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Gambling Harm Minimisation

ABACUS Feedback to the Ministry of Health
regarding
Emerging Trends in National & International Literature.

This summary of research has relevance to the clinical workforce,
it forms part of a regulary six monthly report provided by ABACUS to the Ministry.

Feedback to MOH re Emerging Trends in National & International Literature

Period covered: 1st July 2016 to 31st December 2016

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Literature Findings Comment
Gambling and violence in a nationally representative sample of UK men (2016) Authors: A Roberts, J Coid, R King, R Murphy, J Turner, H Bowden-Jones, K Palmer Du Preez, J Landon Addiction (2016) 111, 2196-2207. doi: 10.1111/add.13522
  • Although this is a UK study, it supports NZ findings and includes NZ researchers in the project (AUT: Dr Landon and K Palmer) and participants
  • It is important as much of the previous research has been with specialised populations (e.g. help-seekers) which may constitute a very small proportion of PGs who may not also be representative of PGs with violence issues; this study population was of the general population which noted that non-problem gamblers also had elevated risk for violence
  • Previous research may have attributed AOD or MH issues in those affected by PG to increased risk for violence, whereas this research was able to identify that the risk remained high even when AOD was statistically adjusted for
  • The high correlation between AOD and PG also is a concern in that the comorbidity may further raise the risk for violence, as well as IPV and violence against children in the family. The authors hypothesised that the risk may be due to the stress and antagonism of gambling, and that violence in turn may result in increased gambling as an increasing cycle
  • There was a call from the researchers to screen for violence amongst those accessing PG treatment services, as well as other services (AOD and MH) where gambling may coexist, with its enhanced risk for violence
  • The availability of the NZ CHAT screen that screens for those who are victims of abuse, as well as anger issues (as a possible surrogate screen for perpetration of violence) provides an opportunity to incorporate the findings of this research into NZ addiction and MH services through use of a validated comprehensive tool.
Literature Findings Comment
Naltrexone: a pan-addiction treatment? (2016) Authors: E Aboujaoude, W Salame CNS Drugs, August 2016, 30(8), 719-733
  • Naltrexone is an approved treatment in Australia (Australian National Health and medical Council) for problem gambling to reduce cravings and minimise the pleasure received through gambling.
  • Most problem gamblers (PG) present with coexisting problems including other addictive behaviours (including tobacco) with limited knowledge of the impact that these may have upon gambling recovery if untreated
  • The findings of this research suggest the opioids produced within the body may have a broad influence on continuing addictions and resistance to change, and this may apply to both substance and behavioural addictions.
  • The use of a drug such as naltrexone that has evidenced impact upon these barriers to change, which may acts across a range of behaviours that coexist with gambling problems, may be an important under-developed tool in succesful interventions for problem gambling
  • Naltrexone appears to have low health risk factors, has no abuse risk, and has been approved in Australia specifically for problem gambling
  • There is however, limited research in problem gambling intervention using naltrexone with and without psychotherapy, but with available evidence, a piloting of using naltrexone could be an important step, either in PG treatment services, or amongst AOD services where PG is identified as a coexisting issue.
  • As naltrexone is currently prescribed for some AOD clients, the identification of clients also affected by PG and who may normally be prescribed naltrexone for their AOD issues, may provide an opportunity to identify the drug’s impact upon the gambling over time alongside the AOD use.
  • Naltrexone has been available since 1963 and may provide a relatively inexpensive addition to psychotherapy in the treatment of PG.
Literature Findings Comment
Twelve-month prevalence of DSM-5 Gambling Disorder and associated gambling behaviours among those receiving methadone maintenance (2016) Authors: S Himelhoch, H Miles-McLean et al J Gambling Studies 2016, March 32(1), 1-10
  • Although this may have a limited impact of therapy provision in NZ (even despite a very high coexistence of PG and methadone use), the finding appears to be related to and may add some support to the last review (naltrexone, above).
  • Methadone does enhance endogenous opioids whereas the authors above suggest that enhanced opioid effects may be an underlying cross addiction factor.
  • The very high (almost 50%) cross addiction between methadone use and PG is similar to that of tobacco use and PG, and Aboujaoude & Salame (2016) noted, (similar to the effects of methadone), that ‘nicotine increases endogenous opioid neurotransmission by binding to nicotinic acetylcholine receptors on presynaptic neuron terminals containing opioid peptides’
  • This finding appears therefore to support an opioid effect and similarities in the addiction process across substance and behavioural addictions.
Literature Findings Comment
Intergenerational childhood maltreatment in persons with DSM-IV Pathological Gambling and their first-degree relatives (2016) S Shultz, M Shaw, B McCormick et al J Gambling Studies, Sept 2016, 32(3), 877-87
  • The high levels of maltreatment associated with PG is again reinforced by this study with findings that this was commonplace and more likely than not in the PG study participants
  • The research would appear to support that for many, the maltreatment preceded the PG and increased the risk for later gambling problems
  • That first degree relatives were also affected by abuse with resulting later risk of anxiety, mood and suicidal ideation, all supports the impact upon adults from their early life experiences
  • This highlights the need to identify and incorporate strategies to address these issues in both PGs and their families
Literature Findings Comment
A randomized controlled trial of brief interventions for problem gambling in substance abuse treatment patients (2016) Authors:N Petry, C Rash, S Alessi J of Consulting & Clinical Psychology, Jun 2016, 10.1037/ccp0000127 • This research provides additional important evidence for even brief interventions in coexisting (to PG) treatment settings • The study may have further benefited from a control group to test for the impact of AOD treatment on PG, and to test if a ‘transfer of addiction effect’ occurred from alcohol and other drug (AOD) to PG • There appeared to be a valuable benefit in the long term effects of PG as well as improved AOD results from the five MET/CBT PG sessions; however, in a busy AOD treatment service, an additional five sessions may be difficult to accommodate and the lesser but beneficial 10-15 min intervention with advice, risk and avoidance topics was significant and valuable • An alternative that may gain the benefits of the third longer brief intervention may be the advice plus an integration of PG into the AOD intervention in the model proposed by Te Ariari (2010) in NZ • Overall, these finding were positive and support the integration of PG interventions into other addiction (or possibly even mental health) services

