The influence of depression and other co-occurring conditions on treatment outcomes for problem gamblers : a cohort study

Objective: To examine the influence of co-occurring conditions on gambling treatment outcomes.

Design, setting and participants: Prospective cohort study of problem gamblers. Participants were recruited from consecutive referrals to a gambling therapy service in 2008. Inclusion criteria were: (i) assessed as a problem gambler based on a screening interview including DSM-IV criteria for pathological gambling, and (ii) suitable for admission to a treatment program. Cognitive-behavioural therapy was based on graded exposure-to-gambling urge. One-to-one treatment was conducted with 1-hour sessions weekly for up to 12 weeks.

Main outcome measures: Problem gambling screening and co-occurring conditions including depression, anxiety and alcohol use.

Results: Of 127 problem gamblers, 69 were males (54%), mean age was 43.09 years, and 65 (51%) reported a duration of problem gambling greater than 5 years. Median time for participants’ enrolment in the study was 8.9 months. Results from mixed effects logistic regression analysis indicated that individuals with higher depression levels had a greater likelihood (13% increase in odds [95% CI, 1%–25%]) of problem gambling during treatment and at follow-up.

Conclusion: Addressing depression may be associated with improved treatment outcomes in problem gambling; conversely, treatment of problem gambling improves affective instability. We therefore recommend a dual approach that treats both depression and problem gambling.

Treatment outcomes and predictors of drop out for problem gamblers in South Australia : a cohort study

OBJECTIVES: Recent prevalence studies in Australia, the USA and Canada have estimated 1-2% of the adult population meet the diagnostic criteria for problem or pathological gambling. The Statewide Gambling Therapy Service (SGTS) provides treatment for problem gamblers in key metropolitan and rural regions in South Australia. The aims of this study were two-fold: to analyse the short and mid-term outcomes following treatment provided by SGTS and to identify factors associated with treatment drop-out. METHOD: A cohort of treatment seeking problem gamblers was recruited through SGTS in 2008. Repeated outcome measures included problem gambling screening, gambling related cognitions and urge. Treatment drop-out was defined as participants attending three or less treatment sessions, whilst potential predictors of drop-out included perceived social support , anxiety and sensation-seeking traits. RESULTS: Of 127 problem gamblers who participated in the study, 69 (54%) were males with a mean age of 43.09 years (SD = 12.65 years) and with 65 (52%) reporting a duration of problem gambling greater than 5 years. Follow up time for 50% of participants was greater than 8.9 months and, overall, 41 (32%) participants were classified as treatment drop-outs. Results indicated significant improvement over time on all outcome measures except alcohol use for both treatment completers and drop-outs, although to a lesser extent for the treatment drop-out group. A significant predictor of treatment drop-out was sensation-seeking traits. CONCLUSION: These results will inform future treatment planning and service delivery, and guide research into problem gambling including aspects of treatment drop-out.

The problem of spontaneous goodness: from Kierkegaard to Løgstrup (via Zhuangzi and Eckhart)

Historically, Western philosophy has struggled to accommodate, or has simply denied, the moral value of spontaneous, non-reflective action. One important exception is in the work of K.E. Løgstrup, whose phenomenological ethics involves a claim that the ‘ethical demand’ of care for the other can only be realized through spontaneous assent to ‘sovereign expressions of life’ such as trust and mercy. Løgstrup attacks Kierkegaard for devaluing spontaneous moral action, but as I argue, Kierkegaard too offers an implicit view of spontaneous moral response (‘second immediacy’) as a regulative ideal. In attempting to articulate the model of character-formation that such an ethics requires, we can see both Løgstrup and Kierkegaard as engaging with an ancient problematic, running from Classical Daoism to medieval mysticism, of achieving spontaneity through purgation rather than edification—not building the subject up, but demolishing personality in order to become a conduit for a transcendent normativity.

Persona - an old public relations problem?

This essay uses the neologism citizen public relations to express a view of the phenomena examined by persona studies implying that public relations studies might be regarded as an antecedent discipline to the former. It goes on to suggest potentially intriguing differences and similarities to do with political and epistemological problematics. The central theme is that the term identity is simultaneously the key link and the key contrast between the two disciplines. This is because the term identity is usually deployed at the internal, psychological, subjective level by scholars of persona while it is usually applied to external, material objects and events by the public relations industry and its academia. The essay also makes the point that both areas of study can be unified as different species of the genera rhetoric in the traditional sense of that still older field. This coincidence and dissonance may invoke a debate which can lead to theory development in all three fields. The fields are not comprehensively surveyed – a process which would be lengthy and might bring up many contrasting perspectives. Instead the work of representative leading authors is presented to make a prima facie case.

Interventions for comorbid problem gambling and psychiatric disorders : advancing a developing field of research

Despite significant psychiatric comorbidity in problem gambling, there is little evidence on which to base treatment recommendations for subpopulations of problem gamblers with comorbid psychiatric disorders. This mini-review draws on two separate systematic searches to identify possible interventions for comorbid problem gambling and psychiatric disorders, highlight the gaps in the currently available evidence base, and stimulate further research in this area. In this mini-review, only 21 studies that have conducted post-hoc analyses to explore the influence of psychiatric disorders or problem gambling subtypes on gambling outcomes from different types of treatment were identified. The findings of these studies suggest that most gambling treatments are not contraindicated by psychiatric disorders. Moreover, only 6 randomized studies comparing the efficacy of interventions targeted towards specific comorbidity subgroups with a control/comparison group were identified. The results of these studies provide preliminary evidence for modified dialectical behavior therapy for comorbid substance use, the addition of naltrexone to cognitive-behavioral therapy (CBT) for comorbid alcohol use problems, and the addition of N-acetylcysteine to tobacco support programs and imaginal desensitisation/motivational interviewing for comorbid nicotine dependence. They also suggest that lithium for comorbid bipolar disorder, escitalopram for comorbid anxiety disorders, and the addition of CBT to standard drug treatment for comorbid schizophrenia may be effective. Future research evaluating interventions sequenced according to disorder severity or the functional relationship between the gambling behavior and comorbid symptomatology, identifying psychiatric disorders as moderators of the efficacy of problem gambling interventions, and evaluating interventions matched to client comorbidity could advance this immature field of study.

Bailouts, monitoring, and penalties: an integrated framework of government policies to manage the too-big-to-fail problem

This paper discusses optimal government bailout policy where the costs of systemic failures and moral hazard problems are considered. We find that a three-tiered bailout policy that includes an ex post monitoring and bailout scheme for financial institutions with large systemic impacts ('too big to fail') is optimal. The optimal policy also requires a randomized bailout for medium-impact institutions ('Constructive Ambiguity'), and no bailout for institutions that have only minimal systemic consequences ('too small to save'). However, in a volatile, innovative market environment where individual institutions may know more than the government regulator, monitoring error could contribute to risk taking, leaving the government regulator to always play a 'catch-up' role in revising policy. Moreover, the optimal bailout policy may not be time-consistent: institutions not deemed 'too big to fail' may still have an incentive to take excessive risks and expect to be bailed out in case of insolvency, primarily due to the short-term orientation of the government. Finally, because an institution's systemic cost affects the probability of a bailout, we show that the boundary of an institution may be extended by the government subsidy.