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Each year, representatives from the National Center for Responsible Gaming (NCRG) and the Institute for Research on Gambling Disorders hit the road to raise awareness about disordered gambling. As reported in theAkron Beacon Journalthis weekend, our representatives will be heading to Cleveland, Ohio for the NCRG’s fourth annual road tour.

These road tours give us the opportunity to ensure the various audiences and individuals who have an interest in gambling disorders and responsible gaming – including regulators, policymakers, researchers, clinicians and gaming industry professionals – have access to the latest information about what’s happening in the field. Our representatives provide an update on the body of peer-reviewed research on gambling disorders, discuss NCRG-funded research projects that have received grants from the Institute and show how the findings from this research are being translated into practical applications for prevention, treatment and responsible gaming education.

If you’re interested in receiving more details about our Ohio trip, e-mailinfo@gamblingdisorders.org, or leave a comment. You can read about last year’s road tour – to Black Hawk and Denver, Colo. – in the fall 2009 issue ofResponsible Gaming Quarterly(PDF link – see cover story).

NCRG staffICRG News

Welcome to Gambling Disorders 360°, the Institute for Research on Gambling Disorders’ new blog exploring the latest news, issues and research relating to gambling disorders and responsible gaming.

On Gambling Disorders 360°, you’ll find a broad range of information and resources, including:

• News and developments relating to research, prevention, treatment and responsible gaming
• Our monthlyIssues & Insightscolumn, which shares the perspectives of experts in the field
• Links to helpful resources and articles, such asThe WAGER
• News from the Institute and theNational Center for Responsible Gaming– including the latest about grants, the NCRG’s annual Conference on Gambling and Addiction and our free webinars
• Book reviews
• Interviews with experts in the field
• And more

Gambling Disorders 360° also will be a forum where researchers, clinicians, regulators, policymakers and industry representatives can come together to share knowledge and best practices, and candidly discuss the field’s most pressing issues.

While you’re here, I encourage you to subscribe to Gambling Disorders 360° via e-mail or RSS (see subscription instructions in the sidebar) to be automatically notified when we have a new post on the blog.

Thank you for stopping by – please feel free to leave a comment with any questions or suggestions you may have. We look forward to hearing your thoughts in the coming weeks and months.

Christine Reilly Executive Director, Institute for Research on Gambling DisordersICRG News

March Madness refers not just to the National Collegiate Athletic Association’s basketball tournament, but also to the uptick in gambling activity that ranges from office pools to betting online. An increased awareness during this time of year about gambling on college sports usually leads to questions about gambling by college students. Consequently, we have devoted the March edition of Issues & Insights to new research on college gambling.

The Task Force on College Gambling Policies emphasized the importance of using evidence-based strategies to help students with gambling problems in itsCall to Actionreport published in September 2009, but raised concerns about the dearth of research on interventions tailored for this population. A recently published study by Dr. Nancy Petry and colleagues fills a serious gap in the literature. Dr. Petry and Dr. Jeremiah Weinstock summarize the findings of this study of brief interventions for disordered gambling in college students (Petry, Weinstock, Morasco, & Ledgerwood, 2009).

College students are in a transition from adolescence to adulthood. This period is important developmentally and marked by increasing responsibility, independence, exploration and identity formation (Arnett, 2000). Unfortunately, engagement in risky behaviors also increases during this time, and gambling is one such risky behavior.

Although most college students gamble without problems, some do develop difficulties, and these difficulties can persist for years (Gourdiann, Slutske, Krull, & Sher, 2009). The prevalence of disordered gambling in college students ranges from 3 percent to 14 percent (Shaffer, Hall, & Vander Bilt, 1999). Disordered gambling is associated with poor academic performance, heavy alcohol consumption, illicit drug use, nicotine use and suicide attempts. (In the context of this article, disordered gambling refers to both problem and pathological gambling.)

Despite the prevalence and adverse consequences of disordered gambling in college students, very few college students seek treatment for gambling. Thus, active identification of students with problems is necessary. In our study, we advertised on college campuses for free and confidential gambling screening and treatment services. We also actively screened students for gambling problems and provided a small incentive (e.g., a pen or candy bar) for students to complete the gambling screen.

