1. Cognitive Behavioural Therapy
2. Cognitive Behavioral Therapy And Problem Gambling Addiction
3. Cognitive Behavioral Therapy And Problem Gambling Disorder

• Cognitive Behavioural Therapy Cognitive Behavioral Therapy or CBT has been found to be helpful for various disorders regarding addiction, binge eating, problem gambling, etc. And remains a standard manualized therapy for addressing addictive processes in the individual setting.
• The aim of this study was to test the effectiveness of motivational interviewing, cognitive behavioral group therapy, and a no-treatment control (wait-list) in the treatment of pathological gambling. This was done in a randomized controlled trial at an outpatient dependency clinic at Karolinska Institute (Stockholm, Sweden).
• Cognitive Behavioural Therapy has since been evolved to successfully treat a number of different mental health conditions including Addiction, Anxiety, Post Traumatic Stress Disorder and Borderline Personality Disorder. Primrose Lodge offer all of our patients Cognitive Behavioural Therapy as part of our rehabilitation treatment programme.

The problem gambling (PG) intervention literature is characterised by a variety of psychological treatments and approaches, with varying levels of evidence (PGRTC in Guideline for screening, assessment and treatment in problem and pathological gambling. Monash University, Melbourne, 2011). A recent PG systematic review (Maynard et al. In Res Soc Work Pract, 2015. Doi: 10.11515606977. Problem gambling is of serious public, social and clinical concern, especially so because ease of access to different types of gambling is increasing. A systematic review and meta-analysis was carried out to determine whether Cognitive-Behavioural Therapies (CBT) were effective in reducing gambling behaviour.

[Adapted from Noorani H, Severn M. Cognitive behavioural therapy for patients with addictions: a review of the clinical and cost-effectiveness. (Health Technology Inquiry Service). Ottawa: Canadian Agency for Drugs and Technologies in Health; 2010.]

For more information on this project, visit https://www.cadth.ca/cognitive-behavioural-therapy-patients-with-addictions-review-clinical-and-cost-effectiveness

Introduction

Addictions are a common mental health concern.¹ One in 10 Canadians who are 15 years of age and older report symptoms consistent with alcohol or illicit drug dependence, and close to 4% of adults are classified as having moderate or severe gambling problems.¹ Substance use (substance dependence and substance abuse) accounts for the greatest burden of disease and mortality of all mental disorders.² The use of psychoactive substances, including alcohol, tobacco, and illicit drugs contributed to 12.4% of deaths worldwide in the year 2000.² Substance use problems often occur in association with depression, anxiety, and virtually all other forms of mental illness.² The use and misuse of alcohol, tobacco, and illicit drugs accounted for 20.0% of deaths, 22.2% of years of potential life lost, and 9.4% of hospital admissions in Canada in 1995.³ The rate of drug use by youth 15 to 24 years of age remains higher than that reported by adults 25 years and older: four times higher for cannabis use (32.7% versus 7.3%), and nine times higher for past-year use of any other illicit drug (15.4% versus 1.7%).⁴

Problem (or pathological) gambling is a common mental health concern in several parts of Canada.⁵ The 12-month prevalence of gambling problems in Canada has been estimated at 2%, with interprovincial variability.⁵ Although there are effective psychosocial treatments, it is estimated that only about 10% of problem gamblers seek treatment.⁶ Apart from a shortage of skilled therapists, long waiting lists, and the cost factor, fear of stigma may prevent many problem gamblers from seeking therapy.⁶ Consequently, a major challenge is to increase the accessibility and affordability of evidence-based psychological treatments for problem gambling.

Cognitive behavioural therapy (CBT) is a structured goal-directed form of psychotherapy in which patients learn how their thought processes contribute to their behaviour.² Increased cognitive awareness is combined with techniques to help patients develop new and adaptive ways of behaving and alter their social environment, which in turn leads to change in thoughts and emotions. CBT is usually time-limited, consisting of approximately 10 to 20 one-hour sessions.² Although CBT is traditionally administered in an individual or group format, CBT administered remotely through technology-based interventions has recently received increased attention in the literature as a means of promoting greater accessibility to psychological interventions.⁷ Self-directed CBT (for example through a web-based or stand alone computer program) or telephone administered CBT (teletherapy) has been introduced to help improve access to CBT for patients in remote areas.⁷ However, there is uncertainty on whether these alternate delivery strategies are as clinically effective or cost-effective as traditional CBT for the treatment of adults with alcohol, drug, or gambling addictions. Moreover, it is not clear if these strategies are appropriate for the entire population with addiction problems or if they are better suited to particular patient subgroups.

