David Hodgins
University of Calgary
AGRI, 2011
Descriptive Accounts/case studies
Uncontrolled Trials
Randomized Controlled Trials (RCTs) - efficacy
Effectiveness Trials/Mechanisms/Systems
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?
Descriptive Accounts/case studies
Uncontrolled Trials
Randomized Controlled Trials (RCTs) - efficacy
Effectiveness Trials/Mechanisms/Systems
 Family
models
 Psychodynamic models
 Gamblers Anonymous
 Cognitive
 Behavioural
 Cognitive-behavioural models
 Motivational Interviewing
 Multimodal Treatment
 Various medications
 Family
models
 Psychodynamic models
 Gamblers Anonymous
 Cognitive
 Behavioural
 Cognitive-behavioural models
 Motivational Interviewing
 Multimodal Treatment
 Various medications
 Family
models
 Psychodynamic models
 Gamblers Anonymous
 Cognitive
 Behavioural
 Cognitive-behavioural models
 Motivational Interviewing
 Multimodal Treatment
 Various medications
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
Response
Response
for drug
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%
Hodgins, Stea & Grant, The Lancet, in press
 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.
 Two
examples….
 Coping
Skills Treatment Trial
 Self-directed Treatment
(Motivational
Interviewing & workbook)
 Nancy
Petry’s 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)
Session 4
26%
Session 8
67%
GA/therapy
support
Cognitive
skills
4%
43%
21%
31%
Distraction
45%
26%
Avoid
triggers
40%
20%
Social
Support
Specific day of the
week
Mood- stressed, bored,
lonely
Unstructured time
Access to money
Gambling cue
A specific time of the
day
33%
30%
27%
22%
19%
17%
Action
% of people
New activities/Change in focus
68%
Stimulus Control/Avoidance
48%
Treatment/GA support
37%
Cognitive skills
34%
Budgeting
31%
Willpower/Decision-making/self-control
23%
Social support
10%
Others – confession, no money, non<5%
gambling external factors, self-reward,
spiritual, addressing other addictions Hodgins et al., 2009
 Motivational
Interviewing Premise: what an
individual says about change during MI is
related to subsequent change
 Theory:
verbalizing an intention to change
(CHANGE TALK) leads to public and
personal obligation to modify one’s behavior
 Does
amount of Change Talk correlate with
change in gambling behavior?
• 12 months
r = -.35*
* p < .05 Hodgins , Ching & MacEwan,, 2009
 Does
MI reduce drop-out?
 Effectiveness of individual versus group
formats?
 Does giving clients a choice of goals
make a difference (Abstinence versus
controlled gambling)?
 Large
issue for CBT, GA, etc.
 Wulfert et al. (2006) pilot study
 Standard treatment dropout 34%, posttreatment SOGS = 10.4
 CBT-MI dropout 0%, post-treatment
SOGS 1.2
 Subsequent CBT-MI combos – perhaps
slight decrease in drop-out?
 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
 Dowling
at al. (2007) women in CBT
 Oei & Raylu (2010) both genders in CBTMI combo
• Treatment manual
 Slight
advantages for 1:1
 Implications?
 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)
 Dowling
at al., (2009) 12 session CBT
Abstinent goal
Cut down goal
Post treatment – 84%
no diagnosis
83%
Six month – no
diagnosis
89%
83%
Depression
(BDI)
Gambling
frequency
8.9
7.1
0.3
0.5
 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.
 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%)
 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 selfdirected recovery or attend treatment?
 General
population knows about
gambling problems
• Perceived addictiveness
• Perceived prevalence
50%
40%
30%
20%
Perceived
Past Year
10%
0%
Wild, Hodgins, Patten, Coleman, el-Guebaly, Schopflocher, 2010
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
1-5 rating
Wild, Hodgins, Patten, Coleman, el-Guebaly, Schopflocher, 2010
 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
 Evidence
that campaigns increase
treatment-seeking
• Productivity Commission Report, 2010 review
• Web-site and helpline spikes
 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