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.<br /

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

Author version made available in accordance with the publisher's policyBackground 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-centered 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

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

Author version made available in accordance with the publisher's policyBackground 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-centered 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

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

The Gambling Urge Scale : reliability and validity in a clinical population

The aim of this study was to establish reliability and validity of the Gambling Urge Scale (GUS) in a clinical population of problem gamblers. This cohort study was conducted in South Australia between March 2008 and March 2009. Participants were problem gamblers aged &ge;18 years (n&thinsp;=&thinsp;158) who were seeking treatment from a range of gambling help services. Measures included gambling urge, problem gambling screening, gambling behaviour and problems caused by gambling, such as personal health and relationships. The psychometric properties investigated were internal reliability, criterion-related validity, concurrent validity and construct validity. Results showed high internal consistency for GUS (&alpha;&thinsp;=&thinsp;0.93) and significant item-rest correlations ranging from 0.72 to 0.86. For criterion-related validity, a GUS cut score of three correctly classified 81.13% of participants as problem gambling with sensitivity 84.75% and specificity 76.6%. Concurrent validity was significant with a number of gambling-related symptoms and problems including psychological disturbance, work and social functioning and gambling-related cognitions (p&thinsp;&lt;&thinsp;0.001). An insignificant correlation was found between gambling urge and sensation seeking traits (p&thinsp;=&thinsp;0.663). When controlling for gender and age the instrument was shown to have significant predictive properties for different levels of gambling severity (p&thinsp;&lt;&thinsp;0.001). A principal component analysis for the one component showed an overall explained variance of 75.54%. These findings indicate that GUS is a valid and reliable instrument for problem gambling screening, to measure treatment outcomes and may predict relapse in problem gambling

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 enrolment 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

Vitamin D receptor: a new risk marker for clinical restenosis after percutaneous coronary intervention

Objective: Restenosis is the main drawback of percutaneous coronary intervention (PCI). Inherited factors may explain part of the risk of restenosis. Recently, the vitamin D receptor (VDR) has been shown to be involved not only in bone metabolism but also in modulating immune responses and cell proliferation. Since the inflammatory response is implicated in restenosis, VDR-gene variants could therefore contribute to the risk of restenosis. Methods/results: Systematic genotyping for 15 haplotype tagging single-nucleotide polymorphisms (SNPs) of the VDR gene was performed with the high throughput TaqMan allelic discrimination assays in the Genetic Determinants of Restenosis (GENDER) population. A haplotype-based survival analysis revealed an association of haplotypes in blocks 2, 3 and 4 of the VDR-gene with the risk of clinical restenosis (p-values 0.01, 0.04 and 0.02 respectively). After adjustment for clinical risk factors for restenosis, the individual effect of the block 2 AA haplotype (p = 0.011) persisted. Conclusions: The present study indicates that VDR plays a role in restenosis after PCI. Therefore, VDR genotype may be used as risk marker for restenosis and may contribute to individual patient screening prior to PCI in clinical practice