This report will review the evidence of clinical and cost-effectiveness of CBT delivered in a self-directed manner or through telehealth applications relative to traditional CBT and guidelines for patient selection. This information could help in decision-making pertaining to which patient groups could benefit from CBT for addictions when delivered in these alternative formats.

Objective

The objective of the report is to answer the following research questions:

• What is the clinical effectiveness of self-directed CBT or teletherapy compared with traditional CBT for the treatment of adults with alcohol, drug, or gambling addictions?
• What is the cost-effectiveness of self-directed CBT or teletherapy compared with traditional CBT for the treatment of adults with alcohol, drug, or gambling addictions?
• What are the guidelines for patient selection criteria for self-directed CBT or teletherapy for the treatment of adults with alcohol, drug, or gambling addictions?

Methods

A limited literature search was conducted on key health technology assessment resources, including PubMed, PsycINFO, The Cochrane Library (Issue 4, 2009), University of York Centre for Reviews and Dissemination (CRD) databases, ECRI, EuroScan, international health technology agencies, and a focused Internet search. The search was limited to English language articles published between 2005 and December 2009. No filters were applied to limit the retrieval by study type.

Results

No health technology assessments, systematic reviews, or economic evaluations were identified that compared self-directed interventions or teletherapy with traditional CBT for the treatment of adults with alcohol, drug, or gambling addictions. No guidelines were identified that addressed patient selection criteria for self-directed CBT or teletherapy for the management of addiction.

Four randomized controlled trials (RCTs), published in six reports, were identified that assessed computer-based (three trials)^8-11 or telephone-based (one trial)^12,13 CBT as therapy for alcohol and/or drug dependence. Of the three trials on computer-based therapy, two studies included a direct comparison of self-directed CBT with traditional therapy^8-10 and one study evaluated the efficacy of two computer-based interventions.¹¹ In addition, one published protocol was identified of a three-arm RCT designed to assess the clinical and economic impact of online CBT-based therapy for problem drinkers.^14,15 One RCT was identified for this report on self-directed CBT on gambling addictions.⁶ None of these studies was a Canadian-based trial.

Cognitive Behavioural Therapy

Alcohol and/or Drug Dependence

An RCT^8,9 evaluating the efficacy and durability of a computer-assisted version of CBT as therapy for substance dependence for adults seeking outpatient treatment for multiple-substance use randomized patients to either standard treatment as usual (weekly individual and group sessions) or treatment as usual with eight weeks of biweekly access to computer-based training for CBT (CBT4CBT).⁸ Random regression analyses of use across time indicated significant differences between groups, such that individuals assigned to treatment as usual increased their drug use across time while those assigned to CBT4CBT tended to improve slightly. Overall, CBT4CBT appeared to have both short-term and enduring effects on drug use during the six-month follow-up period.⁹ The efficacy of self-directed CBT was further analyzed¹⁰ for 97 adults with comorbid depression and alcohol/cannabis use, recruited from a community-based setting in Australia. The investigators reported equivalent 12-month outcomes when therapy was delivered over a three-month period through a computer-based program with brief weekly input from a psychologist relative to face-to-face therapy.¹⁰

Another study¹¹ evaluated the efficacy of two computer-based interventions for problem drinkers. Participants were randomized to either the experimental drinking less (DL) intervention or the control condition. The DL intervention was a web-based, multi-component, interactive self-help intervention for problem drinkers without therapist guidance. The recommended treatment period was six weeks. The control group received access to an online psycho-educational brochure on alcohol use. At six months of follow-up, the DL intervention was successful in curbing alcohol intake. Although both the intervention and control groups achieved a decrease in alcohol consumption, this effect was significantly stronger in the DL intervention in terms of the study outcome measures.¹¹

