David C. Hodgins University of Calgary Financial Forum III, 2009

Transcription

1 PROMOTING SELF- RECOVERY FROM GAMBLING PROBLEMS THROUGH BRIEF INTERVENTION MODELS David C. Hodgins University of Calgary Financial Forum III, 2009

2 ALBERTA = 3 MILLION PEOPLE 24 casinos 11,826 slots 47 race tracks 840 slots 6,000 VLTs 2390 Ticket lottery sites

3 AB (2001) LAST YEAR PREVALENCE non-gamblers 18% social gamblers 77% problem gamblers 4% pathological gamblers 1%

4 WHERE DOES DISORDERED GAMBLING FIT? Lifetime Past year Pathological gambling Antisocial personality Obsessive compulsive disorder Pathological/problem gambling Drug abuse/dependence Major depressive episode Generalized anxiety Alcohol abuse/dependence [Modified from Shaffer et al, 1997]

5 Not Ready to Change Public Awareness, Family Support, Opportunistic interventions Ready to Change MATCHING FACTORS Severity? Other mental health disorders? Social Support? Self-Change Brief Intervention Public Health Stepped Care Model Outpatient Intervention Intensive Intervention

6 THE CASE OF ALCOHOL PROBLEMS Largest literature and best evidence Three types with epirical support Brief opportunistic interventions 1-3 sessions Motivational enhancement approaches 1-3 sessions Self-change/bibliotherapy Generally less severe populations

7 WHAT IS THE EVIDENCE THAT BRIEF INTERVENTIONS HAVE A ROLE TO PLAY? People recover without formal treatment

8 ESTIMATED RECOVERY RATES FROM POPULATION PREVALENCE SURVEYS Prevalence Rate Percent Lifetime Past Year Recovery Pathological Gambling % Problem Gambling % Both % Hodgins, Wynne, Makarchuk, 1999

9 SLUTSKE (2006) US SURVEYS National Epidemiologic Survey on Alcohol & related Conditions (N=43,093) Lifetime PG 0.4%, n=185 No past year symptoms 38%, n=70 Treatment-seekers 11%, n=8 Natural recovery 89%, n=62 American Journal of Psychiatry, 163,

10 Slutske (2006) Gambling Impact & Behavior Study (N=2,417) Lifetime PG 0.9%, n=21 No past year symptoms 43%, n=9 Treatment-seekers 11%, n=1 Natural recovery 89%, n=8 American Journal of Psychiatry, 163, Hispanic & Native American Veterans (N=1624) 30% recovery rate Westermeyer et al., 2006

11 CONCLUSIONS FROM POPULATION SAMPLES Natural recovery is common Estimates difficult to make because PG is a low base rate disorder Do not discriminate intentional versus unintentional change (maturing out) Convenience samples- focus on specifics of the change process of intentional change

12 Convenience Sample Studies Hodgins & el-guebaly, Toneatto et al., 2008 Did you recover successfully from a gambling problem? Tell us your story

13 PROBLEM GAMBLING RECOVERY STUDY Problem Gambling Media Recruitment N = 106 Resolved N = 43 Non-Resolved N = 63 NoTreatment N = 23 Minimal Treatment* N = 6 Treatment* N = 14 No Treatment N = 40 Minimal Treatment* N = 13 Treatment * N = 10 Hodgins & el-guebaly, 2000 *Minimal Treatment <5 Sessions or meetings

14 SAMPLE CHARACTERISTICS Female [%] 50 Age - mean [S.D.] 42 [10.0] Married/Common-Law [%] 47 Single - never married [%] 23 High school education or greater [%] 72 Employment: full-time [%] 56 unemployed [%] 25 Gambling Problem Primarily Electronic gaming machines 47% Primarily Mixed Games 37% Primarily Casino 8% Primarily Horses 4% Primarily Bingo 2% South Oaks Gambling Screen [SOGS] - mean: 12[3.28] Pathological Gambling [DSM-IV 5+ criteria] 94%

15 PREDICTING WHO SEEKS TREATMENT Demographics [age, gender] Comorbidities [alcohol, other drugs, depression] Type of gambling Severity of problem [SOGS, # of DSM-IV criteria] # of DSM-IV Criteria None Minimal Moderate+ TREATMENT *Most frequent reason for no treatment: Wanted to handle problem on own 79%

16 GAMBLERS RESOLUTION (MEAN 3.5 YEARS, MEDIAN 14 MONTHS) Reason reason (2 rater content analysis) Percentage of people stating Negative emotion (stress, panic) 44% Financial concern 42% Family influence 26% Incompatible with desired self-image or goals 23% Lack of financial resources 21% Rock bottom 19% Confrontation 19% Support 14% Spiritual 12% Cognitive appraisal (pros and cons evaluation) 12% Legal 9% Out of awareness 9% Rationalization 9% Environmental change 9% Fear of future negative consequences 2%

17 ACTIONS PER CONTENT ANALYSIS Action Percentage reporting action Stimulus control (avoidance control) 49% New activities (leisure, family) 47% Treatment 28% Cognitive (self-talk, thought stopping) 26% Social support 23% Spiritual 12% Will power/decision making 9% Miscellaneous 7% Nothing 7% Limited access to money 5%* Self-reward 5% Confession 5%

18 Factor Maintenance factors from openended interview questions % of people New activities 44 Remembering negative aspects/anticipating future negative consequences 33 Social support 30 Treatment 28 Focusing on improvements in life 19 Cognitive strategies for urges 16 Stimulus control/avoidance 16 Spiritual 12 Insight into gambling behaviors 9 Lack of finances 9 Focusing on family responsibilities 7 Limiting access to money 5 Self-reward 2

