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Compulsive Gambling Research: 2002-2006
     
J Gambl Stud. 2006 Dec;22(4):355-72.
Treatment of female pathological gambling: the efficacy of a cognitive-behavioural approach.
Dowling N, Smith D, Thomas T.
School of Psychiatry, Psychology and Psychological Medicine, Monash University, Building 17, Clayton, VIC, 3800, Australia, nicki.dowling@med.monash.edu.au.

Given that a substantial proportion of current pathological gamblers are female, it is evident that women are underrepresented in the treatment outcome literature. The current study was designed to redress the limited information on the treatment of female pathological gambling. Although the use of cognitive-behavioural therapy is the most highly recommended approach as 'best practice' for the treatment of pathological gambling, no attempt to date has been made to evaluate the efficacy of this approach for female pathological gambling. Nineteen female pathological gamblers with electronic gaming machine problems were treated with a cognitive-behavioural program. While pathological gamblers placed on a waiting list did not show significant improvement on gambling behaviour and psychological functioning measures, the female pathological gamblers showed significant improvement on these measures over the treatment period, and maintained this improvement at the 6-month follow-up evaluation. By the completion of the follow-up period, 89% of participants no longer met diagnostic criteria for pathological gambling. Although further scientific demonstration and replication are required, the outcomes of this study indicate that the therapy that is considered 'best practice' in the treatment of pathological gambling is effective for female pathological gambling.

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Minn Med. 2006 Sep;89(9):44-8.
Medication management of pathological gambling.
Grant JE, Kim SW.
University of Minnesota Medical School, USA.

Pathological gambling has received little attention from clinicians and researchers despite prevalence rates similar to or greater than those of schizophrenia and bipolar disorder. This article summarizes the phenomenology and associated psychopathology of this public health problem and presents results of studies of 3 types of pharmacological agents used to treat this disorder: serotonin reuptake inhibitors, opioid antagonists, and mood stabilizers.

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Mov Disord. 2006 Sep 13;21(11):1941-1946 [Epub ahead of print]
Pathological gambling in Parkinson's disease improves on chronic subthalamic nucleus stimulation.
Ardouin C, Voon V, Worbe Y, Abouazar N, Czernecki V, Hosseini H, Pelissolo A, Moro E, Lhommee E, Lang AE, Agid Y, Benabid AL, Pollak P, Mallet L, Krack P.
Departement de Neurologie, CHU Grenoble, INSERM U318, Universite Joseph Fourier, Grenoble, France.

Pathological gambling (PG) related to dopaminergic treatment in Parkinson's disease (PD) is part of a spectrum of behavioral disorders called the dopamine dysregulation syndrome (DDS). We describe a series of PD patients with preoperative active PG due to dopaminergic treatment from a total of 598 patients who have undergone surgery for subthalamic nucleus stimulation for disabling motor fluctuations. The patients had systematic open assessment of behavioral symptoms and standardized assessments of motor symptoms, mood, and apathy. Seven patients (6 men, 1 woman; age, 54 +/- 9 years; levodopa equivalent dose, 1,390 +/- 350 mg/day) had preoperative PG over a mean of 7 years, intolerant to reduction in medication. Six had nonmotor fluctuations and four had other behavioral symptoms consistent with a diagnosis of the DDS. After surgery, motor symptoms improved, allowing for 74% reduction of dopaminergic treatment, below the dosage of gambling onset. In all patients, PG resolved postoperatively after 18 months on average (range, 0-48), although transient worsening occurred in two. Improvement paralleled the time course and degree of reduction in dopaminergic treatment. Nonmotor fluctuations, off period dysphoria, and other symptoms of the DDS improved. Two patients developed persistent apathy. In conclusion, PG and other symptoms of the DDS-associated dopaminergic treatment improved in our patients following surgery. Dopaminergic dysregulation commonly attributed to pulsatile overstimulation of the limbic dopaminergic system may be subject to desensitization on chronic subthalamic stimulation, which has a relative motor selectivity and allows for decrease in dopaminergic treatment. (c) 2006 Movement Disorder Society.

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Curr Opin Pediatr. 2006 Aug;18(4):454-8.
Youth gambling: not a safe bet.
Turchi RM, Derevensky JL.
Drexel University College of Medicine, St Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA. renee.turchi@drexelmed.edu

PURPOSE OF REVIEW: To increase awareness and knowledge of the growing problem of adolescent gambling. RECENT FINDINGS: Some risk factors have been established for adolescent gambling. Many of the risk factors for gambling behavior can be addressed in effective prevention of problem gambling. There is an association between some psychiatric comorbid conditions and problem gambling (i.e. depression). Current treatment modalities are based on adult experiences and need further investigation for adolescents. Prevention strategies and education of youth, parents, teachers, educators, and professionals are essential in targeting this serious problem. SUMMARY: Given the increasing overall prevalence of adolescent gambling, it is imperative that pediatricians appreciate that gambling problems can also afflict adolescents. There is a clear link between problem gambling in adolescence and pathologic gambling in adulthood. Thus, like other addictive behaviors (cigarette smoking, alcohol and drug use), youth and parents should be screened and counseled about the risks associated with excessive gambling.

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J Psychol. 2006 Jul;140(4):347-61.
A bird in hand: discouraging gambling on a slot machine simulation.
Weatherly JN, McDougall CL, Gillis AA.
Department of Psychology, University of North Dakota, Grand Forks 58202-8380, USA. jeffrey_weatherly@und.nodak.edu

Using a slot machine simulation, our laboratory has found that participants, given the opportunity not to gamble and to keep the money they have been staked, almost always choose to play the simulation. In this study, the authors investigated whether increasing the salience of the money for which participants played or increasing the response effort required to gamble the money would decrease gambling. In Experiment 1, participants in different groups were told about, were shown, or held the dollars 10 they were to be staked to play the simulation. Results showed that participants who held the money prior to gambling played fewer trials and bet less money than participants in other groups. In Experiment 2, participants in different groups were staked with dollars 5 in nickels, quarters, or their choice of nickels or quarters. Results showed that the participants staked with nickels ultimately gambled a similar amount of money as did participants staked with quarters. They did so by playing the simulation more times than the other participants. Participants staked with nickels did, however, end the session with the most money. Findings suggest ways that gambling and gambling losses can be lessened.

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J Gambl Stud. 2006 Jul 14; [Epub ahead of print]
Preliminary Evaluation of a Coping Skills Training Program for Those with a Pathological-Gambling Partner.
Rychtarik RG, McGillicuddy NB.
Research Institute on Addictions, University at Buffalo, The State University of New York, 1021 Main Street, Buffalo, NY, 14203, USA, rychtari@ria.buffalo.edu.

Individuals living with a pathological-gambling partner can experience significant psychological distress. In this report, we conduct a preliminary evaluation of a coping skills training program (CST) for this population. Twenty-three individuals experiencing stress from living with a pathological-gambling partner who was not in treatment were randomly assigned to either CST or a delayed treatment control (DTC) condition. CST consisted of ten, weekly individual sessions to teach more effective coping skills. At the end of the treatment/delay period, CST participants, relative to those in DTC, showed a large improvement in coping skillfulness that appeared to mediate a corresponding large significant reduction in depression and anxiety relative to DTC. Partner gambling during the period decreased in both conditions but did not differ between them, nor did partner help-seeking differ. CST shows promise as an effective treatment for individuals distressed as a result of a partner's gambling problem. Larger, longer-term evaluations of the intervention, and comparison with alternate treatment models are needed.

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Int Clin Psychopharmacol. 2006 Jul;21(4):203-9.
Escitalopram treatment of pathological gambling with co-occurring anxiety: an open-label pilot study with double-blind discontinuation.
Grant JE, Potenza MN.
Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, Minnesota 55454, USA. grant045@umn.edu

Although co-occurring disorders are common in pathological gambling (PG), investigations of the response to pharmacotherapy in individuals with PG and co-occurring psychiatric symptomatology are limited. Thirteen subjects with DSM-IV PG and co-occurring anxiety were treated in a 12-week open-label trial of escitalopram. Subjects were assessed with the Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling (PG-YBOCS; primary outcome measure), the Hamilton Anxiety Rating Scale (HAM-A), the Clinical Global Impressions scale (CGI), and measures of psychosocial functioning and quality of life. Those subjects who 'responded' (defined as a 30% or greater reduction in PG-YBOCS total score at endpoint) were offered inclusion in an 8-week double-blind discontinuation phase. PG-YBOCS scores decreased from a mean of 22.2+/-4.5 at baseline to 11.9+/-10.7 at endpoint (P=0.002) and 61.5% were responders. Scores on the HAM-A decreased by 82.8% over the 12-week period (mean of 15.9+/-3.2 at baseline to a mean of 2.8+/-3.6 at endpoint) (P<0.001). On the CGI, 38.5% of subjects (n=5) were 'very much improved' and 23.1% (n=3) were 'much improved' by study endpoint. The Sheehan Disability Scale, Perceive Stress Scale and Quality of Life Inventory all showed improvement (P< or = 0.001, P=0.002 and P=0.029, respectively). The mean end-of-study dose of escitalopram was 25.4+/-6.6 mg/day. Of three subjects assigned to escitalopram during the discontinuation phase, none reported statistically significant worsening of gambling symptoms. However, one subject assigned to placebo reported that gambling symptoms returned within 4 weeks. Open-label escitalopram treatment was associated with improvements in gambling and anxiety symptoms and measures of psychosocial functioning and quality of life. Larger, longer, placebo-controlled, double-blind studies are needed to evaluate further the safety and tolerability of escitalopram in the treatment of PG and co-occurring anxiety.

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J Consult Clin Psychol. 2006 Jun;74(3):555-67.
Cognitive-behavioral therapy for pathological gamblers.
Petry NM, Ammerman Y, Bohl J, Doersch A, Gay H, Kadden R, Molina C, Steinberg K.
Department of Psychiatry, University of Connecticut Health Center, Storrs, CT 06030-3944, USA. petry@psychiatry.uchc.edu

Few studies have evaluated efficacy of psychotherapies for pathological gambling. Pathological gamblers (N = 231) were randomly assigned to (a) referral to Gamblers Anonymous (GA), (b) GA referral plus a cognitive- behavioral (CB) workbook, or (c) GA referral plus 8 sessions of individual CB therapy. Gambling and related problems were assessed at baseline, 1 month later, posttreatment, and at 6- and 12-month follow-ups. CB treatment reduced gambling relative to GA referral alone during the treatment period and resulted in clinically significant improvements, with some effects maintained throughout follow-up ( ps = .05). Individual CB therapy improved some outcomes compared with the CB workbook. Attendance at GA and number of CB therapy sessions or workbook exercises completed were associated with gambling abstinence. These data suggest the efficacy of this CB therapy approach. Copyright 2006 APA, all rights reserved.

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J Neurosci. 2006 Jun 14;26(24):6469-72.
Disruption of right prefrontal cortex by low-frequency repetitive transcranial magnetic stimulation induces risk-taking behavior.
Knoch D, Gianotti LR, Pascual-Leone A, Treyer V, Regard M, Hohmann M, Brugger P.
Department of Neurology, PET Center, Division of Nuclear Medicine, University Hospital Zurich, 8091 Zurich, Switzerland. daria.knoch@usz.ch

Decisions require careful weighing of the risks and benefits associated with a choice. Some people need to be offered large rewards to balance even minimal risks, whereas others take great risks in the hope for an only minimal benefit. We show here that risk-taking is a modifiable behavior that depends on right hemisphere prefrontal activity. We used low-frequency, repetitive transcranial magnetic stimulation to transiently disrupt left or right dorsolateral prefrontal cortex (DLPFC) function before applying a well known gambling paradigm that provides a measure of decision-making under risk. Individuals displayed significantly riskier decision-making after disruption of the right, but not the left, DLPFC. Our findings suggest that the right DLPFC plays a crucial role in the suppression of superficially seductive options. This confirms the asymmetric role of the prefrontal cortex in decision-making and reveals that this fundamental human capacity can be manipulated in normal subjects through cortical stimulation. The ability to modify risk-taking behavior may be translated into therapeutic interventions for disorders such as drug abuse or pathological gambling.

