Interventions for comorbid problem gambling and psychiatric disorders: Advancing a developing field of research
Introduction
The evidence base for problem gambling interventions supports the use of cognitive and/or behavioral therapies (CBT), motivational interviewing (MI), and opioid antagonists (Cowlishaw et al., 2012, Thomas et al., 2011). The treatment of problem gambling is, however, complicated by substantial comorbidity with other psychiatric disorders (Dowling et al., 2015a, Dowling et al., 2015, Lorains et al., 2011). Moreover, there is growing empirical support for the presence of subtypes of problem gamblers that may respond preferentially to certain treatments (Milosevic and Ledgerwood, 2010, Rodda et al., 2015, Suomi et al., 2014), as proposed by recent theoretical typologies of problem gambling, such as the pathways model proposed by Blaszczynski and Nower (2002) and the clinical typology proposed by Dannon, Lowengrub, Gonopolski, Musin, & Kotler (2006). Psychiatric comorbidity in problem gambling is associated with more complex clinical presentations (Pietrzak and Petry, 2005, Stinchfield et al., 2005) and may introduce a source of variance that interacts with delivered interventions (Toneatto & Millar, 2004).
The problem gambling treatment outcome literature has, however, generally ignored psychiatric comorbidities, excluded individuals with comorbidities, or employed small samples that preclude the detection of comorbidity subgroup differences in treatment responses. At present, most evidence regarding the identification of particular treatment strategies best suited to particular comorbid psychiatric disorders of problem gamblers is derived from post hoc analyses of treatment delivered to heterogeneous groups of problem gamblers. The existence of problem gambling sub-populations based on psychiatric comorbidity may, however, also have implications for individually tailored intervention approaches (Winters & Kushner, 2003) that could maximize treatment response, enhance client satisfaction, reduce attrition, and lower treatment costs (Grant, Williams, & Kim, 2006).
In this mini-review, we aim to highlight the gaps in the literature that preclude the identification of treatment recommendations for sub-populations of problem gamblers with comorbid psychiatric disorders. We identify: 1) studies examining the influence of comorbid psychiatric disorders and problem gambling subtypes on gambling treatment outcomes, and 2) randomized trials evaluating the efficacy of intervention approaches for problem gamblers with specific psychiatric comorbidities. We conclude with a discussion of the gaps in the current evidence base and suggestions for further research to advance this developing field of research.
Section snippets
Method
This review drew upon two separate systematic literature searches. The first search was designed to explore the influence of client characteristics on gambling treatment outcomes; but it did not emphasise the types of treatment that produced these outcomes (Merkouris, Thomas, Browning, & Dowling, submitted for publication). The second search was designed to explore the efficacy of pharmacological interventions for problem gambling; but it did not emphasise the efficacy of psychological or
Alcohol and substance use disorders
Treatment-seeking problem gamblers display high rates of alcohol use (21.2%) and substance (non-alcohol) use (7.0%) disorders, specifically alcohol abuse (18.2%), alcohol dependence (15.2%), substance abuse (6.6%), substance dependence (4.2%), and cannabis use disorder (11.5%) (Dowling et al., 2015b). Problem gamblers with comorbid substance use, even cigarette smoking, generally have higher gambling severity, problem gambling durations, gambling frequency and expenditures, craving, psychiatric
Discussion
Despite our understanding of the significant heterogeneity in problem gambling, this mini-review indicates that we have very little evidence on which to base treatment recommendations for different subpopulations of problem gamblers based on their psychiatric comorbidity. This study identified only 21 studies that have conducted post-hoc analyses to explore the influence of psychiatric disorders or problem gambling subtypes on well-specified problem gambling treatments. Interestingly, most
Role of funding sources
There was no direct funding for this manuscript. The Problem Gambling Research and Treatment Centre at the University of Melbourne, with which several co-authors were affiliated when the data was collected, was previously supported by the Victorian Responsible Gambling Foundation. The Victorian Responsible Gambling Foundation had no involvement in the current publication.
Contributors
Author A developed the review protocol, extracted the data, and wrote the first draft of the manuscript. Author B conducted the systematic searches, created the PRISMA diagrams, and provided secondary data extraction. Author C contributed to the conceptual rationale for the article and assisted in drafting the initial manuscript and revisions. All authors have contributed to and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
References (85)
- et al.
Cognitive-behavioural treatment of pathological gambling in individuals with chronic schizophrenia: A pilot study
Behaviour Research and Therapy
(2011) - et al.
N-acetyl cysteine, a glutamate-modulating agent, in the treatment of pathological gambling: A pilot study
Biological Psychiatry
(2007) Patterns of substance abuse among treatment-seeking pathological gamblers
Journal of Substance Abuse Treatment
(2003)- et al.
Is control a viable goal in the treatment of pathological gambling?
Behaviour Research and Therapy
(2009) - et al.
The subtyping of pathological gambling: A comprehensive review
Clinical Psychology Review
(2010) - et al.
Problem gambling subtypes based on psychiatric distress, alcohol abuse and impulsivity
Addictive Behaviors
(2014) - et al.
