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| Problem Gambling Resource Kit: Treating symptoms at face value may not reveal the true cause. This is a new resource for GPs, Practice Nurses, and Mental Health Clinicians released as a resource pack by 14 primary care services in South Australia and is also being developed for Victoria. See the South Australian government's website and click on Health Professionals |
This is a comprehensive Kit developed with the assistance of Profs Shane Thomas & Alun Jackson at Problem Gambling Research and Treatment Centre Monash University and includes a manual (Who is at risk), a single question (although an alternative for family members), information (Why screen; How serious is problem gambling?), Information about the governmental authority and laws to assist PGs/family (The Independent Gambling Authority (IGA)) and State support (The South Australian Government’s response to problem gambling in SA), interventions appropriate in primary care (Treatment/Interventions), and various hard cover items for use within practices e.g. Referral Pathway/algorithm, poster, diagnosis summary folder, Referral Pad to PG service, and an awareness card game. A resource contact list is also available for each region. |
- All 14 Divisions/Networks of General Practice in SA are participating.
- At this stage there is no process to review the Kit but some practices appear keen to do this (personal correspondence).
- GPs have not received training (some reluctance identified) but were interested in identifying PGs and referring to specialist PG services – this was the preferred option in the Kit in the absence of training.
- Training possibilities are with Practice Nurses (70% of SA Practices have these), their Practice Managers, or Mental Health Programme Managers.
- Although there are two screens provided for an assessment following a positive on the gambling screen (CPGI and EIGHT screens) there is no similar screen for the family version of the single screen – here the COGS may be appropriate to identify the currency of the harm, the fields in which the harm is occurring, and the patient’s desire for help
- The involvement of PHOs in NZ in the screening of patients for PG as a stand alone exercise has not been successful to date and it will be interesting to ascertain whether the much higher interest in Australia, particularly SA, in addressing PG is effective, and what we can learn from these. An alternative approach may be the CHAT screen approach developed by the Dept of General Practice at Auckland University (see below)
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Goodyear-Smith F, Coupe N, Arroll B, Sullivan S, McGill AT (2008) Case finding of lifestyle and mental health disorders in primary care: validation of the ‘CHAT’ tool. Br J Gen Practice 58(546): 26-31
Earlier articles: Goodyear-Smith F, Arroll B, Ker5se N, Coupe N, Sullivan S, Tse S, Shepherd R, Rossen F, Perese L (2006) Primary care patients reporting concerns about their gambling frequently have other co-occurring lifestyle and mental health issues. BMC Family Medicine, 7:25, U16606465
Goodyear-Smith F, Arroll B, Sullivan S, Elley C, Docherty B, Janes R (2004) Lifestyle screening: development of an acceptable multi-item general practice tool. NZMJ 117(1205), 5 Nov.
Numerous other international Journal papers have been published on the CHAT screen in respect of topics other than PG screened for in it. |
The Case-finding and Help Assessment Tool (CHAT) screen was developed as a tool for Primary Care settings that addressed 9 mental health and lifestyle issues, namely Tobacco use, alcohol problems, drug (recreational and non-prescription) problems, problem gambling, depression, anxiety, abuse, anger problems, and exercise. It is provided to patients either as a spontaneous multi-screen to a particular patient, or as a regular screen to all patients. The screen validation was conducted with 1000 consecutive patients.
Two PG questions are used, and an enquiry as to help wanted :
- Do you sometimes feel unhappy or worried after a session of gambling? (tick no if you do not gamble OR do not feel unhappy about gambling)
- Does gambling sometimes cause you problems? (yes/no)
- Do you want help with your gambling? (no/yes, but not today/yes)
Positives to any of the questions are either assisted by the GP or referred on to specialist PG services The two screen questions were chosen are based upon the GP EIGHT screen (questions 1 and 3) and correlate highly with a positive on that screen. For the validation study they were assessed against the SOGS with high sensitivity (88%) and specificity (97%) found, with likelihood ratios (LR+=30.05 (>10 indicates a good test for ruling PG in), and LR-=0.13 (<0.1 indicates a good test for ruling out PG)).
The CHAT is being used in:
- A joint Harbour and Health West Primary Health PHO initiative as entry into the Primary Options Lifestyle Programme with its funded consultation with free GP follow up, and free/subsidised programmes.