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Tidsskr Nor Laegeforen. 2006 May 11;126(10):1322-4.
[Pharmacological treatment of pathological gambling]
[Article in Norwegian]
Pallesen S, Molde H, Arnestad HM, Skutle A, Menzoni R, Holsten F.
Institutt for samfunnspsykologi, Universitetet i Bergen, Christies gate 12, 5015 Bergen. staale.pallesen@psysp.uib.no

BACKGROUND: The need for effective treatment for pathological gambling is urgent. The majority of treatment studies and available treatments today are based upon cognitive-behavioural therapy. Recently, however, several studies investigating the effects of pharmacological interventions have been published. We conducted a review of these studies. MATERIAL AND METHODS: Studies for inclusion were identified through searches in PubMed covering the period 1950 to June 2005. A total of 12 studies were included. RESULTS: Selective serotonin reuptake inhibitors and similar compounds were associated with improvement in two out of five placebo-controlled studies and in two out of three studies with a pre-post design. Opioid antagonists were associated with improvement in one placebo-controlled study and in one study with a pre-post design. Mood stabilisers gave improvement in the one placebo-controlled study as well as in both studies with a pre-post design. INTERPRETATION: Pharmacotherapy may yield beneficial effects in the treatment of pathological gamblers. Still, more well-controlled studies with control of comorbid psychiatric conditions are needed.

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Behav Modif. 2006 May;30(3):315-40.
Retaining pathological gamblers in cognitive behavior therapy through motivational enhancement: A pilot study.
Wulfert E, Blanchard EB, Freidenberg BM, Martell RS.
Department of Psychology, University at Albany, State University of New York, USA.

Treatment for pathological gambling is in its infancy. Several cognitive and behavioral interventions have shown promise, but high attrition and relapse rates suggest that gamblers requesting treatment are not uniformly committed to change. This article describes an exploratory study with 9 severe pathological gamblers--in their majority horse race bettors--who were recruited from a community treatment center. The gamblers were treated with a hybrid intervention consisting of motivational enhancement and cognitive behavior therapy. All gamblers were retained in treatment and during a 12-month follow-up period. This retention rate was significantly higher than that of a control group of gamblers who received treatment as usual in the same community setting. Of the gamblers who received the experimental treatment, 6 maintained total abstinence during the 12-month follow-up period, 2 were significantly improved, and 1 remained unimproved. In addition to changing their gambling behavior, many clients made successful lifestyle changes. The possible benefits of combining a motivational intervention with cognitive behavior therapy are discussed.

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Behav Modif. 2006 May;30(3):315-40.
Retaining pathological gamblers in cognitive behavior therapy through motivational enhancement: a pilot study.
Wulfert E, Blanchard EB, Freidenberg BM, Martell RS.
University at Albany, State University of New York.

Treatment for pathological gambling is in its infancy. Several cognitive and behavioral interventions have shown promise, but high attrition and relapse rates suggest that gamblers requesting treatment are not uniformly committed to change. This article describes an exploratory study with 9 severe pathological gamblers-in their majority horse race bettors-who were recruited from a community treatment center. The gamblers were treated with a hybrid intervention consisting of motivational enhancement and cognitive behavior therapy. All gamblers were retained in treatment and during a 12-month follow-up period. This retention rate was significantly higher than that of a control group of gamblers who received treatment as usual in the same community setting. Of the gamblers who received the experimental treatment, 6 maintained total abstinence during the 12-month follow-up period, 2 were significantly improved, and 1 remained unimproved. In addition to changing their gambling behavior, many clients made successful lifestyle changes. The possible benefits of combining a motivational intervention with cognitive behavior therapy are discussed.

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Psychol Addict Behav. 2006 Mar;20(1):62-8.
Does learning about the mathematics of gambling change gambling behavior?
Williams RJ, Connolly D.
School of Health Sciences, University of Lethbridge, Lethbridge, AB, Canada. robert.williams@uleth.ca

The present research examined the influence of improved knowledge of odds and mathematical expectation on the gambling behavior of university students. A group of 198 students in an introductory statistics class received instruction on probability theory using examples from gambling. A comparison group of 134 students received generic instruction on probability, and another group of 138 students in classes on unrelated topics received no mathematical instruction. Students receiving the intervention demonstrated superior ability to calculate gambling odds as well as resistance to gambling fallacies 6 months after the intervention. Unexpectedly, this improvement in knowledge and skill was not associated with any decreases in actual gambling behavior. The implication of this research is that enhanced mathematical knowledge on its own may be insufficient to change gambling behavior.

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Curr Psychiatry Rep. 2006 Feb;8(1):53-8.
Update on pathological gambling.
Grant JE, Williams KA, Kim SW.
Department of Psychiatry, University of Minnesota School of Medicine, 2450 Riverside Avenue, Minneapolis, MN 55454, USA. grant045@umn.edu.

Pathological gambling (PG) is a significant public health concern associated with high rates of psychiatric comorbidity and mortality. Although research into the biology of PG is still in an early stage, recent advances in our understanding of motivation, reward, and addiction have provided substantial insight into the possible pathophysiology of this disorder. In addition, over the past 5 years, extraordinary progress has been made in the area of clinical research examining treatments for PG. Although PG is a disabling disorder that continues to represent a clinical challenge for the healthcare professional, our current knowledge of pharmacotherapy and psychosocial interventions offers potentially effective treatment options.

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Am J Psychiatry. 2006 Feb;163(2):303-12. Comment in: Am J Psychiatry. 2006 Feb;163(2):180-1.
Multicenter investigation of the opioid antagonist nalmefene in the treatment of pathological gambling.
Grant JE, Potenza MN, Hollander E, Cunningham-Williams R, Nurminen T, Smits G, Kallio A.
Department of Psychiatry, University of Minnesota Medical School, 2450 Riverside Avenue, Minneapolis, MN 55454, USA. grant045@umn.edu

OBJECTIVE: Pathological gambling is a disabling disorder experienced by approximately 1%-2% of adults and for which there are few empirically validated treatments. The authors examined the efficacy and tolerability of the opioid antagonist nalmefene in the treatment of adults with pathological gambling. METHOD: A 16-week, randomized, dose-ranging, double-blind, placebo-controlled trial was conducted at 15 outpatient treatment centers across the United States between March 2002 and April 2003. Two hundred seven persons with DSM-IV pathological gambling were randomly assigned to receive nalmefene (25 mg/day, 50 mg/day, or 100 mg/day) or placebo. Scores on the primary outcome measure (Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling) were analyzed by using a linear mixed-effects model. RESULTS: Estimated regression coefficients showed that the 25 mg/day and 50 mg/day nalmefene groups had significantly different scores on the Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling, compared to the placebo group. A total of 59.2% of the subjects who received 25 mg/day of nalmefene were rated as "much improved" or "very much improved" at the last evaluation, compared to 34.0% of those who received placebo. Adverse experiences included nausea, dizziness, and insomnia. CONCLUSIONS: Subjects who received nalmefene had a statistically significant reduction in severity of pathological gambling. Low-dose nalmefene (25 mg/day) appeared efficacious and was associated with few adverse events. Higher doses (50 mg/day and 100 mg/day) resulted in intolerable side effects.

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Geriatr Nurs. 2006 Jan-Feb;27(1):51-7.
Assessment and management of pathological and problem gambling among older adults.
Lucke S, Wallace M.
Yale New Haven Hospital, Connecticut, USA.

The incidence of gambling among older adults has risen significantly over the last decade. Pathological and problem gambling disorders among older adults have devastating consequences including stress, alcohol abuse, loss of income and assets, treatment nonadherence, malnutrition, safety risks related to associated alcohol usage and financial losses, and increased psychiatric problems such as depression. This article reviews the theoretical frameworks and literature concerning gambling incidence, prevalence, behavior, diagnostic tools and interventional strategies for older adults, as well as nursing assessment, care planning, and management of gambling disorders.

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J Affect Disord. 2006 Jan 26; [Epub ahead of print]
Pathological gambling and mood disorders: Clinical associations and treatment implications.
Kim SW, Grant JE, Eckert ED, Faris PL, Hartman BK.
Department of Psychiatry, University of Minnesota Medical School, F282/2A West, 2450 Riverside Avenue, Minneapolis, MN 55454, USA.

BACKGROUND: The rapidly expanding gambling business has resulted in an increasing number of gamblers, and the problem is likely to get worse in the future. Traditionally, mood and gambling symptoms have been known to overlap. In the present review we attempt to examine the diagnostic associations and implications for treatment. METHOD: Selected published papers on the frequencies of mood disorders among patients who have gambling disorder or gambling disorder among patients who have mood disorder have been reviewed. Recently emerging new treatment methods for gambling disorder have been reviewed and a brief summary has been added. RESULTS: SCID based study results show a close link between gambling and mood disorders. The prevalence of manic disorder reaches to approximately one fourth of the pathological gambling disorder population. The prevalence of depression is much higher, reaching to over half of the population in some studies. LIMITATIONS: The studies included in the present paper involve inpatients, outpatients, subjects recruited through advertisements and prison populations. Thus the data need to be interpreted as such. Standardized assessment instruments are not used in all studies. Methodological issues such as primary or secondary nature of depression have not been addressed adequately in these studies. The findings, however, offer new insights for the assessment and treatment of complicated gambling disorder cases. CONCLUSIONS: A high prevalence rate of manic and depressive disorders has been recorded among pathological gambling disorder patients. A rational treatment approach to each defined subset of complicated gambling disorder is discussed.

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J Gambl Stud. 2005 Dec 30;:1-22 [Epub ahead of print]
Parental Modeling, Attachment, and Supervision as Moderators of Adolescent Gambling.
Magoon ME, Ingersoll GM.
The Ohio State University/Sandusky County Juvenile Court, 100 N. Park Avenue, Suite 224, Fremont, OH, 43420, USA, mmagoon@ag.osu.edu.

Utilizing Jessor's Problem Behavior Theory as a theoretical foundation, 116 male and female students in grades 9-12 (mean age 16.8) from a Midwestern urban high school were surveyed to determine the prevalence and relationship among gambling behavior and parental and peer influences. To measure these variables, the following instruments were used: The SOGS-RA, the Inventory of Parent and Peer Attachment-Parent Scale, and The Alabama Parenting Questionnaire-Parental Monitoring and Supervision Scale. Almost all of the students (91%) reported gambling at least once in their lifetime while 36.2% reported gambling once a week, 19% reported gambling on a daily basis, and 26% were classified as problem gamblers (10% using the "narrow" SOGS-RA criteria). Parental gambling was related to levels of past year gambling as well as increased likelihood of being classified as a problem gambler. Increased parental attachment was also associated with decreased levels of adolescent gambling, while decreased parental trust and communication resulted in increased problem gambling. Measures of parental monitoring and supervision found similar outcomes in that increased monitoring and supervision resulted in lower levels of adolescent gambling. Additionally, when peer influences were moderated by parental influences, there was a moderating effect on gambling behavior. This study illuminates the continued importance parents play in both risk enhancing and risk inhibiting influences on adolescent participation in problem behaviors.

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Drug Alcohol Depend. 2005 Dec 21; [Epub ahead of print]
Prize-based contingency management does not increase gambling.
Petry NM, Kolodner KB, Li R, Peirce JM, Roll JM, Stitzer ML, Hamilton JA.
Department of Psychiatry, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-3944, United States.

