Healthcare when the bets are off : symptoms, trajectories and treatment of individuals with gambling disorder

Abstract: Gambling Disorder is a debilitating condition associated with several adverse outcomes. Despite available treatment, most of those suffering never seek help and those that do often present a complex clinical picture with a long duration of gambling problems and additional psychiatric disorders. Currently, there are several gaps in knowledge about this patient population, the care provided within addiction services, and the long-term consequences for these individuals in terms of functionality and work life. The current thesis, therefore, aims to address some of these gaps, with the goal of increasing knowledge about the patient group and improving treatments. In addition, when disseminating scientifically evaluated treatment to clinical practice, the problem gambling counselor plays an important role. What treatments are actually offered, by whom, and the role of the counselor has not previously been explored. Moreover, factors contributing to the development and maintenance of GD have been proposed and deserve further investigation; gambling cravings and difficulties in emotion regulation. Therefore, the overall aim of this thesis is to map the harms of GD, the treatment available and the characteristics of those delivering it, and track changes in gambling during the Covid-19 pandemic. Furthermore, the thesis aims to explore individual factors contributing to maintaining the disorder, i.e., craving and difficulties in emotion regulation. Study I is a case-cohort study using merged national registries to investigate GD’s association with work disability and trajectory groups in a longitudinal design over a sixyear period. The results showed that GD is associated with an increased risk of work disability over a four-year period, starting the year before diagnosis and peaking at the time of diagnosis (AOR = 1.89, 95% CIs = 1.67-2.13). The risk was unevenly distributed: females, those with psychiatric comorbidities or having medicated for psychiatric symptoms, and older individuals were at higher risk of work disability. The results add knowledge to what social and financial harms are associated with GD. Study II maps available treatment in a cross-sectional study surveying practicing PG counselors. This study found that CBT and MI are the most frequently offered treatments and that treating more clients monthly is associated with higher adequacy (OR = 1.49, 95% CIs = 1.12 -1.95), legitimacy (OR = 1.38, 95% CIs = 1.08 – 1.75), and willingness (OR = 1.95, 95% CIs = 1.49-2.61 in their role as PG counselors. Standard CBT techniques and addressing motivation were rated as the most important to include in treatment. Notable, most PG counselors (>70%) saw fewer than two clients monthly with PG. Study III is a qualitative study applying thematic analysis to interviews of individuals with GD or alcohol use disorder, all with recent experiences of craving, and exploring content and modes of thought when craving. Participants described their cravings as dominated by mental imagery often involving positive content of anticipation, carrying out the addictive behavior or expected outcomes. Craving for alcohol was more related to seeking relief and craving for gambling to gain financial assets. Study IV evaluated the feasibility of a transdiagnostic intervention, emotion regulation-enhanced CBT, among treatment seekers in addiction care using a mixed methods design. Participants improved on gambling outcomes: a decrease in symptoms of GD from a pretreatment mean of 7.0 to 2.1 at 12 months follow-up and a reduction in gambling expenditure and comorbid symptoms of depression and anxiety. In addition, participants rated the treatment high in acceptance and credibility, and interviews indicated that individual tailoring and prolongation as potential improvements. Adding emotion regulation to the treatment of GD is feasible and deserves further investigation. Study V investigated changes in gambling behavior during the Covid-19 pandemic in a cohort recruited from social media and a gambling helpline. We did not find associations between pandemic restrictions and increased problem gambling, worries about mental health due to the pandemic (OR = 2.85, p < 0.001), and initiating high-risk gambling formats (OR = 7.44, p < 0.001), such as online casino, were associated with PG. We did not observe any significant migrations between gambling formats despite the change in availability during the initial phase of the pandemic. In conclusion, the findings demonstrate that GD is associated with an elevated risk of work disability, CBT and MI are treatments available, but PG counselors seem to lack important clinical practice; cravings are often experienced as mental imagery of anticipation, and emotion regulation could be added to the clinical toolbox in the treatment for GD and deserves further investigation. In addition, Swedish pandemic restrictions did not seem to have been linked to increased gambling, but those initiating a high-risk gambling format or being worried about their mental health during the pandemic were more likely to develop PG.