A Self-Guided Internet-Based Intervention for the Reduction of Gambling Symptoms: A Randomized Clinical Trial.

Importance: Most individuals with problem gambling or gambling disorder remain untreated due to barriers to treatment. Limited research exists on alternative treatments. Objective: To investigate the efficacy of a self-guided internet-based intervention for individuals with gambling problems and to identify potential outcome moderators. Design, Setting, and Participants: This single-center randomized clinical trial was conducted from July 13, 2021, to December 31, 2022, at the University Medical Center Hamburg-Eppendorf. Participants were recruited across Germany for 2 assessments (before intervention [t0] and 6 weeks after intervention [t1]). Eligible participants were individuals aged 18 to 75 years with gambling problems, internet access, German proficiency, and willingness to participate in 2 online assessments. Intervention: The self-guided internet-based intervention was based on cognitive behavioral therapy, metacognitive training, acceptance and commitment therapy, and motivational interviewing. Main Outcome and Measures: The primary outcome was change in gambling-related thoughts and behavior as measured with the pathological gambling adaption of the Yale-Brown Obsessive-Compulsive Scale. Secondary outcomes were change in depressive symptoms, gambling severity, gambling-specific dysfunctional thoughts, attitudes toward online interventions, treatment expectations, and patient satisfaction. Results: A total of 243 participants (154 [63.4%] male; mean [SD] age, 34.73 [10.33] years) were randomized to an intervention group (n = 119) that gained access to a self-guided internet-based intervention during 6 weeks or a wait-listed control group (n = 124). Completion at t1 was high (191 [78.6%]). Results showed a significantly greater reduction in gambling-related thoughts and behavior (mean difference, -3.35; 95% CI, -4.79 to -1.91; P < .001; Cohen d = 0.59), depressive symptoms (mean difference, -1.05; 95% CI, -1.87 to -0.22; P = .01; Cohen d = 0.33), and gambling severity (mean difference, -1.46; 95% CI, -2.37 to -0.54; P = .002; Cohen d = 0.40) but not in gambling-specific dysfunctional thoughts (mean difference, -1.62; 95% CI, -3.40 to 0.15; P = .07; Cohen d = 0.23) favoring the intervention group. Individuals in the intervention group who had a positive treatment expectation and more severe gambling-specific dysfunctional thoughts and gambling symptoms benefited more on the primary outcome relative to the control group. Conclusions and Relevance: In this randomized clinical trial, the effectiveness of a self-guided internet-based intervention for individuals with self-reported problematic gambling behavior was demonstrated when measured 6 weeks after start of the intervention. The study's findings are particularly relevant given the increasing need for accessible and scalable solutions to address problematic gambling. Trial Registration: bfarm.de Identifier: DRKS00024840.

Treatment of harmful gambling: a scoping review of United Kingdom-based intervention research.

BACKGROUND: Understanding and treating the harm caused by gambling is a growing international psychiatric and public health challenge. Treatment of gambling harm may involve psychological and pharmacological intervention, in conjunction with peer support. This scoping review was conducted to identify, for the first time, the characteristics and extent of United Kingdom (UK) based gambling treatment research. We reviewed studies conducted among people seeking treatment for disordered or harmful gambling in the UK, the settings, research designs, and outcome measures used, and to identify any treatment research gaps. METHODS: Systematic searches of PsycInfo, PsycArticles, Scopus, PubMed, and Web of Science databases were carried out for gambling treatment research or evaluation studies conducted in the UK. Studies were included if they evaluated the effectiveness of an intervention or treatment designed to improve symptoms of harmful or problematic gambling, reported outcomes of interventions on treatment adherence, gambling symptoms, or behaviours using standardised measures, were conducted in the UK, and were published since 2000. RESULTS: Eight studies met the inclusion criteria. Four were retrospective chart reviews, two were single-participant case reports, one described a retrospective case series, and one employed a cross-sectional design. None used an experimental design. CONCLUSION: The limited number of studies included in this review highlights a relative paucity of gambling treatment research conducted in UK settings. Further work should seek to identify potential barriers and obstacles to conducting gambling treatment research in the UK.