A contingency management (CM) intervention that provides drug-abstinent patients a chance to win prizes of varying magnitudes is efficacious in retaining patients in treatment and reducing drug use. However, this intervention has been criticized as possibly increasing gambling because it contains an element of chance. Gambling behaviors before, during and 3 months after participation in a multi-site study of CM were compared for stimulant users randomly assigned to 12 weeks of standard care with (N=407) or without (N=396) prize-based CM. Among study participants enrolled in outpatient non-methadone drug abuse treatment (N=415), 26% reported gambling during the observation period, and this rate was 37% among participants (N=388) enrolled in methadone maintenance programs. No differences in gambling over time were noted between those assigned to the prize CM versus standard care conditions, indicating that this prize CM procedure does not adversely impact gambling behavior among stimulant abusers.

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J Gambl Stud. 2005 Winter;21(4):503-20.
Structural changes to electronic gaming machines as effective harm minimization strategies for non-problem and problem gamblers.
Sharpe L, Walker M, Coughlan MJ, Enersen K, Blaszczynski A.
School of Psychology, Gambling Research Unit F12, University of Sydney, 2006, NSW, Australia, louises@psych.usyd.edu.au.

This study aimed to evaluate the effectiveness of three proposed modifications to the structural characteristics of electronic gaming machines as harm minimisation strategies for non-problem and probable problem gamblers. Structural changes included reducing the maximum bet size, reducing reel spin and removing large note acceptors. Behavioural patterns of play were observed in 779 participants attending clubs and hotels. Observations were conducted in the gaming venue during regular gaming sessions. Eight experimental machines were designed to represent every combination of the modifications. 210 participants played at least one modified and one unmodified machine. Following play, the South Oaks Gambling Screen (SOGS) was administered. More problem than non-problem gamblers used high denomination bill acceptors and bet over one-dollar per wager. Machines modified to accept the one-dollar maximum bet were played for less time and were associated with smaller losses, fewer individual wagers and lower levels of alcohol consumption and smoking. It was concluded that the reduction of maximum bet levels was the only modification likely to be effective as a harm minimization strategy for problem gamblers.

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J Clin Psychopharmacol. 2005 Dec;25(6):593-6.
Sustained-release bupropion versus naltrexone in the treatment of pathological gambling: a preliminary blind-rater study.
Dannon PN, Lowengrub K, Musin E, Gonopolski Y, Kotler M.
The Rehovot Community Mental Health and Rehabilitation Center, affiliated with Ness Ziona Medical Center and Tel Aviv University, Rehovot, Israel. pinhasd@post.tau.ac.il

BACKGROUND: Pathological gambling (PG) is a relatively common and highly disabling impulse control disorder. A range of psychotherapeutic agents, including selective serotonin reuptake inhibitors, mood stabilizers, and opioid antagonists, has been shown to be effective in the treatment of PG. The use of selective serotonin reuptake inhibitors and opioid antagonists for PG is consistent with the observation that PG shares features of both the obsessive-compulsive spectrum disorders and addictive disorders. The aim of the study is to compare the effectiveness of sustained-release bupropion versus naltrexone in the treatment of PG. METHODS: Thirty-six male pathological gamblers were enrolled in our study. A comprehensive psychiatric diagnostic evaluation was performed at baseline on all patients, and patients were screened for symptoms of gambling, depression, and anxiety using the South Oaks Gambling Screen, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, and the Clinical Global Impression-Severity Scale. In addition, the patients completed self-report questionnaires about their demographic status. Patients were randomized in 2 groups and received either naltrexone (n = 19) or sustained-release bupropion (n = 17) for 12 weeks in a parallel fashion. Treatment response was monitored using the Clinical Global Impression-Improvement Scale which was performed at weeks 2, 4, 8, and 12. Patients were also assessed for the presence of gambling behavior via an unstructured interview, which was also performed at weeks 2, 4, 6, 8, and 12. Raters were blind to the study treatment. RESULTS: The majority of patients responded well to the drug treatment. Twelve of 17 patients in the sustained-release bupropion group completed the 12-week study, and 13 of 19 naltrexone patients completed the study. Nine (75%) of the 12 completers were rated as full responders in the sustained-release bupropion group versus 10 (76%) of 12 in the naltrexone group. Three (25%) of 12 completers in the bupropion group were rated as partial responders. In the naltrexone group, 3 (23%) of 13 completers were rated as partial responders. Full response was defined as the absence of gambling for a 2-week duration together with improvement on the Clinical Global Impression-Improvement Scale. Partial response was defined as a decrease in the frequency of gambling behavior and a decrease in the amount of money spent on gambling. CONCLUSION: This preliminary study shows that sustained-release bupropion may be effective as naltrexone in the treatment of PG. Further studies are needed to confirm our findings.

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Addiction. 2005 Oct;100(10):1412-22.
Outcome of psychological treatments of pathological gambling: a review and meta-analysis.
Pallesen S, Mitsem M, Kvale G, Johnsen BH, Molde H.
Department of Psychosocial Science, University of Bergen, Norway.

ABSTRACT Aims To investigate the short- and long-term effect of psychological treatments of pathological gambling and factors relating to treatment outcome. Design and setting This study provides a quantitative meta-analytical review of psychotherapeutic treatments of pathological gambling. Studies were identified by computer search in the PsycINFO and Medline databases covering the period from 1966 to 2004, as well as from relevant reference lists. Inclusion criteria The target problem was pathological gambling, the treatment was psychological, the study was published in English and outcomes directly pertaining to gambling were employed. Single case studies, studies where elimination of gambling not was the priority and studies with insufficient statistical information were excluded from the present meta-analysis. Participants A total of 37 outcome studies, published or reported between 1968 and 2004, were identified. Of these 15 were excluded, thus 22 studies were included, involving 1434 subjects. The grand mean age was 40.1 years. The overall proportion of men was 71.5%. Measurements The included studies were coded for outcome measures of pathological gambling. For each condition, means and standard deviations for gambling-related outcome measures, all based upon self-reports or therapist ratings, were compiled at three points in time: baseline, post-treatment and the last follow-up reported. Findings Effect sizes represent the difference between the mean score in a treatment condition and a control condition or the difference between mean scores at separated points in time for one group, expressed in terms of standard deviation units. At post-treatment the analysis indicated that psychological treatments were more effective than no treatment, yielding an overall effect size of 2.01 (P < 0.01). At follow-up (averaging 17.0 months) the corresponding effect size was 1.59 (P < 0.01). A multiple regression analysis showed that the magnitude of effect sizes at post-treatment were lower in studies including patients with a formal diagnosis of pathological gambling only, compared to studies not employing such inclusion criteria. Effect sizes were also higher in randomized controlled trials compared to not randomized controlled trials, higher in within subjects designs compared to between subjects designs and also positively related to number of therapy sessions. No mediator variables were significantly related to the magnitude of the effect sizes at follow-up. Conclusion Psychological interventions for pathological gamble seem to be yield very favourable short- and long-term outcomes.

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J Gambl Stud. 2005 Fall;21(3):273-97.
Alcohol use and prior substance abuse treatment in relation to gambling problem severity and gambling treatment outcome.
Stinchfield R, Kushner MG, Winters KC.
University of Minnesota, USA.

Recent research has made it clear that problematic gambling is often accompanied by problematic alcohol use. Unfortunately, little is known about the nature of this association, especially as it relates to gambling treatment outcome. The purpose of this study is to explore the effect of current alcohol use level and previous substance abuse treatment on the symptoms of a large cohort of pathological gamblers as well as on their response to treatment for pathological gambling. The sample included 464 men and 301 women recruited at six gambling treatment programs in Minnesota. Gambling treatment patients were assessed on a number of gambling problem severity and related clinical variables using the Gambling Treatment Outcome Monitoring System (GAMTOMS). Patients with frequent alcohol use had greater gambling involvement at baseline than infrequent alcohol users. Patients with a previous history of substance abuse treatment had more severe psychosocial problems, ostensibly resulting from their gambling behavior, than patients without past substance abuse treatment. A MANOVA with repeated measures showed that neither pretreatment alcohol use, nor past substance abuse treatment exerted significant effects on gambling treatment outcome. While the level of pretreatment alcohol use and a history of substance abuse treatment are markers for greater gambling problem severity, treatment outcome for pathological gambling was not adversely impacted by these variables.

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Mil Med. 2005 Aug;170(8):683-7.
Review of the first year of an overseas military gambling treatment program.
Kennedy CH, Cook JH, Poole DR, Brunson CL, Jones DE.
Substance Abuse Rehabilitation Program, United States Naval Hospital, Okinawa, Japan.

This study provides descriptive information and preliminary first-year outcome data on the only overseas military gambling treatment option currently available. Implemented in January 2003 within the Substance Abuse Rehabilitation Program, U.S. Naval Hospital, Okinawa, Japan, gambling treatment was developed as a specific track within the overall substance abuse program. The present study explores the various considerations and requirements for setting up such a program, as well as a description of individuals seeking gambling treatment and preliminary outcome data. Participants consisted of all gambling referrals (N = 35, 26 males; mean age, 33.2 years; SD = 8.93) obtained over the first year that gambling services were offered. A significant degree of depression, suicidality, and substance abuse problems were observed in the sample. Results revealed that the gambling program was easily implemented within an established substance abuse program. The program was effective in preventing suicides in both military members and eligible beneficiaries and was effective in facilitating the retention of military members with gambling problems.

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Alcohol Clin Exp Res. 2005 Aug;29(8):1427-31.
Comparison of craving between pathological gamblers and alcoholics.
Tavares H, Zilberman ML, Hodgins DC, el-Guebaly N.
Department of Psychiatry, Gambling Outpatient Unit, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil. hermanot@uol.com.br

BACKGROUND: Craving is a central phenomenon in addiction. Temperament factors are also important for pathologic gambling and other addictions. The aim of this study was to compare craving between pathologic gamblers (PG) and alcohol-dependent subjects (ADS), correlating craving with personality. METHODS: Forty-nine PG and 101 ADS willing to start treatment were recruited. A trained psychiatrist diagnosed them according to DSM-IV criteria. To be included in this study, subjects had to be abstinent for at least five days and no longer than 21 days. Alcoholics should have no significant physical withdrawal symptoms by the time of craving assessment. Subjects with current comorbidity with other addictions were excluded, except nicotine. ADS rated craving for alcohol and PG rated craving for gambling on the same questions, respectively. Both answered a semistructured interview, the Temperament and Character Inventory and the Beck Scales for anxiety and depression. RESULTS: Pathologic gamblers scored higher than ADS on craving measures (p<0.001) and novelty seeking (p=0.01). ADS scored higher in harm avoidance (p=0.01). Alcohol craving correlated positively with anxiety and novelty seeking and negatively with length of abstinence and persistence. Gambling craving correlated positively with depression and negatively with length of abstinence and reward dependence CONCLUSIONS: Pathologic gamblers experienced stronger cravings than did ADS. This may be a disturbing experience for PG and a potential cause for relapse. The higher scores on novelty seeking concur with previous studies that associate PG and impulsivity. ADS higher scores on harm avoidance suggest anxiety vulnerability. The positive relation between alcohol craving, anxiety, and harm avoidance suggests that ADS rely on alcohol to deal with a proclivity to negative emotions. The positive relation of gambling craving to depression and negative relation to reward dependence suggests that individuals who have a lesser susceptibility to experience positive emotions are the ones who most miss gambling when abstaining.

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Int J Geriatr Psychiatry. 2005 Aug;20(8):754-9.
Problem and pathological gambling are associated with poorer mental and physical health in older adults.
Erickson L, Molina CA, Ladd GT, Pietrzak RH, Petry NM.
University of Connecticut Health Center, Farmington, CT 06030-3944, USA.

