1. David Hodgins University of Calgary AGRI, 2011

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

3.  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?

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

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

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

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

8.  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

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

10.  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.

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

12.  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)

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

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

15. Action% of people New activities/Change in focus68% Stimulus Control/Avoidance48% Treatment/GA support37% Cognitive skills34% Budgeting31% Willpower/Decision-making/self-control23% Social support10% Others – confession, no money, non- gambling external factors, self-reward, spiritual, addressing other addictions <5% Hodgins et al., 2009

16.  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 monthsr = -.35* * p <.05 Hodgins, Ching & MacEwan,, 2009

17.  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)?

18.  Large issue for CBT, GA, etc.  Wulfert et al. (2006) pilot study  Standard 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?

19.  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

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

21.  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)

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

23.  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.

24.  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%)

25.  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?

27.  General population knows about gambling problems Perceived addictiveness Perceived prevalence

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

30.  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

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

32.  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