Treatment seeking for gambling disorder in nationwide register data - observations around a major shift in legislation.

Background: Treatment seeking for gambling disorder is known to be low and there has been a lack of longitudinal research regarding treatment opportunities. The present study aimed to assess possible changes in treatment uptake after a formal introduction of gambling disorder in social services and health care legislations, by using register data, including patient characteristics with respect to socio-demographics and comorbidities. Methods: Nationwide register data were collected for the years 2005-2019, describing diagnoses in specialized out-patient health care and in in-patient hospital care. Numbers and characteristics of patients with gambling disorder were followed longitudinally. Also, a new legislation for treatment by public institutions was introduced in 2018, and data were compared for the years before and after the shift in legislation, both nationally, for each of the three major urban regions, and for the rest of the country. Comparisons were made with respect to concurrent mental health comorbidities, age and gender. Results: The number of out-patient gambling disorder diagnoses increased over time, but without any significant step changes around the shift in legislation. Over time, patients were younger, became more likely to have gambling disorder as their primary diagnosis, and less likely to have mental health comorbidities, whereas gender distribution did not change. Among the smaller group of patients diagnosed in in-patient settings, mental health comorbidity increased over time. Despite gradual changes over time, no changes in demographics were seen around the actual shift in legislation, although the psychiatric comorbidity appeared to increase after this change. Conclusion: After the introduction of gambling disorder in the responsibility of social services and health care settings in Sweden, the number of patients diagnosed with gambling disorder increased only modestly. Likely, further implementation of gambling disorder treatment is required in the health care services. Also, longer longitudinal studies are needed in order to understand to what extent patients not seeking health care treatment are received by municipal social services or remain outside the treatment system.

A Systematic Review on Intervention Treatment in Pathological Gambling.

Over the last century, there has been a growing interest in researching pathological gambling, particularly in industrialized nations. Historically, gambling was widely perceived as morally questionable, condemned by religious groups. However, contemporary concerns have shifted towards the health repercussions of gambling disorders and broader societal impacts like increased crime and money laundering. Governments, aiming to mitigate social harm, often regulate or directly oversee gambling activities. The global surge in legal gambling has resulted in a substantial rise in its prevalence, popularity, and accessibility in the last two decades. This paper provides a comprehensive overview of global research on interventions for pathological gambling. Through a systematic search on platforms such as EBSCO, PubMed, and Web of Science, 13 relevant records were identified. The revised findings indicate a heightened occurrence of behavioral addictions, linking them to the early onset of gambling issues and their severe consequences. The research emphasizes the active role that clients play in the process of self-directed change and therapy. Therapists recognizing clients as both catalysts for change and potential obstacles can enhance their effectiveness. A common source of resistance arises when clients and therapists are in different stages of the change process, underlining the importance of therapists aligning with clients' readiness for change. Recognizing the urgent need for a better understanding of this problem in adolescents, this study emphasizes the necessity to tailor prevention and treatment plans based on gender and age-specific requirements.

Operational status of mental health, substance use, and problem gambling services: A system-level snapshot two years into the COVID-19 pandemic.

BACKGROUND: The aim of this paper is to provide a system-level snapshot of the operational status of mental health, substance use, and problem gambling services 2 years into the pandemic in Ontario, Canada, with a specific focus on services that target individuals experiencing vulnerable circumstances (e.g., homelessness and legal issues). METHODS: We examined data from 6038 publicly funded community services that provide mental health, substance use, and problem gambling services in Ontario. We used descriptive statistics to describe counts and percentages by service type and specialisation of service delivery. We generated cross-tabulations to analyse the relationship between the service status and service type for each target population group. RESULTS: As of March 2022, 38.4% (n = 2321) of services were fully operational, including 36.0% (n = 1492) of mental health, 44.1% (n = 1037) of substance use, and 23.4% (n = 78) of problem gambling services. These service disruptions were also apparent among services tailored to sexual/gender identity (women/girls, men/boys, 2SLGBTQQIA + individuals), individuals with legal issues, with acquired brain injury, and those experiencing homelessness. CONCLUSION: Accessible community-based mental health, substance use and problem gambling services are critical supports, particularly for communities that have historically contended with higher needs and greater barriers to care relative to the general population. We discuss the public health implications of the findings for the ongoing pandemic response and future emergency preparedness planning for community-based mental health, substance use and problem gambling services.