OBJECTIVE: To evaluate the prevalence and correlates of problem and pathological gambling in older adults. METHODS: Adults (n = 343) aged 60 years and older attending senior centers, bingo sites and other community activities completed a screening form containing the South Oaks Gambling Screen and the Short Form-12 Health Survey, to evaluate physical and mental health. RESULTS: Overall, 6.4% of the respondents were classified as problem gamblers and an additional 3.8% as pathological gamblers. Problem and pathological gamblers evidenced significantly greater physical and mental health problems than non-problem gamblers. CONCLUSIONS: These data suggest that about 10 percent of active older adults experience gambling problems, which are associated with poor physical and mental health. (c) 2005 John Wiley & Sons, Ltd.

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Postgrad Med. 2005 Jul;118(1):31-7.
Pathologic gambling disorder. How to help patients curb risky behavior when the future is at stake.
Sumitra LM, Miller SC.
Department of Psychiatry, Wright State University School of Medicine, Dayton, Ohio 45401, USA. leena.sumitra@wright.edu

Pathologic gambling disorder and problem gambling are becoming increasingly common in the United States as more states legalize gambling. Although gambling-related disorders can cause devastating consequences, well-studied treatments are few. Fortunately, clinical experience suggests that pathologic gambling disorder is highly treatable. In this article, Drs Sumitra and Miller briefly summarize gambling-related disorders and discuss available, effective treatments.

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J Gambl Stud. 2005 Summer;21(2):117-31.
Structural characteristics of video lotteries: effects of a stopping device on illusion of control and gambling persistence.
Ladouceur R, Sevigny S.
School of Psychology, University Laval, Quebec (Qc), Canada, G1K 7P4, Robert.Ladouceur@psy.ulaval.ca.

Two studies investigated the effects of a video lottery terminal stopping device on gamblers' thoughts and behavior. This structural characteristic allows players to voluntarily stop the spinning of the reels. The first study investigated the effect of this device on the development of illusions of control. It was predicted that players using the stopping device would believe that (1) symbols displayed could differ depending on when the game is stopped, (2) there is a possibility of controlling the outcome of the game, (3) skills may be a factor influencing the results, and finally (4) a stopping device would improve the probability of personal success (i.e., developing the illusion of control). The second study aimed to further evaluate the effects of the stopping device on gambling behavior. It was hypothesised that using the stopping device would encourage players to increase the number of games played in a session. Results confirmed all predictions and showed that offering a stopping device on video lottery terminals modifies gamblers' cognition and behavior. The theoretical and practical implications of these results are discussed in the context of responsible gambling policies.

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Wien Klin Wochenschr. 2005 Mar;117(5-6):188-95.
[Excessive computer usage in adolescents--results of a psychometric evaluation]
[Article in German]
Grusser SM, Thalemann R, Albrecht U, Thalemann CN.
Interdisziplinare Suchtforschungsgruppe Berlin, Institut fur Medizinische Psychologie, Charite--Universitatsmedizin Berlin, Berlin, Deutschland. sabine.gruesser@charite.de

Excessive computer and video game playing among children is being critically discussed from a pedagogic and public health point of view. To date, no reliable data for this phenomenon in Germany exists. In the present study, the excessive usage of computer and video games is seen as a rewarding behavior which can, due to learning mechanisms, become a prominent and inadequate strategy for children to cope with negative emotions like frustration, uneasiness and fears. In the survey, 323 children ranging in age from 11 to 14 years were asked about their video game playing behavior. Criteria for excessive computer and video game playing were developed in accordance with the criteria for dependency and pathological gambling (DSM-IV, ICD-10). Data show that 9.3% (N = 30) of the children fulfill all criteria for excessive computer and video game playing. Furthermore, these children differ from their class mates with respect to watching television, communication patterns, the ability to concentrate in school lectures and the preferred strategies coping with negative emotions. In accordance with findings in studies about substance-related addiction, data suggest that excessive computer and video game players use their excessive rewarding behavior specifically as an inadequate stress coping strategy.

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J Gambl Stud. 2005 Spring;21(1):99-108.
Pharmacological treatments of pathological gambling.
Hollander E, Sood E, Pallanti S, Baldini-Rossi N, Baker B.
Department of Psychiatry, Compulsive, Impulsive and Anxiety Disorders Program, Mount Sinai School of Medicine, Box 1230, One Gustave L. Levy Place, New York, NY, U.S.A., 10029-6574, eric.Hollander@mssm.edu.

Medication treatment studies have demonstrated short-term efficacy of various SRIs, opioid antagonists, and mood stabilizers in sub-samples of adult treatment seeking pathological gamblers. Pathological gambling is frequently comorbid with bipolar spectrum disorders, substance abuse/dependence, and attention-deficit/hyperactivity disorder (ADHD), and comorbidity may influence treatment response in pathological gambling. This review focuses on recent research examining the treatment of pathological gambling and highlights methodological challenges for future studies.

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J Gambl Stud. 2005 Spring;21(1):79-90.
Problems in measuring the effectiveness of cognitive therapy for pathological gambling.
Walker MB.
School of Psychology, University of Sydney, Sydney, NSW, Australia, 2006, michaelw@psych.usyd.edu.au.

Cognitive therapy is a relatively new approach to the treatment of pathological gambling. Theoretically, there are strong grounds for believing that cognitive treatments will be effective in helping individuals cut back and stop excessive levels of gambling. However, there is evidence that cognitive therapy for pathological gambling is being confused with cognitive-behaviour therapy. In this paper, the distinction between treatments that are cognitive and those that are cognitive-behavioural is highlighted. Such a distinction has strong implications for the manualisation of therapy. Additionally, a range of problems that confront the evaluation of all therapies for pathological gambling is considered. Spontaneous recovery without therapeutic intervention has been documented in both field studies of both problem and non-problem players and controlled trials of cognitive therapy compared to a waiting list control group. The implications of the phenomenon of spontaneous recovery for the evaluation of cognitive therapy are described. Other problems common to all evaluations of psychotherapies are considered in relation to gambling and recommendations made for outcome study designs.

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J Gambl Stud. 2005 Spring;21(1):49-57.
Controlled gambling for pathological gamblers.
Ladouceur R.
Ecole de Psychologie, Universite Laval, Ste-Foy, Qc., Canada, G1K 7P4, robert.ladouceur@psy.ulaval.ca.

Despite its high prevalence, pathological gambling often remains untreated. It is estimated that only 10% of the pathological gamblers identified in prevalence studies will enter treatment. Within this small proportion, a high percentage will drop out. Despite the facts that some researchers argue against abstinence as the unique treatment goal and that regaining control appears to be possible for some pathological gamblers, abstinence has been the only treatment goal in most problem gambling interventions thus far. This paper examines the avenue of controlled gambling embedded in a harm reduction context as a viable solution for some pathological gamblers.

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Clin Neuropharmacol. 2005 January/February;28(1):6-10.
Topiramate Versus Fluvoxamine in the Treatment of Pathological Gambling: A Randomized, Blind-Rater Comparison Study.
Dannon PN, Lowengrub K, Gonopolski Y, Musin E, Kotler M.
>From the *Rehovot Community Mental Health & Rehabilitation Center Affililated to Ness Ziona Medical Center and Tel Aviv University, Rehovot, Israel; and daggerNess Ziona and Beer Ya'akov Medical Complex and Tel Aviv University, Rehovot, Israel.

Pathologic gambling (PG) is a highly prevalent and disabling impulse control disorder. Recent studies have demonstrated that PG patients respond well to treatment with SSRIs, mood stabilizers, and opioid antagonists. These findings support the idea that PG and other disorders of impulse control may be conceptualized as part of the obsessive-compulsive spectrum disorders. Pilot studies have shown topiramate to be effective in the treatment of specific disorders of impulse control. The aim of the study is to compare the effectiveness of topiramate versus fluvoxamine in the treatment of PG. Thirty-one male PGs were assigned in a randomized fashion to receive either topiramate (15/31) or fluvoxamine (16/31) pharmacotherapy for 12 weeks. A comprehensive psychiatric diagnostic evaluation was performed on all patients, and all patients were evaluated for symptoms of gambling, depression, and anxiety using the South Oaks Gambling Screen, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Yale-Brown Obsessive Compulsive Symptoms Scale, and the Clinical Global Impression-Improvement Scale. The rating scales were administered at baseline and at the 12-week endpoint. In addition, the patients completed self-report questionnaires about their demographic status. Twelve of the 15 patients from the topiramate group completed the 12-week treatment. Nine of the 12 topiramate completers reported full remission of gambling behavior, and 3 completers had a partial remission. The CGI-improvement score was significantly better for the topiramate group at the 12-week visit as compared with baseline (F = 10.5, P < 0.01, df = 2,31). In the fluvoxamine treatment group 8/16 patients completed the study, and 6/8 fluvoxamine completers reported a full remission, and the remaining 2/8 fluvoxamine completers reported a partial remission. The fluvoxamine group showed improvement in the CGI-improvement score at week 12, although this difference was not significant (F = 3.7, P < 0.08, df = 2,31). Topiramate and fluvoxamine monotherapy may be effective in the treatment of pathologic gambling.

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J Clin Psychiatry. 2005 Jan;66(1):28-33.
Sertraline treatment of pathological gambling: a pilot study.
Saiz-Ruiz J, Blanco C, Ibanez A, Masramon X, Gomez MM, Madrigal M, Diez T.
Department of Psychiatry, Hospital Ramon y Cajal, Universidad de Alcala, Madrid, Spain.

OBJECTIVE: Several open-label and double-blind studies have suggested that selective serotonin reuptake inhibitors may be useful in the treatment of pathological gambling. The purpose of this study was to evaluate the efficacy of sertraline in the treatment of pathological gambling. METHOD: Sixty patients meeting the DSM-IV criteria for pathological gambling were treated for 6 months in a double-blind, flexible-dose, placebo-controlled study of sertraline 50 to 150 mg/day. Data were collected from November 1998 to January 2001. The primary outcome measure assessing change in clinical status was the responder rate with respect to the Criteria for Control of Pathological Gambling Questionnaire (CCPGQ). Secondary measures included the Clinical Global Impressions scale (CGI) (Severity of Illness and Improvement subscales), and Visual Analogue Scales assessing gambling frequency, severity, amount, and improvement. Concomitant medication and psychotherapy were not allowed during the study. RESULTS: At the end of the study, 23 sertraline-treated subjects (74%) and 21 placebo-treated subjects (72%) were considered as responders on the CCPGQ (p = .9). Similar results were obtained when the CGI-Improvement scale limited to symptoms of pathological gambling was used as an outcome measure. Sertraline was well tolerated throughout the study. CONCLUSION: Sertraline was not statistically significantly superior to placebo in the overall sample. The power of the study was limited by the high placebo-response rate and the small sample size.