Feedback to MOH re Emerging Trends in National & International Literature

Period covered: 1st January 2016 to 31st June 2016

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Literature Findings Comment
Mood and anxiety Disorders are the most prevalent psychiatric disorders among pathological and recovered gamblers (June 2016) Authors: Tony Toneatto & Sabina Pillai Mental Health Addiction (2016) 14.217. doi: 10.1007/s11469-016-9647-5
  • Although co-existing mental health problems are known to be high amongst problem gamblers, little was known around whether these persisted post-treatment for PGs, and whether those in recovery may naturally recover from these co-existing disorders once gambling had been successfully addressed
  • Participants were obtained from the general populations (through advertisement) rather than treatment populations and may be more generalisable in findings taking into account that probably less than 10% of PGs seek treatment.
  • High levels of depression and anxiety initially suggest that these are issues to be addressed in PG treatment, and the findings that these do not abate following resolution of the PG would suggest that addressing these coexisting issues within PG treatment may be important.
  • Also, it appeared that AOD issues increase as possibly a ‘transfer’ of addiction, and that escape from problems may be a focus rather than the learning of other coping skills.
  • The very broad range of co-existing problems, which include high levels of sexual abuse, suggest the need for rhe formulation of treatment plans that take into account a wide range of issues, as well as the need to address risk for alcohol and other drug substitution following PG treatment
  • This research is a timely reminder of the need to screen for and address these co-existing problems, and that the stressors caused by PG may not be the primary factors for the presence of these issues.
  • In addition, it is clear that following recovery (or there being a lower level of gambling harm) there still exists high levels of mental health issues and that even those with moderate levels of PG may have much higher than population prevalence levels of mental health disorders.
  • This research raises the importance of screening those with moderate gambling problems as well as those meeting Gambling Disorder criteria. It may also explain much of the rationale behind high rates of relapse with problem gamblers. Also, the increased AOD problems with recovering gamblers indicate the possibility of ‘switching’ addictions and the need to address these issues within treatment formulation.
Literature Findings Comment
Factors associated with suicidal risk among a French cohort of problem gamblers seeking treatment (2016) Authors: M Guillou-Landreat, A Guilleux et al Psychiatry Research, 240 (2016), 11-18
  • The importance of this paper is the high levels of suicidal behaviour that occurs with PG treatment populations, even higher than previously considered.
  • The importance of identifying both depression and anxiety issues in presenting clients, as well as matching these with those believing they have low control over their gambling is an important new understanding.
  • In NZ assessment tools, control over gambling is identified, as is depression. However, use of a broad depression questions or questions such as those used in the CHAT (two questions) may provide an important tool for identifying high risk for suicidal behaviour.
Literature Findings Comment
Single-session interventions for problem gambling may be as effective as longer treatments: results of a randomized control trial Author: T Toneatto Addictive behaviors (2016) 58-65
  • This possibility of an effective brief intervention approach for PG may have considerable interest when costs of effective treatment remain an important factor, as well as treatment drop-out and relapse remaining high in this client population.
  • However, the author notes that the outcomes were not exceptional and classed them as ‘a C-grade’ and that the design of the research (not to vary from the assigned therapy may have at time ‘precluded the most effective clinical response’). He further notes that ‘in community based treatment, interventions would be more flexible and responsive to the client’s clinical needs’. In clinical studies where treatment presenting clients are invited to participate in research, a ‘treatment as usual’ group can often address this factor.
  • The presence of a number of additional contacts does describe this minimal intervention group as more than a single session approach. For example the clients were screened by telephone as to whether they were elgible, then assessed in a separate base-line assessment session before being allocated to a treatment condition. Following this they were contacted by telephone at 30 days ‘post-treatment assessment’ and then at 12 months. In addition the minimal group received a ‘manual’ of the other intervention approaches which the other interventions did not, and the single session at 90 minutes was presumably longer than each of the six sessions in the other interventions. Each of these factors can be described as aspects of ‘treatment’ (including assessments) and the single session could not be described as the only treatment received
  • Nevertheless, even with two sessions (one assessment orientated and the other a longer treatment session at 90 mins), and the takeaway manual, this is a very brief intervention. The content of the session is interesting, as being described as didactic, it does not appear to ascribe to usual therapeutic approaches, such as motivational interviewing (MI). Other research (Hodgins) has supported an MI single session intervention for PG, while workbooks are often comprehensive and use CBT and MI as well are information, and have known effectiveness.
  • Whether a ‘single’ session approach using a workbook plus either CBT, MI or other approach is more effective than this current research is yet to be determined. This does however, again raise the importance of meeting the PG’s desires regarding brevity (in some cases), what should be included in a first session which may be the only session (through client disengaging), and whether a manual should accompany all treatment.
Literature Findings Comment
Child maltreatment and problem gambling: a systemic review Authors W Lan, P Sacco, K Downton et al Child Abuse & Neglect 58 (2016) 24-38
  • Although the findings are not definitive, this paper provides further information around the risk for harm to children that can arise directly or indirectly from PG.
  • There is moderate evidence for the association for both the child developing problems through gambling (e.g. as a dysfunctional way to address harm received as a child (escape), and/or from modelling parents’ gambling) and for current harm through neglect as has arisen in previous research. This does indicate the need for more research due to the relative paucity of evidence for this important impact, especially as NZ law (Vulnerable Childrens Act 2014) requires identification of risk and policies to minimise harm where children may be at risk.
  • Provision of evidence for PG practitioners to screen or make enquiries about current harm may influence this being effected, despite the reluctance of practitioners to ask questions that may be detrimental to their engagement with their clients.
  • Of interest is the advent of imaging of the brain which is beginning to provide biological evidence for interventions and possibility of medical interventions. For example, they refer to the impact of the opioid system with the benefit of partial agonists and antagonists (e.g. Naltrexone) in the treatment of PG. Also, coexisting anxiety disorders were evident in over 70% of PGs with a personality disorder, suggesting there may be other issues that impact on PGs with personality disorders.

Feedback to MOH re Emerging Trends in National & International Literature

Period covered: 1st July 2015 to 31st December 2015

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Literature Findings Comment
Conceptual framework of harmful gambling: an international collaboration revised edition (September 2015) Authors: M Abbott, P Binde, L Clarke, D Hodgins, D Korn et al Gambling Research Exchange Ontario (GREO), Guelph, Ontario, Canada
  • Problem gambling has broad and varied definitions which can lead to complications in a range of important aspects: these include education, initiation and comparison in research, a guide for policy development, and identifying targets for treatment and effective approaches
  • The examination of the complexity of PG is an essential step in effective comprehensive treatment outcomes and from the focus of harm to the individual, whanau and community, this aligns well with NZ legislation (Gambling Act 2003)
  • From the perspective of treatment of PGs, stakeholders in the report considered that the framework could be useful in triaging client activities either prior to or during treatment, including liaising with other social determinants of their health, and perhaps especially coexisting mental health issues. The stakeholders’ consulter for the report “felt that harmful gambling is currently being addressed almost exclusively within the healthcare system, without much consideration of related social determinants”
  • Although there is evidence for this, in NZ, the focus upon a coexisting (CEP) approach to treatment of PGs which includes related social determinants, the need to expand CEP from its initial ‘coexisting mental health problems’ to ‘coexisting mental health and other problems’ is important. In Te Ariari, the definition of CEP does focus upon mental health problems that coexist with the addiction, however in the treatment of PG there is the innovative inclusion of Facilitation as a strategy/ intervention that has the ability to address these related social determinants
  • This framework publication provides important baseline information that can provide a guide to treatment in addition to research and policy development
Literature Findings Comment
Single-session interventions for problem gambling may be as effective as longer treatments: results of a randomised control trial Author: T Toneatto Addictive behaviors 52 (2016), 58-65
  • There are important findings from this research that can impact upon treatment approaches for PG in NZ.
  • This may be that very brief interventions can be offered and choice made by clients as to the number of sessions that they prefer. This may result in a systematic approach to provide what the client at the stage of presentation feels they need rather than what the therapist perceives as needed. In addition, the fact that clients appear to prefer ‘controlling’ their gambling rather than abstinence even when they have severe symptoms and coexisiting issues, is counter-intuitive, but may be important in preventing disengagement from treatment
  • PGs have the added ‘incentive’ to win their way out of financial problems, unlike other addictions; they are often easily bored, may have less support and have higher engagement in the gambling lifestyle than a focus upon abstinence
  • A stepped approach may therefore be an option, with more ‘convenient’ options such as phone calls, emails, self-help books, or even after-hours groups when work obligations can be maintained
  • Evidence does indicate that PGs more than many other addiction clients may be less likely to seek help or engage in extended therapy. The need to tailor options to suit client desires and needs may be a finding that explains approval of minimal interventions despite the costs of gambling behaviour for severely affected PGs.
  • The findings of this research that even very brief interventions can be as effective as more extended therapy is an important finding that may also be important for the buy-in of PG therapists who may otherwise only offer extended therapies, or may approach initial session/s on the assumption that clients will continue to attend, rather than design initial sessions according to the clients’ wishes, with options to extend the therapy as the client desires. This may be a more effective approach than focusing upon engagement or motivation in the initial session or sessions, or combining these with psycho-education, perhaps subject to clients’ readiness to change level
  • It is noted that research currently underway in NZ may provide further support in the future for brief intervention effectiveness.
Literature Findings Comment

Is all Internet gambling equally problematic? Considering the relationship between mode of access and gambling problems (2016) Authors: S Gainsbury, Y Liu, A Russell, T Teichert Computers in Human Behavior, 55, 717-728