- A Waikato PHO project that helps beneficiaries move on to work
- A MSD project through WINZ and MOH Auahi Kore Marae (HB) project for smoke-free
- In research (in High School and PHOs with Samoan and Indian immigrants
- In BPAC best practice guideline in NZ
- Australian Govt DOH & Aging Risk Factor Resource Kit for GP
In HealthCheckPlus, an Internet based health resource in Canada, and integration of alcohol screening in family medicine in Missouri, USA |
- This is an alternative approach to a stand-alone PG screen and can avoid the problems of first identifying symptoms to provide a PG screen.
- It also avoids the reluctance GPs may have to screen for PG and de-prioritisation of PG in favour of other ‘core’ and perceived problematic conditions of patients
- It has the advantage of testing for many other conditions commonly found with PG (eg depression, anxiety, alcohol and other drug misuse, tobacco use) and may raise awareness with both patients and health professionals the widespread health effects of PG.
- By combining these 9 topics, the screen may become regularly used on a consecutive basis with all patients, an important strategy with asymptomatic conditions such as PG
- The CHAT is not a ‘kit’ in the form that the Australian initiative (above) is, and resources such as the next step, referral, brief interventions, and funding for additional time is required.
- The recent Evaluation of the Primary Mental Health Initiatives: Summary Report (July 2009 MOH) refers to MOH funded Primary Mental Health Initiatives (PMHIs) conducted between 2005-2007 , where GPs were funded beyond the usual 15 minute consultation to either 30 or 45 minutes. This would be an advantage to motivate case-finding, while training of other health professionals (eg Practice Nurses or new primary mental health clinicians) may be an alternative to GPs who are themselves ‘time-poor’.
- No outcome assessment has yet been conducted on the CHAT but this has been signalled as an important step by the lead author (personal communication)
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Gebauer L, LaBrie R, Shaffer (in press) Optimising DSM-IV classification accuracy: a brief bio-social screen for gambling disorders among the general household population. Canadian J of Psychiatry
Toce-Gerstein M, Gerstein D, & Volberg R (in press) The NODS-CLiP: a rapid screen for adult pathological and problem gambling. J of Gambling Studies, epub ahead of print |
The WAGER has reported upon these two soon to be published articles on brief problem gambling screens. The 1st is the Brief Bio-Social Gambling Screen (BBGS) by Gebauer et al.
The screen was developed from a large US survey (NESARC) that used the PG criteria during the previous 12 months. As with the PGD criteria, those who answered 5 or more with ‘yes’ were included as positives, and the items chosen tested for sensitivity and specificity against these. BBGS screen is 3 items:
- 1. During the past 12 months, have you become restless, irritable or anxious when trying to stop/cut down on gambling? (Withdrawal)
- During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled? (Deceive)
- During the past 12 months, did you have such financial trouble that you had to get help with living expenses from family, friends, or welfare? (Bailout/Need Money)
The 2nd is the NODS-CLiP which uses ‘lifetime’ or doesn’t restrict the time for the questions based also upon DSM-IV, and analysed answers from several studies using a DSM based screen comprising all of its criteria with the same specificity/sensitivity focus.
Again, the NODS-CLiP comprises 3 items:
- Have you ever tried to stop, cut down, or control your gambling? (Loss of Control)
- Have you ever lied to family members, friends or others about how much you gamble or how much money you lost on gambling? (Lying)
- Have there been periods lasting 2 weeks or longer when you spent a lot of time thinking about your gambling experiences, or planning out future gambling venues or bets? (Preoccupation)
The WAGER notes that DSM-IV criteria are not a gold standard for PG, nor does it from experimental evidence include all PG harm, nor provide valid diagnostic criteria as concepts of PG harm vary from different perspectives. It also notes all data upon which the screens were developed were from self-reports and this can include uncertainty from recollection, and reluctance to disclose. It further notes that without a time limit some positives may not be current PG, and that even on the researchers’ psychometrics, the BBGS will correctly identify only one in three, and the NOD-CLiP only one in eight. This high sensitivity may be suitable for problem estimate, but such poor specificity is clinically unsuitable. |
- Brief screens are far more practical for brief interventions, where time is limited and opportunity will not be taken if impractical screens which require excessive time to complete, or to score, or both.
- However, what the WAGER has not addressed is that although the specificity is low, especially for the NODS-CLiP, this is for DSM-IV positives. It has alluded to the narrow perspective of DSM-IV criteria, but does not comment upon the screens’ ability to identify sub-clinical PG harm, or Level 2 or Level 1 gambling.
- In NZ, the definition of harm in the Gambling Act is ‘harm of any kind’ and includes personal, social or economic harm not just to the gambler. This definition of harm includes Level 1-3 gambling and is not defined to (possibly only part of) Level 3 as defined by 5 DSM-IV criteria.
