Management of gambling disorders


Guideline Developer(s)

Singapore Ministry of Health

Date Released

2011 Jun

Full Text Guideline

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Audit Criteria/Indicators
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
Staff Training/Competency Material

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Early identification may help prevent a problematic gambling behaviour from escalating to a serious problem.
  • It is logical that if pathological gambling can be effectively managed, there would be gains from money saved and social problems avoided.
  • Appropriate management of gambling disorders
Potential Harms

When prescribing medications for pathological gamblers, the medical practitioner must be aware of the off-label use of these medications and their side-effects, and the patient should be informed.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendation

Grade Recommendation
A At least one meta-analysis, systematic review of randomised controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
GPP
(good practice points)
Recommended best practice based on the clinical experience of the guideline development group

Qualifying Statements

Qualifying Statements
  • These guidelines are not intended to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge advances and patterns of care evolve.
  • The contents of this publication are guidelines to clinical practice, based on the best available evidence at the time of development. Adherence to these guidelines may not ensure a successful outcome in every case. These guidelines should neither be construed as including all proper methods of care, nor exclude other acceptable methods of care. Each physician is ultimately responsible for the management of his/her unique patient, in the light of the clinical data presented by the patient and the diagnostic and treatment options available.
  • Evidence-based clinical practice guidelines are only as current as the evidence that supports them. Users must keep in mind that new evidence could supersede recommendations in these guidelines. The workgroup advises that these guidelines be scheduled for review five years after publication, or if new evidence appears that requires substantive changes to the recommendations.

Methodology

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases
Searches of Unpublished Data

Description of Methods Used to Collect/Select the Evidence

Searches were run on PubMed (1966-2010); EMBASE (1947-2010), and PsycINFO (1806-2010) for searching evidence related to management of gambling disorders. Additionally both the Cochrane Library (2010, Issue 11) and Centre for Reviews and Dissemination databases (DARE, NHS EED and HTA) were searched for systematic reviews and cost effectiveness studies. The guideline developers also performed Internet search on websites of guidelines agencies and professional societies that published clinical practice guidelines and consensus evidence on the given condition. These include the search for the last five years of the existing clinical practice guidelines (2006-2010) from sources of overseas guidelines agencies and professional bodies, e.g., National Guideline Clearinghouse, National Health Service (NHS) National Library of Guidelines, the Guidelines International Network, Agency for Healthcare Research and Quality (AHRQ), Canadian Medical Association (CMA) Clinical Practice Guidelines, New Zealand Guidelines Group, Australia's Clinical Practice Guidelines Portal websites.

Inclusion/exclusion criteria were used specific to the clinical questions to be answered. In general, search filters were used to further focus the type of studies to randomised controlled trials and systematic reviews of randomised controlled trials. If there is a paucity of higher level evidence, lower level evidence may be considered.

All searches used keywords and MeSH headings or the controlled vocabulary specific to the databases for the condition specified.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level Type of Evidence
1++ High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3 Non-analytic studies, e.g., case reports, case series
4 Expert opinion
Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

These guidelines have been produced by a committee comprising psychiatrists in hospitals and private practice, family physicians, addiction counsellors and a psychologist.

Cost Analysis

See Section 7 of the original guideline document for a discussion of cost-effectiveness issues.

Method of Guideline Validation

Not stated

Description of Method of Guideline Validation

Not applicable

Identifying Information and Availability

Bibliographic Source(s)

Singapore Ministry of Health. Management of gambling disorders. Singapore: Singapore Ministry of Health; 2011 Jun. 37 p. [124 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Singapore Ministry of Health

Guideline Committee

Workgroup on Management of Gambling Disorders

Composition of Group That Authored the Guideline

Workgroup Members: Dr Lee Kae Meng Thomas (Chairperson), Consultant & Chief, Department of Addiction Medicine, Institute of Mental Health (till 8 May 2011), Consultant Psychiatrist & Medical Director, The Resilienz Mind Psychological Medicine and Counselling Centre; Dr Chan Herng Nieng, Associate Consultant, Department of Psychiatry, Singapore General Hospital; Dr Benjamin Cheah, Deputy Head, NHG Polyclinics, Jurong Polyclinic; Ms Grace Fatima C. Gentica, Psychologist, Mental Wellness Service, KK Women's and Children's Hospital; Dr Guo Song, Consultant, Department of Addiction Medicine, Institute of Mental Health; Ms Lim Hui Khim, Senior Counsellor, National Addictions Management Service; Dr Lim Yun Chin, Consultant Psychiatrist, Raffles Hospital; Dr Noorul Fatha, Assistant Director, Hospital Services Division, Ministry of Health; Dr Tan Hwee Sim, Consultant & Deputy Chief, Department of Addiction Medicine, Institute of Mental Health; Mr Patrick Teo, Senior Counsellor, National Addictions Management Service; Dr Yeo Hui Nan, Family Physician, NHG Polyclinics, Jurong Polyclinic

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Singapore Ministry of Health Web site.