Link

  • With the growth of cell phone use, their power, screen size and app efficiency, many of the advantages of PC/computers over supplementary devices will have reduced. Younger people may no longer be more proficient that older people in use of phones accessing the internet and gambling. In addition, phones are often used for business applications and even as mainstream work devices
  • Previous advantages in 2011 of ‘ease of use, better security, larger screen, and better internet connection’ will have changed with now fewer PC advantages, while greater prevalence of use (as a main work tool as well as entertainment) by PCs over phones and tablets will have waned
  • This may suggest that the number of problem gamblers using the internet has now increased in prevalence, whereas research has fallen behind in this rapidly moving problem gambling factor. Nevertheless, the evidence from this study does have continuing relevance and suggests that these gamblers should be comprising a much higher proportion of those seeking treatment, and as this is not the case, what strategies are required to provide resources to meet this under-presenting population?
  • One finding described the complexity of PG; in this study, when age was combined with marital and occupational status, they found those over 50 were three times more likely to gamble online using supplementary devices if separated or divorced than if married. Also, those over 50 who worked, were less likely to use supplementary devices to gamble with. This may be explained with having more free time and able to be away from home, thereby having more time to use these supplementary devices.
  • Another expected finding was that younger people were more likely to use supplementary devices to gamble with than older people, and may be more comfortable and proficient with them
  • Supplementary device gambling was correlated in greater problems (possibly from greater desire to access them by existing PGs, or alternatively, these devices increase the risk of PG) with 80% of users reporting some negative gambling issues and had the highest severity scores when compared with PC/computer or land-based gamblers. These supplementary gamblers also behave differently by gambling on a wider range of activities, which the authors conclude suggests their higher level of PG could be due to the amount of time (increased) that they spend on the Internet gambling.
  • Although the authors state that the Internet is not of itself more likely to cause more severe PG, it would appear that devices that offer more Internet gambling use can cause problems and that supplementary devices can do just this. With the increased use of such devices rather than PCs over time, and the reduced difference between PCs and supplementary devices, the statement becomes less significant, and Internet gambling more problematic.
Literature Findings Comment
Gambling content in Facebook games: a common phenomenon (2016) Authors: Jacques C, Fortin-Guichard D, Bergeron P, Boudreault C, Levesque D & Giroux I Computers in Human Behavior, 57, 48-53
  • Facebook games are very popular and as many gambling games exist on the Internet, exposure of many millions of players who may not participate in gambling online to gambling content may increase gambling participation in a covert process
  • Familiarisation is a possible process that may introduce and normalise gambling to many Facebook users who would not otherwise contemplate gambling on the internet or even land-based gambling
  • This research does not connect those players who are exposed to gambling content with gambling sites and therefore cannot determine causation or even that these players use gambling sites more for other possible reasons
  • However, although there weren’t more gambling content Facebook games owned by gambling companies than non-gambling companies, the existance of gambling content was evident in over half of the 100 most popular Facebook sites, which does suggest the importance of future research into this field
  • In addition, that of the 100 most popular game sites n=13 were gambling themed and over half the remainder contained gambling content, suggests that many Facebook players are being exposed to a level of gambling unlikely in any other mainstream interactive behaviour
  • Passive behaviours such as sports events that offer direct gambling may also have increased audiences, however practising the behaviour as well as receiving inaccurate feedback as to chances of winning when money was at stake (i.e. gambling), may encourage new gamblers to incorrectly assess their level of skill and/or their chanes of winning when games move from entertainment alone to risking money on perceived skill • This new field of gambling is very under-explored, with the assumption that reacting to a need is sufficient harm minimisation strategy required. However, this assumes that problem development will emerge over time as with land-based gambling and be identifed and addressed effectively in a timely manner.
  • When such low percentages of problem gamblers seek help, with additional covert issues for online gambling problems exist, and the reduced ability to control access once the problem may have gained a foothold, this argues for a proactive solution that appears to be almost overdue
  • The authors raise interesting further research that will assist in the identification of problems, but also that Facebook games already contain a substantial number of both gambling themed and gambling content games amongst the most popular games available to a substantial proportion of the population, irrespective of their age.
Literature Findings Comment
Neural and psychological underpinnings of gambling disorder: a review (2016) Authors: Grant J, Odlaug B, Chamberlain S Progress in Neuro-Psychopharmacology & Biological Psychiatry 65, 188-193
  • This paper is a useful summary of the current understandings of the brain and its processes together with psychological disorders and traits, in respect of problem gambling
  • Many treatment providers will recognise the behaviours described and that there is a strong relationship between neural pathways and psychological problems with those affected by their gambling
  • It is important to understand however, that many other issues and domains also impact upon gambling and although these are alluded to, it may well be that social or environmental drivers have much of the influence in the development, maintenance and relapsing risk for gambling. Also, that many of the recent findings at a genetic level may change, or be established through such environmental impact.
  • The authors do refer to hereditary risk, and this raises the need to understand what protective factors exist for the understandably less than 50% of those with GD risk who do not develop this problem.
  • The coexisting impact of different neurotransmitter systems also describes the complexity of GD and whether many of the coexisting issues are caused by the gambling or whether they pre-exist, and longitudinal studies will assist us to understand them better in the future.
  • The presence of more than one personality disorder (albeit a developing and imprecise field), anxiety and other coexisting issues, further raises the complexity of GD, but also may emphasise that the current approach to address GD in a holistic approach is the appropriate strategy for good treatment outcomes.

Feedback to MOH re Emerging Trends in National & International Literature

Period covered: 1st January 2015 to 30 June 2015

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Literature Findings Comment
A naturalistic study of recovering gamblers: what gets better and when they get better Authors: D. Rossini-Dib, D Fuentes, H Tavares (2015) Psychiatry Research Vol 227, 17-26
  • Problem gamblers fell within the moderate to severe range despite having to meet all the criteria of DSM-IV-TR. Some 60% of the samples were smokers of tobacco, a similar finding to other studies of presenting problem gamblers. More than half of the gamblers met criteria for ADHD compared with the usual finding of one in four or five. There were the expected high rates of depression (43%), anxiety (35%), alcohol disorder (22%), and past suicide attempts (25%) and those at current risk (30%) were also high. These findings confirmed the high psychiatric severity of problem gamblers.
  • Focusing upon emotion, fantasising less about winning, and being more rational about chances of winning may result in better decisions and may improve outcomes in therapy. Current therapy may focus upon gambling behaviours, its consequences, and impulsivity control, yet in the view of the authors, may not be the core aspect of problem gambling. The confirmed high co-existing mental health disorders may support this focus.
  • The study confirms the NZ approach to identify all coexisting issues and integrate these into a formulation. With the anxiety and depression levels identified, and addressing emotions and lifting depression as well as ensuring decisions are rational rather than those based upon skewed perceptions may be a more effective approach to treatment.
  • This research suggests that the NZ problem gambling treatment workforce may benefit from use of CBT approaches in its delivery of therapy. This paper does not, however, compare other therapies with CBT, and psycho-education was the only alternative. However, these conclusions were independent of either therapy and are a core approach of CBT (correcting distortions, providing coping skills, relapse prevention).
Literature Findings Comment
Predictors of outcome among pathological gamblers receiving cognitive behavioural therapy Authors: Jimenez-Murcia S, Granero R, Fernandez-Aranda F et al (2015) Eur Addiction Research Vol 21, 169-178
  • As a follow-up to the above findings, these researchers identified that CBT based group therapy was an effective intervention through a focus upon self-control and emotional regulation. These findings similarly address the importance of emotional dysregulation similar to the study above using a group therapy approach.
  • The added finding of the need to include individual needs and manage partner impact suggests a combination of group and individual therapy using a CBT approach may be an effective focus for therapy. In addition, it also highlights the impact of problem gambling on the partner and the importance of inclusion of the partner in addressing their own needs with therapy. Skills that are required in a couples approach when addressing problem gambling are additional skills required of workforce therapists.
Literature Findings Comment
Cognitive behavioural group treatment for Chinese problem gamblers in Hong Kong Authors: D Wong, C Chung, J Wu, J Tang, P Lau (2014) J Gambling Studies, April
  • This study has been included as a further evidence of the effectiveness of CBT in the treatment of problem gambling. This was a relatively brief therapy term (10 weeks) and with a culture that appeared to benefit from the precise, concrete approach of CBT.
  • The inclusion of both CBT therapy groups and individual CBT (see above) may be an approach beneficial to NZ therapists addressing problem gambling issues.
  • Similar findings with CBT approaches in this population were found in other studies (Guo, Manning et al 2014) and the combination of CBT and pharmacological approaches for problem gambling for Chinese problem gamblers (Raylu, Loo & Oei, 2013).
Literature Findings Comment
Co-morbidity between gambling problems and depressive symptoms: a longitudinal perspective of risk and protective factors Authors: Dussault F, Brendgen M, Vitaro F et al (2015) J Gambling Studies, May 21
  • As has been identified in other studies (Rossini-Dib et al 2015, above), depression and gambling problems commonly coexist. This study provides evidence that problem gambling can overwhelm protective factors such as family relationships unless addressed early in life. The authors note that other issues that may arise because of economic disadvantages tend to reduce after adolescence for many, but that gambling problems may continue and affect mood, and be difficult to remove because they are similar to substance-related addictions.
  • Impulsivity or impulse control was a predictor of four different pathways to problem gambling and depression, with poor child-parent relationship more likely to result in depression. Although the age group of the study was at the last data selection, just 28 years, there was no indication of moderation in severity of depression or gambling - an expectation in other adolescent issues, but a likelihood of greater severity for these in the future.
  • Although this may be a cohort of increased risk for problem gambling (economic disadvantage) the finding of 3% at 28 years of age is considerably above the estimation of DSM5 of 0.2%-0.3% ie. 10x the prevalence, and may suggest that the difficulties of population estimates are resulting in considerable under-estimation of problem gambling. This, associated with high levels of depression, which untreated, will increase in severity alongside gambling problems, supports the addressing of both issues in an integrated approach.
Literature Findings Comment
Suicidal events among pathological gamblers: the role of comorbidity of axis 1 and axis II disorders Authors: Bishof A, Meyer C, Bishof G, Ulrich J et al (2015) Psychiatry Research 225, 413-419
  • This is an important study in that it not only confirms the high levels of suicide attempts with pathological gamblers, but also that the majority of problem gamblers will be affected by thoughts of suicide. The ideation and attempt rates were at the higher range of previous findings with half of the participants meeting these risk factors, emphasising the importance for screening and checking for suicide risk throughout therapy. With the higher severity previously found with problem gamblers presenting for treatment, and the current finding that presentation for problem gambling therapy is itself a risk factor, the prevalence with clients in treatment may well be higher than this finding (participants were not only treatment clients).
  • Personality disorders (PDs) have been found to coexist with many problem gamblers, and particularly those meeting cluster B PDs. These comprise Antisocial PD, Borderline PD, Histrionic PD and Narcissistic PD. The presence of such PDs does result in a client with complex needs and requires insight to identify and modify treatment to take such perspectives into account. That these also raise the risk factor for suicide is an important factor in that clients with PDs can be complex to engage and may disconnect from treatment more readily. Training of the workforce to identify, address and maintain treatment with such clients is important, as therapists may find such clients to be difficult, seemingly unmotivated, or confusing in their responses if not identified. Those who had attempted suicide had higher levels of personality disorders (over half (52.4%) met criteria for PD; 39% cluster B) while those with only ideation had levels of over one-third (35.4% met PD; 18.5% cluster B).
  • The highest risk for suicide is mood disorders, a common finding. This highlights the need to screen for depression as well as other disorders with mood symptoms. Post-traumatic Stress Disorder was identified in over one-third of problem gambling suicide attempters and one in six of those with ideation only. Almost all attempters (92.7%) were affected by mood disorders and 70% of those with suicidal ideation only; even 28% of those gamblers without ideation were affected by mood disorders.
  • The importance of treating the mood disorders in an integrated approach with the gambling problems, formulated in keeping with the personality disorder, is an important factor in both addressing suicide risk, problem gambling issues, and also maintaining engagement with clients who, as this research explains, are more likely to have a higher risk for suicide through the fact of being a presenting client.
  • Training of the problem gambling workforce should include identification and addressing mood disorders, substance use disorders, PDs, and also anxiety issues, and these finding should inform the formulation of a treatment plan.
Literature Findings Comment
Personality traits of problem gamblers with and without alcohol dependence Authors: Lister J, Milosevic A Ledgerwood D (2015) Addictive Behaviours vol 47, 48-54
  • Many problem gambling clients will be also affected by alcohol problems and this study provides a possible insight into why such clients may be less likely to engage in treatment or disconnect from treatment.
  • Motivational Interviewing is a common approach in addiction treatment and this study supports its continued use, especially where the client is dually affected. The emotional control suggested indicates that for these clients, there may be a dysfunctional coping approach in the use of alcohol to raise mood and reduce negative emotions.
  • This study may also contribute to understanding why support groups such as Gamblers Anonymous may be so poorly attended when compared with AA, in that possibly a high proportion of problem gamblers may also be affected by alcohol, and be less attracted to the rules of desiring abstinence such that 12-step groups require.
  • Alternative coping strategies elicited from the client, self-elicited goals and self-awareness about inconsistencies in continued behaviours and attaining these goals may be a more effective approach.

