AUT was contracted by the Ministry of Health in January 2009 to deliver a study of the effectiveness of interventions for problem gambling. Five key aims were agreed for this project. AUT is contracted to:
- generate reliable findings on the effectiveness of intervention services in producing positive outcomes on a range of measures and impact on others
- increase the body of evidence available on the clinical effectiveness of common problem gambling intervention practices in New Zealand and inform future clinical practice
- compare the effectiveness (on a range of outcomes) of common problem gambling interventions in New Zealand with common problem gambling intervention practices that have been validated internationally, including pharmaceutical interventions
- identify client characteristics that mitigate the effectiveness of validated interventions, with particular attention to client ethnicity and primary gambling mode
- develop a potential two stage research proposal that builds upon this project to provide additional evidence on the long-term effectiveness and outcomes of the treatment under trial.
Methodology
The study was designed as a single-site Randomised Controlled Trial (RCT). The inclusion criteria were: minimum age of 18 years; perception of having a gambling problem; and willingness to read a short workbook (to ensure reading ability), have calls recorded, provide follow-up data on gambling, and provide the name of collateral/s. Present or past involvement in treatment or mutual help groups for gambling or other mental health problems was documented and did not preclude participation. Callers were excluded from the trial if they were considered by the counsellor to be actively psychotic, or they required immediate crisis or police intervention because they posed a serious risk to themselves or others.
Four hundred and sixty-two first-time helpline callers who met eligibility criteria were randomly assigned to four groups on a 1:1:1:1 ratio using a computer-generated block randomisation procedure. The block size was 20, allocating participants to one of the four treatment groups. Random assignment continued until there was a minimum of 110 participants in each group. The trial had 70% power to significantly detect a one-day difference in mean days gambled between treatment groups (after accounting for time changes), a $20/day difference in dollars gambled between treatment groups and a quit or improved gambling rate difference of 0.13.
The treatments were: (1) Helpline standard care (TAU)1, (2) Single motivational interview (MI), (3) Single motivational interview plus cognitive-behavioural self-help workbook (MI+W) and, (4) Single motivational interview plus workbook plus four follow-up motivational telephone interviews (MI+W+B). Callers could choose their own treatment goal (quit some or all forms of gambling, or control their gambling). The primary outcome measures were self-reports of days gambled, money lost gambling and treatment goal success. Secondary outcome measures included problem gambling severity, control over gambling, gambling impacts, psychiatric comorbidity, general psychological distress and quality of life. Initial assessments were conducted by helpline counsellors prior to participants receiving a randomly allocated intervention. Further information2 was collected by research staff, blind to treatment allocation, within seven days after the telephone intervention and the primary and secondary outcome measures were generally repeated at three, six and 12 months post-intervention. Collateral information3, from one or more persons nominated by callers, was obtained at three and 12 months. Intention To Treat and Per Protocol analyses were used.
The primary hypotheses are:
1. All four groups will evidence significant reduction in gambling
2. The Motivational Interview (MI) group will show similar improvement to Helpline standard care (TAU)
3. The Motivational Interview plus Workbook group (MI+W) and the Motivational Interview plus Workbook plus Booster group (MI+W+B) will show greater improvement than the MI and TAU groups
4. The MI+W+B group will show greater improvement than the other three groups at the 12-month follow-up.
The trial was registered with the Australian New Zealand Clinical Trials Registry (registration number ACTRN12609000560291). The study was approved by the Multi-region Ethics Committee (reference number MEC/09/04/043, 3 June 2009).
Key Results
All Helpline counsellors involved in the trial were successfully trained to reliably and consistently deliver motivational interviews, the standard helpline intervention and follow-up booster sessions. Following training, the new counselling approach and other trial procedures became integrated into the operations of the helpline service. The great majority of the 462 callers recruited into the trial (N = 451) received the applicable, randomised intervention, although only a minority of MI+W+B participants received all four booster sessions (N = 39, 34%). Overall trial retention was 81%, 74% and 64% at three-, six- and 12-months respectively, with participant retention varying slightly across the four interventions. Interview duration did not differ across the intervention groups and there was no significant differential loss to follow-up between the study groups or overall.
With respect to treatment outcome, participants in all four intervention groups evidenced statistically and clinically significant, sustained improvement on the three primary measures self-reports of days gambled, money lost gambling and treatment goal success). This applied when performance was time-averaged across the duration of the trial and when assessed at 12 months. Substantial improvement was also found for problem gambling severity and other measures including self-ratings of control over gambling, gambling impacts on work, social life, family and home and health, psychological distress, major and minor depression and quality of life. Little or no change was evident with respect to alcohol misuse and tobacco use.
As hypothesised, there were no significant outcome differences between the MI and TAU interventions. Contrary to expectation, participants in the more intensive MI+W and MI+W+B interventions did not have better outcomes on the primary outcome measures than those who received MI and TAU. Although there were no significant primary outcome differences between participants in each of the treatment groups overall, differences were found for a number of subgroups. Usually these differences were evident for only one or a few outcome measures. In most cases MI+W+B participants had significantly better outcomes than their counterparts receiving MI alone. MI participants with lower levels of belief in their success in achieving their treatment goal did worse on one outcome measure than those in TAU. In this case those in the more intensive MI+W+B condition had better outcomes than their MI counterparts. Participants who, at the baseline assessment, had more serious gambling problems or whose goal was to control/reduce their gambling rather than quit gambling had better outcomes in the MI+W+B group than in the TAU and MI groups. Similarly, participants in the MI+W+B group with higher levels of psychological disorder and lower alcohol misuse levels had better outcomes in relation to money lost gambling and/or having quit or improved control over gambling, compared with their counterparts in the MI group. The only finding related to ethnicity was that Maori in the MI+W+B group showed greater improvement in money lost gambling (i.e. lost less money on average) at the 12-month assessment than Maori in the MI group.