Treatment Professionals Conference

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Presentation transcript:

Treatment Professionals Conference Dr Heidi Sinclair November 2017

Goals of Treatment? Symptoms: Abstinence vs Reduction Quality of Life Co-occurring problems Reduction in suicide rates Family/ Interpersonal relations

Treatment Approaches Gamblers Anonymous Psychosocial Treatments: CBT-- Functional Analysis, Brief Interventions, Imaginal Exposure, Motivational Interviewing, Relapse Prevention Medication: Opioid Antagonists, N-acetylcysteine New research: decreased caffeine intake, transcranial magnetic stimulation

Gamblers Anonymous 22.4% attended only 1 meeting, 15.5% attended only 2 meetings, 7.5% earned a 1-year abstinence pin. Those who stayed more likely to have initial realistic expectations of GA and a spouse in GamAnon. Those who dropped out more likely to endorse “controlled gambling,” and did not identify with severity of problems as other members.

Psychosocial Treatments Multiple controlled studies Cognitive Behavioral Therapy Sessions 1 to 16 Group, Online, In Person

Cognitive Behavioural Therapy Psychoeducation Increased awareness of irrational cognitions, and cognitive restructuring. Identification of gambling triggers and the development of non- gambling sources to compete with the reinforcers associated with gambling.

Functional Analysis A Antecedent B Behaviour Consequence Particular people Environment Feelings e.g., urges, argument with spouse, boredom, anxiety B Behaviour Gambling/alternate behavior e.g. I drove by the casino, next thing I knew it was 2am Abstinence e.g. I thought about the effect it would have on my family and I took a different route home Consequence Positive e.g. I gambled and I forgot about the argument with my wife Negative e.g. the next day I felt like I’m a failure

Brief Interventions Interventions ranging from a single brief session to 4 sessions Self-Help Workbooks Designed to introduce treatment, engage patient into treatment and to target at-risk and problem gamblers Easy to implement

Groups Group CBT – 3 studies Cognitive restructuring Coping skills and identification of high-risk situations. Imaginary exposure with response prevention. Financial limit setting and activity scheduling of leisure activities. Problem-solving training Relapse prevention

Imaginal Exposure Client and Therapist develop an imaginal exposure script that includes all the relevant internal and external triggers that relate to the gambler’s gambling Urges or cravings can be activated using exposure to triggering events via imaginal exposure exercises.

Motivational Interviewing A directive, client-centered method for enhancing intrinsic motivation to change by exploring and resolving ambivalence Style vs. therapy Client centered – listening and reflecting Focused on ambivalence Focused and goal directed

Relapse Prevention Variant of cognitive-behavioural therapy; main approach is: Identification of ‘triggers’ to resume use Planning and rehearsal of avoidance Planning and rehearsal of escape ‘slip’ not equal to relapse

Opioid Antagonists The mu-opioid system: urge regulation through the processing of reward, pleasure and pain, at least in part via modulation of dopamine neurons in the mesolimbic pathway through GABA interneurons.

N-acetylcysteine (NAC) Amino-acid and antioxidant Potentially modulates brain glutamate transmission Levels of glutamate within the nucleus accumbens mediate reward-seeking behavior Lacks significant side effects Open-Label study of NAC in Gambling Disorder n=27 subjects, mean age 50.8 years, 44.4% female Dose titration from 600mg/d to 1800mg/d • Required to have moderate cravings to gamble

Open-Label Study of NAC in GD Results: YBOCS: Scores decreased 41,9% from baseline to endpoint Mean effective dose: 1476mg/day

Newer research Transcranial Magnetic Stimulation---suppress cravings Decreased caffeine intake—less impulsivity

Outcomes Drop-out rates are high for all treatments (>50%) Relapse rates after treatment are high (up to 75%)

Predictors Those who had previously relapsed or dropped out showed higher impulsivity. Reduction of cognitive distortions and better decision making were the best predictors of recovery, regardless of the type of treatment received. Smoking status

Problems with treatment research Short term studies Homogeneous groups/lack of diversity Lack of co-occurring disorders Evidence of subtyping not yet being used How many people use the manual and do it properly? How do quality of life improve?

Conclusions Disordered Gambling is treatable Data suggest that CBT and medications are most effective treatments Moving from research settings to clinical settings is the challenge.

Questions?