Feedback to MOH re Emerging Trends in National & International Literature

Period covered: 1st July 2014 to 31st December 2014

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Literature Findings Comment
Pathological and problem gambling in substance use treatment: a systematic review and meta-analysis Authors: Cowlishaw S, Mercouris S, Chapman A (2014) Journal of Substance Abuse Treatment Vol 46 (2), 98-105 doi:10.1016-j.jsat.2013.08.019
  • Pathological and problem gambling (PG) and AOD problems in AOD treatment have been found to be strongly linked, with up to 50% of AOD clients also affected by PG (Weinstock, Blanco, Petry, 2006). Similar links have been found in NZ*
  • Competency requirements in NZ recognise that AOD practitioners should have knowledge, skills, and appropriate attitude to address co-existing PG amongst their clients (and similarly PG practitioners with AOD affecting their clients)**
  • However, there is little evidence as to what competence current AOD practitioners possess, and as to whether there is a systematic approach to these clients in screening, brief or minimal interventions, or strategies to avoid transfer of addictions (increase in severity of a secondary addiction)
  • This research supports the need for identification and coexisting treatment of PG as an adjunctive issue. This will accord with Te Ariari (2010) coexisting approach, where addictions and other mental health issues (including other addictions such as PG) coexist.

*Sullivan S, Steenhuisen R (2006) The CADS/ABACUS Problem Gambling Screening Project: gambling problems commonly co-exist in AOD clients. In Adamson SJ & Schroder R (eds). NZ Addiction Treatment Research Monograph. Research Proceedings from the Cutting Edge Conference, September 2006.
Sellman D, Adamson S, Robertson P, Sullivan S & Coverdale J (2002) Gambling in mild-moderate alcohol-dependent outpatients. J Substance Use & Misuse 37(2):199-213

** Parsonage P, Sullivan S, DAPAANZ, Matua Raki (Program) (2011) Addiction intervention competency framework: a competency framework for professionals specialising in problem gambling, alcohol, and other drug and smoking cessation intervention. Wellington, DAPAANZ

