David Hodgins University of Calgary AGRI 2011 Typical Treatment Research Progression Effectiveness TrialsMechanismsSystems Does this work in the real world Real clients group vs individual therapists competence ID: 419621
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Slide1
The Big Questions in Treatment for Pathological Gambling
David HodginsUniversity of CalgaryAGRI, 2011Slide2
Typical Treatment Research Progression Slide3
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?Slide4
Typical Treatment Research Progression Slide5
Descriptive Accounts
Family modelsPsychodynamic modelsGamblers AnonymousCognitiveBehavioural
Cognitive-behavioural models
Motivational Interviewing
Multimodal Treatment
Various medicationsSlide6
Uncontrolled Trials
Family modelsPsychodynamic modelsGamblers AnonymousCognitiveBehavioural
Cognitive-behavioural models
Motivational Interviewing
Multimodal Treatment
Various medicationsSlide7
Randomized Controlled Trials
Family modelsPsychodynamic modelsGamblers AnonymousCognitiveBehavioural
Cognitive-behavioural models
Motivational Interviewing
Multimodal Treatment
Various medicationsSlide8
Psychosocial Metaanalysis
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 treatmentSlide9
Response for drug
Response
for placebo
Naltrexone
[2 studies]
62%
34%
Nalmefene [2 studies]
52%
46%
Fluvoxamine [2 studies]
72%
48%
Paroxetine [2 studies]
63%
40%
Sertraline [1 study]
68%
66%
Bupropion
[1 study]
36%
47%
Olanzapine [2 studies]
67
%
71%
Medication RCTs
Hodgins,
Stea
& Grant, The Lancet, in pressSlide10
CBT Metaanalysis
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. Slide11
How does therapy work?
Two examples….Coping Skills Treatment TrialSelf-directed Treatment (Motivational Interviewing & workbook)Slide12
Morasco et al., 2007
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)Slide13
Clients Effective Coping Skills
Session 4
Session 8
Social
Support
26%
67%
GA/therapy support
4%
43%
Cognitive skills
21%
31%
Distraction
45%
26%
Avoid triggers
40%
20%Slide14
Session 3 – High Risk Situations
Specific day of the week
33%
Mood- stressed, bored, lonely
30%
Unstructured time
27%
Access to money
22%
Gambling cue
19%
A specific time of the day
17%Slide15
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-gambling external factors, self-reward, spiritual,
addressing other addictions
<5%
Hodgins et al
., 2009
What worked in Self-directed Treatment?Slide16
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
How does Brief self-directed treatment work?Slide17
Other important questions about effective mechanisms of CBT-MI?
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)?Slide18
How can we reduce drop-out?
Large issue for CBT, GA, etc. Wulfert et al. (2006) pilot studyStandard treatment dropout 34%, post-treatment SOGS = 10.4
CBT-MI dropout 0%, post-treatment SOGS 1.2
Subsequent CBT-MI combos – perhaps slight decrease in drop-out?Slide19
Carlbring et al., 2010
MI (4 sessions) Group CBT (8 sessions)WaitlistMI, 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-outSlide20
Group vs. Individual?
Dowling at al. (2007) women in CBTOei & Raylu (2010) both genders in CBT-MI combo
Treatment manual
Slight advantages for 1:1
Implications?Slide21
Goal Choice (quit or cut down?)
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)Slide22
Systematic studies of goal choice
Dowling at al., (2009) 12 session CBT
Abstinent
goal
Cut
down goal
Post treatment – no diagnosis
84%
83%
Six month – no diagnosis
89%
83%
Depression (BDI)
8.9
7.1
Gambling frequency
0.3
0.5Slide23
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.Slide24
Ladouceur
at al. (2009)CBT (12 sessions) aimed at controlNo 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%) Slide25
Conclusions
People do move towards the appropriate goal – does offering goal choice increase treatment seeking?Moving in the right direction in terms of offering better treatments, that people stick with.
Both RCTs and effective studies are useful
Treatment system issues largely unaddressed - < 10% treatment uptake – how do we get people to participate in self-directed recovery or attend treatment?Slide26Slide27
Some clues about promoting treatment
General population knows about gambling problemsPerceived addictivenessPerceived prevalenceSlide28
Perceived Problem Prevalence in Alberta (N = 6000)
Wild, Hodgins, Patten, Coleman, el-
Guebaly
, Schopflocher, 2010 Slide29
Perceived Addictiveness
Wild, Hodgins, Patten, Coleman, el-
Guebaly
, Schopflocher, 2010 Slide30
Some clues about promoting treatment
Reasons for seeking treatment studiesConsistent findingsTrying 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 budSlide31
Some clues about promoting treatment
Evidence that campaigns increase treatment-seekingProductivity Commission Report, 2010 reviewWeb-site and helpline spikesSlide32
Conclusions
Moving in the right direction in terms of offering better treatments, that people stick with. Both RCTs and effective studies are usefulTreatment system issues largely unaddressed but research suggests some
strategies to get
people to participate in self-directed recovery or attend treatment