- As such the criteria may not identify Level 1 or Level 2 gambling at all. There is no evidence that Level 1 and Level 2 criteria are just lesser strengths or versions of Level 3 criteria. For example, it would be hard to describe a lesser version of the PGD criteria of committing illegal acts to support their gambling (Thinking of illegal acts? Minor illegal acts?)
- As regards the failure to set a finite period (eg 12 months) as being problematic, this has not proven to be the case. Many problem gamblers interpret this as meaning within recent time, ie relatively current, while periods of non-PG are typical in the disorder and by insisting upon a 12 month period, both assumes the person can estimate this (uncertain with instant gratification disorders) and may wrongly identify someone temporarily not gambling problematically as a NP gambler (ie a false negative).
- PG is a ‘recurrent’ disorder and can comprise periods when gambling or problem gambling doesn’t occur. In these circumstances, people are still often ‘problem gamblers’ and at risk for gambling problematically again. They may not have received treatment, but environmental influences such as moving to a new area (past environmental controlling stimuli no longer present), greater support for non-gambling behaviours, reduction of stressors that lead to gambling ‘self medication’, and others. Restricting enquiry to arbitrary periods, especially for cognitively ‘concrete’ PGs, may imply to both those being screened, and practitioners, that periods of non problem gambling are indicators of non-current gambling problems. In addition, PGs (and those with other addictions) often have poor time perception, because of their focus upon the present
- Scoring for the BBGS is not yet available, however the NODS-CLiP is. This latter screen suggests any positive response is sufficient to warrant referral for assessment. Further information indicates that just one positive response out of three indicates high risk (for Level 3 gambling – see above) but the person may not be at this stage a problem gambler. The exception to this is the loss of control question as chasing losses is a strong predictability of dependency (loss of control, tolerance, withdrawal) and this single response would be an indicator of probable pathological gambling. Two or three ‘yes’ responses indicate a need for complete assessment for the PG, especially if there is a dependency ‘yes’ response.
- These screens are useful for identifying severe problem gambling, or the risk for it. However, as stated they do focus upon Level 3 (severe) PG, while items that identify Level 1 or Level 2 may not be included. Not all Level 2 PG may progress to Level 3 but may be causing harm, especially to others. The Gambling Act’s wide definition of harm would not appear to be addressed by screens based upon severe levels of gambling as restricted to DSM-IV.
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Park S, Cho M, Jeon H, Lee H, Bae J, Park J, Sohn J, Lee Y, Lee J, Hong J (2009) Prevalence, clinical correlations, comorbidities, and suicidal tendencies in pathological Korean gamblers: results from the Korean Epidemiological Catchment Area Study. Social Psychiatry and Psychiatric Epidemiology J DOI 10.1007/s00127-009-0102-9 |
A national survey (n=6,510) in South Korea using the CIDI and DIS explored problem gambling, with 5 positive DSM criteria considered pathological gambling and one or more problem gambling. 0.8% surveyed was identified as pathological gamblers and 3.0% problem gamblers.
- 79.1% of pathological gamblers had at least one psychiatric illness (cf control 28.1%)
- 62% of problem gamblers had at least one psychiatric condition
- Associations between pathological/problem gambling and alcohol use disorder, nicotine dependence, mood disorder, anxiety disorder and suicidality were overwhelmingly positive and significant (p<0.05) even after controlling for age, gender, marital status, and urban living, all higher PG factors.
- Concluded practitioners should carefully evaluate and treat such psychiatric disorders in gamblers.
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- A conservative measure of screening for pathological gambling (5 DSM PGD criteria) reflecting in a relatively low prevalence (0.8%) for this population, however the criteria for problem gambling (1 – 4 DSM criteria) was less conservative and identified 3% of the population using a conservative population survey method.
- Although this population may not be seen to be similar to the NZ population at first light, the cultural and environmental differences may not be as dissimilar as first considered, while PG conditions may be relatively stable while findings in this study are not unlike other study findings throughout the world
- Public access to casinos have only been less than a decade, with NZ public accessing these for twice this period suggesting that gambling accessibility may not be considerably different from that in NZ
- The high levels of psychiatric illness identified parallels the Kessler et al findings (2008)
- The recommendation that these coexisting disorders (alcohol, tobacco, depression, anxiety and depression is also focussed upon in the NZ assessment tool (other than anxiety) already, although intervention training is just commencing for these issues.
- The findings also support the current alignment of AOD, Tobacco Cessation and Problem Gambling competencies currently underway
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ABACUS Counselling Training & Supervision Ltd 31st August 2009
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