Literature Findings Comment
Decision-making deficits in patients diagnosed with disordered gambling using the Cambridge Gambling task: the effects of substance use disorder comorbidity. Authors: Zois E, Kortlang N, Vollstadt-Klein S, Lemenager T, Beutel M Mann K & Fauth-Buhler M (2014) Brain and Behavior, Vol 4 (4), pages 484-494 doi: 10.1002/brb3.231
  • This study has important implications for treatment. Whereas many of the people affected by their gambling may be also nicotine dependent, there has been a tendency to treat this nicotine use as a parallel addiction, with little evidence that it impacted upon the gambling.
  • These findings that nicotine may cause more severe gambling, with poorer decision making, support the requirement to integrate the screening for intervention and treatment planning, as well as training implications for PG practitioners. The ability to be qualified for, and be able to provide a prescription for reduced cost nicotine replacement therapy, to relate the smoking to the gambling in an appropriate manner, and to motivate clients to address coexisting smoking, is an important finding.
  • Addressing smoking in an integrated manner may raise the need to consider modification of the stand alone ABC model for smoking cessation, which may otherwise clash with the harm reduction model used in gambling therapy.
Literature Findings Comment
The ‘light drugs’ of gambling? Non-problematic gambling activities of pathological gamblers Authors: Thege B & Hodgins D (2014) International Gambling Studies, Vol 14 (1) Doi: 10.1080-14459795.2013.839732
  • This paper has interest for the NZ environment. Many practitioners may be uncertain as to whether abstinence from all gambling may be best practice in encouragement, while a harm minimisation approach may not only encompass reduced playing of the problematic gambling mode, but also, whether or not advice can be given around other non-problematic modes
  • Gamblers attending groups or Gamblers Anonymous may be philosophically opposed to other gambling, while those with coexisting alcohol problems may feel conflicted when different advice is given for alcohol (cease use) as opposed to gambling (change use).
  • The difficulty is identifying what specific skills or supports will protect continuing gamblers, especially when transfer of addiction, and similar issues exist (betting upon uncertainties, chances of a large win (Lotto), continued focus upon gambling and others). The advantages may be that gambling in less problematic modes may still result in losses, but may be manageable, and may be an ‘acceptable’ treatment alternative to ceasing all gambling.
  • This paper provides some evidence that this alternative is possible, and is useful information for practitioners to provide to a gambler, should they be uncertain around living with the absence of gambling. Lotto provides enjoyment for the majority of the population and belonging may be an important desire for gamblers in recovery. Also, self awareness raising can be an important goal in managing this strategy of alternative gambling.
  • Of importance, may be the rapid changing complexity of gambling modes and that rather than concrete categorisation, yhere should be monitoring of their gambling and self-awareness. For example, although in this study, lotteries were stated by recovering gamblers as the least problematic, this may change when in NZ Lotto and Instant Kiwi become more easily accessible online, and jackpots increase in size and regularity. Instant Kiwi may, if provided online electronically, resemble more gambling machines than paper scratchies. Similarly, sports and racing have mixed opinions amongst the participants in the study. In NZ there are dedicated TV channels, online credit gambling, and 24 hour live racing/sports events.
  • The importance of this study is that an open mind is considered in working alongside gamblers in their therapy and that this paper suggests that agreeing to trial another mode of gambling is not a dangerous, unprofessional option to discuss with an uncertain client.
Literature Findings Comment
Characteristics and help-seeking behaviours of internet gamblers based on most problematic mode of gambling Authors: Hing N, Gainsbury S, Blaszczynski A (2015) J Medical Internet Research Vol 17(1) Jan doi: 10.2196/jmir.3781
  • This study has some relevance for NZ being similar to Australia, with many gambling access similarities.
  • Although the findings suggest less problems with on-line gamblers, many on-line gamblers may also access land-based gambling, and although these on-line gamblers appeared to be less problematic, factors such as unlimited access, credit betting (cards), lack of monitoring by venues, with a growing range of gambling opportunities, all raise questions around why lower risk was found with on-line gamblers
  • The conclusions raised by the authors that more targeted and innovative efforts be available on-line for both land-based and on-line gamblers are timely, with the previous findings that most problem gamblers would prefer to address their own problems (rather than seek expert help; i.e. self-directed treatment) suggesting the need for stepped online help that can be initially self accessed and delivered.
Literature Findings Comment
Problem gambling Author: Thomas S (2014) Australian Family Physician 43(6) June, 362-4
  • It is notable that although the author notes that GPs have a low level of screening, the supports for screening through professional guidelines appear to be relatively strong and perhaps more evident than in NZ medical professional bodies
  • GPs provide an important source for both early and intensive treatment (through referral) and may be under-utilised as a resource. The CHAT screen developed as a brief broad combined screen that includes two validated gambling questions has been gradually taken up in NZ and elsewhere, and can provide an important solution as to whether to screen for problem gambling (at which point a screening decision has been made, with high risks for false negatives), the possible reason for low GP intervention in Australia.
Literature Findings Comment
Psychological treatments for gambling disorder Authors: Rash C & Petry N (2014) Psychology Research & Behavior Management Vol 7, 285-295
  • This American study has several important applications to NZ problem gambling treatment.
  • Although peer treatment options are usually applied to AA or GA/GamAnon (Gamblers Anonymous/Family of problem gamblers), in NZ, with AOD treatment combinations of peer and practitioners, interventions have successfully been provided in outreach treatments (e.g. Phoenix) and these approaches could be extended to problem gamblers and their families
  • Although CBT is the most likely approach in the USA, in NZ, it is more likely to be Motivational Interviewing, which has benefits not only for at-risk gamblers, but also severe gamblers • An important finding was the option of self-help strategies, with the brief involvement of practitioners. This suggests that providing telephone, text, or on-line practitioner support such as the specialist helpline for problem gamblers and their families, where counselling as well as resource referral could be provided, is useful. This paper, however, does emphasise the benefits are through opportunistic treatment provision, over resource referral.
  • Self referral options appear to be relatively rare in NZ, and the opportunity to develop online self-help options alongside problem gambling advertising to raise awareness of their availability, appears to be supported. Currently, the referral to a helpline appears to be second stage (direct to practitioner, even if brief) opportunity, while a first stage (self screen, information and options, self-applied strategies) may be less utilised. The researchers emphasise the extension to self-help options may increase help-seeking by problem gamblers, which is currently relatively low.

Feedback to MOH re Emerging Trends in National & International Literature

Period covered: 1st January 2014 to 30th June 2014

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Literature Findings Comment

Problem gambling and family violence: family member reports of prevalence, family impacts and family coping Authors: Suomi A, Jackson A, Dowling N, Lavis T, Patford J et al (2013) Asian Journal of Gambling Issues and Public Health, 3:13

Link

  • This is an important study that is currently underway also in NZ, with this paper reporting upon Australian early findings.
  • The paper has also been reported on by WAGER (Feb 2014) as part of its focus upon family effects of problem gambling (Special Series on Addiction within Relationships), indicating an new or increased international focus upon violence and problem gambling
  • Violence was identified on the basis of (within the past year) anyone physically hurting, insulted, talked down to, threatened with harm, screamed or cursed the person; also participants were asked if they either received (were victims of) or caused (perpetrated) this violence. The paper did not differentiate each of these forms of violence; however, the consequences of insult or being talked down to may be as harmful as physical harm, and this has been accepted for some time • Although some families may have had a culture of violence before gambling became a problem, the paper supports the expectation that such violence is more likely to be exacerbated by the gambling
  • Perhaps the most important finding is the increased likelihood of violence, even when taking into account the wide range of findings (gambling problems may increase family violence from 2 to 25 times) and that this Australian finding may have relevance to NZ, with some cultural similarities.
  • From a treatment perspective, there may be an expectation that unidentified family violence may result in a range of negative treatment outcomes, including resistance to change behaviours, relapse risk, as well as less well-being for the gambler or their family. Gambling is described as a hidden disorder, with difficulty confirming that gambling has stopped or reduced from overt symptoms; this may reduce family support when gamblers are receiving counselling, and in the absence of support, may maintain a culture of perpetration or victimisation within the family • Also, relatively few family members seek help for their own issues arising from the problem gambling of a member, and one important harm other than financial stress may be violence; this paper suggests that this may be the majority of gamblers, and family members may be affected by family violence
  • Currently, it is unlikely in NZ problem gambling services that clients (gamblers or their significant others) are screened verbally or otherwise for violence. A possible solution is to use the CHAT screen in a systematic approach for all clients, as three of the 16 screening questions would be appropriate and have been validated for the NZ population. These questions are: “Is there anyone in your life whom you are afraid of or who hurts you in any way?”; “Is there anyone in your life who controls you and prevents you doing what you want?”; and “Is controlling your anger sometimes a problem for you?”
  • The above questions are in addition to the 2 gambling questions and 11 co-existing issue questions that would support a CEP approach currently rolling out in NZ for a mental health and addictions strategy
  • Help-seeking by family members of problem gamblers is an even lower level that the acknowledged low level help-seeking by gamblers (compared with AOD). A family approach recommended by the authors could provide both relevance and enhance help-seeking by family members, as well as addressing what appears to be an important barrier to change and recovery for all affected family members.
  • These findings of high levels of family violence and problem gambling are found in other recent research. In a recent study (Echeburua, Gonzalez-Ortega, Corral, Polo-Lopezn (2013) Spanish J of Psychology, 16 (1)) problem gamblers (n=103) were matched to non-problem gamblers (n=103) with many negative findings for the problem gamblers (more anxious and impulsive; lower education, family history of alcohol abuse, greater CEP by way of DSM Axis 1 disorders, more adjustment difficulties with daily problems, female problem gamblers with more unemployment and lower socio-economic status, male problem gamblers more affected by alcohol problems). The most striking finding was the high level (68.6%) of family violence, with female problem gamblers reporting high levels of intimate partner violence when compared with female non-problem gamblers experiencing such violence (9.8%).
  • Violence in problem gambling has not previously been identified as a topic for inclusion in either screening or treatment, and the growing findings of violence associated with problem gambling suggests the need to move this topic to the forefront of consideration through systematic screening and treatment formulation.
Literature Findings Comment

The concerned significant others of people with gambling problems in a national representative sample in Sweden – a one year follow-up study. Authors: Jessika Svensson, Ulla Romild , Emma Shepherdson (2013) BMC Public Health, 13:1087 doi:10.1186/1471-2458-13-1087