Print copies: Available from the Singapore Ministry of Health, College of Medicine Building, Mezzanine Floor 16 College Rd, Singapore 169854.

Availability of Companion Documents

The following are available:

  • Management of gambling disorders. Executive summary of recommendations. Singapore: Singapore Ministry of Health; 2011 Mar. 4 p. Electronic copies: Available in Portable Document Format (PDF) from the Singapore Ministry of Health Web site.
  • Various slide presentations and videos for understanding gambling disorders, how to assess gambling disorders, and management of gambling disorders are available from the Singapore Ministry of Health Web site.

Self-assessment questions and clinical quality improvement parameters are also available in the original guideline document.

Patient Resources

The following is available:

  • Your guide to understanding problem gambling. Singapore: Singapore Ministry of Health; 2011. 8 p. Electronic copies: Available in Portable Document Format (PDF) from the Singapore MOH Web site.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on March 15, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Ministry of Health, Singapore by e-mail at MOH_INFO@MOH.GOV.SG.

Scope

Disease/Condition(s)

Gambling disorders

Guideline Category

Diagnosis
Evaluation
Management
Screening
Treatment

Clinical Specialty

Family Practice
Psychiatry
Psychology

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers

Guideline Objective(s)

To raise awareness and assist in the detection, diagnosis and treatment of gambling disorders

Target Population

Individuals who suffer from gambling disorders

Interventions and Practices Considered

Diagnosis/Screening/Evaluation

  1. Screening for gambling disorders
  2. Corroborative history in relation to gambling patterns and behaviour (from family members and significant others)
  3. Full psychiatric history including:
    • History of presenting complaints
    • Psychiatric, family, treatment, past and personal histories
  4. Detailed assessment of gambling behaviour:
    • Initiation
    • Progression
    • Current frequency, current severity, types of games played, maintaining factors, features of dependence
    • Consequences (financial, interpersonal, vocational, social and legal)
    • Reasons for consultation, motivation to change and expectations of treatment
    • Assessment of suicide risk
    • Assessment of Axis I and II comorbidities, including alcohol and substance use disorders
    • Comprehensive mental state examination
    • Comprehensive clinical interview, including psychiatric assessment and mental state examination
  5. Evaluation and confirmation of a diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnostic criteria for pathological gambling

Management/Treatment

  1. Development of a comprehensive treatment plan, incorporating a multi-disciplinary and multi-modal approach
  2. Opioid antagonists (naltrexone, nalmefene)
  3. Selective serotonin reuptake inhibitors (fluvoxamine, paroxetine)
  4. Psychological interventions (cognitive-behavioural therapy)
  5. Motivational enhancement therapy (face-to-face or telephone counselling) and self-help workbooks
  6. Mindfulness therapy
  7. Self-help support groups
  8. Financial counselling, limiting access to money and restricting admission into gambling venues
  9. Management of specific populations
    • Screening tools that are specific to the adolescent population (e.g., South Oaks Gambling Screen–Revised for Adolescents [SOGS-RA], DSM-IV-J [adapted for juveniles])
    • Cognitive behavioural therapy
    • Screening for gambling disorders in older adults
    • Clinical assessment of older adults who are suspected or diagnosed to have a gambling disorders
    • Empirical treatment using best practices for the treatment of older adults with gambling disorders
    • Screening for and treatment of comorbid psychiatric conditions in individuals with gambling disorders
    • Engagement of family members and significant others in treatment
Major Outcomes Considered

Gambling-related symptoms and behaviour including thoughts and urges

Recommendations

Major Recommendations

Definitions of the level of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) and the grades of recommendations (A, B, C, D, GPP) are defined at the end of the "Major Recommendations" field.