A three-arm RCT is currently underway^14,15 to assess the clinical and economic impact of online therapy (based on CBT and motivational enhancement training) compared with a waiting list control group. Two online treatment programs for problem drinkers completed within three months following randomization will be compared in this trial: one is an anonymous, online, non-therapist involved, fully automated self-guided treatment program; and the other is a real-time, online, non-anonymous therapist-guided program. The primary outcome measure is the change in alcohol consumption from baseline to the three-month and six-month follow-up period. Secondary outcome measures include changes in Alcohol Use Disorders Identification Test (AUDIT) scores, quality of life, and quality of functioning at work. Incremental cost-effectiveness ratios for both online treatment programs will be calculated.¹⁴ The trial is at the recruitment phase, and there is at present no specific publication date for the research findings.¹⁵

A comparison of telephone-based continuing care (teletherapy), with two more intensive face-to-face interventions in alcohol and/or cocaine-dependent adult participants who had completed an initial phase of intensive outpatient treatment^12,13 indicated that teletherapy and brief counselling yielded higher abstinence rates over 24 months than intensive face-to-face interventions for most patients with alcohol and cocaine dependence.¹² Further analysis examining the mediators of this treatment effect suggested that the greater therapeutic effects of teletherapy were partially accounted for by participation in self-help meetings and related activities during the continuing care phase of treatment, and by subsequent increases in commitment to abstinence and the maintenance of self-efficacy.¹³ These results further revealed that increases in self-help behaviours are associated with increases in self-efficacy, which accounted for the treatment differences from seven to 24 months.^12,13

Problem Gambling

The one trial identified on gambling addictions⁶ compared an eight-week Internet-based CBT program that included minimal therapist contact through email with a wait-list control group. To maximize compliance, the investigators supplemented the self-directed CBT program with short weekly telephone calls. Participants randomized to the self-directed group achieved significant improvement on measures of problem gambling, general anxiety, depression, and quality-of-life; these effects of self-directed therapy were maintained up to 36 months of follow-up.⁶ No significant differences on the outcome measures were observed in the wait-list control group during the treatment period. No between-group comparisons were undertaken at follow-up as individuals on the waiting list received therapy before follow-up data were collected. The investigators acknowledged that a substantial proportion of individuals with a history of problem gambling undergo recovery without therapy and this may have led to an overestimate of the true effect of self-directed CBT within the study.⁶

Limitations

Cognitive Behavioral Therapy And Problem Gambling Addiction

Only a few technology-based interventions have been investigated in RCTs for the treatment of adults with alcohol, drug, or gambling addictions. Accuracy of the study findings on self-directed CBT or teletherapy cannot be assured given the lack of direct comparisons with traditional face-to-face therapy. The duration of aftercare interventions in the current trials was limited to within two months, and further analyses are required to investigate dose-response associations between the frequency of interventions and outcomes. Another limitation involves the generalizability of the results to a more heterogeneous population: for example, the participants recruited within the studies were mostly middle-age males presenting with multiple substance use problems. Differences in outcomes with participants seeking treatment and those referred to treatment may also be a factor limiting generalizability. Furthermore, it is difficult to assess the overall clinical significance of the treatment effects given the use of varied definitions for addiction, wide range of outcome measures, and high attrition rates among the study participants resulting in incomplete data at follow-up.

Conclusions

For alcohol, drug, and gambling addictions, the literature suggests that computer or telephone-based interventions may be a viable alternative or a useful adjunct to conventional face-to-face therapy. Further research on this topic directed at discerning the active components of treatments that are deemed effective, such as duration and intensity of therapy, especially among adolescents, is required because of the potential for computer or telephone-based interventions to reach individuals who are underserved by traditional therapy. There were no cost-effectiveness studies identified comparing alternative delivery models and face-to-face delivery, and therefore, conclusions about cost-effectiveness cannot be made. In addition, no guidelines indicating which patients with addictions would be best suited to self-directed CBT or teletherapy were identified. Economic analyses should be routinely incorporated into future studies so that the real costs and benefits of technology-based interventions can be compared with those of intensive inpatient programs.