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Am J Psychiatry. 2005 Jan;162(1):137-45.
Does sustained-release lithium reduce impulsive gambling and affective instability versus placebo in pathological gamblers with bipolar spectrum disorders?
Hollander E, Pallanti S, Allen A, Sood E, Baldini Rossi N.
Compulsive, Impulsive, and Anxiety Disorders Program, Department of Psychiatry, Mount Sinai School of Medicine, New York, NY 10029, USA. eric.hollander@mssm.edu

OBJECTIVE: Selective serotonin reuptake inhibitors may be effective for some patients with pathological gambling, but those with comorbid conditions, such as bipolar spectrum disorders, may relapse during treatment. To the authors' knowledge, this is the first placebo-controlled treatment study in pathological gamblers with bipolar spectrum disorders; it compares sustained-release lithium carbonate to placebo. METHOD: Forty pathological gambling patients with bipolar spectrum disorders entered a 10-week randomized, double-blind, placebo-controlled treatment study of sustained-release lithium carbonate. Outcome measures included gambling severity, mood, anxiety, and impulsivity scales. RESULTS: Pathological gambling patients with bipolar spectrum disorders significantly improved while taking sustained-release lithium carbonate compared to placebo on total pathological gambling scores on the Yale-Brown Obsessive Compulsive Scale, including both thoughts/urges and behavior, as well as on the Clinical Global Impression severity of pathological gambling scale. Affective instability (the Clinician-Administered Rating Scale for Mania score) was also lower in the group treated with sustained-release lithium carbonate compared to placebo. Ten (83%) of 12 completers were rated as responders in the sustained-release lithium group versus five (29%) of 17 in the placebo group. Of note, improvement in gambling severity was significantly correlated with improvement in mania ratings. CONCLUSIONS: Sustained-released lithium may be an effective treatment in reducing both gambling behavior and affective instability in pathological gamblers with bipolar spectrum disorder. This study highlights the need to identify subgroups of pathological gambling patients with bipolar spectrum conditions because this may have important treatment implications.

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J Gambl Stud. 2004 Winter;20(4):373-89.
Gambling participation and social support among older adults: a longitudinal community study.
Bilt JV, Dodge HH, Pandav R, Shaffer HJ, Ganguli M.
Western Psychiatric Institute and Clinic, 230 McKee Place, Room 407, Pittsburg, PA 15213, USA ( vanderbiltj@msx.upmc.edu ).

The purpose of this preliminary study was to examine associations between leaving home to engage in bingo or gambling activity and indices of physical and mental health and social support among a representative community cohort of 1016 elderly people. Cross-sectional and longitudinal data gathered from a prospective epidemiological study in a rural, low socio-economic status, area of Pennsylvania was employed. The cohort had a mean age of 78.8 (SD = 5.1) (range 71-97) and participated in three consecutive biennial "waves" of data collection. Nearly half (47.7) of the cohort reported gambling. To predict gambling, the independent variables included age, sex, education, employment, social support, depressive symptoms, self-rated health, alcohol use, cigarette use, and cognitive functioning. In cross-sectional, univariate analyses, gambling was associated with younger age, sex (male), fewer years of education, greater social support, lower depression scores, better self-rated health, alcohol use in the past year, and higher cognitive functioning. In a cross-sectional multiple regression model, younger age, greater social support, and alcohol use in the past year remain strongly and independently associated with gambling activity. Longitudinally, age, sex, social support, alcohol use, and gambling are predictive of future gambling activity. The results revealed that gambling may offer a forum of social support to older adults who are often isolated as they age.

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J Clin Psychopharmacol. 2004 Dec;24(6):628-31.
The advantages of choosing antiobsessive therapy according to decision-making functioning.
Cavedini P, Bassi T, Zorzi C, Bellodi L.
Department of Neuropsychiatric Sciences, San Raffaele Hospital Scientific Institute, Vita-Salute San Raffaele University, School of Psychology, Milan, Italy. cavedini.paolo@hsr.it

OBJECTIVE: Previous studies stressed the role of decision-making functioning in predicting antiobsessive treatment outcome with serotonin reuptake inhibitors drugs in patients with obsessive-compulsive disorder. Nevertheless, the use of an augmentation strategy with atypical antipsychotic drugs has proved to be effective in obsessive-compulsive patients nonresponding to serotonin reuptake inhibitors treatment. We investigated whether the performance at the Iowa Gambling Task (IGT), a used neuropsychologic task which assesses decision-making, can be an effective criterion for pharmacologic treatment choice in these patients and whether the use of different treatment strategies, according IGT performance, can increase the rate of antiobsessive outcome. METHOD: Thirty patients with obsessive-compulsive disorder were treated in a single-blind design with fluvoxamine plus placebo or fluvoxamine plus risperidone according to their IGT performance. Treatment outcome was recorded after 6 and 12 weeks. RESULTS: Patients with good IGT performance showed a good antiobsessive treatment outcome with fluvoxamine only, while only adopting an augmentation strategy with risperidone, the number of responders patients within the subjects with bad IGT performance increased. CONCLUSIONS: IGT performance may be considered an effective criterion for pharmacologic treatment choice in obsessive-compulsive patients given that antiobsessive treatment outcome is increased to 85% of responders choosing an appropriate drug strategy according to the IGT performance.

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Psychol Addict Behav. 2004 Sep;18(3):293-6.
Brief motivational treatment for problem gambling: a 24-month follow-up.
Hodgins DC, Currie S, el-Guebaly N, Peden N.
Department of Psychology, University of Calgary, Calgary, Alberta, Canada. dhodgins@ucalgary.ca.

A 24-month follow-up of a randomized clinical trial of 2 brief treatments for problem gambling (N = 67) revealed an advantage for participants who received a motivational telephone intervention plus a self-help workbook compared with participants who received only the workbook. Although the 2 groups did not differ in the number of participants reporting 6 months of abstinence, the motivational intervention group gambled fewer days, lost less money, and had lower South Oaks Gambling Screen scores. They were more likely to be categorized as improved compared with the self-help workbook only group. Overall, the results support the effectiveness of a brief telephone- and mail-based treatment for problem gamblers. (c) 2004 APA

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Can J Psychiatry. 2004 Aug;49(8):517-25.
Assessing and treating problem gambling: empirical status and promising trends.
Toneatto T, Millar G.
Clinical Research Department, Center for Addiction and Mental Health, Toronto, Ontario. tony_toneatto@camh.net

OBJECTIVE: Ways to clinically assess and treat problem gambling evolve as our knowledge about this disorder increases. This paper summarizes current knowledge about treating problem gambling and describes developments in the assessment, psychology, and biology of problem gambling that may be important for treatment. METHODS: We reviewed recent published literature reporting advances in the assessment, psychology, and biology of problem gambling. We retained for review only controlled clinical trials in which subjects were randomized to either psychological or pharmacologic treatment. RESULTS: Although several gambling treatments were found to be efficacious, support for any specific treatment modality is still limited. Cognitive-behavioural treatments were most effective. Although diagnostic assessment has improved, there are still very few measures of gambling-related variables. The contribution to gambling of sex, concurrent psychiatric disorders, cognitive distortions, and impulsivity has been described. Evidence implicating decision-making areas of the cortex and disturbances in serotonin and dopamine functioning has been reviewed. Available evidence for a genetic contribution to problem gambling is weak. CONCLUSIONS: Improvements in the methodology of gambling-treatment research were discussed to advance the clinical approach to this disorder. Developments in the area of assessment, psychology, and biology of gambling should inform clinical approaches to a greater degree than they currently do. We identified the need to study different types of gambling separately, rather than combining them, as an important goal.

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Eur Psychiatry. 2004 Aug;19(5):299-302.
Comorbid psychiatric diagnoses in kleptomania and pathological gambling: a preliminary comparison study.
Dannon PN, Lowengrub K, Sasson M, Shalgi B, Tuson L, Saphir Y, Kotler M.
Rehovot Community Mental Health and Rehabilitation Center, Affiliated to Ness Ziona Medical Center and Tel Aviv University, Remez Street 80, Rehovot 76449, Israel. pinhasd@post.tau.ac.il

Kleptomania and pathological gambling (PG) are currently classified in the DSM IV as impulse control disorders. Impulse control disorders are characterized by an overwhelming temptation to perform an act that is harmful to the person or others. The patient usually feels a sense of tension before committing the act and then experiences pleasure or relief while in the process of performing the act. Kleptomania and PG are often associated with other comorbid psychiatric diagnoses. Forty-four pathological gamblers and 19 kleptomanics were included in this study. All enrolled patients underwent a complete diagnostic psychiatric evaluation and were examined for symptoms of depression and anxiety using the Hamilton depression rating scale and the Hamilton anxiety rating scale, respectively. In addition, the patients completed self-report questionnaires about their demographic status and addictive behavior. The comorbid lifetime diagnoses found at a high prevalence among our kleptomanic patients included 47% with affective disorders (9/19) and 37% with anxiety disorders (7/19). The comorbid lifetime diagnoses found at a high prevalence in our sample of pathological gamblers included 27% with affective disorders (12/44), 21% with alcohol abuse (9/44), and 7% with a history of substance abuse (3/44). A larger study is needed to confirm these preliminary results.

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Cas Lek Cesk. 2004;143(4):231-5.
[New trends in the treatment and prevention of addictive disorders]
[Article in Czech]
Nespor K.
Oddeleni lecby zavislosti (muzi)-Psychiatricka lecebna, Praha-Bohnice. nespor@plbohnice.cz

Some trends in the treatment and prevention of diseases related to alcohol, drugs and gambling are reviewed. Brief intervention is crucially important, considering high prevalence of addictive diseases. Motivation enhancement according to the stage of motivation is used in brief intervention and also during more comprehensive therapy. Psychological and pharmacological management of craving is used more than before. Close and systematic co-operation between professional services and Alcoholics Anonymous and/or other self-helping groups is common and useful. Prevention of addictive diseases includes measures such as taxation, restriction of availability, age limits, restrictions of advertisements, and prevention of drinking under the influence of alcohol and other drugs. Effective school based prevention utilises interactive programmes and training of relevant skills (e.g. refusal skills, relaxation and decision making). Prevention on family level includes appropriate family monitoring and rules, moderate and consistent family discipline and family conflict resolution. Special attention should be paid to the children whose parents are alcohol or drug dependent. These children should, even as adults, abstain from alcohol and other addictive substances.

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J Gambl Stud. 2004 Summer;20(2):121-6.
Factor analysis of barriers to treatment for problem gambling.
Rockloff MJ, Schofield G.
Department of Psychology and Sociology, Central Queensland University, Rockhampton, Queensland 4702, Australia. matthew@rockloff.net

Attitudes toward problem gambling treatment were investigated in a telephone survey of 1,203 persons in Central Queensland Australia (598 women and 605 men, mean age = 45.8 years). Survey items were compiled from existing substance abuse questionnaires (Center on Alcoholism, Substance Abuse and Addictions, 1995; Sobell et al., 1991). An exploratory factor analysis identified five potential barriers to treatment, including: availability, stigma, cost, uncertainty, and avoidance. Relative to those with few problems, respondents who had numerous gambling problems were more concerned about treatment costs, and the availability and effectiveness of treatment. In addition to the above concerns, older persons more often negatively judged the treatment seeker. In contrast, educated respondents had generally more positive attitudes towards problem gamblers and treatment seeking.

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Psychol Addict Behav. 2004 Jun;18(2):170-9.
Psychosocial variables associated with adolescent gambling.
Hardoon KK, Gupta R, Derevensky JL.
International Centre for Youth Gambling Problems and High-Risk Behaviors, McGill University, Montreal, Quebec, Canada.

The authors empirically examined the relations between several psychosocial variables associated with adolescent problem gambling. Participants were 2,336 students in Grades 7-13, and all completed a questionnaire regarding gambling activities, gambling severity, perceived social support, drug and alcohol dependence, and various social, emotional, and behavioral problems. With respect to gambling severity, 4.9% of adolescents met the criteria for pathological gambling, and 8.0% were found to be at risk. Psychosocial difficulties associated with problem gambling include poor perceived familial and peer social support, substance use problems, conduct problems, family problems, and parental involvement in gambling and substance use. A set of predictor variables that may lead to problem gambling includes having family problems, having conduct problems, being addicted to drugs or alcohol, and being male. (c) 2004 APA, all rights reserved

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Ann Clin Psychiatry. 2004 Jan-Mar;16(1):27-34.
Impulse control disorders: clinical characteristics and pharmacological management.
Grant JE, Potenza MN.
Department of Psychiatry and Human Behavior, Brown Medical School, Butler Hospital, Providence, Rhode Island 02906, USA. Jon_Grant@Brown.edu

This article reviews the current knowledge of the clinical characteristics and pharmacological management of pathological gambling, kleptomania, and compulsive buying. Specifically, the article summarizes the phenomenology and associated psychopathology of these disorders and presents study results of the various pharmacological agents used to treat these disorders--serotonin reuptake inhibitors, opioid antagonists, mood stabilizers, and atypical antipsychotics.