Differences in gambling disorder recovery capital toolkits in mothers versus childless women.

This study focused on mothers and childless women in recovery from a gambling disorder (GD) in the context of risk society. Mothers with GD suffer from dual social stigma as gamblers and as women who put their children at risk. Mothers in "risk society" tend to recognize that their choices can affect their children's future. The recovery capital (RC) toolkit comprises internal and external resources and barriers enacted in recovery. This longitudinal study: (a) compared the RC toolkits of mothers versus childless women and their effects on these women's dropout and relapse rates; (b) explored the resources and barriers that predict dropout and relapse in each group. Analysis of the clinical data of 211 women with GD (N = 146 mothers) who received cognitive behavioral therapy for 16 weeks in Spain indicated that mothers reported lower levels of education and were from more disadvantaged socioeconomic groups, were older, and developed gambling-related problems in older age. Mothers had significantly lower relapse rates but not lower dropout rates. There were more personal predictors of dropout among childless women, whereas low levels of family support and the absence of gambling debts predicted dropout in the mothers' group. These findings were interpreted by combining the concepts of risk society and recovery capital in action, highlight the differences between resources and barriers in the RC toolkits used by mothers versus childless women and their interplay with the sociocultural contexts of risk society and childfree lifestyles. Therapists and policymakers should consider these differences during recovery. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Duration of untreated illness in gambling disorder.

OBJECTIVE: Gambling disorder is common, affects 0.5-2% of the population, and is under-treated. Duration of untreated illness (DUI) has emerged as a clinically important concept in the context of other mental disorders, but DUI in gambling disorder, has received little research scrutiny. METHODS: Data were aggregated from previous clinical trials in gambling disorder with people who had never previously received any treatment. DUI was quantified, and clinical characteristics were compared as a function of DUI status. RESULTS: A total of 298 individuals were included, and the mean DUI (standard deviation) was 8.9 (8.4) years, and the median DUI was 6 years. Longer DUI was significantly associated with male gender, older age, earlier age when the person first started to gamble, and family history of alcohol use disorder. Longer DUI was not significantly associated with racial-ethnic status, gambling symptom severity, current depressive or anxiety severity, comorbidities, or disability/functioning. The two groups did not differ in their propensity to drop out of the clinical trials, nor in overall symptom improvement associated with participation in those trials. CONCLUSIONS: These data suggest that gambling disorder has a relatively long DUI and highlight the need to raise awareness and foster early intervention for affected and at-risk individuals. Because earlier age at first gambling in any form was strongly linked to longer DUI, this highlights the need for more rigorous legislation and education to reduce exposure of younger people to gambling.

Do attention-deficit/hyperactivity symptoms influence treatment outcome in gambling disorder?

BACKGROUND AND AIMS: Numerous studies point to the comorbidity between gambling disorder (GD) and attention deficit hyperactivity disorder (ADHD). However, there is a lack of research exploring how ADHD symptoms might influence psychological treatment outcomes for GD. Therefore, we aimed to explore differences between patients with GD with and without self-reported ADHD symptoms regarding psychopathology, personality, sociodemographic and treatment outcome measures. METHOD: This longitudinal study included 170 patients with GD receiving cognitive behavioral therapy. Multiple self-reported instruments were used to assess clinical variables and sociodemographic measures prior to treatment. RESULTS: A clinical profile characterized by greater GD severity, higher psychopathology and impulsivity, and less adaptive personality features was observed in patients with self-reported ADHD symptoms compared to those without. No significant differences in treatment response (measured by dropout and relapse rates) were observed between the two groups. However, patients with self-reported ADHD symptoms experienced more severe relapses (i.e., gambled more money) and GD patients who relapsed scored higher on measures of ADHD, particularly inattention. CONCLUSION: Individuals with GD and self-reported symptoms of ADHD may experience more severe relapses following treatment, suggesting a need for more vigilant follow-up and interventions for patients with this comorbidity.

