Patient Preference and Satisfaction Discussion 2

Abstract Self-directed treatments for gambling disorder have been developed to attract individuals who are reluctant to seek formal treatment. Self-directed treatments provide individuals with information and support to initiate a recovery program without attending formal treat- ment. In this study, an online version of a previously evaluated telephone-based interven- tion package is compared to a brief online normative feedback intervention called Check Your Gambling. In a randomized controlled trial design, participants with gambling prob- lems who were not interested in formal treatment (N = 181) were recruited through media announcements. After a baseline telephone assessment, participants were assigned to have access to either the brief Check Your Gambling, or the extended self-management tools intervention. Follow-up assessments were conducted at 3, 6, and 12 months post baseline by blinded interviewers. Participant nominated collaterals were contacted to validate self- reported gambling involvement. The follow-up rate at 12  months was 78%. Participants in both conditions showed significant reductions in days of gambling and problem sever- ity but no differences between conditions were found, contrary to the primary hypothesis. Lack of previous treatment for gambling and higher baseline self-efficacy predicted fewer days of gambling in both conditions. Self-efficacy increased over time but did not appear to mediate changes in gambling. Participants who were most engaged in the extended online program showed better outcomes. Those with low engagement showed a slower trajectory of change but equivalent improvements by 12  months. The extended online intervention was not associated with better outcomes than the brief Check Your Gambling interven- tion. Future research needs to explore the attractiveness, uptake, and effectiveness of online interventions with and without therapist support to understand their potential role in gam- bling disorder treatment systems. Trial Registration ISRCTN06220098.

Keywords Clinical trial · Brief intervention · Gambling disorder · Online intervention · Normative feedback

* David C. Hodgins dhodgins@ucalgary.ca Patient Preference and Satisfaction Discussion 2

Extended author information available on the last page of the article

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Introduction

Previous research has demonstrated the effectiveness of brief interventions for people with gambling difficulties (Swan and Hodgins 2015). These interventions have been delivered in face-to-face formats (Diskin and Hodgins 2009; Petry et al. 2008), by telephone (Abbott et  al. 2018) and via self-help workbooks delivered through the mail (Boudreault et  al. 2018; Hodgins et al. 2009; Labrie et al. 2012; Oei et al. 2018). Clinical trials have shown modest positive impacts compared with waitlist controls (Petry et  al. 2017; Yakovenko and Hodgins 2016), that are sustained over 12–24-month follow-up periods. Because the majority of individuals with gambling problems do not seek formal treatment, even if it is readily available (Cunningham 2005), this brief, largely self-directed approach is promis- ing. Individuals frequently report a desire to “do it on their own”, or at least try. Providing attractive and effective alternatives that offer people brief support for self-recovery is a sen- sible public health response to minimizing harms associated with gambling.

Internet-based treatment for mental health and substance use disorders is increasingly popular and is consistently found to be efficacious (Andersson and Carlbring 2017; Riper et  al. 2014). However, only a limited amount of controlled research has been conducted with gambling disorder, despite the fact that individuals with gambling problems often report accessing information and support online (Castren et  al. 2013; Rodda et  al. 2018). Most recently, an Australian randomized controlled study (Casey et al. 2017) compared an internet-based cognitive behavioural treatment (CBT) program to an internet-based moni- toring, feedback and support intervention, and a waitlist control. Both internet-based treat- ments were associated with better gambling severity outcomes than the 6-week waitlist, although the attrition rate was very high in both interventions (61%). Relative to the moni- toring, feedback and support intervention, the CBT intervention had better outcomes on stress reduction and quality of life, and it was rated as more satisfactory. Outcomes were maintained over a 1-year follow-up.

An earlier controlled study from Sweden evaluated a web-based therapist-assisted CBT intervention compared with a waitlist control (Carlbring and Smit 2008). Three-month out- comes for participants receiving the treatment were superior to those on the waitlist. In a subsequent uncontrolled trial of the CBT intervention, early results were sustained over 3 years (Carlbring et al. 2012).

