Sustained-release bupropion in the treatment of SSRI nonresponder pathologic gamblers: pilot study and review of the literature

Pharmacological management of gambling disorder: an update of the literature

INTRODUCTION

Gambling disorder (GD) is a mental health condition characterized by persistent and problematic betting behavior. GD generates distress and impairment, and treatment options include psychological and pharmacological interventions.

AREAS COVERED

This narrative review explores existing pharmacological treatments for GD. The following classes of medications were considered: opioid-receptor antagonists (e.g. naltrexone and nalmefene), serotonin reuptake inhibitors (e.g. fluvoxamine, paroxetine, sertraline, escitalopram, and citalopram), glutamatergic agents (e.g. N-acetylcysteine (NAC), acamprosate, and memantine), mood stabilizers (e.g. topiramate, carbamazepine, lithium), and other medications (e.g. modafinil, nefazodone, olanzapine, haloperidol, tolcapone, and bupropion).

EXPERT OPINION

Due to the limitations of the studies reviewed, solid conclusions regarding the optimal choice of pharmacotherapy for individuals with GD are challenging to draw at this time. Despite some medications, such as naltrexone and nalmefene, showing promising results, efficacy has varied across studies. The review highlights current gaps/limitations, including small sample sizes, limited diversity in participant demographics, the need for exploring different gambling subtypes and treatment responses, high placebo response rates, lack of longer-term longitudinal information, limited investigation of neurobiological correlates and co-occurring disorders, and the importance of implementation research. Further research is needed to address these gaps and explore additional medications, as well as interventions like neuromodulation.

Pharmacotherapy of pathological gambling: review of new treatment modalities

Pathological gambling is classified in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition as an impulse-control disorder. In the International Classification of Diseases of the WHO, pathological gambling is coded under the heading of 'Habit and Impulse Disorders'. Pathological gambling is a chronic, progressive disorder, which has a prevalence of 1-3.4% among western civilizations. The enormous personal and social consequences of this disorder include a high rate of suicide attempts, job loss, marital and family problems, legal problems, and criminal behavior. Recent studies have demonstrated that pathological gambling patients respond well to treatment with selective serotonin reuptake inhibitors, mood stabilizers and opioid antagonists. These findings support the idea that pathological gambling and other disorders of impulse control may be conceptualized as part of the obsessive-compulsive spectrum disorders or addictive disorders. This article will discuss possible treatment strategies according to different behavior patterns in pathological gambling and also remind the physicians who intend to treat this disorder of the possible diagnosis of pathological gambling.

Die Wirksamkeit psychologischer und psychopharmakologischer Interventionen bei pathologischem Glückspiel – eine Metaanalyse

Fragestellung: Die vorliegende Studie berichtet über eine Meta-Analyse zur Wirksamkeit psychologischer und psycho-pharmakologischer Behandlungsmethoden des pathologischen Spiels. Methode: Dazu wurde eine systematische Literaturanalyse bis einschließlich Juli 2006 der Datenbanken PsycInfo, PsyndexPlus, Pascal, Biomed, Medline und Scopus durchgeführt. Von den daraus resultierenden 144 Studien erfüllten 56 mit einem N = 3.551 die Einschlusskriterien. Inkludiert wurden sowohl Studien mit einem Prä-Post-Katamnese-Design wie auch solche mit einer Vergleichs- oder Kontrollgruppe. Effektstärken wurden nach Cohen’s d berechnet. Bei Studien mit mehr als einem Outcome-Kriterium wurden diese gemittelt. Ergebnisse: Psychopharmakologische Behandlungen (d = .83; p ≤ .01; CI(95 %) = .72 – .95) erwiesen sich zum Therapieende als effektiver als psychologische (d = .63; p ≤ .01; CI(95 %) = .54 – .72). Deren Effekte waren zum Follow-up (M = 17 Monate) jedoch hoch (d = 1.26; p ≤ .01; CI(95 %) = 1.15 – 1.37): Wegen fehlender Studien konnten keine entsprechenden Effekte für pharmakologische Behandlungen berechnet werden. Im Hinblick auf die spezifischen Behandlungen erwiesen sich Psycho-Stimulantien und Stimmungsstabilisierer als am effektivsten; bei den psychologischen Methoden waren es multimodale Programme, die aus einer Kombination von Selbsthilfe, Kompetenztrainings und Familieninterventionen bestanden. Allerdings wurden diese primär über Prä-Postvergleiche evaluiert. In diesem Design erwiesen sich jedoch in einer Reanalyse verhaltenstherapeutische Interventionen den multimodalen Programmen überlegen. In den Moderatoranalysen zeigte sich das Studiendesign als einzige bedeutsame Variable. Diskussion: Die Ergebnisse müssen als vorläufig gewertet werden, denn das Feld weist noch viele Mängel auf. So fehlen vor allem kontrollierte randomisierte Studien mit langfristigen Katamnesen. Auch wurden Kombinationstherapien noch nicht untersucht.

Extended release carbamazepine in the treatment of pathological gambling: an open-label study

BACKGROUND

The efficacy and tolerability of extended release carbamazepine was tested in the treatment of pathological gambling (PG).

METHOD

Non-depressed outpatients with DSM-IV PG received flexibly dosed extended release carbamazepine in a prospective 10-week open-label trial following a two-week observation period. Subjects were evaluated at baseline and at one week intervals during a four week titration period, and every two weeks thereafter for assessment of gambling behavior, mood, and adverse experiences. The primary efficacy measure was the Yale-Brown Obsessive-Compulsive Scale modified for PG (YBOCS-PG).

