Research Update

How do clinicians determine an appropriate treatment plan for clients with gambling problems? The current dearth of research on treatment outcomes and the lack of a treatment standard make this a challenge for treatment providers. However, Dr. Jon Grant argues that new research will bridge the gap, allowing clinicians to select the most effective treatment options based on cognitive, neuroimaging and genetic data. Dr. Grant, professor of psychiatry at the University of Minnesota and principal investigator of the NCRG Center of Excellence in Gambling Research at the University of Minnesota, delivered a keynote address on this topic at the 8^th Annual Midwest Conference on Problem Gambling and Substance Abuse on July 20 in Kansas City, Mo.

Part two of the series recapping Dr. Howard Shaffer’s keynote address at the 25^th National Conference on Problem Gambling in Boston, Mass. To read part one of the Gambling Disorders 360° series, click here.

After laying the foundation for his presentation by outlining the theoretical revolutions that have defined our understanding of gambling disorders, Dr. Howard Shaffer then proposed that the next revolution in understanding gambling disorders will come from the way online gambling behavior can now be studied. Until recently, information about people’s gambling behavior has come almost exclusively from self-report (asking a person questions about their past gambling behaviors). Self-report is considered to be acceptably accurate by the scientific community, but it relies on recollections of individuals that may be influenced by a variety of factors such as desire to please interviewers or to downplay losses. For years these problems with self-reported data have presented a challenge to researchers studying gambling disorders. However, Dr. Shaffer suggested that new innovations in research methods will decrease the role of self-report and allow researchers to look directly at the gambling behavior of online gamblers.

As we have mentioned on Gambling Disorders 360˚, the NCRG staff has been attending and speaking at various conferences and meetings this summer. The first one of the summer was the National Conference on Problem Gambling on July 1-2.

This is the first post in a two-part series about the July 1 keynote address by Dr. Howard Shaffer. Dr. Shaffer, whose publications and research reviews we have featured previously on Gambling Disorders 360˚, is an associate professor of psychiatry at Harvard Medical School and director of the Division on Addictions at The Cambridge Health Alliance, a Harvard Medical School teaching affiliate. His talk was entitled “Scientific Revolutions: Understanding Gambling Disorders” in the spirit of the conference theme, “Celebrating 25 Years: Revolutionary Changes and Emerging Innovations” (Shaffer, 2011).

The people who work in casinos and other gaming venues are an important and under-researched group in the pathological gambling literature. Gaming employees constitute a unique group not only because they interact daily with customers in casinos, but because they are slightly more vulnerable to gambling disorders than the general population (Shaffer, Vander Bilt, & Hall, 1999). Because of these and other factors, most states and casino operators in the U.S. require gaming employees to go through training on the specifics of disordered gambling and responsible gaming.  However, there has been very little published research done on the effectiveness of employee training programs used by casinos. In fact, the first study of an employee training program by a U.S. research team was recently published in the Journal of Gambling Studies (Laplante, Gray, Labrie, Kleschinsky, & Shaffer, 2011). 

What affects the prevalence of gambling disorders in a given area? Is it access to gambling activities in general, access to a specific type of gambling activity, demographic characteristics, local norms, the presence of an underlying addictive syndrome, or some combination of these factors and others? These questions have been asked for many years and have inspired much debate in both political and academic circles. Studying a question like this requires competent and willing researchers, but also a favorable situation for research.

Unlike clinical trials, people cannot be randomly assigned to live within a certain distance of a casino, to prefer a particular gambling activity, or to have some particular demographic trait. This limitation can be overcome by taking advantage of “natural experiments,” times when some variable in a community changes and researchers can isolate the effect that variable has on the prevalence of gambling disorders in the community.

One such natural experiment will take place in Maryland over the next several years with the legalization of slot machines. The results of the first study measuring baseline disordered gambling in the state has just been released to the public, and further studies will be completed over the next several years to assess the effect (if any) of the addition of slot machines to existing gambling opportunities (Shinogle, Norris, et al., 2011).              

Toll-free help lines have been a common first line of intervention for addictive disorders for many years with successful statewide tobacco help lines leading the way. While there has been research on gambling help lines since the 1990s, to our knowledge there has not been a study tracking help-line callers from their initial call to attendance at a counseling session – until now. With the percentage of people with a gambling disorder who seek treatment from a counselor, psychologist or self-help group such as Gamblers Anonymous at only between 7 and 12 percent (Slutske, 2006), the ability of a help line to promote attendance at a counseling session is vitally important. A new study published in Psychology of Addictive Behaviors provides data on the matriculation of people with gambling disorders from calling the help line to attending a counseling session and suggests potential best practices for increasing the number of callers seeking treatment (Weinstock et al., 2011).

To understand pathological gambling (PG) one must understand the disorders that co-occur with PG. A 2005 study of more than 43,000 representative Americans found that people with PG often have other mental health disorders at the same time (called comorbid disorders). Examples of these include alcohol use disorders (73 percent), drug use disorders (38 percent), mood disorders (49 percent), anxiety disorders (41 percent) and personality disorders (60 percent) (N. M. Petry, Stinson, & Grant, 2005). While it is reasonable to hypothesize that genetic and environmental factors are both responsible for these co-occurrences, more research is necessary to learn how the two variables work together. One study that addresses these questions was recently published in the Journal of Affective Disorders (Giddens, Xian, Scherrer, Eisen, & Potenza, 2011). The study used data from 7,869 male twins to examine the relationship between PG and two anxiety disorders, generalized anxiety disorder (GAD) and panic disorder (PD).     

The American Psychiatric Association (APA) has proposed new criteria for a diagnosis of pathological gambling (PG) in the next edition of the Diagnostic and Statistical Manual of Mental Disorders, slated for publication in 2013.  As reported in Issues and Insights and discussed at the 2010 NCRG Conference on Gambling and Addiction, the proposed revisions included moving PG from the impulse control category into a new classification, “addiction and related disorders.” It also proposes dropping illegal acts from the 10 criteria and possibly reducing the number of criteria needed for a diagnosis from five to four. A new review article by Howard J. Shaffer and Ryan Martin in the 2011 Annual Review of Clinical Psychology (Shaffer & Martin, 2011) provides a critical review of these recommendations.

Have you ever been screened for a health problem? The answer is probably yes if you’ve ever been questioned by your doctor about symptoms or responded to a telephone survey about health. There are numerous screening instruments used by clinicians to determine if a client has a gambling problem, and some often appear in general population surveys to research the prevalence of the disorder. The Division of Addictions at Cambridge Health Alliance, a teaching affiliate of Harvard Medical School, recently released the Brief Biosocial Gambling Screen (BBGS) to help people decide on their own whether to seek a formal evaluation of their gambling behavior.  Development of the screen was funded by the NCRG.

Why do so many people relapse when they are trying to stop gambling? It has been estimated that 50 to 75 percent of gamblers resume gambling after attempting to quit (N. M. Petry et al., 2006), but what are the thoughts, feelings and situations that precede these events? Researchers who study alcohol and drug abuse – disorders with similarly high rates of relapse –  have developed a questionnaire designed to answer these questions for their audiences. A recent study published in the journal Experimental and Clinical Psychopharmacology attempts to validate this same type of questionnaire for people with gambling disorders (Nancy M Petry, Rash, & Blanco, 2010). The new study attempts to extend and validate Petry’s previous work adapting the Inventory of Drinking Situations for gambling situations (called the Inventory of Gambling Situations, IGS).