Australian guideline for treatment of problem gambling: an abridged outline

The Problem Gambling Research and Treatment Centre (PGRTC) has developed the first evidence-based guideline to address problem gambling in Australia — Guideline for screening, assessment and treatment in problem gambling. The entire guideline and related appendices have been approved by the Chief Executive Officer of the National Health and Medical Research Council (NHMRC) under s. 14A of the National Health and Medical Research Council Act 1992. In approving the guideline, the NHMRC considered that it meets the NHMRC’s standard for clinical practice guidelines. The guideline will be available on the PGRTC websites (http://www.med.monash.edu.au/sphc/pgrtc and http://www.education.unimelb.edu.au/problemgambling). The full guideline addresses screening, assessment and treatment issues relating to problem gambling; in this abridged outline, we focus solely on treatment interventions for problem gamblers.

A range of terms have been used to describe problematic gambling, including pathological, disordered, compulsive and problem gambling. In Australia, “problem gambling” is the most commonly used term and describes the situation in which a person has “difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community”.1 The Productivity Commission found that the prevalence of problem gambling was approximately 2.1% of the adult Australian population.2 Recent statewide gambling surveys suggest that between 1.4% and 3.1% of adults report problem or moderate-risk gambling, based on the Problem Gambling Severity Index (PGSI) of the Canadian Problem Gambling Index.3-9 Some variation in rates between states may be the result of variable administration of the PGSI.10

A comprehensive and systematic process was used to develop the guideline (Box 1), as outlined in the NHMRC standards and procedures for externally developed guidelines.11 Due to the impact of internal validity on studies of interventions for problem gambling, articles were only included if they were classified as Level I or Level II evidence.

A total of 34 randomised controlled trials, reported in 37 articles, met the inclusion criteria for the clinical questions and formed the basis of seven evidence-based recommendations for treatment (Box 2). Each recommendation was accompanied by a grade that reflected the volume, consistency, clinical impact, generalisability and applicability of the evidence (Box 3), and practice points to provide practical advice and information.

The recommendations are expected to result in a consolidation of current practices in the treatment of problem gambling in Australia. CBT is already widely used as the therapy of choice for problem gambling and is a standard component in clinical training curricula for psychology and psychiatry. In comparison, motivational interviewing and motivational enhancement therapy are not commonly included in standard training programs, and practitioners who wish to deliver these interventions for problem gambling should undertake training. Furthermore, as outlined in the practice points, appropriately qualified and trained practitioners are advised to consider client preferences, availability of services, and manualised delivery of any chosen intervention. These considerations are especially pertinent given that practitioner-delivered psychological interventions largely underpinned the recommendations and, importantly, were found to be more effective than self-help interventions.

Two of the seven recommendations related to pharmacological interventions, and only one of these provided support for the use of a medication (naltrexone) to reduce gambling severity. Despite this recommendation, pharmacological interventions for the treatment of problem gambling should be applied with caution and with careful consideration of each patient’s needs. Specific details in the product information for each drug regarding dosage, adverse effects, method and route of administration, and contraindications should be studied and followed carefully. As yet, no drugs have been approved by the Australian Therapeutic Goods Administration in the form of a registered indication or approved use for treatment of problem gambling. However, this does not preclude the use of drugs for non-registered indications or off-label prescribing. Registered indications ensure that the appropriate research and approval processes have been followed to ensure effectiveness and safety of the drug.

While the clinical questions and inclusion/exclusion criteria developed for the guideline ensured that all relevant evidence was retrieved with respect to different subgroups (based on co-occurring psychiatric symptoms, sex, age, and gambling type), the paucity of available evidence means that the final recommendations must be applied with caution with respect to specific groups. However, this limitation in the evidence base has been acknowledged and accounted for in the formulation and grading of the recommendations.

Given the current immaturity of the research literature in the field of problem gambling, relevant and high-quality evidence could be found to address only six of the 22 clinical questions regarding treatment, leading to the formulation of only seven evidence-based recommendations. This outcome was not unexpected. Rather, it was intended that by conducting this review, formal identification of the gaps in knowledge would assist the strategic advancement of the field through targeted research and development, as well as in guiding practitioners regarding the evidence available to inform their practice. The Guideline Development Group made several recommendations for further research that can be found in the full guideline.