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J Gambl Stud. 2004 Spring;20(1):83-93.
Indicated prevention of problem gambling among college students.
Takushi RY, Neighbors C, Larimer ME, Lostutter TW, Cronce JM, Marlatt GA.
University of Washington, Seattle, WA, USA. rytakushi@hotmail.com

This research provides a brief qualitative description of the development of an indicated prevention intervention for college student gamblers. The proposed intervention integrates alcohol prevention strategies with elements of gambling treatment. The intervention combines cognitive-behavioral skills-training and motivational interviewing and includes personalized normative feedback, cognitive correction, discussion of gambling consequences, and relapse prevention techniques. Examples detailing all phases of the intervention are provided from interviews conducted in a pilot of the intervention. Preliminary pilot data suggests the intervention shows promise in reducing high risk gambling among college students.

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Pain. 2004 Mar;108(1-2):129-36.
Chronic pain patients are impaired on an emotional decision-making task.
Apkarian AV, Sosa Y, Krauss BR, Thomas PS, Fredrickson BE, Levy RE, Harden RN, Chialvo DR.
Department of Physiology, Northwestern University Medical School, 303 E Chicago Avenue, Chicago, IL 60611, USA. a-apkarian@northwestern.edu

Chronic pain can result in anxiety, depression and reduced quality of life. However, its effects on cognitive abilities have remained unclear although many studies attempted to psychologically profile chronic pain. We hypothesized that performance on an emotional decision-making task may be impaired in chronic pain since human brain imaging studies show that brain regions critical for this ability are also involved in chronic pain. Chronic back pain (CBP) patients, chronic complex regional pain syndrome (CRPS) patients, and normal volunteers (matched for age, sex, and education) were studied on the Iowa Gambling Task, a card game developed to study emotional decision-making. Outcomes on the gambling task were contrasted to performance on other cognitive tasks. The net number of choices made from advantageous decks after subtracting choices made from disadvantageous decks on average was 22.6 in normal subjects (n = 26), 13.4 in CBP patients (n = 26), and -9.5 in CRPS patients (n = 12), indicating poor performance in the patient groups as compared to the normal controls (P < 0.004). Only pain intensity assessed during the gambling task was correlated with task outcome and only in CBP patients (r = -0.75, P < 0.003). Other cognitive abilities, such as attention, short-term memory, and general intelligence tested normal in the chronic pain patients. Our evidence indicates that chronic pain is associated with a specific cognitive deficit, which may impact everyday behavior especially in risky, emotionally laden, situations.

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J Geriatr Psychiatry Neurol. 2004 Mar;17(1):9-12.
Pharmacotherapy outcome in older pathological gamblers: a preliminary investigation.
Grant JE, Grosz R.
Department of Psychiatry and Human Behavior, Butler Hospital and Brown Medical School, 345 Blackstone Blvd., Providence, RI 02906, USA. jon_grant@brown.edu

Although pharmacotherapy is often effective for pathological gambling, little is known about how it affects older populations. The present study examines the response to pharmacotherapy in a series of pathological gamblers age 60 years and older. Fourteen older patients who fulfilled DSM-IV criteria for pathological gambling were treated in an outpatient clinic. Subjects were assessed retrospectively with the Clinical Global Impressions scale (both severity and improvement measures) using information collected on gambling symptoms during clinic visits. Eight (57.1%) older patients achieved sustained response to pharmacotherapy. The present findings indicate that many older pathological gamblers respond to "off-label" use of pharmacotherapy. The present findings are preliminary. Further studies with larger samples are needed to confirm these findings.

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Curr Psychiatry Rep. 2004 Feb;6(1):58-65.
Compulsive disorders.
Kuzma JM, Black DW.
Department of Psychiatry, University of Iowa Carver College of Medicine, Psychiatry Research MEB, Iowa City, IA 52242, USA. donald-black@uiowa.edu

Compulsive disorders include a diverse group of conditions characterized by excessive thoughts or preoccupations combined with poorly controlled behaviors. They include trichotillomania, kleptomania, pathologic gambling, compulsive buying disorder, compulsive sexual behavior, and compulsive computer use. Some investigators have suggested that these conditions constitute a spectrum of disorders linked to obsessive-compulsive disorder. Others have questioned the validity of this conceptualization, and have debated the relationship between these disorders. Nevertheless, much has been learned about compulsive disorders, and there have been some successes with psychotherapeutic and psychopharmacologic treatments. Recent therapy-based interventions have moved from psychodynamic treatments toward cognitive-behavioral modalities. Serotonin reuptake inhibitors remain the best-studied pharmacologic treatment, but researchers have also explored other antidepressants, opioid agonists, mood stabilizers, and atypical antipsychotics.

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Behav Res Ther 2003 May;41(5):587-96
Group therapy for pathological gamblers: a cognitive approach.
Ladouceur R, Sylvain C, Boutin C, Lachance S, Doucet C, Leblond J.
Ecole de Psychologie, Universite Laval, Quebec, G1K 7P4, Ste-Foy, Canada

This study evaluated the efficacy of a group cognitive treatment for pathological gambling. Gamblers, meeting DSM-IV criteria for pathological gambling, were randomly assigned to treatment (N=34) or wait-list control (N=24) conditions. Cognitive correction techniques were used first to target gamblers' erroneous perceptions about randomness, and then to address issues of relapse prevention. The dependent measures used were the DSM-IV criteria for pathological gambling, perceived self-efficacy, gamblers' perception of control, desire to gamble, and frequency of gambling. Post-treatment results indicated that 88% of the treated gamblers no longer met the DSM-IV criteria for pathological gambling compared to only 20% in the control group. Similar changes were observed on all outcome measures. Analysis of data from 6-, 12- and 24-month follow-ups revealed maintenance of therapeutic gains. Recommendations for group interventions are discussed, focusing on the cognitive correction of erroneous perceptions toward the notion of randomness.

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Curr Psychiatry Rep 2003 Feb;5(1):9-15
Diagnosis and treatment of pathologic gambling.
Sood ED, Pallanti S, Hollander E.
*Department of Psychiatry, The Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1230, New York, NY 10029, USA. eric.hollander@mssm.edu

Pathologic gambling (PG) is an impulse control disorder characterized by recurrent and maladaptive gambling behaviors that significantly disrupt the patient's functioning in the personal, familial, or vocational spheres. Pathologic gambling is estimated to currently affect 1% to 3.4% of the adult US population and is frequently comorbid with substance abuse or dependence, attention-deficit/hyperactivity disorder (ADHD), and affective disorders. Studies show evidence for the involvement of the serotonergic, noradrenergic, and dopaminergic systems in the etiology of PG. Medication treatment studies performed in PG patients demonstrated the short-term efficacy of various serotonin reuptake inhibitors, opioid antagonists, and mood stabilizers in a subsample of adult pathologic gamblers who seek treatment. This review focuses on recent research examining the neurobiology and treatment of PG.

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J Gambl Stud 2003 Spring;19(1):85-109
Advances in the pharmacological treatment of pathological gambling.
Grant JE, Kim SW, Potenza MN.
Department of Psychiatry, University of Minnesota School of Medicine, 2450 Riverside Avenue, Minneapolis, MN 55454-1495, USA. grant045@umn.edu

In the present paper we discuss the current status of drug treatment for pathological gambling and the scientific rationales underlying the various pharmacological approaches. Specifically, we summarize the treatment study results of serotonin reuptake inhibitors, mood stabilizers, opioid antagonists, and atypical antipsychotics in pathological gambling. We also discuss dosage strategies, the duration of treatment, issues surrounding medication compliance, and approaches to treatment-refractory pathological gambling, such as pharmacological and behavioral augmentation.

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Ann Clin Psychiatry 2002 Sep;14(3):155-61
Effectiveness of pharmacotherapy for pathological gambling: a chart review.
Grant JE, Kim SW.
Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, Minnesota 55454-1495, USA. grant045@umn.edu

Although pathological gambling is a relatively common disorder, there exists only limited information regarding the effectiveness of pharmacotherapy for this illness. This study examines which medications may be effective, dose and duration of medication trials needed to achieve response, and possible predictors of response. Using a chart review, 50 adult outpatients with DSM-IV pathological gambling treated in clinical practice were assessed regarding response to a variety of medications, including augmentation strategies, and response to concomitant psychotherapy. All subjects received pharmacotherapy for gambling symptoms. Thirty-nine (78%) achieved response to medication treatment. Mean duration of treatment needed for response was 104.9 +/- 85.0 days. Of those treated with an adequate trial of naltrexone as monotherapy, 90.9% were responders, whereas only 45.5% of those treated with an adequate trial of an SSRI achieved response. Patients with poorer social and occupational functioning due to urges and thoughts about gambling were less likely to respond to medication. These findings from a clinical setting suggest that a majority of pathological gamblers improve with medication treatment. Naltrexone, or augmentation of naltrexone with an SSRI, appears to be most effective in relieving gambling symptoms.

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Exp Clin Psychopharmacol 2002 Aug;10(3):213-27
Clinical uses of naltrexone: a review of the evidence.
Modesto-Lowe V, Van Kirk J.
Alcohol Research Center, Department of Psychiatry, University of Connecticut School of Medicine, Farmington 06030-2103, USA. modesto@neuron.uchc.edu

The implication of the opioidergic system in the pathogenesis of various substance use disorders has led to renewed interest in expanding the clinical uses of naltrexone, an opioid antagonist. This article examines the evidence for the efficacy of naltrexone in a variety of substance use and psychiatric disorders. Naltrexone can be an effective treatment for alcohol and opioid dependence if issues of compliance are adequately addressed. Thus far, no definitive role has been found for naltrexone in the treatment of other psychiatric disorders. Further research needs to be done in self-injurious behavior, gambling, cocaine, and nicotine dependence.

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J Clin Psychiatry 2002 Nov;63(11):1034-9
Nefazodone treatment of pathological gambling: a prospective open-label controlled trial.
Pallanti S, Baldini Rossi N, Sood E, Hollander E.
Department of Psychiatry, Mount Sinai School of Medicine, New York, N.Y., USA.

BACKGROUND: Pathological gambling is a disabling and highly prevalent impulse-control disorder not otherwise specified (NOS). According to the hypothesis of abnormal serotonin function in the pathophysiology of poor impulse control and pathological gambling, we assessed the efficacy and tolerability of nefazodone, a 5-HT antagonist reported to be effective in other impulse-control disorders NOS, in the treatment of pathological gambling. METHOD: Fourteen outpatients who met DSM-IV criteria for pathological gambling were enrolled in a prospective 8-week open-label oral nefazodone trial. Nefazodone was initiated at 50 mg/day and titrated upward to a maximum of 500 mg/day based on patient's response and side effects, with a minimum daily dose of 100 mg. Improvement in gambling was assessed via the pathological gambling modifications of the Yale-Brown Obsessive Compulsive Scale (PG-YBOCS), the Clinical Global Impressions-Improvement scale (PG-CGI-I), and self-rated gambling scales. Response was defined a priori as both a 25% reduction in PG-YBOCS score and a score of 1 (very much improved) or 2 (much improved) on the PG-CGI-I scale. RESULTS: Twelve subjects completed the study, and 2 subjects were early dropouts who did not receive the minimum required dose. Significant improvements were noted in all gambling outcome measures, as well as in depression and anxiety ratings (which did not significantly correlate with gambling reduction). Nine (75%) of 12 patients were rated as responders according to a priori criteria. Side effects (dry mouth and sedation) of moderate severity occurred in 4 subjects. CONCLUSION: These preliminary results suggest that nefazodone may be effective in reducing symptoms of pathological gambling and is well tolerated.

