Cognitive versus exposure therapy for problem gambling: Randomised controlled trial.

BACKGROUND: Problem gambling-specific cognitive therapy (CT) and behavioural (exposure-based) therapy (ET) are two core cognitive-behavioural techniques to treating the disorder, but no studies have directly compared them using a randomised trial. AIMS: To evaluate differential efficacy of CT and ET for adult problem gamblers at a South Australian gambling therapy service. METHODS: Two-group randomised, parallel design. Primary outcome was rated by participants using the Victorian Gambling Screen (VGS) at baseline, treatment-end, 1, 3, and 6 month follow-up. FINDINGS: Of eighty-seven participants who were randomised and started intervention (CT = 44; ET = 43), 51 (59%) completed intervention (CT = 30; ET = 21). Both groups experienced comparable reductions (improvement) in VGS scores at 12 weeks (mean difference -0.18, 95% CI: -4.48-4.11) and 6 month follow-up (mean difference 1.47, 95% CI: -4.46-7.39). CONCLUSIONS: Cognitive and exposure therapies are both viable and effective treatments for problem gambling. Large-scale trials are needed to compare them individually and combined to enhance retention rates and reduce drop-out.

Predictors of relapse in problem gambling: a prospective cohort study.

To explore the variation of predictors of relapse in treatment and support seeking gamblers. A prospective cohort study with 158 treatment and support seeking problem gamblers in South Australia. Key measures were selected using a consensus process with international experts in problem gambling and related addictions. The outcome measures were Victorian Gambling Screen (VGS) and behaviours related to gambling. Potential predictors were gambling related cognitions and urge, emotional disturbance, social support, sensation seeking traits, and levels of work and social functioning. Mean age of participants was 44 years (SD = 12.92 years) and 85 (54 %) were male. Median time for participants enrollment in the study was 8.38 months (IQR = 2.57 months). Patterns of completed measures for points in time included 116 (73.4 %) with at least a 3 month follow-up. Using generalised mixed-effects regression models we found gambling related urge was significantly associated with relapse in problem gambling as measured by VGS (OR 1.29; 95 % CI 1.12-1.49) and gambling behaviours (OR 1.16; 95 % CI 1.06-1.27). Gambling related cognitions were also significantly associated with VGS (OR 1.06; 95 % CI 1.01-1.12). There is consistent association between urge to gamble and relapse in problem gambling but estimates for other potential predictors may have been attenuated because of methodological limitations. This study also highlighted the challenges presented from a cohort study of treatment and support seeking problem gamblers.

The acceptability and outcomes of a peer- and health-professional-led Stanford self-management program for Vietnam veterans with alcohol misuse and their partners.

OBJECTIVE: The purpose of this study was to determine the acceptability of peer- and health-professional-led self-management education using the Stanford Program with Australian veterans and their partners. METHODS: The 6-week program taught problem-solving and decision-making skills to activate healthful behaviors, including action-planning and goal-setting. The evaluation included a participant and facilitator postprogram questionnaire; group interview; and alcohol, posttraumatic stress disorder, anxiety, depression, anger, relationship, and quality-of-life measures as part of a randomized controlled study. RESULTS: Participants included 25 male veterans with comorbid alcohol dependency, psychiatric and medical conditions, and 18 female partners (n = 43), 61.5% of who reported a chronic condition. The primary outcome was a self-reported improvement in self-management of their conditions in 69% of participants, with another 22.2% reporting that their confidence to self-manage had improved. There was an improvement in all measures at 9 months. CONCLUSIONS: The program resulted in improvements in lifestyle and confidence in self-management for Vietnam veterans, a cohort difficult to engage in healthy behaviors. Most participants were also accompanied by their partners. The program is a valuable resource for providing self-management education to veterans with alcohol dependency and various chronic conditions and needs to be considered in the suite of rehabilitation programs available to Defense Force personnel, veterans, and their partners.

Two-group randomised, parallel trial of cognitive and exposure therapies for problem gambling: a research protocol.

