Guideline for Screening, Assessment and Treatment in Problem Gambling

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1 Guideline for Screening, Assessment and Treatment in Problem Gambling

2 This guideline development was supported by: and THE PROBLEM GAMBLING RESEARCH AND TREATMENT CENTRE A joint initiative of the Victorian Government, the University of Melbourne and Monash University Approved citation: Problem Gambling Research and Treatment Centre (PGRTC) (2011). Guideline for screening, assessment and treatment in problem gambling. Clayton: Monash University Monash University Printed publication This work is copyright. You may reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Problem Gambling Research and Treatment Centre to do so. Requests and inquiries concerning reproduction and rights are to be sent to Professor Shane Thomas, Director, Problem Gambling Research and Treatment Centre, Monash University, 1/270 Ferntree Gully Rd, Notting Hill, Victoria 3168 or ISBN Print: Monash University Electronic document This work is copyright. You may download, display, print and reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Problem Gambling Research and Treatment Centre to do so. Requests and inquiries concerning reproduction and rights are to be sent to Professor Shane Thomas, Director, Problem Gambling Research and Treatment Centre, Monash University, 1/270 Ferntree Gully Rd, Notting Hill, Victoria 3168 or ISBN Online: Disclaimer This document is a general guide to appropriate practice, to be followed subject to the circumstances, clinician s judgement and patient s preferences in each individual case. It is designed to provide information to assist decision making. Recommendations contained herein are based on the best available evidence published up to March The relevance and appropriateness of the information and recommendations in this document depend on the individual circumstances. Moreover, the recommendations and guidelines are subject to change over time. Each of the parties involved in developing this document expressly disclaims and accepts no responsibility for any undesirable consequences arising from relying on the information or recommendations contained herein. Copies of this guideline can be downloaded from or Publication Approval These guidelines were approved by the Chief Executive Officer of the National Health and Medical Research Council (NHMRC) on 11 August 2011, under Section 14A of the National Health and Medical Research Council Act In approving these guidelines the NHMRC considers that they meet the NHMRC standard for clinical practice guidelines. This approval is valid for a period of 5 years. NHMRC is satisfied that they are based on the systematic identification and synthesis of the best available scientific evidence and make clear recommendations for health professionals practising in an Australian health care setting. The NHMRC expects that all guidelines will be reviewed no less than once every five years. This publication reflects the views of the authors and not necessarily the views of the Australian Government.

3 Foreword The guideline summarises the research and the current state of knowledge concerning problem gambling and includes a series of evidence-based recommendations concerning screening, assessment and treatment practices for problem gambling. The development of this guideline is an endorsed activity of the International Gambling Think Tank. The Think Tank is an invitational meeting of the world s leading scientists in gambling and addiction and the jurisdictions within which they operate with representation from the US, Canada, European Union, UK and Nordic countries, Asia, Australia and New Zealand. The guideline has been developed in response to a growing research base in problem gambling and the need for problem gambling services, practitioners and policy makers to have evidence-based guidance in the design and delivery of treatments for people with gambling problems. It should be noted that for the purpose of this Australian guideline, the term problem gambling is used to refer to the full continuum of gambling-related harm, which is in accordance with standard practice in the Australian context. The term pathological gambling is only used in the context of the DSM classification in this guideline. It is acknowledged that in some other jurisdictions the term pathological gambling is used to refer to people with a diagnosed or diagnosable gambling disorder and that the term problem gambling is sometimes used to refer to people who are at risk of developing problem gambling, ie. a sub- clinical state. As this guideline is oriented to the Australian jurisdiction the term problem gambling has been employed. The use of this terminology does not alter the generalisability of these guidelines to other jurisdictions for the screening, assessment and treatment of people with problem or pathological gambling. While we acknowledge that the prevention of problem gambling is an important objective, the focus of this guideline is squarely upon the screening and treatments for people with or at risk of problem gambling. Thus this document is focused upon dealing with people who are at the secondary and tertiary end of the continuum in developing problem gambling. This guideline does not provide advice as to the prevention of problem gambling. The prevention of problem gambling involves a completely different research evidence base and different approaches to those included in the current guideline. We also acknowledge that problem gambling can have a significant impact upon the problem gambler s family, friends and the community more broadly. However, the treatment of others impacted by the problem gambler s issues is outside the scope of our guideline. The guideline has been based upon the best available research evidence. In relation to the treatment aspects of our work we undertook two related Cochrane systematic reviews of psychological and pharmacological treatments for problem gambling. The protocols for the reviews have been published (1, 2) and we envisage that the actual reviews will also be published soon. Dr Harriet Radermacher, Dr Sean Cowlishaw, Christopher Anderson and Stephanie Merkouris from Monash University have labored very hard in the extensive and technical support work that is required to complete these reviews and also in the technical work required to translate the evidence into an effective guideline. Our colleagues at the University of Melbourne, Dr Nicki Dowling and Professor Alun Jackson have also contributed significantly to the drafting of the guideline. We have also been very ably supported by the Australasian Cochrane Centre through the offices of Dr Marie Misso and Professor Sally Green. The Expert Advisory Panel, which was constituted as outlined in NHMRC standards and procedures for externally developed guidelines (3) and A guide to the development, implementation and evaluation of clinical practice guidelines (4), has provided excellent expert and consumer commentary in the drafting and re-drafting of the guideline and we thank them for their contributions. Shane Thomas Chair, Guideline Development Group Chair, Expert Advisory Panel Deputy Dean Faculty of Medicine, Nursing and Health Sciences Monash University April, 2011 Guideline for screening, assessment and treatment in problem gambling i