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J Clin Psychiatry 2002 Jul;63(7):559-64
Lithium and valproate treatment of pathological gambling: a randomized single-blind study.
Pallanti S, Quercioli L, Sood E, Hollander E.
Mount Sinai School of Medicine, New York, NY, USA. s.pallanti@agora.it

OBJECTIVE: The aim of the present study was to evaluate the efficacy and safety of lithium and valproate in nonbipolar pathological gamblers. METHOD: Forty-two subjects with DSM-IV-defined pathological gambling entered a 14-week single-blind trial with lithium (N = 23) or valproate (N = 19). A total of 15 subjects on lithium treatment and 16 patients on valproate treatment completed the 14-week protocol. RESULTS: At the end of the 14-week treatment period, both the lithium and the valproate groups showed significant (p <.01) improvement in mean score on the Yale-Brown Obsessive Compulsive Scale modified for pathological gambling. This improvement did not significantly differ between groups. Fourteen (60.9%) of the 23 patients taking lithium and 13 (68.4%) of the 19 patients taking valproate were responders based on a Clinical Global Impressions-Improvement score of much or very much improved. CONCLUSION: Findings from the present study suggest the efficacy of both lithium carbonate and valproate in the treatment of pathological gambling. This is the first controlled trial of the efficacy of mood stabilizers in pathological gambling. A double-blind, placebo-controlled trial is required to confirm these findings.

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J Clin Psychiatry 2002 Jun;63(6):501-7
A double-blind placebo-controlled study of the efficacy and safety of paroxetine in the treatment of pathological gambling.
Kim SW, Grant JE, Adson DE, Shin YC, Zaninelli R.
Department of Psychiatry, University of Minnesota, Minneapolis, USA. kimxx003@umn.edu

BACKGROUND: This randomized, double-blind, placebo-controlled study investigated the efficacy and tolerability of paroxetine in the treatment of pathological gambling. METHOD: Patients fulfilling DSM-IV criteria for pathological gambling and scoring > or = 5 on the South Oaks Gambling Screen were enrolled if no other Axis I disorder was present. A 1-week placebo run-in phase was followed by 8 weeks' treatment with paroxetine or placebo. The initial paroxetine dose of 20 mg/day could be increased after week 2 by 10 mg/week to a maximum of 60 mg/day. Changes in clinical status were assessed using the Gambling Symptom Assessment Scale (G-SAS) and the Clinical Global Impressions scale (CGI). Treatment-emergent symptoms were assessed weekly. RESULTS: Forty-five patients were included in an intent-to-treat analysis (N = 23 paroxetine, N = 22 placebo). Statistically significantly greater reductions in the total score of the G-SAS were observed in the paroxetine group compared with the placebo group at weeks 6 through 8 (p = .003, .003, and .042, respectively). Improvement on the CGI was also significantly greater in the paroxetine than in the placebo group at the same timepoints (p = .033, .014, and .025, respectively). A significantly greater proportion of patients in the paroxetine group were responders at weeks 7 and 8 (p = .011 and .010, respectively). CONCLUSION: The results of this trial indicate that paroxetine may be effective in the treatment of pathological gambling. There were no unexpected side effects from this treatment. However, additional studies with larger patient samples and a longer treatment phase are required to establish conclusively the efficacy and safety of paroxetine for this indication.

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Ann Clin Psychiatry 2002 Mar;14(1):9-15
A pilot placebo-controlled study of fluvoxamine for pathological gambling.
Blanco C, Petkova E, Ibanez A, Saiz-Ruiz J.
Department of Psychiatry, Columbia University, New York, New York, USA. cb255@columbia.edu

The objective of this study was to evaluate the efficacy of fluvoxamine in the treatment of pathological gambling. Thirty-two patients were treated for 6 months in a double-blind, placebo-controlled study of fluvoxamine 200 mg/day. Outcome measures included reduction in money and time spent gambling per week. Longitudinal mixed effects models and completers analyses were used for estimation and hypothesis testing. Fluvoxamine was not statistically significantly different from placebo in the overall sample. However, fluvoxamine was statistically significantly superior to placebo in males and in younger patients. The power of the study was limited by the high (59%) placebo-response rate. Fluvoxamine may be a useful treatment for certain subgroups of patients with pathological gambling. Several methodological recommendations are made for future pharmacological trials of pathological gambling.

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J Clin Psychiatry 2002 Jan;63(1):44-8
An open-label study of citalopram in the treatment of pathological gambling.
Zimmerman M, Breen RB, Posternak MA.
Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI, USA.

BACKGROUND: This study evaluated the effectiveness of citalopram in the treatment of pathological gambling. METHOD: Fifteen adult pathological gamblers (DSM-IV criteria) were administered citalopram in an open-label fashion for up to 12 weeks. Subjects were rated at baseline and at 2-week intervals on measures of gambling severity and depression, and monthly on quality of life. RESULTS: Patients reported significant (p < .05) improvements on all gambling measures including the number of days gambled, the amount of money lost gambling, preoccupation with gambling, and urges to gamble. Thirteen (86.7%) of the patients were rated as "much improved" or "very much improved" on a clinician-rated Clinical Global Impressions scale for gambling. Patients reported improvement in depression and overall quality of life. Patients with major depressive disorder (MDD) (N = 8) improved to approximately the same degree as patients without MDD (N = 7). For most patients, clinical improvement occurred during the first 2 weeks of treatment; for the 9 patients who completed the entire 12-week trial, these gains were maintained. CONCLUSION: Citalopram appears to be an effective treatment for pathological gambling, and this benefit was independent of its antidepressant properties. Future studies employing a control group will be important to examine the extent of the response to nonspecific factors of treatment.

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Semin Clin Neuropsychiatry 2001 Jul;6(3):184-94
The psychopharmacology of pathological gambling.
Kim SW, Grant JE.
Department of Psychiatry, University of Minnesota, School of Medicine, Minneapolis, MN 55454-1495, USA.

We discuss the rationale of the pharmacological approaches to pathological gambling and review the current status of drug treatments in this area. Specifically, we summarize the treatment study results of serotonin reuptake inhibitors, mood stabilizers, and opioid antagonists in pathological gambling. We also briefly describe the animal and human studies of other pharmacologic agents that show future promise in treating this disorder. Finally, we discuss a research agenda to be addressed in future drug treatment studies in pathological gambling. Copyright 2001 by W.B. Saunders Company.

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Int Clin Psychopharmacol 2001 Sep;16(5):285-9
An open naltrexone treatment study in pathological gambling disorder.
Kim SW, Grant JE.
Department of Psychiatry, University of Minnesota Medical School, Minneapolis 55454-1495, USA. kimxx003@umn.edu

The present study was designed to test the short-term efficacy and safety of naltrexone in the treatment of pathological gambling disorder. Seventeen subjects (seven men, 10 women) who fulfilled DSM-IV criteria for pathological gambling disorder, and were free from other Axis I diagnoses by Structured Clinical Interview for DSM-III-R screening, participated in a 6-week open naltrexone flexible dose trial. Gambling symptom change was assessed with the patient-rated Clinical Global Impression (CGI) Scale, the clinician-rated CGI and the Gambling Symptom Assessment Scale. Side-effects were monitored weekly and liver function tests biweekly. Naltrexone reduced urges to gamble and gambling behaviour. The mean change in gambling frequency per week was 1.40 +/- 0.28 episodes per week; the mean change in dollars lost per week was $66.95 +/- 13.77; and the mean change in clinician-rated CGI Improvement was 0.40 +/- 0.04. Of those who responded to the medication, the majority had done so by the end of the fourth week. Men responded to naltrexone as well as women. The average naltrexone dose required for effective symptom control was 157 mg/day. Nausea was common during the first week (47%). The present findings provide evidence that naltrexone may be effective in the treatment of pathological gambling disorder. The present report is preliminary and controlled trials are needed to confirm these findings.

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Clin Neuropharmacol 2001 May-Jun;24(3):170-2
Pathologic gambling in patients with Parkinson's disease.
Gschwandtner U, Aston J, Renaud S, Fuhr P.
Psychiatric Outpatient Department, University Hospital Basel, Basel, Switzerland.

Patients with Parkinson's disease frequently have depression, anxiety, and obsessive-compulsive disorder. We observed two patients who had episodes of pathologic gambling. At the same time, their Parkinson's disease deteriorated and they initiated self-medication with dopaminergic drugs. In both patients, signs were present of an addiction to dopaminergic medication. Pathologic gambling ceased in these patients after a few months. The significance of an insufficient dopaminergic reward system in patients with stereotypical addictive-like behavior (e.g., pathologic gambling) is discussed in this report. The most likely explanation for this newly recognized behavioral disorder in patients with Parkinson's disease is enhanced novelty seeking as a consequence of overstimulation of mesolimbic dopamine receptors resulting from addiction to dopaminergic drugs.

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J Clin Psychiatry 2003 Jan;64(1):81-5
Impulsive aggressive behavior: open-label treatment with citalopram.
Reist C, Nakamura K, Sagart E, Sokolski KN, Fujimoto KA.
Mental Health Care Group, VA Long Beach Healthcare System and Department of Psychiatry and Human Behavior, University of California, Irvine, USA. creist@uci.edu

BACKGROUND: Results from open-label and placebo-controlled trials suggest that the selective serotonin reuptake inhibitors reduce impulsive aggressive behavior. The objective of this open-label study was to investigate whether citalopram treatment has anti-aggressive effect on impulsive aggressive subjects meeting DSM-IV criteria for a cluster B personality disorder or intermittent explosive disorder. METHOD: In this 8-week trial, subjects were initiated on 20 mg/day of citalopram and titrated up to 60 mg/day by the fourth week, if tolerated. The primary outcome measure was the Overt Aggression Scale-Modified (OAS-M), a scale used to quantify verbal and physical aggression, subjective irritability, and overt irritability. Secondary outcome measures included the Barratt Impulsiveness Scale and Buss-Durkee Hostility Inventory. RESULTS: Of 25 subjects enrolled, 20 completed the study. The mean daily dose was 45.5 mg, and citalopram was generally well tolerated. Statistically significant decreases were found in the OAS-M aggression scores (32.82 +/- 19.76 to 4.73 +/- 7.57, p =.000), subjective irritability scores (3.50 +/- 0.60 to 1.45 +/- 1.18, p =.000), and overt irritability scores (3.23 +/- 0.81 to 0.91 +/- 1.02, p =.000). CONCLUSION: These results suggest that citalopram is an effective treatment for reducing impulsive aggressive behavior.