Link

  • The study identified that CSOs are affected by serious and long-term mental health, social support, and financial problems. Gender differences were that male CFOs were also more likely to be problem gambling as well as having more work, debt, and legal problems than their female counterparts.
  • Both male and female CSOs were more likely than the general population to have poorer mental health, abuse alcohol, have greater problems financially, and more likely to have experienced violence within the previous 12 months
  • This research, although with a population that may not be as similar to the NZ population as the population in the above study (Australians) still supported increased risk for violence in families affected by problem gambling, while also expanding the range of problems affecting family units
  • Low help-seeking was noted by CSOs despite these increased needs
  • As does the above research, there is further support for provision of assistance for CSOs; these may require proactive strategies to help them access treatment. However, as supported by their literature review, involvement of CSOs in treatment increases positive outcomes for gamblers in treatment – in addition, the needs of the CSO are able to be addressed with benefits for the children in the family unit. Many families appear to separate in this study and as there is little research into this topic in NZ or elsewhere, this may be an expected outcome with mixed results.
  • In a further recent study (Kourgiantakis, Saint-Jacques, Temblay (2013) Problem gambling and families: a systematic review, J Social Work Practice in Addictions 13(4), 353-372), 30 empirical studies were reviewed, including the impact of family involvement in treatment, and concluded that problem gambling has a number of adverse effects on families and their functioning, while involvement of families in problem gambling treatment is linked with ‘better treatment outcomes and improved individual and family functioning’
  • Again, the screening for family violence (gamblers and CSOs), identifying alcohol misuse (CSOs as well), and the development of supports post-therapy (e.g. GamAnon) may be valid goals for CSOs, who may be in higher need than previously identified. In addition, proactive engagement of families in treatment appears to ensure better outcomes for the gambler and their families. Family therapies have become a less used approach in NZ treatment settings and these recent finding may suggest the need to reaffirm the benefits of this approach.
Literature Findings Comment
Health behaviour and body mass index among problem gamblers: results of a nationwide survey Authors: Algren M, Ekholm O, Davidson M, Larsen C, Juel K (2014) J of Gambling Studies DOI 10.1007-s10899-013-9437-y
  • Although it is known that problem gambling can have financial, legal, inter-personal costs that affect socially and emotionally, health behaviours are less well researched
  • These findings support the CEP approach adopted in NZ for problem gambling interventions, and also support (as do the above papers) the benefits of broad screening of those who seek help for gambling issues.
  • The CHAT screen addresses smoking, alcohol consumption, lifestyle drug use, and exercise; this paper therefore adds to the support for systematic screening of all clients seeking help for gambling issues, and the incorporation of these coexisting issues in a treatment plan
Literature Findings Comment
Psychiatric co-morbidity in problem and pathological gamblers: investigating the confounding influence of alcohol use disorder. Authors: Abdollahnejad R, Delfabbro P, Denson L (2014) Addictive Behaviours, 39(3), 566-572 DOI: 10.1016-j.addbeh.2013.11.004
  • The importance of this study lies in the CEP approach in NZ, as well as the importance of ensuring that alcohol, and presumably other drug misuse, may be a major factor in the existence of additional problems required to be addressed in treatment
  • The higher levels of mental health issues found with alcohol use problems raises the importance of screening for substance abuse and other coexisting problems. Positive findings for AUD should take into account the likelihood of pre-existing underlying issues that may be required to be addressed in treatment, including the approach to be taken in the management plan. For example, if the use of gambling and alcohol is a dysfunctional coping mechanism, and suicidality is high (a common finding), then removal of even a problematic coping mechanism may raise risk in the absence of establishment of other coping mechanisms. This may also suggest more regular sessions at the commencement of therapy, or strategies to establish coping mechanisms between sessions (e.g. CBT), as well as designing programmes to address the higher likelihood of personality disorders that may otherwise act as barriers to change, when AUD coexists.
  • The use of a community sample does address the possibility that treatment seeking problem gamblers have different needs (are a subgroup of all problem gamblers that may have important differences), and although the sample is relatively small, the findings are significant and are supported by a range of other studies.
  • The study does describe most problem gamblers as having complex problems, with those affected also by AUD as being even more complex again. It reinforces the need to screen, and to design a management programme tailored to the findings, rather than providing a ‘standard approach’ to treatment.
  • Clients who present with coexisting addictions to a problem gambling service may not be motivated to address a coexisting alcohol issue; however, if the ‘underlying issues finding’ which this paper supports is correct, then there is a likelihood that if it is not addressed, then the risk of resistance to treatment change, relapse risk, and cross-over intensification of the alcohol use (as a dysfunctional coping mechanism) may have a poorer outcome for the client.
  • This is an important study of a similar gambling culture (Australia), that has relevance for NZ treatment approaches.
Literature Findings Comment
Characteristics of gamblers using a national online counselling service for problem gambling Authors: Rodda S, Lubman D (2014) J of Gambling Studies, 30 (2), 277-289
  • With the recent expansion of online gambling and the difficulties that problem gamblers and their families encounter in accessing face to face treatment, alternative options need to be explored
  • In particular young people are comfortable in using distance counselling services, yet may be less likely to access face to face counselling
  • Problem gamblers and their families are often constrained through finances in travelling to treatment, may have tenuous employment as a result of unreliability associated with their gambling, and are unable to take time off during week days, while few counsellors would be available weekends
  • Distance and online options offer earlier opportunities to access low intensity help (self help, information, screening and automatic feedback, 24 hour accessibility, repeated access free of concerns), and can provide encouragement to step-up access to more intensive (but less than direct telephone conversations or face-to-face) therapies
  • These two online options offered in this programme (chat room and email) provide an alternative to telephone or face to face counselling, and could be regarded as a second tier access, after self-directed interventions
  • For many problem gamblers, where shame and guilt are high and confidentiality is important, talking directly to a counsellor may be a difficult first step and may be a barrier against help-seeking (which is low amongst these clients)
  • Although these services are not new to NZ, with the goal of removing barriers and use of technology to enhance intervention availability, the Australian experience supports these aims. For the majority of contacts to the two programmes, these were the first steps taken by these problem gamblers, suggesting that the needs of younger clients were being met, while the first time contacts, many over 40 years of age, had not previously sought help for gambling issues and may not have otherwise, in the absence of these services
  • Strategies to provide online interventions, especially with the growth of smart-phone use and technology, such as chat and email/twitter and other strategies, including client prompts used in other addictions (e.g. smoking) are options yet to be developed.
Literature Findings Comment
The impacts of problem gambling on concerned significant others accessing web-based counselling Authors: Dowling N, Rodda S, Lubman D, Jackson A (2014) Addictive Behaviors 39(8), 1253-7 (in press)
  • As with the above paper, this research reports upon use of a chat service, and this paper addresses the impacts on those affected by another’s gambling
  • Most significant others were under 30 years of age and reported high levels of a wide range of impacts
  • The different impacts can provide a pathway of issues to be addressed in an intervention, with the chat service providing feedback on each. Alternatively, the online options can be expanded to provide advice, support, and other resources (including direct counselling) for each of these impacts
  • The use by younger clients supports the acceptability of online interventions for these significant others and may provide an alternative for many clients who may not otherwise seek help for the impact of another’s problem gambling on their lives.

Feedback to MOH re Emerging Trends in National & International Literature

Period covered: 8th August 2013 to 31st December 2013

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Literature Findings Comment

Comorbid Axis 1-disorders among subjects with pathological, problem, or at-risk gambling recruited from the general population in Germany: Results of the PAGE study Authors: Bischof A, Meyer C, Bischof G, Kastirke N, John U, Rumpf H-J (2013) Psychiatry Research

