Clinical Assessment and Management of Pathological Gambling

By Jon E. Grant, JD, MD, MPH and Suck Won Kim, MD | March 1, 2007

Dr Grant is associate professor of psychiatry at the University of Minnesota in Minneapolis. He reports that he is a consultant to Somaxon Pharmaceuticals and receives research grant support from Forest Pharmaceuticals, GlaxoSmithKline, and Somaxon Pharmaceuticals. Dr Kim is professor of psychiatry at the University of Minnesota in Minneapolis. He reports that he is a consultant to Somaxon Pharmaceuticals and BioTie Therapies.

Mood stabilizers. Because some pathological gamblers appear to have either co-occurring bipolar disorder or subsyndromal hypomania, the use of mood stabilizers has also been examined (see Table 2). There has been only one randomized placebo-controlled trial of a mood stabilizer in PG. In a double-blind placebo-controlled study of 40 subjects who were pathological gamblers with bipolar spectrum disorders (bipolar type II, bipolar not otherwise specified, or cyclothymia), sustained-release lithium(Drug information on lithium) carbonate (mean lithium blood level of 0.87 mEq/L) was shown to be superior to placebo in reducing PG symptoms during a 10-week treatment.²³

Psychosocial interventions
Controlled studies support the efficacy of cognitive and behavioral therapies for PG (Table 3). Cognitive therapy focuses on changing the patient's beliefs regarding his or her perceived control over randomly determined events. Randomized trials have demonstrated success with cognitive therapy.²⁴ Individual cognitive therapy has resulted in reduced gambling frequency and increased perceived self-control over gambling when compared with a wait-list control group. Cognitive therapy that includes relapse prevention has also produced improvements in gambling symptoms when compared with a wait- list group.


	Table 3 Controlled psychological treatment trials for PG
	Design			Outcome


	Stimulus control and in vivo exposure with relapse prevention; cognitive restructuring; combined treatment; or wait list25			At 12 months, 69% were abstinent or much reduced in the first group compared with 38% for cognitive restructuring or combined treatment

	Cognitive therapy plus relapse prevention compared with wait list³⁸			36% improved on 5 variables compared with 6% on wait list

	Cognitive therapy plus relapse prevention compared with wait list³⁹			32% improved on 4 variables compared with 7% on wait list

	Group cognitive therapy plus relapse prevention compared with wait list⁴⁰			65% no longer met PG criteria compared with 20% for wait-list group

	Manualized CBT in individual counseling; use of CBT workbook; or referral to Gamblers Anonymous²⁶			Individual CBT more effective than Gamblers Anonymous and use of workbook; at 12 months, groups did not differ in terms of abstinence rates

	Use of CBT workbook compared with use of a workbook plus a single in-depth interview²⁷			Both groups showed improvement at 6 months

	Use of CBT workbook; use of workbook plus motivational enhancement intervention via telephone; or wait list²⁸			74% with motivational enhancement improved according to Clinical Global Impression compared with 61% with use of workbook and 44% with wait list

	Aversion therapy compared with imaginal desensitization²⁹			Improvement in both groups over 12 months

	Aversion therapy; imaginal desensitization; in vivo desensitization; or imaginal relaxation³⁰			Improvements at 1-month and at 9-year follow-up with imaginal desensitization

	PG, pathological gambling; CBT, cognitive-behavioral therapy.

Cognitive-behavioral therapy (CBT) has been used to treat PG. One study compared 4 groups: (1) an individual stimulus control and in vivo exposure with response prevention; (2) group cognitive restructuring; (3) a combination of 1 and 2; and (4) a wait-list control.²⁵ At 12 months, the rates of abstinence or minimal gambling were higher with individual treatment (69%) than with both the cognitive restructuring and the combined treatment groups (38% abstinence or minimal gambling rate in each).

Based on CBT used in the treatment of substance use disorders and including relapse prevention strategies, an independent controlled trial of 231 subjects also demonstrated short-term improvement relative to a referral to Gamblers Anonymous (GA); at 12-month follow-up, however, abstinence rates did not differ between the 2 groups.²⁶

Brief interventions have demonstrated significant reductions in gambling at 6-month follow-up for gamblers assigned either to the use of a workbook (that included cognitive-behavioral and motivational enhancement techniques) or to the use of a workbook and an interview with a clinician.²⁷ A separate study assigned patients who were pathological gamblers to the use of a workbook, the use of a workbook and a motivational enhancement intervention over the telephone, or a wait list. Compared with the group who used the workbook alone, the group assigned to use motivational intervention and the workbook showed a reduction in gambling throughout the 2-year fol-low-up period.²⁸ Two studies that examined aversion therapy and imaginal desensitization in randomized designs found that both treatments resulted in improvement.^29,30

GA is perhaps the most popular and well-known treatment for PG, but few studies have systematically analyzed the outcomes of participation. Although controlled studies are lacking, most of the studies that examined treatment outcomes for patients who attended GA demonstrated the program's potential effectiveness, particularly when combined with professional therapy.³¹

CONCLUSION
PG has historically received relatively little attention from clinicians and researchers. Despite having prevalence rates similar to or greater than those of schizophrenia and bipolar disorder, there is much less research on PG that investigates treatment strategies. As a consequence, our understanding of effective and well-tolerated pharmacotherapies for PG lags behind that of other major neuropsychiatric disorders. Emerging data from controlled clinical trials, however, suggest that PG frequently responds to both pharmacological and psychosocial intervention.

The approaches reviewed in this article represent significant advances over the past several years—it is hoped that progress in the treatment of PG will continue to be made at this rate. More definitive treatment recommendations await the completion of additional large-scale controlled treatment studies and comparative investigations of trials of pharmacological agents. Advances in these areas hold the potential for significantly improving the lives of pathological gamblers and those directly or indirectly affected by their behavior.

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Clinical Assessment and Management of Pathological Gambling

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