BACKGROUND: Problem gambling is a serious public health concern at an international level where population prevalence rates average 2% or more and occurs more frequently in younger populations. The most empirically established treatments until now are combinations of cognitive and behavioural techniques labelled cognitive behaviour therapy (CBT). However, there is a paucity of high quality evidence for the comparative efficacy of core CBT interventions in treating problem gamblers. This study aims to isolate and compare cognitive and behavioural (exposure-based) techniques to determine their relative efficacy. METHODS: A sample of 130 treatment-seeking problem gamblers will be allocated to either cognitive or exposure therapy in a two-group randomised, parallel design. Repeated measures will be conducted at baseline, mid and end of treatment (12 sessions intervention period), and at 3, 6 and 12 months (maintenance effects). The primary outcome measure is improvement in problem gambling severity symptoms using the Victorian Gambling Screen (VGS) harm to self-subscale. VGS measures gambling severity on an extensive continuum, thereby enhancing sensitivity to change within and between individuals over time. DISCUSSION: This article describes the research methods, treatments and outcome measures used to evaluate gambling behaviours, problems caused by gambling and mechanisms of change. This study will be the first randomised, parallel trial to compare cognitive and exposure therapies in this population. ETHICS AND DISSEMINATION: The study was approved by the Southern Adelaide Health Service/Flinders University Human Research Ethics Committee. Study findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN 12610000828022.

A randomised controlled trial of the Flinders Program™ of chronic condition management in Vietnam veterans with co-morbid alcohol misuse, and psychiatric and medical conditions.

OBJECTIVE: To evaluate the efficacy of the Flinders Program™ of chronic condition management on alcohol use, psychosocial well-being and quality of life in Vietnam veterans with alcohol misuse. METHOD: This 9-month wait-list, randomised controlled trial used the Alcohol Use Disorders Identification Test (AUDIT) score ≥ 8 as the entry criterion. Intervention veterans received the Flinders Program plus usual care and controls received usual care. The primary outcome measure was AUDIT score at baseline, 3, 6 and 9 months. Secondary measures included quality of life, alcohol dependence (DSM-IV), anxiety and depression. All measures were repeated at variable trial end dates between 9 and 18 months in the intervention group. RESULTS: Randomisation resulted in 46 intervention and 31 control participants. Intent-to-treat analyses showed AUDIT scores improved significantly from baseline to 9-month follow-up (p = 0.039) in the intervention group compared to control group. The control group had 1.46 times the risk of alcohol dependence than the intervention group at 9 months (p = 0.027). There were no significant differences between groups for secondary measures. Within-group analyses showed that both groups significantly improved in AUDIT (p < 0.001), anxiety and depression (p < 0.01), anger (p < 0.001), and post-traumatic stress (p < 0.01). Improvements in AUDIT (p < 0.001) and alcohol dependence were maintained in the intervention group to 18 months. CONCLUSIONS: Use of the Flinders Program in addition to usual care resulted in reduced alcohol use, reduced alcohol dependence, and global clinical improvement in Vietnam veterans with risky alcohol behaviours and chronic mental health problems. The findings demonstrate that the Flinders Program provides a structured framework for delivering self-management support, case management and coordinated care for people with chronic conditions. This clinical approach has the potential to bridge the gap between physical and mental illness service delivery for people with long-term conditions in Australia.

The influence of depression and other co-occurring conditions on treatment outcomes for problem gamblers: a cohort study.