Link

  • Problem gamblers at different levels of gambling severity were all significantly more likely to be experiencing coexisting Axis-1 mental health problems than non-problem gamblers. Although this research results from problem gamblers in a German population, the high levels of co-existing mental health problems found reflect similar prevalence levels to non-German problem gamblers, suggesting the findings are generalisable to other populations, such as New Zealand.
  • Of importance, is that this research also looks at problem gamblers who meet some of the criteria for Pathological Gambling (‘sub-clinical problem gamblers’), although it is acknowledged that criteria for this lower problem gambler level is not well defined, especially with the advent of DSM-5 where lesser threshold criteria (4) are now required from fewer total criteria (9) for current diagnosis of Gambling Disorder (formerly Pathological Gambling).
  • This research may align with the Co-existing Problem (CEP) initiative in NZ, in that high levels of coexisting problems appear to exist even for those with lower gambling criteria, with all the compared problems being elevated for each of the three problem gambling levels, and even the lowest (1-2 criteria).
  • It is possible that this research may be interpreted as those with existing mental health problems being more at risk for subclinical or clinical problem gambling (and Kessler et als’ (2008) findings suggest this may be over half of clinical problem gamblers), but even if so, this still provides important information for treatment that supports the CEP initiative. Treatment should take into account the need to assess all presenting clients for coexisting mental health problems, and should proactively provide advice and motivation for those affected by subclinical problem gambling in respect of the likelihood of other coexisting mental health issues (including other addictions). These levels of coexisting problems were very similar in subclinical gamblers to gamblers with severe gambling problems.
  • One of the few differences between the severity gambling levels of the participants was that subclinical problem gamblers were likely to have had more school education.
  • These findings, notwithstanding that subclinical gamblers are less defined, support the high need for treatment resources for subclinical and clinical problem gamblers, and that these resources should also target coexisting mental health problems. The CEP initiative fits appropriately within this finding, with broad screening, assessment and integrated treatment across mental health issues when identifying all levels of problem gambling.
Literature Findings Comment
An overview of and rationale for changes proposed for Pathological Gambling in DSM-5 Authors: Petry N, Blanco C, Auriacombe M, Borges G, Bucholz K, Crowley T, Grant B, Hasin D, O’Brien C (2013) Journal of Gambling Studies DOI 10.1007-s10899-013-9370-0
  • APA states that DSM provides accurate and consistent diagnosis of mental health disorders through defining criteria for them. It also enables researchers to compare treatments, risk factors and causes, prevalence and incidence of mental health disorders.
  • Problem gambling has been a challenge for DSM, commencing in 1980 (DSM-III) when the first description of pathological gambling was as ‘an impulse disorder which caused chronic financial loss and met three out of seven criteria’. This was followed by the review of DSM in 1987 when criteria increased to nine, and any four would meet the diagnosis. With the advent of DSM-IV in 1994, criteria increased to ten, with any five meeting the diagnosis. The new DSM-5 released in 2013 has reduced criteria to nine, of which, any four meets the diagnosis of its new, less pejorative description, ‘gambling disorder’. It also is no longer regarded as an impulse disorder, and sits within the category of Substance-related and Addictive Disorders as the only behavioural addiction under the sub-category ‘Non-substance-Related Disorders’.
  • Its inclusion is accepted because of there being sufficient evidence that ‘gambling behaviours activate reward systems similar to those activated by drugs of abuse and produce some behavioural symptoms that appear comparable to those produced by substance use disorders’.
  • There are also now various subcategories of gambling disorder. The first is that there may be periods when the criteria are met, and others when the symptoms may subside. This would be required to occur more than once, and this type of gambling disorder would be regarded as Episodic. Where the criteria were continuously present, the type of gambling disorder would be regarded as Persistent. Secondly, where the criteria for gambling disorder were met, and all criteria were in remission for at least three months but less than twelve months, then gambling disorder would be categorised as ‘In early remission’. Where this remission extended for twelve or more months, this gambling disorder would be categorised as ‘In sustained remission’. Finally, there are now three levels of severity for gambling disorder: Mild (4-5 criteria met), Moderate (6-7 criteria met), and Severe (8-9 criteria met).
  • Although each of the nine criteria have equal weighting in the diagnosis of gambling disorder (an unlikely outcome), DSM-5 does indicate that preoccupation with gambling and chasing losses are criteria more likely to be present with mild gambling disorder, while jeopardising relationships/careers and requiring bailouts are more likely to occur with severe gambling disorder. It is also stated that those who present for treatment of their gambling disorder are more likely to meet moderate to severe gambling disorder, and of these, about 17% will have attempted suicide (down from 20% in DSM-IV).
  • Although many of the above issues describe important changes to DSM, some were not canvassed in the article, probably due to size constraints and that at the time of publication, DSM-5 had not been released.
  • Several issues raised do, however, have important influence in the use of this important manual, which is the primary mental health disorder categorisation tool in NZ. Firstly, the authors note support for a sub-clinical level of gambling disorder was not approved because of the lack of evidence, resulting in not meeting the requirements of APA. There is a ‘Mild’ subcategory for gambling disorder and this may be taken by some to be a de-facto sub-clinical condition for problem gambling. However, one must meet the full criteria of the disorder even for a mild level of gambling disorder, while research indicates (see Bischoff et al 2013 above) that even people with a single criterion for pathological gambling are very likely to also have coexisting mental health disorders. As research (Kessler et al 2008) suggests that problem gambling is highly likely to include many conditions (similar to a syndrome), and as stated in DSM-5 that only those with moderate to serious gambling disorder are likely to seek help, this appears to be a lost opportunity to provide help to ‘mild’ problem gamblers who are experiencing considerable harm. DSM-5 does, however, acknowledge that ‘Individuals with gambling disorder have high rates of comorbidity with other mental disorders, such as substance use disorder, depressive disorders, anxiety disorders, and personality disorders’. Recent research by Weinstock et al, 2013 – reference below) concluded that ‘subclinical gamblers experience significant adverse consequences’).
  • The changes in both the description of the criteria and the cut-offs are based upon sound evidential research, however there is a possible side-effect that the many screens that exist to identify problem gambling have usually been validated against one or other of the DSM criteria and diagnoses, and their validity may therefore be affected by any changes, such as have occurred in DSM-5. Over time, existing screens may be compared with DSM-5 criteria, however the elusiveness of a ‘gold standard’ for problem gambling to which a screen can be compared, remains out of reach. DSM diagnoses of problem gambling therefore become a de facto ‘gold standard’ which in turn, changes over time.
  • Weinstock J, Rash C, Burton S, Moran S, Biller W, O’Neil K, Kruedelbach N. (2013) Examination of proposed DSM-5 changes to pathological gambling in a helpline sample. Journal of Clinical Psychology doi:10.1002-jclp.22003
Literature Findings Comment
Gamblers Anonymous: overlooked and underused? Authors: George S, Ijeoma O, Bowden-Jones H (2013) Advances in Psychiatric Treatment, 19, 23-29 doi:10.1192-apt.bp.111.009332
  • This appears to be an important reminder for those working in the problem gambling field that clients may have ongoing access to a support (and therapeutic) programme post-treatment, that may be effective and accessible.
  • At first instance, the wording and focus may appear off-putting for a growing secular population in which harm reduction rather than solely abstinence as a goal is widely accepted. However, the limited research conducted in the last decade suggests GA clients have more favourable outcomes, while the design overall of the programme appears to align itself with arguably the most efficacious form of therapy, CBT. Earlier research suggests GA is more suited to severely affected problem gamblers, which in turn, fits with the evidence-based DSM-5 findings (above) that therapy is more likely to be sought out by moderate to severely affected gamblers (rather than early stage, mildly affected gamblers).
  • This research article is written by UK authors, but the limited research and the GA programme itself (although initiated in the US) is world-wide. Processes are similar and structure follows the steps and processes in the Orange Book.
  • NZ situations may require further therapist support, expansion of chapter numbers, and education and motivation of clients to provide a further ongoing option for problem gambling clients. Currently, there are only 19 GA chapters throughout NZ, with just 4 in Auckland, with no Gam-Anon or Gam-A-Teen chapters operating. This may compare with 38 operating in the mid-1990s when some funding was directed towards the employment of a GA member in a treatment service, and alignment with the gambling helpline to establish new chapters when consenting callers from a particular region agreed. The employed GA member would then attend the first few sessions in the new chapter and mentor members in the processes. Approval was obtained to move the NZ regional office from Australia to NZ and the treatment service then provided the Orange and Little Blue Book (and other resources) to each of the chapters. The reduction of chapter numbers eventually to half following the cessation (1997) of the treatment service providing the helpline suggests that either the GA programme has become less relevant, or the programme itself requires support to attain and maintain a critical size.
  • There is evidence that in NZ, problem gamblers may be amenable to a programme operated and driven by those affected by gambling. A recent study (MOH 2013) identified that a barrier to help-seeking by problem gamblers is that the majority (59%) may prefer to resolve their gambling issues on their own. This was followed by a barrier of being too ashamed to disclose issues (44%); although attending GA may be seen to be shaming, and may not necessarily be seen as self-therapy, the strong fellowship focus, socialising and normalising may overcome these barriers.
  • Therapists can apply to attend chapter sessions as an observer, and this, together with knowledge of the programme, supportive attitude, and client education about GA, may all result in the establishment of a highly cost-effective ongoing support programme for problem gamblers (and their families). Problem gambling is a persistent and recurrent disorder, suggesting the need for ongoing support for an acknowledged enduring and often relapsing disorder. GA may be an important option that may also provide better outcomes when integrated into a therapeutic treatment plan.
  • For GA to be an effective option, a strategy may have to be established to educate therapists, while supporting the establishment of further chapters. Formative evaluation may also play a part to compensate for the low level of evidence available. However, this paper provides a start for consideration of this low cost, long established option.