4 Table of contents Foreword...i Table of contents...ii List of tables...v List of figures...v List of abbreviations... 2 Guideline development... 4 Summary of recommendations... 6 Recommendations for screening and assessment... 8 Evidence-based recommendations for screening and assessment... 8 Consensus-based recommendations for screening and assessment... 8 Practice points for screening and assessment... 8 Recommendations for treatment Evidence-based recommendations for treatment Consensus-based recommendations for treatment Part 1 Guideline overview What is this document and what is its purpose? When will this guideline be updated? Background Gambling in Australia Conceptualising and defining problem and pathological gambling Prevalence of gambling Gambling modalities Gambling issues for different sub-populations People with gambling problems and co-occurring psychiatric symptoms Gender and gambling Age and gambling Young people Seniors Indigenous communities and gambling Culturally and linguistically diverse (CALD) communities and gambling Guideline objectives Scope of the guideline Target audience for the guideline ii Guideline for screening, assessment and treatment in problem gambling

5 Focus of the guideline Methods used to develop the guideline Funding and editorial independence Multidisciplinary contribution to guideline development Identification of clinical questions Selection criteria Identification and review of existing relevant gambling guidelines Identification of evidence Review of evidence Screening of the evidence Assessment of methodological quality Data extraction How recommendations were formulated Public consultation process Limitations of the guideline Generalisability and applicability of the studies reviewed to support the guideline Medical information Lack of evidence Cost effectiveness Part 2 Screening and assessment of problem gambling Conceptualising screening and assessment Potential benefits of screening and assessment Clinical questions used for the development of screening and assessment recommendations Outcomes used for the development of screening and assessment recommendations Evidence-based recommendations for screening and for assessment Important background issues to consider for screening and for assessment Measurement tools used for screening, assessment and diagnosis in problem and pathological gambling Validation issues in tools used to screen and assess potential problem gamblers Who should be screened and what type of screening should be used? Lifetime and past year gambling What should be assessed in addition to gambling measures for people who potentially have problem gambling? What is the role of general practitioners in screening and assessment of problem gambling? Review of potential screening and assessment tools for problem gambling Commentary about the available screening and assessment tools How to assess which tools should be recommended Guideline for screening, assessment and treatment in problem gambling iii

6 Recommendations for screening and for assessment of problem gambling Consensus-based recommendations Practice points Recommendations for further research for screening and for assessment of problem gambling Part 3 Treatment of problem gambling Overview of the problem gambling treatment evidence base Clinical questions used for the development of treatment recommendations Outcomes used for the development of treatment recommendations Recommendations for treatment of problem gambling Psychological interventions for problem gambling Cognitive-behavioural therapy (cbt) Other psychological interventions Voluntary self-exclusion Practitioner involvement in psychological interventions Length of psychological interventions Group psychological interventions Setting of psychological interventions Goals of psychological interventions Pharmacological interventions for problem gambling Antidepressant medications Opioid antagonists Mood stabilisers/anticonvulsants Other pharmacological interventions Psychological and pharmacological interventions for problem gambling Pharmacological versus psychological interventions Combined psychological and pharmacological interventions Targeted interventions for pproblem gambling Gambling problems and co-occurring psychiatric symptoms Women and gambling Men and gambling Young people and gambling Seniors and gambling Gambling modality Part 4 Dissemination and evaluation Proposed dissemination and implementation strategy Evaluation of guideline implementation Glossary References iv Guideline for screening, assessment and treatment in problem gambling

