Barcelona, Spain
| | - Gemma Mestre-Bach
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain.,Ciber Fisiopatologia Obesidad y Nutrición, Instituto Salud Carlos III, Barcelona, Spain
| | - María Lozano-Madrid
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain.,Ciber Fisiopatologia Obesidad y Nutrición, Instituto Salud Carlos III, Barcelona, Spain
| | - Teresa Mena-Moreno
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain.,Ciber Fisiopatologia Obesidad y Nutrición, Instituto Salud Carlos III, Barcelona, Spain
| | - Núria Mallorquí-Bagué
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain.,Ciber Fisiopatologia Obesidad y Nutrición, Instituto Salud Carlos III, Barcelona, Spain
| | - José C Perales
- Department of Experimental Psychology, University of Granada, Granada, Spain.,Brain, Mind and Behavior Research Center (CIMCYC), University of Granada, Granada, Spain
| | - Juan F Navas
- Department of Experimental Psychology, University of Granada, Granada, Spain.,Brain, Mind and Behavior Research Center (CIMCYC), University of Granada, Granada, Spain
| | - Carles Soriano-Mas
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain.,Departament de Psicobiologia i Metodologia de les Ciències de la Salut, Universitat Autònoma de Barcelona, Barcelona, Spain.,Ciber de Salud Mental, Instituto Salud Carlos III, Madrid, Spain
| | - Neus Aymamí
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain
| | - Mónica Gómez-Peña
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain
| | - Zaida Agüera
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain.,Ciber Fisiopatologia Obesidad y Nutrición, Instituto Salud Carlos III, Barcelona, Spain
| | - Amparo Del Pino-Gutiérrez
- Departament d'Infermeria de Salut Pública, Salut Mental i Maternoinfantil, Escola Universitària d'Infermeria, Universitat de Barcelona, Barcelona, Spain
| | | | - José M Menchón
- Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain.,Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain.,Ciber de Salud Mental, Instituto Salud Carlos III, Madrid, Spain
| |
Collapse
|