A systematic review and meta-analysis «Cowlishaw S, Merkouris S, Dowling N ym. Psychologi...»1 included clinical trials using random allocation to groups, considering pathological or problem gamblers, and evaluating a psychological therapy for pathological or problem gambling. Control conditions included 'no treatment' controls, referral to Gamblers Anonymous and non-specific treatment component controls.
Primary outcomes were measures of gambling symptom severity, financial loss from gambling and frequency of gambling. Secondary outcomes were occurrence of pathological gambling diagnoses and depression and anxiety symptoms. Treatment effects were defined by comparisons between therapy and control conditions at post-treatment assessments (conducted from 0 to 3 months following completion of treatment) and follow-up assessments (conducted from 9 to 12 months following completion of treatment), respectively, using the standardised mean difference (SMD) or risk ratio (RR).
Eleven studies compared CBT with control and comparisons at 0 to 3 months post-treatment showed beneficial effects of therapy that ranged from medium (when defined by financial loss from gambling: SMD -0.52; 95% confidence interval (CI) -0.71 to -0.33, n = 505) to very large (for gambling symptom severity: SMD -1.82; 95% CI -2.61 to -1.02, n = 402). Only one study (n = 147) compared groups at 9 to 12 months follow-up and produced smaller effects that were not significant.
This review supports the efficacy of CBT in reducing gambling behaviour and other symptoms of pathological and problem gambling immediately following therapy. However, the durability of therapeutic gain is unknown.
A systematic review «Petry NM, Ginley MK, Rash CJ. A systematic review ...»2 synthesized data from trials for psychosocial treatments of gambling problems. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Standards, they identified 21 randomized trials. Eleven studies evaluated interventions delivered via multisession, in-person therapy: cognitive therapies, cognitive-behavioral (CB) therapies, and motivational interventions (MI) alone or with CB therapies. An additional 10 studies used approaches that involved 1 or fewer in-person sessions; these included workbooks with CB exercises alone or in combination with MI and brief feedback or advice interventions. Nearly half the studies used waitlist controls. Populations differed markedly across studies, from nontreatment-seeking persons who screened positive for gambling problems to those with severe gambling disorder.
Although most studies found some benefits of CB therapy (alone or combined with MI) and brief feedback or advice relative to the control condition in the short term, only a handful of studies demonstrated any long-term benefits. Although problem gamblers with less pronounced symptoms may benefit from very minimal interventions, therapist contact generally improved outcomes relative to entirely self-directed interventions, and at least some therapist contact may be necessary for patients with more severe gambling pathology to benefit from CB interventions. As treatment services for gambling continue to grow, this review provides timely information on best practices for gambling treatment. Different populations may require different interventions.
A systematic review and meta-analysis «Pfund RA, Forman DP, Whalen SK, ym. Effect of cogn...»3 searched seven databases and two clinical trial registries to identify peer-reviewed studies and unpublished studies of randomized controlled trials. The Cochrane Risk of Bias tool assessed risk of bias in the included studies. A random effect meta-analysis with robust variance estimation was conducted to measure the effect of CBTs relative to minimally treated or no treatment control groups.
The review identified 29 studies with 3991 participants. CBTs significantly reduced gambling disorder severity (g = -1.14, 95% CI = -1.68, -0.60, 95% prediction interval [PI] = -2.97, 0.69), gambling frequency (g = -0.54, 95% CI = -0.80, -0.27, 95% PI = -1.48, 0.40) and gambling intensity (g = -0.32, 95% CI = -0.51, -0.13, 95% PI = -0.76, 0.12) at post-treatment relative to control. CBTs had no significant effect on follow-up outcomes. The review noted that very few study designs evaluated post-treatment results. Therapist-assisted treatments were significantly associated with larger reductions in gambling intensity than self-guided treatments.
Cognitive-behavioral techniques are effective for reducing gambling disorder and gambling behavior but their effect gambling disorder severity and gambling frequency and intensity at post-treatment has been overestimated. Analyses supported the presence of publication bias and high heterogeneity in effect size estimates. Attrition rates in past studies have been high resulting in possible overestimation of effect sizes which have been reported for completers. CBTs might not be reliably efficacious for everyone seeking treatment for problem gambling and gambling disorder.
Comment: An additional RCT comparing four active psychological treatment interventions supports the effectiveness of CBT for gamblind disorder «Thomas S, Jackson A, Browning C ym. Psychological ...»4. A randomised controlled trial was conducted to examine the effectiveness of four manualized psychological treatments for problem gambling: cognitive behaviour therapy, motivational interviewing, behaviour therapy and client-centred therapy.
The study is one of the largest ever conducted examining treatments for problem gambling. Alltogether 297 eligible participants were randomly allocated to the four treatment groups. The primary outcome measures were frequency of gambling sessions (in days on which the person gambled in the past 4 weeks), total time spent gambling (in hours in the past four weeks), amount of money spent gambling (net loss in the past four weeks) and the Gambling Symptom Assessment Scale (G-SAS) total scores, urge scores and frequency scores.
The results showed a robust post treatment drop in gambling behaviours across all treatment groups that were sustained up to the 12-month post treatment measurement point. For the GSAS scores a similar pattern of results was observed, i.e. post treatment means fell and the reductions were maintained at the 6 month and 12-month data collection points. Medium to large effects were observed for all outcomes. All four treatment groups have experienced significant reductions in the behavioural and symptom gambling measures and these reductions have been sustained to 12-months post treatment. Co-occuring risky alcohol consumption, drug use or psychiatric symptoms did not have a statistically significant effect on the results.