Internet-delivered therapist-assisted cognitive behavioral therapy for gambling disorder: a randomized controlled trial

A minimum of two independent treatment effects were required for a meta-analysis to be conducted (with only meta-analytic findings reported in this abstract). Two out of four randomized, double-blind, placebo-controlled trials have found significant improvement with naltrexone compared with placebo, and positive results have been found in the two trials with nalmefene. A thorough meta-analysis concluded that opiate antagonists demonstrated a small but significant benefit compared with placebo70. A more recent review11 of the use of opioid antagonists on behavioral addictions concluded that both naltrexone and nalmefene were the only evidence-based pharmacological treatments for GD. Once again, baseline scores were relatively better than at the first visit, although not as much as for the NODS (PHQ-9, GAD-7, and GBQ all had higher scores at the first visit, and for the BBQ the score was lower at the first visit, but here a low score is worse).

A prospective 6 month follow-up study found that a majority of individuals who respond to naltrexone maintain the response after medication discontinuation 37. Furthermore, pooled analyses of those who responded to opioid antagonists demonstrated significant reduction in gambling urges, particularly among participants with a positive family history of alcohol dependence 38. The purpose of this article is to review the double-blind, placebo-controlled trials of various pharmacological agents used for pathological gambling for a comprehensive review of open-label studies, please see (11,12). We utilized search engines, including Medline, PubMed and professional library resources to obtain information on the double-blind, placebo-controlled trials conducted for PG over the past approximately 10 years. The pharmacological trials identified and reviewed in this article include antidepressants, opioid antagonists, mood stabilizers, atypical antipsychotics, glutamateric agents or atypical stimulants for treating PG.

Pathological gambling (PG) is a psychiatric disorder characterized by persistent and recurrent maladaptive patterns of gambling behaviour 1. Although the majority of individuals participate in gambling as a social activity, individuals who develop PG become over involved in terms of time invested and money wagered, and continue to gamble despite the significantly negative impact on their personal, social and financial well-being 2. Background Guidelines remain unclear on which medications for gambling disorder are to be preferred in terms of efficacy and tolerability. To see whether there were any statistical differences in perceived working alliance (WAI), treatment credibility (TCS), and patient-rated impact of adverse events (NEQ) between the treatment groups in the FAS and ITT sample, ANOVA was used. The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a structured screening interview based on diagnostic criteria from the DSM-5 (3) and covers a wide range of psychiatric diagnoses. It has shown excellent inter-rater reliability (all kappa values over 0.75) and good test retest reliability (61% of kappa values over 0.75) (41).

Mood stabilizers

Although these might not work for everyone, they might be a cost-effective way to treat GD for at least a subset of the population. Based on previous research, these interventions should include some form of therapist guidance but could be limited in scope—perhaps even more so than the control treatment in this study. It is still possible that treatments of higher intensity or using tools from CBT are better at sustaining treatment effects over time. It is important to continue studying the lasting effects of online treatments regarding both high-intensity CBT treatments and more low-intensity formats using long-term follow-ups. It is possible that depending on GD severity, comorbidities, social factors, etc., treatments might have different effects. It might be that online treatments or treatments of lower intensity are useful for a subset of patients while some need more intensive or face-to-face treatment.

Pharmacological treatments in pathological gambling

The telephone support consisted of further discussion on important aspects of the module with a focus on CBT methods and exercises. The telephone call was also used to set up and review homework assignments for participants to work on during the week (Table 1). The content of the ICBT treatment is similar to several other ICBT treatments for GD published in recent years (34, 42, 43) both in that they all offer a wide variety of interventions and that the types of interventions are similar.

Participants

Perhaps what we see here is a reaction of stress trying to balance negative emotions without gambling and that relapse is once again used as a way to cope with these emotions. It is not possible to know whether the rate of relapse would have been even higher without treatment, and only further long-term follow-up can determine whether participants will continue to deteriorate or not. Interestingly, the effects regarding cognitive distortions and quality of life were maintained at 6 months.