7 List of tables Table 1. Categories of recommendation... 7 Table 2. Definition of terms used in formulating evidence-based recommendations... 7 Table 3. Gambling expenditure in Australia 2008/ Table 4. Some recent Australian statewide prevalence rates Table 5. Prevalence of comorbid mental health disorders in problem and pathological gambling Table 6. Evaluation of adult problem gambling screening and assessment tools Table 7. Evaluation of children and adolescents problem gambling screening and assessment tools Table 8. Some intervention delivery characteristics Table 9. Key evaluation terms and definitions Table 10. Objectives and indicators of program and cost effectiveness List of figures Figure 1. Screening, assessment and treatment decisions Figure 2. Diagnostic decision outcomes Figure 3. DSM-IV criteria for pathological gambling Figure 4. The relationship between screening, diagnosis and assessment Figure 5. Dissemination strategy Figure 6. Evaluation strategy Appendices A. Summary of adult, adolescent and children screening and assessment tools As a separate volume: A1. Methods A2. Screening and assessment A2.1 Body of evidence matrices A2.2 Body of evidence reviews A2.3 Data extraction/appraisal tables A2.4 Excluded studies table A2.5 PICO tables A3. Treatment A3.1 Body of evidence matrices A3.2 Body of evidence reviews A3.3 Data extraction/appraisal tables A3.4 Excluded studies table A3.5 PICO tables Guideline for screening, assessment and treatment in problem gambling v

8 The development of evidence-based care recommendations for the screening, assessment and treatment of problem gambling is the first stage in ensuring that the best possible care is provided to people with problem gambling. vi Guideline for screening, assessment and treatment in problem gambling

9 1 The Screening, Assessment and Treatment of Problem Gambling Draft Guideline Submitted to the National Health and Medical Research Council

10 List of abbreviations ADHD AGREE APA AUDADIS-IV BBGS CAGI CALD CBT CPGI DIGS DSM DSM-IV-J DSM-IV-MR-J EGM EIGHT FLAGS GA GA20 GDG GP GPSS MAGS MET MI MINT NHMRC NICE NODS PGRTC PGSI Attention Deficit Hyperactivity Disorder Appraisal of Guideline for Research and Evaluation American Psychiatric Association Alcohol Use Disorder and Associated Disabilities Interview Schedule IV Brief Bio-Social Gambling Screen Canadian Adolescent Gambling Inventory Culturally and Linguistically Diverse Cognitive-Behavioural Therapy Canadian Problem Gambling Index Diagnostic Interview for Gambling Severity Diagnostic and Statistical Manual of Mental Disorders Diagnostic and Statistical Manual IV Adapted for Juveniles Diagnostic and Statistical Manual IV Multiple Response Adapted for Juveniles Electronic Gaming Machine Early Intervention Gambling Health Test Focal Adult Gambling Screen Gamblers Anonymous Gambler Anonymous Twenty Questions Guideline Development Group General Practitioner Gambling Problem Severity Subscale Massachusetts Gambling Screen Motivational Enhancement Therapy Motivational Interviewing Motivational Interviewing Network of Trainers National Health and Medical Research Council National Institute for Health and Clinical Excellence National Opinion Research Center DSM Screen for Gambling Problems Problem Gambling Research and Treatment Centre Problem Gambling Severity Index 2 Guideline for screening, assessment and treatment in problem gambling

11 PICO PPGM RCT ROC SCIP SES SOGS SOGS-R SOGS-RA SSRI TGA VGS Participants, Intervention, Comparison and Outcomes Problem and Pathological Gambling Measure Randomised Controlled Trial Receiver Operator Curve Structured Clinical Interview for Pathological Gambling Socioeconomic status South Oaks Gambling Screen South Oaks Gambling Screen Revised South Oaks Gambling Screen Revised for Adolescents Selective Serotonin Reuptake Inhibitor Therapeutic Goods Administration Victorian Gambling Screen Guideline for screening, assessment and treatment in problem gambling 3