Guided versus unguided chatbot-delivered cognitive behavioral intervention for individuals with moderate-risk and problem gambling: A randomized controlled trial (GAMBOT2 study).

BACKGROUND: Internet-based interventions can be a promising option for individuals with problem gambling facing barriers to seeking help. This study aimed to directly compare the effects of therapist-guided Internet interventions with unguided ones on gambling-related behavior, cognition, and stage of change including help-seeking intention. METHODS: We conducted a participant-blinded randomized controlled trial of therapist-guided versus unguided groups with a 12-week follow-up. Both groups received self-help chatbot-delivered cognitive behavioral therapy. Additionally, at baseline and weeks 1, 2, 3, and 4, the guided group received personalized feedback messages from therapists based on their gambling diary and questionnaire responses. The unguided group received reminders of assessments from research assistants. The primary outcome was the change in scores on the Gambling Symptoms Assessment Scale (G-SAS) over 12 weeks. Secondary outcomes included the stage of change including help-seeking intention, money wagered, gambling frequency, and gambling-related cognitions. RESULTS: We included 139 participants with a mean Problem Gambling Severity Index total score of 14.6 and a mean G-SAS total score of 27.0 who sought information about gambling problems. Both groups demonstrated substantial decreases in their G-SAS scores from baseline to week 12 (-10.2, 95% CI: -7.67 to -12.7 for the guided group, and 11.7, 95% CI: -9.05 to -14.3 for the unguided group). However, we did not find a significant between-group difference (1.49, 95% CI: -2.20 to 5.17). Regarding the stage of change including help-seeking intention, there were also no between-group differences. CONCLUSIONS: Minimum therapist support did not have an additive effect on the self-help chatbot intervention on gambling symptoms, behavior, and the stage of change including help-seeking intention.

Effectiveness of a web-based self-help tool to reduce problem gambling: A randomized controlled trial.

Background and Aims: Problem gambling constitutes a public health concern associated with psychopathological comorbidity, substance use, and financial difficulties. Most individuals with gambling problems avoid counseling services due to perceived stigma and their preference for self-reliance. Treatment accessibility could be improved through web-based interventions. Methods: We recruited 360 individuals with gambling problems and randomized them to a web-based intervention (n = 185) or an active control group consisting of a self-help manual for problem gambling (n = 175). The primary outcome was the number of days of gambling in the last 30 days. Secondary outcomes included money spent in the last 30 days, time gambling in the last 7 days, gambling-related problems, consumption of alcohol and cigarettes, and psychopathological comorbidity measured at posttreatment and 6-month follow-up. Results: The primary outcome decreased significantly for both groups, with no significant difference between the groups. There were significant group × time interactions according to the Gambling Symptom Assessment Scale (F = 8.83, p <0 .001), the Problem Gambling Severity Index (F = 3.54, p = 0.030), for cigarettes smoked in the last 7 days (F = 26.68, p < 0.001), the Patient Health Questionnaire-9 (F = 19.41, p <0 .001), and the Generalized Anxiety Disorder-7 (F = 41.09, p <0 .001) favoring the intervention group. We experienced an overall high dropout rate (76%). Conclusions: Win Back Control seems to be an effective low-threshold treatment option for individuals with gambling problems that might otherwise be unapproachable for outpatient treatment services. Nevertheless, the high dropout rate should be considered when interpreting the study results, as they may have introduced a degree of variability.

Dissociative experiences reduce online problem gambling treatment effectiveness.