This Swedish intervention included the active involvement of a therapist. The issue of whether individuals benefit from brief contact with a professional, even if they are want- ing to direct their own recoveries, is unresolved (Goslar et al. 2017). In our previous work, individuals who received a brief motivational interview by telephone and a mailed self- help workbook had better outcomes than individuals who received the workbook with- out the telephone contact. Similarly, a recent study of callers to a gambling helpline also showed that callers who only received telephone support had outcomes similar to those who also received a mailed workbook (Abbott et al. 2018). Although these results suggest that personal contact may be the most influential feature of the intervention, other studies across a variety of mental health disorders have not found a benefit of therapist support over entirely self-directed interventions (Campos et al. 2015; Labrie et al. 2012).

In another line of research, the effect of providing brief personalized normative feed- back on reducing problematic gambling has also been examined in a small group of rand- omized controlled trials. In personalized normative feedback (PNF) interventions, an indi- vidual’s gambling behaviours and beliefs are compared with population norms to facilitate individual movement toward the norm. A meta analyses uncovered six randomized trials

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that generally found that these PNF interventions are associated with reduced gambling on at least some variables (Marchica and Derevensky 2016). However, the interventions were inconsistent in their effects and further research is necessary to explore the impact of PNF implementation on a wide-scale basis.

Two of these six PNF studies evaluated Check Your Gambling (CYG), a Canadian internet-based intervention that invites individuals to complete a self-assessment of gam- bling that leads to a personalized feedback report (Cunningham et  al. 2012; Cunningham et  al. 2009). In the first of these studies, CYG was associated with reduced spending on gambling at a 3-month follow-up when compared with a no intervention control group. The second study, which had a 6-month follow-up, included an additional condition, CYG excluding the normative feedback component, which was hypothesized to be less effec- tive than the full CYG, but more effective than the no intervention control. In fact, results showed that CYG without the normative feedback was the most effective intervention. It was associated with less frequent gambling compared with the other groups.

More recently, Luquiens and colleagues conducted a randomized trial in the context of a commercial online poker site in France (Luquiens et al. 2016). Customers were invited to complete a brief screen for gambling problems and those who scored in the problem range were invited to participate in a study where they were randomly assigned to one of four groups: (a) an email report that provided PNF on their problem gambling screening score; (b) a downloadable cognitive behavioural workbook; (c) the workbook plus six sessions of email guidance by a therapist; or (d) a waitlist control. Follow-ups at 6 and 13 weeks were conducted when the problem gambling screening measure was re-administered. A major finding of the study was the large drop-up rate across all conditions, ranging from 83% in the waitlist to 97% in the guided workbook conditions. However, gambling expenditure data were available for all participants from the online gambling site. These data showed no overall group differences and few changes in gambling over time. Unfortunately, whether participants used the resources provided (e.g., downloaded the workbook, opened the email report) was not tracked. Moreover, the study incorporated a very minimal PNF intervention as it was limited to the problem gambling screening score and did not include any gambling behaviour variables. The Cunningham et al. (2012) study suggested that per- sonalized feedback on gambling behaviour variables, but not necessarily normative feed- back, was important (although the authors do stress that the lack of impact observed could be due to the way the norms were presented in this particular trial). These inconsistencies emphasize the need for further research to clarify the effectiveness of PNF interventions.

The current study extends the previous research in two ways. First, the self-help work- book provided to individuals by mail in previous evaluations (Hodgins et al. 2001, 2004a, 2009; Hodgins and Makarchuk 2002) was programmed to be an interactive online self- management program. It included a comprehensive set of self-management tools along with motivational goal setting exercises without the provision of therapist support (i.e., the extended intervention). Second, the study compared this relatively more comprehensive intervention to a briefer one. The comparison condition was Check Your Gambling (Cun- ningham et al. 2009), which also was entirely self-directed, but much briefer in style (i.e., the brief intervention).

The study hypotheses are outlined in the study protocol paper (Hodgins et al. 2013). The primary hypothesis was that individuals assigned to the extended intervention would show greater reductions in gambling over a 12-month follow-up than those assigned to the brief intervention. Two potential moderators were hypothesized: higher baseline self-efficacy (hypothesis 2) and no treatment-seeking history would be associated with better outcome (hypothesis 3). Additionally, two mediators were hypothesized: The level of engagement with

Patient Preference and Satisfaction Discussion 2

638 Journal of Gambling Studies (2019) 35:635–651