References

Cognitive Behavioral Therapy And Problem Gambling Disorder

1. Centre for addiction and mental health [Internet]. Toronto: The Centre. Mental health and addiction statistics; 2009 [cited 2010 Jan 28]. Available from: http://www.camh.net/News_events/Key_CAMH_facts_for_media/addictionmentalhealthstatistics.html
2. Somers J, Querée M. Cognitive behavioural therapy core information document [Internet]. Victoria: Mental Health and Addictions Branch, Ministry of Health, Government of British Columbia; 2007 [cited 2010 Jan 13]. Available from: http://www.health.gov.bc.ca/library/publications/year/2007/MHA_CognitiveBehaviouralTherapy.pdf
3. Single E, Rehm J, Robson L, Truong MV. The relative risks and etiologic fractions of different causes of death and disease attributable to alcohol, tobacco and illicit drug use in Canada. CMAJ [Internet]. 2000 Jun 13 [cited 2010 Jan 22];162(12):1669-75. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1232500
4. Drug prevention and treatment [Internet]. Ottawa: Health Canada; 2009. (Drug and alcohol use statistics). [cited 2010 Jan 22]. Available from: http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/stat/index-eng.php
5. Cox BJ, Yu N, Afifi TO, Ladouceur R. A national survey of gambling problems in Canada. Can J Psychiatry. 2005 Mar;50(4):213-7.
6. Carlbring P, Smit F. Randomized trial of internet-delivered self-help with telephone support for pathological gamblers. J Consult Clin Psychol. 2008 Dec;76(6):1090-4.
7. Germain V, Marchand A, Bouchard S, Drouin MS, Guay S. Effectiveness of cognitive behavioural therapy administered by videoconference for posttraumatic stress disorder. Cognitive Behav Ther. 2009;38(1):42-53.
8. Carroll KM, Ball SA, Martino S, Nich C, Babuscio TA, Nuro KF, et al. Computer-assisted delivery of cognitive-behavioral therapy for addiction: a randomized trial of CBT4CBT. Am J Psychiatry [Internet]. 2008 Jul [cited 2010 Jan 6];165(7):881-8. Available from: http://ajp.psychiatryonline.org/cgi/reprint/165/7/881
9. Carroll KM, Ball SA, Martino S, Nich C, Babuscio TA, Rounsaville BJ. Enduring effects of a computer-assisted training program for cognitive behavioral therapy: a 6-month follow-up of CBT4CBT. Drug Alcohol Depend. 2009 Feb 1;100(1-2):178-81.
10. Kay-Lambkin FJ, Baker AL, Lewin TJ, Carr VJ. Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: a randomized controlled trial of clinical efficacy. Addiction. 2009 Mar;104(3):378-88.
11. Riper H, Kramer J, Smit F, Conijn B, Schippers G, Cuijpers P. Web-based self-help for problem drinkers: a pragmatic randomized trial. Addiction. 2008 Feb;103(2):218-27.
12. McKay JR, Lynch KG, Shepard DS, Pettinati HM. The effectiveness of telephone-based continuing care for alcohol and cocaine dependence: 24-month outcomes. Arch Gen Psychiatry [Internet]. 2005 Feb [cited 2010 Jan 6];62(2):199-207. Available from: http://archpsyc.ama-assn.org/cgi/reprint/62/2/199
13. Mensinger JL, Lynch KG, TenHave TR, McKay JR. Mediators of telephone-based continuing care for alcohol and cocaine dependence. J Consult Clin Psychol [Internet]. 2007 Oct [cited 2010 Jan 6];75(5):775-84. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677065/pdf/nihms106218.pdf
14. Blankers M, Koeter M, Schippers GM. Evaluating real-time internet therapy and online self-help for problematic alcohol consumers: a three-arm RCT protocol. BMC Public Health [Internet]. 2009 [cited 2010 Jan 6];9:16. Available from: http://www.biomedcentral.com/content/pdf/1471-2458-9-16.pdf
15. International clinical trials registry platform [Internet]. version 3.2. Geneva (CH): World Health Organization; 2007 -. Evaluating real-time internet therapy for alcohol dependence: a three-arm open randomized clinical trial, NTR1155; 2010 [cited 2010 Jan 20]. Available from: http://apps.who.int/trialsearch/Trial.aspx?TrialID=NTR1155