12 Guideline development The guideline was developed by the Guideline Development Group (GDG) and supported by the Expert Advisory Panel, as well as other technical and operational support. The Guideline Development Group comprised: Chair Professor Shane Thomas (Chair), Director PGRTC, Monash University Members Mr Christopher Anderson, Project Manager, Executive Officer (PGRTC), Monash University Dr Nicki Dowling, Senior Research Fellow PGRTC, University of Melbourne Professor Alun Jackson, Director PGRTC, University of Melbourne Ms Stephanie Merkouris, Research Assistant PGRTC, Monash University Dr Marie Misso, Research Fellow, Australasian Cochrane Centre, Monash University Dr Harriet Radermacher, Project Manager, Research Fellow PGRTC, Monash University With technical and operational support from: Ms Anna Chapman, Research fellow PGRTC, Monash University Dr Sean Cowlishaw, Biostatistician PGRTC, Monash University Ms Felicity Lorains, Research assistant PGRTC, Monash University Ms Sylvia Niele, Research assistant PGRTC, Monash University We are very grateful to Professor Sally Green, of the Australasian Cochrane Centre, for providing methodological review of the draft guideline. The Expert Advisory Panel comprised: Chair Professor Shane Thomas, Psychometrics and ethical conduct, Monash University Clinicians with Specialist Expertise Professor Malcolm Battersby, Psychiatry, Flinders University Dr Nicki Dowling, Clinical Psychology, University Of Melbourne Professor Alun Jackson, Social Work, University Of Melbourne Professor Leon Piterman, General Practice, Monash University Professor Jim Westphal, Psychiatry, University Of Hawaii Clinician with General Expertise Associate Professor Danielle Mazza, General Practice, Monash University 4 Guideline for screening, assessment and treatment in problem gambling

13 Consumer Representatives Mr Wayne Seiler Ms Gabi Byrne Health Economist Ms Lara Donovan, Centre for Health Economics, Monash University Indigenous Representative Mr Ashley Gordon, Indigenous Research and Gambling Consultant Industry Representatives Ms Sonja Bauer, Responsible Gaming, Crown Melbourne Ms Nadine Grinblat, Australasian Gaming Council Public Policy/Government Representatives Mr Trevor Hunt, Victorian Department of Justice (Up to October 2010) Ms Sue Hughes, Victorian Department of Justice (From November 2010) Ms Leeanne Head, Office for Problem Gambling, South Australia Specialist in evidence review and Guideline Development Dr Marie Misso, Australasian Cochrane Centre, Monash University The two Cochrane systematic reviews of problem gambling treatments we conducted to support this guideline development were supported by the Cochrane Depression, Anxiety and Neurosis Group at Bristol University. We received additional technical advisory support for the two reviews from the Australasian Cochrane Centre. Guideline for screening, assessment and treatment in problem gambling 5

14 Summary of recommendations There are three categories of recommendations used in this guideline as outlined in Table Evidence-based recommendations Evidence-based recommendations were assigned a grade (see Table 1) based on the strength of the evidence, the consistency of the evidence across studies, the likely clinical impact, and the degree to which the evidence can be generalised and applied to the Australian context. Evidence-based recommendations were only made where there was sufficient evidence (see Table 2 for a definition of what constituted sufficient and insufficient evidence). Full details of the process used to formulate evidence-based recommendations can be found in Appendix A1. The process used to assign grades to evidence-based recommendations is outlined in NHMRC levels of evidence and grades for recommendations for developers of guidelines (5). Where appropriate, these recommendations are accompanied by practice points. 2. Consensus-based recommendations In the absence of sufficient evidence, and where appropriate, consensus-based recommendations were formulated based on clinical opinion and expertise. 3. Practice points Practice points may stand alone, or accompany evidence- or consensus-based recommendations. They were formulated to provide relevant practical advice and information. 6 Guideline for screening, assessment and treatment in problem gambling

15 Table 1. Categories of recommendation Recommendation category Description Evidence-based Consensus-based Practice Point A B C D Body of evidence can be trusted to guide practice Body of evidence can be trusted to guide practice in most situations Body of evidence provides some support for recommendation(s) but care should be taken in its application Body of evidence is weak and recommendation must be applied with caution Recommendation based on expert opinion as insufficient evidence available Practical advice and information based on expert opinion Table 2. Definition of terms used in formulating evidence-based recommendations No evidence No studies were identified. This does not mean there was no evidence available, just that it did not meet our inclusion criteria. Insufficient evidence Only one study met the inclusion criteria, and this was not of sufficient quality (and therefore not reliable evidence) to make an evidence-based recommendation. OR More than one study met the inclusion criteria, but the studies were not comparable or the findings were inconsistent, therefore it was not appropriate to synthesise to make an evidence-based recommendation. Sufficient evidence More than one study met the inclusion criteria, and the findings were comparable, consistent and of sufficient quality to make an evidence-based recommendation. Guideline for screening, assessment and treatment in problem gambling 7