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J Clin Psychiatry 2003 Mar;64(3):250-8
Efficacy and tolerability of paroxetine for the long-term treatment of generalized anxiety disorder.
Stocchi F, Nordera G, Jokinen RH, Lepola UM, Hewett K, Bryson H, Iyengar MK; Paroxetine Generalized Anxiety Disorder Study Team.
Institute of Neurology, Istituto Ricerca Carattere Scientifico Neuromed, Pozzill Italy. fabstocc@tin.it

BACKGROUND: Paroxetine has demonstrated efficacy in depression and anxiety disorders, including generalized anxiety disorder (GAD). This 32-week study evaluated the maintained efficacy and safety of paroxetine in GAD by assessing the potential for relapse after discontinuation of medication. METHOD: Adults (N = 652) with DSM-IV GAD and a Clinical Global Impressions-Severity of Illness (CGI-S) score > or = 4 received paroxetine (20-50 mg/day) for 8 weeks. Patients whose CGI-S score had decreased by at least 2 points to < or = 3 at week 8 were randomly assigned to double-blind treatment with paroxetine (N = 278) or placebo (N = 288) for a further 24 weeks. The primary efficacy parameter was the proportion of patients relapsing (an increase in CGI-S score of at least 2 points to a score < or = 4 or withdrawal resulting from lack of efficacy) during double-blind treatment. RESULTS: Significantly fewer paroxetine than placebo patients relapsed during the 24-week double-blind phase (10.9% vs. 39.9%; p <.001). Placebo patients were almost 5 times more likely to relapse than paroxetine patients (estimated hazard ratio = 0.213 [95% CI = 0.1 to 0.3]; p <.001). Statistical significance in favor of paroxetine was demonstrated for all secondary efficacy parameters, including functional status. Twice as many paroxetine patients as placebo patients (73%) achieved remission. Paroxetine was well tolerated, with no unexpected adverse events reported. CONCLUSION: Paroxetine was found to be effective and well tolerated for both the short- and long-term treatment of DSM-IV GAD. Continued treatment with paroxetine significantly reduced the potential for relapse of GAD symptoms.

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CNS Drugs 2003;17(5):343-62
Escitalopram : a review of its use in the management of major depressive and anxiety disorders.
Waugh J, Goa KL.
Adis International Limited, Auckland, New Zealand. demail@adis.co.nz

Escitalopram is the therapeutically active S-enantiomer of RS-citalopram, a commonly prescribed SSRI. The R-enantiomer is essentially pharmacologically inactive. Escitalopram 10 or 20 mg/day produced significantly greater improvements in standard measurements of antidepressant effect (Montgomery-Asberg Depression Rating Scale [MADRS], Clinical Global Impressions Improvement and Severity scales [CGI-I and CGI-S] and Hamilton Rating Scale for Depression [HAM-D]) in patients with major depressive disorder (MDD) than placebo in several 8-week, placebo-controlled, randomised, double-blind, multicentre studies. Symptom improvement was rapid, with some parameters improving within 1-2 weeks of starting escitalopram treatment. In addition, escitalopram showed earlier and clearer separation from placebo than RS-citalopram, at one-quarter to half the dosage, in 8-week, placebo-controlled trials; had significantly better efficacy than RS-citalopram in a subgroup of patients with moderate MDD in a 24-week trial; and produced sustained response and remission significantly faster than venlafaxine extended release in patients with MDD. Escitalopram reduced relapse rate compared with placebo and increased the percentage of patients in remission in long-term trials (up to 52 weeks). Consistently significant improvements for all efficacy parameters were also observed in patients with generalised anxiety disorder, social anxiety disorder and panic disorder treated with escitalopram for 8-12 weeks in individual, randomised, placebo-controlled, double-blind investigations.The good tolerability profile of escitalopram is predictable and similar to that of RS-citalopram. Such adverse events as nausea, ejaculatory problems, diarrhoea and insomnia are expected but, with the exception of ejaculatory problems and nausea, which is mild and transient, these were generally no more frequent than with placebo in fully published clinical trials. No adverse events not previously seen in acute trials were reported with long-term use.CONCLUSIONS: Escitalopram, the S-enantiomer of RS-citalopram, is a highly selective inhibitor for the serotonin transporter, ameliorates depressive symptoms in patients with MDD at half the RS-citalopram dosage, has a rapid onset of symptom improvement and has a predictable tolerability profile of generally mild adverse events. Like RS-citalopram, escitalopram is expected to have a low propensity for drug interactions, a potential benefit in the management of patients with comorbidities. In combination, these properties place escitalopram, like other SSRIs, as first-line therapy in patients with MDD. Escitalopram is indicated for use in patients with panic disorder in Europe and, should further evidence confirm early findings that escitalopram reduces anxiety, the drug may well find an additional role in the management of anxiety disorders.Pharmacodynamic Properties Escitalopram is the therapeutically active S-enantiomer of RS-citalopram, which is a highly selective and effective serotonin reuptake inhibitor. The antidepressant mechanism of escitalopram is presumed to be a result of stimulation of serotonergic neurotransmission in the CNS as a consequence of higher serotonin levels resulting from inhibition of the serotonin transporter. Escitalopram has no or very low affinity for a variety of other serotonin, dopamine, alpha- and beta-adrenergic, histamine, muscarinic and benzodiazepine receptors. It also does not bind to or has low affinity for a range of ion channels including those for Na(+), K(+), Cl(-) and Ca(2+). In rat models predictive of antidepressant activity, escitalopram demonstrated higher activity than RS-citalopram. The minimum effective dose was 4-fold lower with escitalopram than with RS-citalopram in reducing aggressive behaviour in the resident-intruder rat model and in reducing panic-like anxiety in rats after electrical stimulation of the dorsal peri-aquaductal grey matter. A trial using a conditioned fear model in rats found that escitalopram reversed suppression of exploratory activity more rapidly than aactivity more rapidly than a comparable dose of S-citalopram in RS-citalopram. This qualitative difference between S-citalopram and RS-citalopram was confirmed by another in vivo trial that showed higher extracellular serotonin concentrations in the frontal cortex of rats after injection with escitalopram than in rats treated with a racemic mixture of S-citalopram and R-citalopram, indicating inhibition of the S-enantiomer by the R-enantiomer in the racemate. PHARMACOKINETIC PROPERTIES: Escitalopram shows linear and dose-proportional pharmacokinetics with steady-state plasma concentrations achieved in 1 week in healthy volunteers. The mean steady-state area under the plasma concentration-time curve (0-24h) after a dosage of 10 mg/day was 360.2 ng x h/mL in healthy volunteers.After a single dose of escitalopram 20mg, peak plasma concentrations were reached in 4-5 hours and were not affected by food intake. Absolute bioavailability of RS-citalopram is about 80% and binding to human plasma proteins of escitalopram is approximately 56%. The apparent volume of distribution of escitalopram after oral administration is 12-26 L/kg. The pharmacokinetic profile of the S-enantiomer is the same whether given as escitalopram 10mg or RS-citalopram 20mg. Escitalopram is transformed to two metabolites, S-demethylcitalopram and S-didemethylcitalopram, both of which are much less potent than the parent drug. Alternatively, the nitrogen atom may be oxidised to the N-oxide metabolite. Escitalopram is the predominant plasma compound. The primary isoenzymes involved in metabolising escitalopram are cytochrome p450 (CYP) 2C19, CYP3A4 and CYP2D6.Elimination of escitalopram is principally via hepatic and renal routes as metabolites. Oral clearance of escitalopram is 36 L/h (600 mL/min) and the elimination half-life (t(half;)) is between 27 and 32 hours.There are no sex-related differences in escitalopram pharmacokinetics; however, escitalopram is eliminated more slowly in the elderly but maximum plasma concentration is unchanged thus increasing systemic exposure. In addition, oral clearance of RS-citalopram was reduced by 37% and t(half;) doubled in patients with hepatic impairment. THERAPEUTIC EFFICACY: Antidepressive efficacy was observed in patients with major depressive disorder (MDD) in 8-week trials with significant improvements in Montgomery-Aberg Depression Rating Scale (MADRS) scores in patients receiving escitalopram 10 or 20 mg/day versus those receiving placebo noted as early as 1-2 weeks after starting therapy. Follow-on studies found that escitalopram reduced the long-term risk of relapse and continued to reduce MADRS scores. Significant improvements were also observed in all secondary efficacy parameters including the Hamilton Rating Scale for Depression (HAM-D) and the Clinical Global Impressions Improvement and Severity scales (CGI-I and CGI-S) scores, and at least half of patients receiving escitalopram responded to treatment. Escitalopram showed earlier and better efficacy than RS-citalopram in a subgroup of patients with moderate MDD after 24 weeks and produced sustained response and remission significantly more rapidly (p < 0.05) than venlafaxine extended release (XR) at several timepoints over 8 weeks in patients with this disorder. In addition, improvements in quality of life (QOL) were experienced in the one study to report this. Significantly greater reductions in Hamilton Rating Scale for Anxiety (HAM-A) scores were observed in 124 patients, meeting the DSM-IV criteria for generalised anxiety disorder (GAD), who received escitalopram than in 128 patients meeting the same criteria who received placebo for 8 weeks. Improvements were also observed in several secondary efficacy parameters in the patients receiving escitalopram.In a 12-week study in patients who met the DSM-IV criteria for social anxiety disorder (SAD), those receiving escitalopram (n = 181) showed greater reductions in all SAD measurement scores and in disability scores than those receiving placebo (n = 177). The primary efficacy parameter was changes in Liebowitz Social Anxiety Scale scores from baseline to week 12. Secondary efficacy parameters included CGI-I scores, changes in CGI-S scores and Sheehan Disability scores over the same period. Escitalopram was significantly more effective than placebo in the treatment of panic disorder for all efficacy parameters in a 10-week trial. Efficacy measurements included frequency of panic attacks, the Panic and Anticipatory Anxiety Scale, Panic and Agoraphobia Scale, HAM-A, CGI-I and CGI-S scores, the Patient Global Evaluation and a QOL questionnaire. Improvements were apparent by week 4 in patients with GAD or panic disorder. PHARMACOECONOMICS: Two decision analytic studies carried out in Finland and Sweden found that, when used to treat MDD, escitalopram was more cost effective than RS-citalopram, fluoxetine or venlafaxine. In addition, the Finnish study found that cost utility (cost per quality-adjusted life-year gained) was greater for escitalopram than for the other three drugs. TOLERABILITY: The adverse events profile for escitalopram is similar to that observed with RS-citalopram in both MDD and anxiety disorders. Discontinuation rates due to adverse events were similar in patients receiving escitalopram or placebo in several trials.Nausea and ejaculatory problems were reported in both fully published trials in patients with MDD. In addition, diarrhoea, insomnia, dry mouth, headache and upper respiratory tract infections were experienced by patients receiving escitalopram, although the incidence of these events was not significantly higher than in patients receiving placebo. Fewer patients receiving escitalopram withdrew because of adverse events than patients treated with venlafaxine XR. (ABSTRACT TRUNCATED)

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J Clin Psychiatry 2003;64 Suppl 3:21-7
The role of GABA in anxiety disorders.
Lydiard RB.
Medical University of South Carolina, Charleston, USA. lydiardb@mindyourhealth.net

Anxiety stems from and perpetuates dysregulation of neurobiological systems, but the exact mechanisms of anxiety disorders are still only partially understood. Gamma-aminobutyric acid (GABA) is the primary inhibitory neurotransmitter known to counterbalance the action of the excitatory neurotransmitter glutamate. Several pharmacologic agents target the GABA system and modulate the overall effect of GABA. This article highlights multiple neurobiological interactions that play a role in anxiety and reviews selected studies of plasma neurosteroid levels, plasma GABA levels, and benzodiazepine binding site sensitivity and density in patients with anxiety disorders. The article concludes with further support for the role of the GABA system in anxiety by summarizing the current evidence supporting the use of novel GABAergic agents including tiagabine in the treatment of anxiety disorders.

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J Clin Psychiatry 2003;64 Suppl 3:3-6
Anxiolytics: past, present, and future agents.
Nemeroff CB.
Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Ga 30322, USA. cnemero@emory.edu

Although anxiety disorders were classified as neurotic disorders and not systematically studied before DSM-III, researchers and clinicians have been searching for effective, safe agents to treat anxiety symptoms and disorders for over a century. In that time, barbiturates, benzodiazepines, and many classes of antidepressants have been used as anxiolytics, all with side effect profiles that made them less than optimal treatments for anxiety. The recognition of the role of GABA in anxiety disorders has led researchers to develop anxiolytics that target GABA. The long-sought-after class of anxiolytics that are both effective and safe may be found in the new research being conducted with agents that selectively target GABA receptors and their subtypes.

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