AIMS: To determine whether dissociative experiences moderate online problem gambling treatment effectiveness, and to characterize the temporal persistence of the relationship between dissociation and problem gambling. DESIGN: Repeatedly measured self-report data on a guided online cognitive behavioral therapy for problem gambling collected on four occasions: before treatment, after treatment, and at 6- and 12-month follow-ups. SETTING AND PARTICIPANTS: The data (N = 1243, 59.2% males) were collected in Finland between 2019 and 2021. MEASUREMENTS: The primary outcome variable was the self-reported level of problem gambling. The predictors were the treatment phase and dissociative experiences, their interaction, and the demographic covariates of age, education, income, and gender. FINDINGS: Problem gambling scores and dissociative experiences declined significantly following treatment and remained low through the follow-ups (retention rates: 52.6% [post-treatment], 26.3% [at the 6-month follow-up], and 16.1% [at the 12-month follow-up]). However, the treatment was significantly less effective in reducing problem gambling for individuals who kept experiencing dissociation after the treatment. CONCLUSIONS: Dissociation is an integral sign of problem gambling severity and sustained dissociative experiences may significantly reduce the long-term effectiveness of online problem gambling treatments. Treatment efforts should be customized to account for individual differences in dissociative tendencies, and future research should broaden the study of dissociative experiences to other behavioral addictions.

Comorbid psychiatric diagnoses and gaming preferences in US armed forces veterans receiving inpatient treatment for gambling disorder.

Armed Forces Veterans are uniquely vulnerable to problem gambling and gambling disorder. Even so, research regarding the full clinical profile of veterans with gambling problems lags. Gambling activities vary widely from each other, but most gambling activities can be understood as either strategic (i.e., involving some measure of skill and decision-making as a part of the gambling practice) or non-strategic (i.e., gambling activities that are entirely based on chance). Prior works have found that gamblers that prefer strategic gambling activities and those that prefer nonstrategic gambling activities often differ from each other in key ways, with the two preferences being linked to varying motivations for gambling, varying cognitions about gambling, and the course of gambling disorder. The present work sought to examine how preferences for strategic vs. nonstrategic gambling might be related to psychiatric comorbidities among U.S. Armed Forces Veterans receiving inpatient treatment for Gambling Disorder. Data from U.S. Armed Forces Veterans (N = 401) receiving residential treatment for GD between the years of 2010-2016 were analyzed. Results demonstrated that gamblers that preferred strategic gambling, as opposed to non-strategic gambling, were more likely to be younger, more likely to be men, less likely to have a nicotine use disorder, and less likely to have PTSD. Such findings suggest that gamblers with PTSD are likely to prefer nonstrategic games and may imply a unique vulnerability to gambling problems related to non-strategic gambling among armed forces veterans.

Addiction substitution and concurrent recovery in gambling disorder: Who substitutes and why?

Objectives: When individuals recover from gambling disorder, their involvement in other potentially addictive substances and behaviors may also subsequently increase (substitution) or decrease (concurrent recovery). The objectives of this study were to identify and compare recovery processes associated with substitution and concurrent recovery in gambling disorder. Methods: A mixed-method study was conducted with 185 people who were recovered from gambling disorder. Semi-structured interviews were used to: (i) establish onset and recovery of gambling disorder as well as other substance and behavioral addictions; and (ii) assess processes (e.g., reasons, emotional state, helpfulness) associated with addiction substitution and concurrent recovery. Participants also completed a survey assessing demographic characteristics, gambling behaviors, and psychological characteristics to compare demographic and clinical differences between participants who engaged in addiction substitution, concurrent recovery, or neither (controls). Results: The most frequently reported reason for engaging in addiction substitution was as a substitute coping mechanism. The most reported reason for engaging in concurrent recovery was due to the addictions being mutually influenced. Negative emotional states were common when engaging in both addiction substitution and concurrent recovery. Although the three groups did not differ on gambling characteristics, addiction substitution was associated with greater underlying vulnerabilities including childhood adversity, impulsivity, emotion dysregulation, and, maladaptive coping skills. Conclusion: Transdiagnostic treatments that target the underlying mechanisms of addictions may reduce the likelihood of engaging in addiction substitution.