RESULTS

Eight subjects (6 men, 2 women) had at least one post-baseline visit, and five subjects (63%) completed the protocol. Significant improvement was found on the YBOCS-PG (P< .001). Seven of the eight subjects with post-baseline assessment (88%) were considered responders (i.e., achieved "much" or "very much" improvement on the CGI). Four subjects (50%) abstained from gambling during their final month of study participation. Several patients were dropped because of adverse experiences.

CONCLUSION

The results suggest that extended release carbamazepine may be effective in the treatment of PG.

Pathological gambling: an update on neuropathophysiology and pharmacotherapy

Neurobiological research has shown the potential involvement of serotonergic, dopaminergic and opioid dysfunction in the pathophysiology of pathological gambling. In this review, we present current theories of the neuropathology of pathological gambling, paying particular attention to the role of the neural circuitry underlying motivation, reward, decision-making and impulsivity. This review also presents a literature review of current pharmacological treatment strategies for pathological gambling, such as selective serotonin reuptake inhibitors (SSRIs), opioid receptor antagonists, anti-addiction drugs and mood stabilizers, and also discusses the role of nonpharmacological interventions.A hypothetical model of the clinical subtypes of pathological gambling is presented, e.g. the impulsive subtype, the obsessive-compulsive subtype and the addictive subtype. This model attempts to integrate current knowledge in the field of pathological gambling regarding neuropathology, psychiatric co-morbidity, family history, genetics, course of illness, gender and response to pharmacological treatment. Finally, it is proposed that the existence of possible clinical subtypes of pathological gambling may provide a potential framework for matching the various subtypes with specific pharmacotherapies.

12-month follow-up study of drug treatment in pathological gamblers: a primary outcome study

BACKGROUND

Pathological gambling (PG) is a relatively common and highly disabling impulse control disorder. A range of psychotherapeutic agents including selective serotonin reuptake inhibitors, antiepileptic drugs, and opioid antagonists are shown to be effective in the short-term treatment of PG. The use of a wide range of pharmacological treatments for PG is consistent with the observation that PG shares features of obsessive-compulsive spectrum disorders, impulse control disorders, and addictive disorders. The aim of the study is to assess the rate of relapse in treatment-responder pathological gamblers after discontinuation of the active treatment.

METHODS

Our study sample was composed of 43 male pathological gamblers who had been full responders to 1 of 4 drug treatment regimens (fluvoxamine, topiramate, bupropion SR, or naltrexone) from several previous acute open-label (12-week) comparison studies. Full response was defined as the absence of gambling for a 1-month duration together with improvement on the Clinical Global Improvement scale. The 43 full responders were then followed prospectively for an additional 9 months, which included a 3-month open-label continuation phase and a 6-month medication-free follow-up phase. Follow-up visits were performed on a monthly basis throughout the duration of study. At every follow-up visit, a comprehensive psychiatric diagnostic evaluation was performed on all patients, and patients were assessed for symptoms of gambling using a self-report instrument and collateral family reports. The Clinical Global Impression Improvement scale was also administered at every follow-up visit. Raters were blind to the previous drug treatment.

RESULTS

Most patients did not relapse during the 6-month medication-free follow-up phase. Three of 6 patients with fluvoxamine, 3 of 9 with topiramate, 7 of 18 with bupropion SR, and 4 of 10 with naltrexone relapsed. Relapse was strictly defined as gambling behavior at any time during the 6-month medication-free follow-up period. Most of the patients did not gamble during the follow-up period, and the patients that did gamble reported a decrease in gambling losses.

CONCLUSIONS

This naturalistic long-term follow-up outcome study demonstrates that among pathological gamblers who respond to a 6-month trial of medication, most patients seem to maintain full-response during a 6-month medication-free follow-up phase. Further studies are needed to confirm our findings.

Bupropion in the treatment of pathological gambling: a randomized, double-blind, placebo-controlled, flexible-dose study

We tested the efficacy of bupropion in the treatment of persons with pathological gambling (PG). Nondepressed, healthy subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition PG were randomly assigned to placebo or flexibly dosed bupropion in a 12-week double-blind trial. Outcome measures included the Yale-Brown Obsessive-Compulsive Scale modified for PG, the Gambling Severity Assessment Scale, the Clinical Global Impression Improvement and Severity Scales, the Global Assessment Scale, the Timeline Follow Back, the Attention-Deficit/Hyperactivity Disorder Rating Scale, and the Sheehan Disability Scale. Thirty-nine subjects (28 men, 11 women) were randomized to bupropion (n = 18) or placebo (n = 21). The 2 groups were similar on demographic and clinical measures. There were few differences between the treatment groups on any primary or secondary outcome measure, although subjects in each cell experienced significant improvement. Of subjects with at least 1 postrandomization visit, 35.7% of bupropion and 47.1% of placebo recipients experienced "much" or "very much" improvement on the Clinical Global Impression Improvement Scale. The trial was complicated by a high noncompletion rate (43.6%). Bupropion was well tolerated. Bupropion and placebo recipients did equally well in a short-term trial, with improvement seen as early as the first week of treatment. The high placebo response rate and the high noncompletion rate each reflect the challenge inherent in treating persons with PG.