OBJECTIVE: To examine the influence of co-occurring conditions on gambling treatment outcomes. DESIGN, SETTING AND PARTICIPANTS: Prospective cohort study of problem gamblers. Participants were recruited from consecutive referrals to a gambling therapy service in 2008. Inclusion criteria were: (i) assessed as a problem gambler based on a screening interview including DSM-IV criteria for pathological gambling, and (ii) suitable for admission to a treatment program. Cognitive-behavioural therapy was based on graded exposure-to-gambling urge. One-to-one treatment was conducted with 1-hour sessions weekly for up to 12 weeks. MAIN OUTCOME MEASURES: Problem gambling screening and co-occurring conditions including depression, anxiety and alcohol use. RESULTS: Of 127 problem gamblers, 69 were males (54%), mean age was 43.09 years, and 65 (51%) reported a duration of problem gambling greater than 5 years. Median time for participants' enrolment in the study was 8.9 months. Results from mixed effects logistic regression analysis indicated that individuals with higher depression levels had a greater likelihood (13% increase in odds [95% CI, 1%-25%]) of problem gambling during treatment and at follow-up. CONCLUSION: Addressing depression may be associated with improved treatment outcomes in problem gambling; conversely, treatment of problem gambling improves affective instability. We therefore recommend a dual approach that treats both depression and problem gambling.

Chronic condition self-management support: proposed competencies for medical students.

OBJECTIVE: Governments and the medical profession are concerned that there continues to be less than optimal health outcomes despite escalating expenditure on health services from the effect of the ageing population with chronic illnesses. In this context, doctors will need to have knowledge and skills in effective chronic condition management (CCM) and chronic condition self-management (CCSM). METHOD: A national workshop of representatives of eight medical schools from the CCSM special interest group (SIG) of the Australian and New Zealand Association on Medical Education met in September 2004, to consider curriculum content in CCM and CCSM. RESULTS: The workshop recommended that the Committee of Deans of Australian Medical Schools and the Commonwealth Department of Health and Ageing consider the identification and possible development of a specific curriculum for CCM and CCSM within the curricula of Australian Medical Schools. DISCUSSION: Consideration needs to be given to the changing nature of medical practice and that as part of this; doctors of the future will need skills in team participation, continuity of care, self-management support and patient-centered collaborative care planning. Doctors will also need skills to assist patients to better adhere to medical management, lifestyle behaviour change and risk factor reduction, if optimal health outcomes are to be achieved and costs are to be contained.

Working effectively with patients with comorbid mental illness and substance abuse: a case study using a structured motivational behavioural approach.

This case describes the use of innovative person-centred motivational behaviour change tools to enhance chronic condition self-management with a person with chronic paranoid schizophrenia, significant drug abuse and multiple psychosocial issues. In standard care, the complexity of this patient's presentation, their cognitive impairment level and history of violence would likely exclude them from many therapies and treatment programs as unsuitable or in the "too hard" basket. In fact, using a motivational and highly person-centred approach proved to be extremely necessary and rewarding for the person and their mental health worker. This approach provided a clear structure, actual tools and a clear rationale for what many would argue, yet is often ill-defined, was "just good clinical practice". However, it also facilitated the development of "something special" in the relationship between the person and their worker that is central to person-centred care. Through a semistructured, motivational, sequential process that encouraged gradual disclosure and greater self-awareness by the client and active listening by the worker, greater collaboration and shared responsibility was enhanced.

Coordinated care in the management of patients with unexplained physical symptoms: depression is a key issue.

OBJECTIVE: To evaluate the diagnosis of patients with somatisation disorders in primary care, and the effectiveness of coordinated care and evidence-based care planning on psychiatric symptoms and quality of life for these patients. DESIGN, SETTING AND PARTICIPANTS: This was a project of the SA HealthPlus Coordinated Care Trial, comprising a randomised controlled trial of 124 subjects recruited by general practitioners in southern Adelaide. Eligible patients had a GP diagnosis of somatisation, including unexplained physical symptoms as part of anxiety, chronic pain or somatoform disorders. Diagnoses were checked using the Composite International Diagnostic Interview (CIDI). The study was conducted from December 1997 to December 1999. INTERVENTION: A care plan including treatment for depression and anxiety disorders, a containment strategy for somatisation, and service coordinator-assisted self-management. Control patients received standard treatment. MAIN OUTCOME MEASURES: Psychiatric symptoms; quality of life; medication use; and depression, anxiety and hostility scores. RESULTS: Compared with CIDI diagnoses, mood disorders in patients were underdiagnosed by GPs (64 v 31), particularly major depression (46 v 1). At 12 months, the intervention group showed reductions in depression (P = 0.002), guilt (P = 0.006) and anxiety (state, P = 0.043; trait, P = 0.001). Compared with the control group, physical role functioning improved for the intervention group (P = 0.006), and their medication use decreased by 8.9%. CONCLUSIONS: Conservative management, treatment of depression, and case management by service coordinators is effective in managing somatising patients in primary care. GPs require training in the diagnosis of depression and how to say "no" to patients with unexplained physical symptoms who request further unnecessary investigations or referrals.