Assessment

C - Screening for gambling disorders at the primary care setting is recommended for patients who present with frequent physical and psychological complaints, or who have a history of substance/alcohol use problems. (Grade C, Level 2+)

D - Screening for gambling disorders is recommended if gambling is a regular and habitual activity. (Grade D, Level 4)

C - Screening for gambling disorders should be routinely performed as part of all psychiatric assessment, especially in those individuals with mental health conditions. (Grade C, Level 2+)

GPP - Corroborative history in relation to gambling patterns and behaviour should be obtained from family members and significant others as far as possible. (GPP)

D - An individual who is screened positive for gambling disorder should be referred to the appropriate professionals for further clinical evaluation. (Grade D, Level 4)

D - The key aspects of assessment should include the following:

  • Full psychiatric history including:
    • History of presenting complaints
    • Psychiatric, family, treatment, past and personal histories
  • Detailed assessment of gambling behaviour:
    • Initiation
    • Progression
    • Current frequency (days per week or hours per day)
    • Current severity (money spent on gambling proportionate to income)
    • Types of games played
    • Maintaining factors
    • Features of dependence
  • Consequences: financial, interpersonal, vocational, social and legal
  • Reasons for consultation, motivation to change and expectations of treatment
  • Assessment of suicide risk
  • Assessment of Axis I and II comorbidities, including alcohol and substance use disorders
  • Comprehensive mental state examination

(Grade D, Level 4)

GPP - A comprehensive clinical interview that includes a psychiatric assessment and mental state examination should be performed when assessing gambling disorders. A multi-disciplinary assessment is recommended. (GPP)

D - Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnostic criteria for pathological gambling should be used to evaluate and confirm a diagnosis of pathological gambling. (Grade D, Level 4)

Management: Interventions

GPP - A comprehensive treatment plan that incorporates a multi-disciplinary and multi-modal approach should be developed for the management of pathological gambling. (GPP)

GPP - When prescribing medications to treat pathological gambling, the medical practitioner should inform the patient of the off-label use and the possible side effects of these medications. (GPP)

A - An opioid antagonist like naltrexone or nalmefene may be considered for reduction of gambling urges and thoughts in pathological gamblers. (Grade A, Level 1+)

B - Fluvoxamine and paroxetine may be considered for reduction of gambling behaviour, urges and thoughts in pathological gamblers. (Grade B, Level 1+)

B - Psychological interventions utilising the components of cognitive-behavioural therapy are recommended for the treatment of pathological gambling. (Grade B, Level 2++)

A - Motivational enhancement therapy (face-to-face or telephone counselling) and self-help workbooks are recommended for the treatment of gambling disorders, especially for individuals who are ambivalent about quitting gambling or entering treatment, or who are not keen on long-term therapy. (Grade A, Level 1+)

D - Mindfulness therapy may be used as an adjunct intervention in the treatment of gambling disorders. (Grade D, Level 3)

GPP - Self-help support groups should only be considered as complementary services to professional treatment for individuals with gambling-related problems. (GPP)

GPP - Financial counselling, limiting access to money and restricting admission into gambling venues are complementary and practical approaches that should be considered for those who have gambling-related problems. (GPP)

Management: Special Populations

C - Screening tools that are specific to the adolescent population (e.g., South Oaks Gambling Screen–Revised for Adolescents [SOGS-RA], DSM-IV-J [adapted for juveniles]) should be used in the screening for gambling disorders among adolescents. (Grade C, Level 2+)

D - Cognitive behavioural therapy may be used in the treatment of adolescent pathological gambling. (Grade D, Level 3)

D - Therapy for adolescent gambling disorders should include components such as acceptance of the problem, establishment of mutual trust, involvement of family, restructuring of leisure time, cognitive restructuring of erroneous beliefs and enhancement of effective coping skills. (Grade D, Level 3)

C - Screening for gambling disorders is recommended in older adults who engage in gambling activities. (Grade C, Level 2+)

C - Clinical assessment of older adults who are suspected or diagnosed to have a gambling disorders should include a comprehensive evaluation of physical, psychiatric and social histories. (Grade C, Level 2+)

GPP - Empirical treatment using best practices in adult problem/pathological gamblers is recommended for the treatment of older adults with gambling disorders. (GPP)

C - Screening for comorbid psychiatric conditions in individuals with gambling disorders is highly recommended. (Grade C, Level 2+)

GPP - Appropriate treatment for the identified comorbid psychiatric disorders in individuals with gambling disorders should be instituted. (GPP)

B - Family members and significant others of individuals with gambling disorders should be engaged in treatment as far as possible. (Grade B, Level 2++)

Definitions:

Levels of Evidence

Level Type of Evidence
1++ High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3 Non-analytic studies, e.g., case reports, case series
4 Expert opinion

Grades of Recommendation

Grade Recommendation
A At least one meta-analysis, systematic review of randomised controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
GPP
(good practice points)
Recommended best practice based on the clinical experience of the guideline development group
Clinical Algorithm(s)

None provided

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

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