The Price of Gambling: Examining Gambling Disorders.

Gambling disorders are a serious public health problem. This manuscript will provide a comprehensive overview on this topic. Gambling disorder involves repeated patterns of gambling behaviors, that result in significant distress or impairment in a person's interpersonal relationships, employment, educational/career opportunities, and finances over a period of 12 months. Gambling is defined as an activity that involves risking something of value with the hopes of acquiring something of greater value. Comparable to substance use disorders, individuals with a gambling disorder may be unsuccessful in exercising control over their problematic behavior, engage in the behavior despite negative consequences, and have preoccupations/cravings to gamble. Gambling disorder has higher comorbidity rates of mental disorders including depression, anxiety, substance use, and personality disorders. Gamblers rarely seek treatment. Treatments must be tailored to the individual which may include psychological interventions, cognitive behavioral therapy, gamblers anonymous, and psychopharmacological agents such as selective serotonin reuptake inhibitors, mood stabilizers, and opioid antagonists to treat clinical symptoms.

Addiction: A treatise from 1561.

BACKGROUND AND AIMS: In 1561, physician and philosopher Pascasius Justus Turq published a monograph on the description and treatment of pathological gambling. When the monograph came to the attention of the authors in 2006, there existed no known translation of it in any modern language. In 2014, it was translated and published in French. This paper analyses the monograph's key content elements and its place in the history of the concept of addiction. METHODS: A contextual analysis of the late Italian Renaissance, followed by key excerpts from the text and commentaries on the meaning and significance of the monograph. FINDINGS AND CONCLUSIONS: Pascasius Justus Turq's 1561 monograph on pathological gambling outlines a disease view of gambling, identifies cognitive processes and biological vulnerabilities as aetiological factors, avoids religious or moral judgements and recommends cognitive treatment to change the beliefs and expectancies of gamblers. This study shows that a 'disease formulation' of addiction was enunciated as early as the 16th century, and its contemporary resonance suggests that current clinical features of addictive disorders have existed for centuries.

Psychological intervention for gambling disorder: A systematic review and meta-analysis.

Background and aims: Increasingly, gambling features migrate into non-gambling platforms (e.g., online gaming) making gambling exposure and problems more likely. Therefore, exploring how to best treat gambling disorder (GD) remains important. Our aim was to review systematically and quantitatively synthesize the available evidence on psychological intervention for GD. Methods: Records were identified through searches for randomized controlled trials (RCTs) evaluating psychological intervention for GD via six academic databases without date restrictions until February 3, 2023. Study quality was assessed with the revised Cochrane risk-of-bias tool for randomized trials (RoB2). Primary outcomes were GD symptom severity and remission of GD, summarized as Hedges' g and odds ratios, respectively. The study was preregistered in PROSPERO (#CRD42021284550). Results: Of 5,541 records, 29 RCTs (3,083 participants analyzed) were included for meta-analysis of the primary outcomes. The efficacy of psychological intervention across modality, format and mode of delivery corresponded to a medium effect on gambling severity (g = -0.71) and a small effect on remission (OR = 0.47). Generally, risk of bias was high, particularly amongst early face-to-face interventions studies. Discussion and conclusions: The results indicate that psychological intervention is efficacious in treating GD, with face-to-face delivered intervention producing the largest effects and with strongest evidence for cognitive behavioral therapy. Much remains to be known about the long-term effects, and investigating a broader range of treatment modalities and digital interventions is a priority if we are to improve clinical practice for this heterogeneous patient group.

Longitudinal associations between psychiatric comorbidity and the severity of gambling disorder: Results from a 36-month follow-up study of clients in Bavarian outpatient addiction care.

