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Pathological Gambling: Update on Assessment and Treatment: Page 2 of 3

Pathological Gambling: Update on Assessment and Treatment: Page 2 of 3

Brief interventions for pathological gambling include either single or limited sessions that target gambling and also include the use of self-help workbooks and telephone counseling.15,16 Recent work by Petry and colleagues17 indicates that a single 10-minute informational session or a single 1-hour motivational enhancement interview reduces problem gambling behaviors. Brief interventions with self-help workbooks are also emerging as effective ways to reduce problem gambling behaviors.15

Individual psychotherapy is most widely used to address pathological gambling. Compared with other psychotherapies, CBT has the most evidence for the management of pathological gambling.18

Several recent studies highlight the importance of targeting cognitive distortions and irrational beliefs associated with continued gambling.18 Individual therapy reduces gambling frequency, increases perceived self-control over gambling, and strengthens relapse prevention. For therapists interested in using CBT for pathological gamblers, clinically tested manuals and guides are available.19,20 A recent meta-analysis of CBT for pathological gambling suggests that the effect size is promising and that the effect of reduced pathological gambling behavior extends to at least 12 months.18

There is compelling evidence that pathological gambling behaviors not previously evident may develop in a subset of persons with Parkinson disease who are taking dopamine agonists.

Social support through Gamblers Anonymous is often recommended for pathological gambling. Gamblers Anonymous has been in operation for more than 50 years; meetings are held daily throughout the United States. Gamblers Anonymous offers peer support, fellowship, and a confidential network to support recovery. Variables that predict abstinence include attendance, participation, and higher social status.19,20

Practical techniques to use with pathological gamblers include discussions of how to limit access to casinos, credit, and transportation to gambling venues. Financial counseling is an essential component in working with pathological gamblers—an area that many therapists find challenging, since they lack formal training. Finally, engaging family members early in treatment is critical to foster treatment retention and adherence, and to minimize enabling behaviors.

Common pitfalls in treating pathological gamblers include nonadherence to therapy, ambivalence, and low motivation. Shame and guilt are palpable in pathological gamblers and their families. A nonjudgmental attitude is critical in dealing with the harmful consequences of continued gambling.

Pharmacological approaches. There are no FDA-approved medications for pathological gambling. Therefore, when prescribing medications to target pathological gambling, clinicians need to inform their patients of the off-label use of the drug and that the use is based on limited research.

The pursuit of effective medications for pathological gambling has been hindered by clinical trials that report a high placebo response rate, a lack of understanding of pathophysiology, the heterogeneous nature of pathological gambling, and the use of a wide variety of outcome measures.21,22 Evidence for the use of medications in treating pathological gambling has been inconclusive.23,24

The dopaminergic system, which influences reward, motivation, reinforcement of reward, and appetitive urges has been implicated in addic-tive disorders—including pathological gambling.25 In randomized clinical trials, the opiate antagonists, naltrexone and nalmefene, have been shown to reduce gambling urges, thoughts of gambling, and behaviors in primary pathological gamblers but not in pathological gamblers with comorbid alcohol abuse.26-29

Antidepressants, namely SSRIs, have been tested because pathological gamblers have demonstrated serotonergic dysfunction in the laboratory, which has contributed to possible explanations of impaired disinhibition and impulsivity. Data from clinical trials in which SSRIs have been used to treat pathological gamblers have not been conclusive: some trials have found moderate reductions in gambling while others have not been able to find a significant response.30 One trial showed bupropion to be as effective as naltrexone in pathological gamblers, but other trials have not been able to show efficacy greater than that with placebo.31-33

Mood stabilizers have also been examined for the management of pathological gambling because of the high co-occurrence of bipolar disorder and dysfunctional impulsivity in pathological gamblers. To date, lithium, divalproex, carbamazepine, and topiramate have been tested.34 In a double-blind placebo-controlled study of 40 pathological gamblers who had bipolar spectrum disorders (bipolar II disorder, bipolar not otherwise specified, or cyclothymia), sustained-release lithium carbonate (mean lithium blood level of 0.87 mEq/L) was superior to placebo in reducing pathological gambling symptoms during 10 weeks of treatment.35

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