Mean differences in the outcome variables post-treatment and at 6-month follow-up were calculated using estimated marginal means. In both interventions, participants once a week also received telephone support from their therapist for a maximum of 15 min. When a new module was started, they received a short text message reminding them of the new module.

• The Treatment Credibility Scale is an adapted version of the Credibility Scale (58).
• Another strength was that gambling symptoms were measured at the first visit, which made it possible to discover that change started well before treatment start.
• The present review provides an understanding of current attempts at developing more inclusive GD treatment approaches.
• Research on the pharmacological treatment of PG appears promising, particularly in the case of opioid antagonists.
• Time spent gambling each week and the amount of money bet each week were derived from the Time-Line Follow Back adapted to gambling (G-TLFB) and used as secondary outcome measures.

In contrast, the findings are inconclusive with regard to the effects of mood stabilisers (including anticonvulsants) in the treatment of disordered or problem gambling, and there is limited evidence to support the efficacy of antidepressants. However, these conclusions are based on very low to low certainty evidence characterised by a small number of included studies, high risk of bias, modest pooled sample sizes, imprecise estimates, moderate between-study heterogeneity, and exclusion of participants with psychiatric comorbidities. Moreover, there were insufficient studies to conduct meta-analyses on many outcome measures; to compare efficacy across and within major categories of interventions; to explore dosage effects; or to examine effects beyond post-treatment.

Participants were then randomized to either the ICBT treatment or a control treatment consisting of limited psychoeducation and motivational support using simple randomization. Finally, upon the inclusion of a participant, a research assistant opened the topmost envelope in the stack and started the participant on the correct condition. During treatment, participants were blinded as to which treatment they had been randomized to. At the end of the treatment period, all participants were contacted and interviewed by a psychologist about the need for additional treatment at the clinic. If participants expressed a need or the psychologist deemed that the treatment results were insufficient, additional treatment or follow-up was offered. Participants were also contacted by telephone and reminded to respond to questionnaires by a research assistant post-treatment and at follow-up.

Everyone seeking treatment for gambling problems at the Clinic for Gambling Addiction and Screen Health, either by referral or self-referral, with a first visit at the clinic between May 2019 and November 2022 and who were considered eligible were asked about participation in the study. The trial ended when the target number of participants (at least 32 in each treatment group) was met and the last follow-up measure was collected in June 2023. The first visit was conducted by a psychiatric nurse, social worker, or psychologist at the clinic and included an anamnestic interview, as well as a structured clinical interview (SCI-GD). Owing to this, some were immediately recognized as not fulfilling the inclusion criteria during the first visit, i.e., by not fulfilling the criteria for a GD diagnosis or by having other psychiatric conditions contraindicating treatment. All eligible that declined participation were offered the standard treatment at the clinic, consisting of CBT in individual or group format.

These findings suggest that medication dosing may be an important consideration in achieving symptom control 36. A variety of antidepressant medications have been studied for the treatment of PG, but controlled clinical trials have demonstrated mixed results. The first 8 week study demonstrated significantly greater improvement for those pathological gamblers assigned to paroxetine compared with placebo (61% of subjects on paroxetine showed improvement vs. only 23% on placebo) 26. A 16 week, multicentre study of paroxetine, however, failed to find a statistically significant difference between active drug and placebo, perhaps in part due to the high placebo response rate (48% to placebo, 59% to active drug) 27.

However, it should be noted that, despite the relevant research advances in psychiatric disorder management, the understanding of treatment options for GD remains limited17. Gambling problems can lead to severe consequences for gamblers, their family members and friends, and the community. A range of medications are used to treat people with gambling problems, but there are few high-quality reviews of the research evidence to guide which ones should be used in practice. Declaration of competing interest Dr. Ioannidis is clinical lead for the Southern Gambling Service and receives a stipend from Elsevier for journal editorial work. Professor Chamberlain receives a stipend from Elsevier for journal editorial work.