Exposure therapy for problem gambling via Videoconferencing: a case report.

This case report of a 31 year old woman who described her main problem as an uncontrollable urge to gamble on electronic gaming machines describes the application of exposure therapy (ET) by videoconferencing and the use of a clinical therapy assistant in the treatment of pathological gambling. The case study is used to demonstrate the effectiveness of this treatment with six sessions of therapy and 4 year follow up. The use of videoconferencing is discussed in relation to treatment effectiveness, ongoing follow up for the client and education and support for a community mental health nurse, therapy assistant, in a rural setting in South Australia. The implications of using this modality for the treatment of rural patients with problem gambling is discussed.

The mental health expert patient: findings from a pilot study of a generic chronic condition self-management programme for people with mental illness.

BACKGROUND: Less than optimal outcomes and escalating costs for chronic conditions including mental illness have prompted calls for innovative approaches to chronic illness management. AIMS: This study aimed to test the feasibility and utility of combining a generic, clinician administered and peer-led self-management group approach for people with serious mental illness. METHOD: General practitioners and mental health case managers used a patient-centred care model (the Flinders model) to assist 38 patients with serious mental illness to identify their self-management needs, and match these with interventions including Stanford peer-led, self-management groups and one-to-one peer support. Self-management and quality of life outcomes were measured and qualitative evaluation elicited feedback from all participants. RESULTS: Collaborative care planning, combined with a problems and goals focused approach, resulted in improved self-management and mental functioning at 3 to 6 months follow-up. The Stanford self-management course was applicable and acceptable to patients with serious mental illnesses. Qualitative feedback was highly supportive of this approach. CONCLUSIONS: Generic, structured assessment and care planning approaches, resulting in self-management education targeted to the individual, improved self-management and quality of life. Patients and service providers reported considerable gains despite the challenges associated with introducing a generic model within the mental health and general practice sector.

Smoking and quitting: a qualitative study with community-living psychiatric clients.

This paper reports the findings of a study investigating the smoking behaviours of a community-based psychiatric population. Using a qualitative, grounded theory approach, the four diagnostic categories of schizophrenia, bi-polar affective disorder, depression, and personality disorder were studied (24 interviews in total) in order to identify similarities and differences in smoking behaviours and perceptions of links between illness and cigarette smoking. A number of theoretical constructs emerged from the data, many of which confirm and enhance current understandings of issues, such as the role of cigarettes in managing the symptoms of illness. However, several themes not found in the existing literature also emerged. Smoking was found to play a significant existential role in the lives of participants: alleviating the effects of stigma, promoting positive and negative freedoms, and providing core needs as part of quality of life decisions. Perceptions of the nature and degree of interaction between psychiatric symptoms and the 'need' to smoke were also found to be significant. Variations in smoking between the different diagnostic groups were also found, in particular in the process of smoking itself the nature of the nicotine dependence as predominantly physical or psychological, attitudes towards the quitting process and sense of control, and the degree of significance of existential factors. The research findings suggest that we may be able to add new methods to our current ways of intervening to assist people with a mental illness who want to quit smoking. Differences in perceptions and patterns of use suggest that intervention may be more effective if psychiatric diagnosis is also taken into consideration. Because the paper is descriptive and hypothesis generating, its findings need to be tested using a larger sample.