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David Hodgins University of Calgary AGRI, 2011

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Effectiveness Trials/Mechanisms/Systems Randomized Controlled Trials (RCTs) - efficacy Uncontrolled Trials Descriptive Accounts/case studies

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Does this work in the real world? Real clients, group vs. individual, therapists competence? How does it work? Can we make it more efficient or more effective? What place does it have in the overall range of treatment options?

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Effectiveness Trials/Mechanisms/Systems Randomized Controlled Trials (RCTs) - efficacy Uncontrolled Trials Descriptive Accounts/case studies

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Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment Various medications

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Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment Various medications

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Family models Psychodynamic models Gamblers Anonymous Cognitive Behavioural Cognitive-behavioural models Motivational Interviewing Multimodal Treatment Various medications

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Pallesen et al. (2005) 22 uncontrolled and controlled studies, 1434 clients Large effect of treatment post-treatment and at follow-up (17 months), compared with no treatment

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Response for drug Response for placebo Naltrexone [2 studies]62%34% Nalmefene [2 studies]52%46% Fluvoxamine [2 studies]72%48% Paroxetine [2 studies]63%40% Sertraline [1 study]68%66% Bupropion [1 study]36%47% Olanzapine [2 studies]67%71% Medication RCTs Hodgins, Stea & Grant, The Lancet, in press

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Gooding & Tarrier (2009) 25 CBT trials - very diverse Mode: Individuals, group, self-directed Therapy: CBT, Imaginal desensitization, CBT-MI combos Type of gambling: Length: 4 to 112 sessions (Median = 14.5) Large effects at 3, 6, 12, and 24 months Better quality studies, smaller effects File drawer effect 585 studies required.

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Two examples. Coping Skills Treatment Trial Self-directed Treatment (Motivational Interviewing & workbook)

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Nancy Petrys 8 session CBT (Petry, 2005) Each session has a worksheet Overall goal is to improve coping skills Petry et al. (2007) coping skills improvement does lead to better outcomes (i. e., effective ingredient)

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Session 4Session 8 Social Support 26%67% GA/therapy support 4%43% Cognitive skills 21%31% Distraction45%26% Avoid triggers 40%20%

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Specific day of the week 33% Mood- stressed, bored, lonely 30% Unstructured time27% Access to money22% Gambling cue19% A specific time of the day 17%

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Action% of people New activities/Change in focus68% Stimulus Control/Avoidance48% Treatment/GA support37% Cognitive skills34% Budgeting31% Willpower/Decision-making/self-control23% Social support10% Others confession, no money, non- gambling external factors, self-reward, spiritual, addressing other addictions

MI (4 sessions) Group CBT (8 sessions) Waitlist MI, GCBT > waitlist Attendance Mi: M = 2.9 of 4 sessions (72%) GCBT: 5.6 of 8 sessions (70%) Mi: 43% attended all 4 GCBT: 29% attended all 8 More to learn we need to do better with drop-out

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Dowling at al. (2007) women in CBT Oei & Raylu (2010) both genders in CBT- MI combo Treatment manual Slight advantages for 1:1 Implications?

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Alcohol field appropriate goal for less severe dependence, more socially stable clients; people choose appropriately over time recovered individuals in community surveys are typically doing some gambling (Slutske et al., 2010) Some treatment studies offer this (e.g. Hodgins)

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Dowling at al., (2009) 12 session CBT Abstinent goalCut down goal Post treatment no diagnosis 84%83% Six month no diagnosis 89%83% Depression (BDI) 8.97.1 Gambling frequency 0.30.5

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Toneatto & Dragonetti (2008) CBT (8 sessions) Abstinence goal 35% Twelve-step facilitation (8 sessions) Abstinence goal 96% No difference in treatments Clients choosing abstinence had more severe problems, attended more treatment, and were more likely to meet their personal goals at 12 mos.

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Ladouceur at al. (2009) CBT (12 sessions) aimed at control No diagnosis post treatment -63%, six months- 56%, 12 months -51% 66% shifted goal to abstinence, more likely to meet their goal Offering choice did not seem to reduce dropout. (31%)

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People do move towards the appropriate goal does offering goal choice increase treatment seeking? Moving in the right direction in terms of offering better treatments, that people stick with. Both RCTs and effective studies are useful Treatment system issues largely unaddressed - < 10% treatment uptake how do we get people to participate in self- directed recovery or attend treatment?

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General population knows about gambling problems Perceived addictiveness Perceived prevalence

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Wild, Hodgins, Patten, Coleman, el-Guebaly, Schopflocher, 2010

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Reasons for seeking treatment studies Consistent findings Trying it on your own is the first step (98%) Worries about future consequences is a major motivator (Suurvali et al., 2010) Messages: Early signs of problems Basic change strategies Nipping it in the bud

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Evidence that campaigns increase treatment-seeking Productivity Commission Report, 2010 review Web-site and helpline spikes

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Moving in the right direction in terms of offering better treatments, that people stick with. Both RCTs and effective studies are useful Treatment system issues largely unaddressed but research suggests some strategies to get people to participate in self-directed recovery or attend treatment