19 COMBINED METHOD: CUNNINGHAM, HODGINS & TONEATTO, 2009 Less severe problems than nonrecovered

20 NATURAL RECOVERY ASSESSMENT

21 CAN YOU PLEASE TELL ME WHAT LEAD YOU TO QUIT OR CUT DOWN ON YOUR GAMBLING? Negative consequences 25% Drifting out 42% Reflective/maturation 42% more severe problems

22 IN ORDER TO HELP US DESIGN MORE EFFECTIVE WAYS TO HELP PEOPLE WITH THEIR GAMBLING, WE ARE INTERESTED IN ANYTHING THAT YOU CAN TELL US ABOUT WHAT HELPED YOU TO QUIT OR CUT DOWN ON YOUR GAMBLING. CAN YOU TELL ME ABOUT ANY STRATEGIES YOU USED TO HELP YOU CUT DOWN ON YOUR GAMBLING?

23 STRATEGIES IDENTIFIED Common sense/figured out what was important and stuck to it/came to realization 32% Set a limit/stick to it/don t bring credit or debit cards 23% Avoided gambling situations 19% Took up other hobbies/activities/kept busy- 8%

24 Conclusions from natural recovery studies o o o o Many people recover successfully on their own and want to do it on their own Related to less severe but not insignificant or short-term problems Recovery strategies are practical, problemfocused, cognitive-behavioural We need a range of treatment options, including promoting self-recovery

25 Problem Gambling Self-recovery Program Hodgins, Currie & el-guebaly, 2004

26 MINIMAL TREATMENT TRIAL (HODGINS ET AL., JCCP, 2001) Media Recruitment Random assignment to 3 conditions (N=102) waiting list control (1 month). self-help workbook through the mail. self-help workbook through the mail plus a minute motivational telephone interview. Telephone follow-up 1, 3, 6,12 24 months. Collateral verification

27 Motivational Interview = Motivational Nudge 1. Elicit client concerns - normative feedback 2. Explore ambivalence 3. Promote self-efficacy 4. Suggest strategies

28 MINIMAL TREATMENT DEMOGRAPHICS (N=102) Gender (female) 52% Problem Type VLT s 86% Casinos 19% Bingo 10% Horse racing 4% Lotteries 4% Slots 3% Card games 3% Speculative investments 1% Games of skill 1% South Oaks Gambling Screen M =12 Previous Treatment 56%

29 Minimal Treatment - 24 Month Outcome days prior 3months 6months 12months 24months workbook only motivational interview

30 MINIMAL TREATMENT CONCLUSIONS o Results are promising. Gamblers report reading the manual and following the strategies. o Media recruitment is an effective way to attract problem gamblers not seeking treatment particularly women o Significant reduction in gambling at 24 months o Support for Stepped Care Model o Motivational enhancement helpful

31 REPLICATION STUDY (N=314) Waitlist control Workbook only Minimal Treatment - Workbook plus MI telephone Brief Treatment Workbook plus MI plus 5 booster calls Hodgins et al., 2009, JCCP

32 REASONS FOR NOT SEEKING TREATMENT (N=314)

33 REPLICATION STUDY DAYS GAMBLED/MONTH Days Pre Weeks MI-brief MI-booster Workbook only waitlist

34 HYPOTHESIZED PREDICTORS OF OUTCOME individuals with less severe problems, no comorbid mood or substance use disorders, greater social support and greater self-efficacy

35 Yes Male TENTATIVE PREDICTORS OF OUTCOME No previous treatment High self-efficacy High motivation Not depressed/bipolar Family support No mental health treatment No SOGS/NODS/ CPGI scores Substance abuse history

36 IDEAL CANDIDATE FOR BRIEF TREATMENT Male pathological gambler who has no previous gambling or mental health treatment, is not depressed, has good family support and is highly motivated and believes that he/she can succeed with brief treatment

37 All Problem/Pathological Gamblers Not Ready to Change Public Awareness, Family Support, Opportunistic Interventions Ready to Change MATCHING FACTORS no previous tx; Family Support; Client Preference Self- Change Brief Intervention Public Health Stepped Care Model Outpatient Intervention Intensive Intervention

38 WHAT WORKED? (MODE = 1,MEAN =1.6) Action % of people New activities/change in focus 68% Stimulus Control/Avoidance 48% Treatment 37% Cognitive 34% Budgeting 31% Willpower/Decision-making/self-control 23% Social support 10% Others confession, no money, nongambling external factors, self-reward, <5% spiritual, addressing other addictions Hodgins et al., in press

39 HOW DOES BRIEF TREATMENT WORK? Premise: what an individual says about change during the interview is related to subsequent change Verbalizing an intention to change (CHANGE TALK) leads to public and personal obligation to modify one s behavior

40 HOW DOES BRIEF TREATMENT WORK? Coded therapy transcripts for Change Talk Does amount of Change Talk correlate with change in gambling behavior? 3 months r = -.39* 6 months r = -.36* 12 months r = -.35* * p <.05 Hodgins, Ching & MacEwan, 2009

41 THOUGHTS Stepped care make sense Use of fewest resources per person Promoting self-change makes sense Maximizing the number of people addressing a problem Focusing on motivation makes sense Maximizing effectiveness

42 FUTURE DIRECTIONS Comparative designs Search for matching factors Dismantling studies Strategies, MI, Normative feedback

43 FUTURE DIRECTIONS Practical applications How to offer it Helpline - New Zealand Project Web Applications Canada & Sweden Free standing service-?

44 THANKS CIHR Alberta Gaming Research Institute Ontario Problem Gambling Research Centre Alberta Heritage Foundation for Medical Research