16 Recommendations for screening and assessment Evidence-based recommendations for screening and assessment Due to a lack of evidence, no evidence-based recommendations could be made regarding the screening or the assessment of people who may have gambling problems. Consensus-based recommendations for screening and assessment Consensus-Based Recommendation 1 Section 2.1 Those who screen positive for problem gambling using an initial brief (ie. 1-3 items) screening tool could be referred for further assessment and treatment by appropriately trained specialist practitioners in problem gambling. Screening could be used in primary care settings where at risk clients may be presenting for services. These may include: People who present for other mental health problems People who come from groups with relatively high rates of problem gambling Consensus-Based Recommendation 2 Section 2.1 Adults with high risk of mental health problems including those who are presenting for treatment or for assessment for mental health problems could be screened and assessed for problem gambling using a validated measurement tool or tools. The recommended tools are: Brief (1 3 items) Brief Bio-Social Gambling Screen (BBGS)* Lie-Bet Questionnaire* NODS-CLiP* Medium (4 12 items) Problem Gambling Severity Index (PGSI) of the Canadian Problem Gambling Index (CPGI) Long (>13 items) South Oaks Gambling Screen (SOGS) Victorian Gambling Screen (VGS) Problem and Pathological Gambling Measure (PPGM)* *Validation study information only 8 Guideline for screening, assessment and treatment in problem gambling

17 Consensus-Based Recommendation 3 Section 2.1 Adolescents and children with high risk of mental health problems including those who are presenting for treatment or for assessment for mental health problems could be screened and assessed for problem gambling using a validated measurement tool or tools. The recommended tools are: Diagnostic and Statistical Manual-IV-Multiple Response-Adapted for Juveniles (DSM-IV-MR-J) Gambling Problem Severity Subscale (GPSS) of the Canadian Adolescent Gambling Inventory (CAGI)* *Validation study information only Guideline for screening, assessment and treatment in problem gambling 9

18 Practice points for screening and assessment Practice Point 1 Section 2.2 The original and validated versions and scoring protocols of all tools could be utilised in epidemiological and clinical settings. Practice Point 2 Section 2.2 A structured clinical interview may be required for a full assessment (eg. Diagnostic Interview for Gambling Severity (DIGS), Structured Clinical Interview for Pathological Gambling (SCIP)). Practice Point 3 Section 2.2 People with high risk of gambling problems including those who are presenting for treatment or for assessment for gambling problems could be screened for other mental health problems including: Anxiety disorders Depression* Personality disorders Alcohol dependence Drug dependence Other impulse control disorders Family violence * If depression is evident then suicide risk screening protocols ought be considered 10 Guideline for screening, assessment and treatment in problem gambling

19 Recommendations for treatment Evidence-based recommendations for treatment In contrast to the screening and assessment recommendations, practice points accompany the evidence-based recommendations for treatment Evidence-Based Recommendation 1 Section 3.1 Individual or group Cognitive-Behavioural Therapy should be used to reduce gambling behaviour, gambling severity and psychological distress in people with gambling problems. B Practice Point Where Cognitive-Behavioural Therapy is to be prescribed, the following could be considered: Practitioners with appropriate qualifications and training Manualised delivery of the intervention Evidence-Based Recommendation 2 Section 3.2 Motivational Interviewing and Motivational Enhancement Therapy should be used to reduce gambling behaviour and gambling severity in people with gambling problems. B Practice Point Practitioners with appropriate qualifications and training Manualised delivery of Motivational Enhancement Therapy could be considered Evidence-Based Recommendation 3 Section 3.4 Practitioner delivered psychological interventions should be used to reduce gambling severity and gambling behaviour in people with gambling problems. B Practice Point Where practitioner delivered psychological interventions are to be prescribed, the following could be considered: Client preferences Availability of services Practitioners with appropriate qualifications and training Manualised delivery of the intervention Guideline for screening, assessment and treatment in problem gambling 11

20 Evidence-Based Recommendation 4 Section 3.4 Practitioner delivered psychological interventions should be used over self-help psychological interventions to reduce gambling severity and gambling behaviour in people with gambling problems. B Practice Point Where practitioner delivered psychological interventions are to be prescribed, the following could be considered: Client preferences Availability of services Practitioners with appropriate qualifications and training Manualised delivery of the intervention Evidence-Based Recommendation 5 Section 3.6 Group psychological interventions could be used to reduce gambling behaviour and gambling severity in people with gambling problems. C Practice Point Where group psychological interventions are to be prescribed, the following could be considered: Client preferences Availability of services Practitioners with appropriate qualifications and training Manualised delivery of the intervention Evidence-Based Recommendation 6 Section 3.9 Antidepressant medications should not be used to reduce gambling severity in people with gambling problems alone. B Practice Point Due to the nature of the samples studied, this recommendation is applicable to those with gambling problems only, and not to those who may have other comorbidities, such as depression and anxiety. This recommendation is predominantly based on evidence evaluating the effectiveness of selective serotonin-reuptake inhibitors. 12 Guideline for screening, assessment and treatment in problem gambling

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