Feedback to MOH re Emerging Trends in National & International Literature

Period covered: 1st January 2013 to 30th June 2013

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Literature Findings Comment

Australian Medical Association: Health Effects of Problem Gambling – 2013

https://ama.com.au

  • The medical sector provides a substantial opportunity to identify problem gambling issues amongst gambling individuals and their whanau.
  • Screening resources currently exist that have been developed specifically for medical providers (and extended to others) in NZ, and have been validated for NZ populations (e.g. CHAT, COGS and Eight Screens).
  • It is estimated that around 80% of the public access their GP annually, although problem gamblers are more likely to access their GP for other health issues. The screening of those affected by problem gambling provides an opportunity to access the estimated over 90% of problem gamblers and their families who do not seek help for their health-affected gambling issues, and at an earlier stage for those that do, through pro-active systematic screening.
  • The AMA proposals are based upon the concern that ‘an estimated 2.5% of Australians experience moderate to severe problems caused by gambling. For every person with a gambling problem, it is estimated that an additional 5 to 10 people are adversely affected by their gambling’. These figures are considerably above the NZ estimates (NZ Health Survey 2006/7 of 1.7%; 2011/12 of 1.3%), but such estimates have been considered to under-estimate problem gambling prevalence rates because of a range of factors, including high stigmatism and concealment issues. Accessibility to gambling is high for both NZ and Australia compared with most countries, and prevalence rates of problem gambling may be elevated for both countries, while cultures and accessibility to medical help, may have sufficient similarities to consider the relevance of this AMA gambling release.
  • Although there have been several publications of articles on problem gambling in NZ medical journals, best-practice initiatives for medical professionals on gambling have been few, e.g. Sustance use and addiction in Māori, Bpac 2010
  • The AMA paper calls for Australian health professionals to systematically screen for gambling problems (when conducting a lifestyle assessment or when symptoms indicate the possibility of problem gambling). in NZ, there is available a validated brief lifestyle and mental health screen (the CHAT) that addresses a range of mental health, addiction, and lifestyle issues (9 in total), that align with the CEP (addiction and coexisting mental health problems). The CHAT further tests for issues commonly present with addictions both within the mental health and social sphere, which can impact upon the course of the addiction and the wellbeing of the person.
  • The call for GPs to work with other services mirrors the NZ CEP and Facilitation strategies.
  • Overall, this new Australian initiative with GPs and other medical professionals to screen for gambling problems amongst patients, is a substantial step towards systemic screening of all patients for problem gambling (and associated problems), which may have a substantial impact upon problem gambling aetiology in NZ (early intervention, as well as accessing the high percentage of those affected who don’t seek help). The goal of further integrating GPs into addiction intervention may receive support from this influential source, the AMA.
Literature Findings Comment
The clustering of psychiatric disorders in high-risk gambling populations. Authors: Abdollahnejad M, Delfabbro P, Denson L (2013) Journal of Gambling Studies (in press)
  • Although previous research has highlighted the high presence of co-existing disorders with problem gambling (e.g. Kessler et al, 2008), this is a very recent study of a community population in Australia (possibly more generalisable to NZ) for a disorder that is subject to constantly varying environment and gambling modes
  • The reference to treatment services and the question of which to treat as the primary disorder is addressed in NZ through the roll- out of its CEP programme in treatment of addictions and coexisting problems, where all problems are treated with equal focus
  • However, this research does emphasise the importance of assessing problem gambling clients for a range of other mental health problems, and particularly, mood or depressive disorders and anxiety disorders
  • Training of practitioners who work with problem gamblers, whether PG specialists or other health professionals, should be resourced to identify both mood and anxiety problems, and when problem gambling is identified, further steps should be taken to address these mood/anxiety problems which have been found in this study to be present in the majority of pathological gamblers
  • Review of the full text may provide even further factors of significance to NZ when available.
Literature Findings Comment
An empirical evaluation of proposed changes for gambling diagnosis in DSM-5 Petry N, Blanco C, Stinchfield R, Volberg R (2013) Addiction (in press)
  • This research was conducted by prominent researchers and addresses important changes to the criteria for problem gambling following the release this year of DSM-5, the most commonly used diagnostic manual in USA (and NZ). The other manual, the WHO ICD-10, is more commonly used in Europe. o Pathological Gambling has been moved from ‘Impulse Disorders not elsewhere classified’ to ‘Substance-related and addictive disorders’ and is renamed ‘Gambling Disorder’)
  • The reduction of criteria as well as reducing the threshold from five to four criteria may have significance for validity of problem gambling screens, comparison of past research with new research (when the measure used has changed), as well as the target or focus of this research, the statistical effects of this change
  • Review of the full text when available, will enable a further assessment of whether all the DSM-5 changes were considered outside of the statistical analysis. For example, DSM-5 changes to criteria include adding the qualifier ‘often’ to the DSM-IV criteria ‘Is preoccupied with gambling’, such that it is not always present ( for example, a PG may consider that there are sometimes occasions when they think of other things, and therefore are not (always) preoccupied with gambling and answer ‘no’). Another change is, instead of ‘Gambles as a way to escape from problems’, it becomes ‘Gambles when feeling distressed’; and ‘chasing one’s losses’ refers to often long-term , not short-term, chasing. Finally, all criteria must occur within a 12-month period, whereas in DSM-IV, there was no time requirement. These changes may possibly alter how a PG may respond to these criteria, and so change the comparison outcome. This may be clarified in review of the full text.
Literature Findings Comment
Examination of proposed DSM-5 changes to Pathological Gambling in a helpline sample Authors: Weinstock J, Rash C, Burton S, Moran S, Biller W, O’Neil K, Kruedelbach N (2013) J Clinical Psychology (In press)
  • This paper tests aspects of the above statistical analysis with apparent additional variability with this helpline population than the Petry et al paper above. Although the difference at a five criteria cut-off without the ‘illegal’ criterion was very low in the reduced prevalence finding for the callers, (presumably because either few answered yes to the ‘illegal’ criterion, or those that did scored more than six and when the criterion was removed, remained positive), the change in prevalence rates at an increased 9% seems relatively substantial.
  • This difference then, does suggest that changes may be substantial in prevalence rates in surveys using the new criteria, and raises the possibility that screens may need to be re-validated, and care taken in before/after DSM-% comparisons. However, further research would have to be considered first, as well as study of the full paper when released, to reach this conclusion
  • Perhaps more importantly at this stage, the finding that even sub-clinical callers were significantly affected, raises the question as to whether screens are identifying moderate-severe PG, or even whether screens that identify severe PG are sensitive enough (i.e. whether they are identifying false negatives).
Literature Findings Comment
Characteristics and predictors of problem gambling on the Internet Authors: McCormack A, Shorter G, Griffiths M (2013) International J of Mental Health and Addiction (In press)
  • Although little in differences were identified between online and offline characteristics of problem gamblers, the characteristics of problem gamblers were confirmed for both environments
  • The higher likelihood of smoking, drinking, longer sessions and having other disabilities indicates the possible need to address a wide range of issues in therapy o NZ approaches of CEP (addressing coexisting issues) are supported when this strategy is matched to the potential needs of both online and offline problem gamblers.
Literature Findings Comment
Characteristics of gamblers using a national online counselling service for problem gambling Authors: Rodda S Lubman D (2013) J of Gambling Studies (In press)
  • This Australian initiative describes an alternative to a telephone-only service for PG clients that appears to provide a further electronic initiative.
  • The email option appears to be most popular, especially for younger males and women over 40. Gamblers may prefer the additional anonymity of emails, the reduced pressure for instant responses (although the service was real-time and delays may be relatively small), as well as the immediacy over telephone contact, the reduced pressure of email over live conversations, and the option to delay response at their choice.
  • It would appear that the approximately 2000 clients that accessed the services over the two years did so on many occasions, (although a lesser number may have contacted many times – the full text tables may clarify when the paper is published) – online may engender more contacts, and possibly more efficient counsellor participation. It is possible that a counsellor could respond to more than one email ‘conversation’ at a time, should the demand require, and so ensure that accessibility remains high (telephone conversations are discrete events)
  • The chat option appears to find favour with a female younger cohort, suggesting a range of online options are seen as desirable and may further extend to Skype, smartphones and suchlike programmes (groups as well).
  • New clients appeared not to be focused upon youth who might prefer an online option, but rather, on a range of new clients (especially female), who may have reasons to prefer online over telephone.
  • Although these options have been offered in NZ, the uptake appears to be lower and the full text when available, may offer strategies that may optimise this immediate and highly accessible series of options to new cohorts that otherwise would be unlikely to access PG services.