Brief online interventions for concerned gamblers in a gambling helpline

Abstract: Background: Problem gambling (PG) is common throughout the world and affects approximately 2% of the adult population in Sweden and most other western countries. Individuals who gamble in a problematic way experience negative consequences in various life domains, such as, economy, physical and mental health, work life and/or in the relations with family and friends. Few individuals with gambling problems (IGPs) seek formal help in the health care system, mainly due to stigma or a desire to solve the gambling problems on their own. Gambling helplines offer a natural first way of contact for IGPs. Previous research suggests that brief interventions offered in a gambling helpline setting can be effective to mitigate gambling problems. This thesis includes four original papers. The first paper is based on data from a problem gambling screener, the second on data from an online self-help program without therapist support, the third paper on data from randomized controlled pilot study on a brief online program based on cognitive behavioral therapy (CBT) with therapist support in conjunction to a help line telephone counselling session, and the fourth paper is based on data from a longitudinal web survey exploring the effects of COVID-19 restrictions on gambling behaviors and PG. Aims: the aims of this thesis were three-fold, firstly, to describe the individuals who use the PG screener and to see which game types were associated with increased PG severity levels, secondly, to evaluate the feasibility of two different brief interventions in the context of a gambling helpline, and thirdly, the effects of COVID-19 restrictions on gambling behaviors and gambling problems. Methods: Study I is an observational study (N=7,350) that investigated the association between different game types and PG as measured by the Problem Gambling Severity Index (PGSI) using two different approaches. First, an unsupervised learning algorithm was used to subtype IGPs based on gambling participation into different patterns of gambling activities (PGA). PGA were compared with regards to PG severity levels. Secondly, we tested the association between certain game types and PG while adjusting for involvement in other game types. In study II (N=4,655), we investigated the feasibility of a very brief online selfhelp program at the Swedish gambling helpline. Participants were followed for up to four years. Study III (N=43) is a randomized controlled pilot study investigating the feasibility and effect of a brief four-module therapist guided online CBT program in conjunction to a helpline telephone counselling session. Participants were randomized either to the CBT program or to log gambling losses once a week for six consecutive weeks. The main objective was to evaluate the feasibility of the program. In this study the participants were followed for 12 weeks. Study IV is a combined cross-sectional and longitudinal study (crosssectional N=325 and longitudinal N=123) exploring migration from sports betting to online casino games and the effects of COVID-19 restrictions on gambling behaviors and PG during the first and second waves of the COVID-19 pandemic. Results: In study I, we found that most participants gambled on online casino games and that few were engaged in several different game types. Moreover, PGA with high probability of online casino gambling were associated with higher PG severity levels compared to PGA with low probability of online casino gambling. We also found that the effect of adding more game types were weak for online casino games, Electronic Gambling Machines (EGM) and online poker, but strong for lotteries and horse betting. The result points in the direction that fast and continuous games, such as online casino games had strong associations with PG severity regardless of engagement in other game types. In study II, we found that it was relatively easy to engage individuals in a self-directed program at gambling helpline website. However, few logged in to the program more than once and gambling expenditures increased for those who logged their gambling expenditures for a longer period. Study III showed that it was relatively difficult to recruit participants and that attrition was high. Both the intervention group and the control group reduced their gambling losses and levels of anxiety and depression, but all between group comparisons were inconclusive. Study IV showed that few sports bettors added online casino games, and none migrated from sports betting to online casino games during the initial phase of COVID-19. Cross-sectional and longitudinal data revealed that restrictions due to COVID-19 were not associated with gambling problems nor increased gambling frequency. Engaging in high-risk games (online slots, live betting, or EGM) were associated with both gambling problems and increased gambling frequency during the first and second wave of the pandemic. Conclusion: Online casino gambling was common among gamblers who screened their gambling habits. This game type was also strongly associated with increased PG severity level in this sample of gamblers. Brief online interventions in a gambling helpline setting may be helpful to mitigate gambling problems and improve mental health, however, it remains unclear if more extensive interventions are better than shorter. Finally, COVID-19-restriction do not seem to affect gambling behaviors nor gambling problems during the COVID-19 pandemic but engaging in high-risk games does.