No difference was found between treatments, or over time during treatment, in the total sample for the secondary outcomes from the gambling diary (G-TLFB) of amount of money bet per week and time spent gambling per week. This lack of change over time might be due to low values already at baseline, paired with a large variability in scores. As abstinence from gambling gives scores of zero, while a setback for a few participants might give large scores at certain time points, there is an innate variability in this type of measurement. This can be seen when studying the IMI group, where both the amount bet per week and time spent gambling per week are down to zero at week 7 and then back to baseline scores at week 8 (with large standard deviations). Based on a small amount of low-quality evidence, we conclude that opioid antagonists and atypical antipsychotics (but seemingly not antidepressants) may be effective in reducing gambling symptom severity.

If gambling symptoms are this susceptible to intervention, it is possible that some of the changes seen in treatment studies are caused by the effect of assessment and monitoring alone. It might be that the effect of assessment and monitoring is particularly strong when it comes to symptoms of GD, and this could also explain the lack of effect seen between treatment groups in numerous trials of online interventions for GD. There are several different CBT-based treatment programs for GD, and the contents can vary somewhat between treatments. Commonly featured interventions are identifying and managing triggers to gamble, cognitive restructuring of gambling-related cognitive distortions, and focusing on alternative activities to gambling (14). CBT can also be delivered to patients in a number of ways, i.e., by meeting a therapist individually face-to-face, in a group format, or via the Internet.

In addition, it has also been found effective at reducing distress and functional impairment in various chronic somatic conditions (21), further establishing the relevance of the treatment format. The modules in an ICBT treatment are often paired with some form of therapist support, usually via e-mail or telephone, but unguided treatments are also common. Guided ICBT seems to have higher rates of adherence to treatment (24, 25), and some evidence points to it being slightly more effective than unguided treatments, although more research is needed (19, 26). In a recent meta-analysis of ICBT treatment for depression, the combination of telephone and e-mail support was found to perform better than other types of minimal guidance (15). Patients can interact with the treatment when and where they want as long as they have Internet access, it can potentially reach patients that would have otherwise not sought treatment, and it is less time-consuming for therapists and probably cost-effective (27, 28). The possibility of reaching those that would otherwise have not sought treatment is particularly interesting when it comes to GD as only 21% of problem gamblers seek treatment globally (29).

However, this does not necessarily mean this approach works for everyone with GD, and quite possibly a subset of those with GD need more intensive interventions such as face-to-face CBT. If they did not want to participate, they could instead receive face-to-face or group-based CBT. It is therefore possible that a self-selection has occurred where those with less severe problems or greater self-regulation chose to participate.

This bug resulted in the treatment missing most of its content, and the participant was therefore deemed to not have received the planned treatment. As this problem came to our attention during the study, we opted to include one extra participant in this group. Due to the use of a simple randomization process, this also had the effect of an extra participant being included in the ICBT group.

The IMI treatment, in comparison with the ICBT treatment, lacked CBT elements and had less content. In MI, it is possible for therapists to give advice if participants ask for it (45), and as the therapists were all trained in both CBT and MI, it might be that the advice given at times was based on the therapist’s knowledge of effective CBT strategies. This might have made the treatments more similar than intended, even though no structured CBT content or homework assignments were used.

Currently, there is no drug approved for GD, although clinical practice guidelines usually have a section on the use of psychopharmacology in the disorder. For instance, the guideline for GD published in 2011 in Australia66 accepted that naltrexone could be employed to reduce gambling severity in people with gambling problems. Owing to the complexity of GD and CBT limitations, unifying gullybet login different approaches in order to enhance their effectiveness—instead of focusing on selecting only one clinical option—has been considered by the medical community in recent years9. Some of the CBT limitations are high dropout and relapse rates during treatment6,29–32, low compliance with therapeutic guidelines, specific personality traits such as novelty seeking and impulsivity, and deficits in emotion regulation33–35. On the other hand, these underlying factors may be more difficult to modify through standard CBT36,37. Recent findings on different therapeutic approaches for GD will be presented in this review.