Background and aims: Individuals with gambling disorder (GD) often suffer from psychiatric comorbidities. Previous studies demonstrated greater severity of GD among gamblers with psychiatric comorbidities. However, evidence on the association between psychiatric comorbidity and course of GD severity during and after outpatient treatment is sparse. This study analyses data from a longitudinal one-armed cohort study on outpatient addiction care clients over three years. Methods: We investigated the course of GD severity using data from 123 clients in 28 outpatient addiction care facilities in Bavaria using generalized estimation equations (GEE). We applied time* interaction analyses to examine different development profiles in participants with and without (1) affective disorders, or (2) anxiety disorders, and (3) to account for the co-occurrence of both. Results: All participants benefitted from outpatient gambling treatment. Improvement in GD severity was poorer in participants with anxiety disorders compared to participants without anxiety disorders. The co-occurrence of affective and anxiety disorders was linked to a less favourable course of GD than the presence of affective disorders alone. However, the combined occurrence of both disorders was more favourable than the presence of anxiety disorders alone. Discussion and conclusions: Our study suggests that clients with GD, with and without psychiatric comorbidities, benefit from outpatient gambling care. Psychiatric comorbidity, especially comorbid anxiety disorders, seems to be negatively associated with the course of GD within outpatient gambling care. Addressing psychiatric comorbidity within the treatment of GD and offering individualised help are required to meet the needs of this clientele.

Effect of cognitive-behavioral techniques for problem gambling and gambling disorder: A systematic review and meta-analysis.

AIMS: To measure the effect of cognitive-behavioral techniques (CBTs) on gambling disorder severity and gambling behavior at post-treatment and follow-up. METHOD: Seven databases and two clinical trial registries were searched to identify peer-reviewed studies and unpublished studies of randomized controlled trials. The Cochrane Risk of Bias tool assessed risk of bias in the included studies. A random effect meta-analysis with robust variance estimation was conducted to measure the effect of CBTs relative to minimally treated or no treatment control groups. RESULTS: Twenty-nine studies representing 3991 participants were identified. CBTs significantly reduced gambling disorder severity (g = -1.14, 95% CI = -1.68, -0.60, 95% prediction interval [PI] = -2.97, 0.69), gambling frequency (g = -0.54, 95% CI = -0.80, -0.27, 95% PI = -1.48, 0.40) and gambling intensity (g = -0.32, 95% CI = -0.51, -0.13, 95% PI = -0.76, 0.12) at post-treatment relative to control. CBTs had no significant effect on follow-up outcomes. Analyses supported the presence of publication bias and high heterogeneity in effect size estimates. CONCLUSIONS: Cognitive-behavioral techniques are a promising treatment for reducing gambling disorder and gambling behavior; however, the effect of cognitive-behavioral techniques on gambling disorder severity and gambling frequency and intensity at post-treatment is overestimated, and cognitive-behavioral techniques may not be reliably efficacious for all individuals seeking treatment for problem gambling and gambling disorder.

Longing to act: Bayesian inference as a framework for craving in behavioral addiction.

Traditionally, craving is considered a defining feature of drug addiction. Accumulating evidence suggests that craving can also exist in behavioral addictions (e.g., gambling disorder) without drug-induced effects. However, the degree to which mechanisms of craving overlap between classic substance use disorders and behavioral addictions remains unclear. There is, therefore, an urgent need to develop an overarching theory of craving that conceptually integrates findings across behavioral and drug addictions. In this review, we will first synthesize existing theories and empirical findings related to craving in both drug-dependent and -independent addictive disorders. Building on the Bayesian brain hypothesis and previous work on interoceptive inference, we will then propose a computational theory for craving in behavioral addiction, where the target of craving is execution of an action (e.g., gambling) rather than a drug. Specifically, we conceptualize craving in behavioral addiction as a subjective belief about physiological states of the body associated with action completion and is updated based on both a prior belief ("I need to act to feel good") and sensory evidence ("I cannot act"). We conclude by briefly discussing the therapeutic implications of this framework. In summary, this unified Bayesian computational framework for craving generalizes across addictive disorders, provides explanatory power for ostensibly conflicting empirical findings, and generates strong hypotheses for future empirical studies. The disambiguation of the computational components underlying domain-general craving using this framework will lead to a deeper understanding of, and effective treatment targets for, behavioral and drug addictions.