Personality disorders and pathological gambling: A review and re-examination of prevalence rates
Journal of Personality Disorders
(2008) - et al.
Bupropion in the treatment of pathological gambling: A randomized, double-blind, placebo-controlled, flexible-dose study
Journal of Clinical Psychopharmacology
(2007) - et al.
Antisocial personality disorder and pathological gambling
Journal of Gambling Studies
(1994) - et al.
A pathways model of problem and pathological gambling
Addiction
(2002)
Personality disorders among pathological gamblers
Journal of Gambling Studies
A comparison of relapsed and non-relapsed abstinent pathological gamblers following behavioural treatment
British Journal of Addiction
Control versus abstinence in the treatment of pathological gambling: A two to nine year follow-up
British Journal of Addiction
Impulsivity in pathological gambling: The antisocial impulsivist
Addiction
Cognitive changes in pathological gamblers following a 28-day inpatient program
Psychology of Addictive Behaviors
Young adult gambling behaviors and their relationship with the persistence of ADHD
Journal of Gambling Studies
An empirical study of personality disorders among treatment seeking problem gamblers
Journal of Gambling Studies
Internet-based treatment of pathological gambling with a three-year follow-up
Cognitive Behaviour Therapy
Disordered (pathologic or problem) gambling and Axis I psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions
American Journal of Epidemiology
Gambling participation and problem gambling severity in a stratified random survey: Findings from the second social and economic impact study of gambling in Tasmania
Journal of Gambling Studies
Psychological therapies for pathological and problem gambling
Cochrane Database of Systematic Reviews
Naltrexone in the treatment of pathological gambling and alcohol dependence
The Canadian Journal of Psychiatry
Pathological gambling: A review of phenomenological models and treatment modalities for an underrecognized psychiatric disorder
Journal of Clinical Psychiatry
The impact of comorbidity on the management of pathological gambling
CNS Spectrums
Client characteristics associated with treatment attrition and outcome in female pathological gambling
Addiction Research and Theory
Prevalence of psychiatric co-morbidity in treatment-seeking problem gamblers: A systematic review and meta-analysis
Australian and New Zealand Journal of Psychiatry
Prevalence of psychiatric co-morbidity in treatment-seeking problem gamblers: A systematic review and meta-analysis
Journal of Personality Disorders
National estimates of Australian gambling prevalence: Findings from a dual-frame omnibus survey
Addiction
Youth risk and protective factors for problem gambling: A systematic review and meta-analysis of longitudinal studies
Pharmacological therapies for pathological and problem gambling
Cochrane Database of Systematic Reviews
Problem gamblers, problem substance users, and dual-problem individuals: An epidemiological study
American Journal of Public Health
Attention deficit hyperactivity disorder among pathological and at-risk gamblers seeking treatment: A hidden disorder
European Addiction Research
Comorbidity of impulse control disorders in pathological gamblers
Acta Psychiatrica Scandinavica
Escitalopram treatment of pathological gambling with co-occurring anxiety: An open-label pilot study with double-blind discontinuation
International Clinical Psychopharmacology
Memantine shows promise in reducing gambling severity and cognitive inflexibility in pathological gambling: A pilot study
Psychopharmacology
A 6-month follow-up of imaginal desensitization plus motivational interviewing in the treatment of pathological gambling
Annals of Clinical Psychiatry
Predicting response to opiate antagonists and placebo in the treatment of pathological gambling
Psychopharmacology
Paroxetine treatment of pathological gambling: A multi-centre randomized controlled trial
International Clinical Psychopharmacology
A randomized, placebo-controlled trial of n-acetylcysteine plus imaginal desensitization for nicotine-dependent pathological gamblers
The Journal of Clinical Psychiatry
Update on pathological gambling
Current Psychiatry Reports
Predictors of treatment outcome among Asian pathological gamblers: Clinical, behavioural, demographic, and treatment process factors
Journal of Gambling Studies
Does sustained-release lithium reduce impulsive gambling and affective instability versus placebo in pathological gamblers with bipolar spectrum disorders?
American Journal of Psychiatry
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2020, Internet InterventionsCitation Excerpt :Mental health distress is common among people with disordered gambling, as are the experience of other addictive behaviours (Bischof et al., 2013; Desai and Potenza, 2008; Kessler et al., 2008; Lorains et al., 2011; Martin et al., 2014; Petry et al., 2005). While there is an emerging literature on whether there are benefits associated with providing assistance for other mental health concerns and/or other addictions alongside care for gambling concerns (Dowling et al., 2016; Geisner et al., 2014; Hodgins and el-Guebaly, 2010; Stea and Hodgins, 2011; Toneatto and Ladouceur, 2003; Wynn et al., 2014), this area is still in its infancy (Yakovenko and Hodgins, 2018). In the domain of assisted self-change for gambling (i.e., self-help books, internet interventions), there is little or no published literature to-date on interventions specific to concurrent disorders (Cunningham, Godinho, et al., 2019).