Students identified with problem or pathological gambling in the screening process were invited to participate in a brief intervention study. We evaluated three brief interventions that focused on reducing gambling behavior in comparison to an assessment-only control condition (i.e., they were assessed for gambling problems but were not involved in an intervention). The interventions were: 10 minutes of brief advice; one session of motivational enhancement therapy[1]; and one session of motivational enhancement therapy plus three sessions of cognitive behavioral therapy.[2]

A total of 117 college students with disordered gambling participated in the study and were randomly assigned to one of the three interventions or the assessment-only control condition. We assessed demographics and gambling behavior three times: at the beginning of the study, six weeks later, and nine months later.

The vast majority of student participants were male, with a mean age of 20 years. The average age they started gambling was 14 years, and about a third met criteria for pathological gambling (with the remainder classified as problem gamblers). The most common form of problematic gambling in the sample was betting on card games, endorsed by about half the participants.

In comparison to the assessment-only condition, students randomized to any of the brief interventions significantly decreased the number of days gambled and dollars wagered. On average, they gambled about 14 days per month at the start of the study. Nine months later, those who had received the brief interventions reduced the number of days gambled per month to approximately five to six days, while those assigned to the assessment-only control condition were still wagering an average of 10 days per month. In comparison to the assessment-only control condition, students who received the motivational enhancement intervention were almost three–and-a-half times more likely to demonstrate clinically significant reductions in gambling, defined as wagering less than 10.5 percent of their incomes.

Overall, results from this study show that administering very brief intervention strategies – such as one session of motivational enhancement therapy – can assist in substantially decreasing gambling for up to at least a nine-month period in almost two-thirds of college students with disordered gambling. Given the lack of efficacious interventions for this population, these results are noteworthy. As awareness of gambling problems on college campuses grows, more counselors, administrators and professors are expressing interest in learning about this disorder, and this study provides support for brief interventions in college students.

Nancy M. Petry, Ph.D., is professor of psychiatry at the University of Connecticut Health Center. Dr. Jeremiah Weinstock is assistant professor in the Calhoun Cardiology Center, University of Connecticut Health Center.

References

Arnett, J.J. (2000). Emerging adulthood: A theory of development from the late teens through the twenties.American Psychologist, 55, 469-480.

Gourdiann, A.E., Slutske, W.S., Krull, J.L., & Sher, K.J. (2009).Longitudinal patterns of gambling activities and associated risk factors in college students.Addiction, 104, 1219-1232.

Miller, W.R., Zweben, A., DiClemente, C.C., & Rychtarik, R.G. (1994).Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence.Project MATCH Monograph Series, Vol. 2. DHHS Publication No. 94-3723. Rockville MD: NIAAA.

Petry, N.M., Weinstock, J., Morasco, B.J., & Ledgerwood, D. M. (2009). A randomized trial of brief interventions for problem and pathological gambling college students.Addiction, 104, 1569-1578.

Reilly, C., & Shaffer, H.J. (2007). Roads to recovery from gambling addiction. InRoads to Recovery from Gambling Addiction(pp. 2-5). Washington, DC: National Center for Responsible Gaming.Shaffer H.J., Hall M.N., & Vander Bilt, J. (1999). Estimating the prevalence of disordered gambling behavior in the United States and Canada: A research synthesis.American Journal of Public Health,89, 1369-1376.

[1]According to theMotivational Enhancement Therapy Manualpublished by the National Institute on Alcohol Abuse and Alcoholism, “Motivational Enhancement Therapy is based on principles of motivational psychology and is designed to produce rapid, internally motivated change. This treatment strategy does not attempt to guide and train the client, step by step, through recovery, but instead employs motivational strategies to mobilize the client’s own resources.” (Miller, Zweben, DiClemente, & Rychtarik, 1994).

[2]Using cognitive behavioral therapy (CBT) for gambling problems involves a focus on reducing the individual’s excessive gambling by correcting erroneous perceptions about probability, skill and luck that only reinforce problematic gambling behaviors. Cognitive behavioral treatment techniques include: cognitive correction, social skills training, problem solving training and relapse prevention (Reilly & Shaffer, 2007).

NCRG staffIssues & Insightsbrief interventionscollege gamblingdisordered gambling

To understand why tribal governments are reluctant to allow “outside” researchers to study their communities, consider the following story. In 2004, the Havasupai Tribe filed a lawsuit against Arizona State University (ASU) charging that ASU researchers had misused blood samples taken from tribal members who had been told that the sample material would be used for a study on the genetics of diabetes. The Havasupai later learned that the samples were also used for research on schizophrenia, inbreeding and migration patterns, without the tribe’s consent. This case reinforced Indian Country’s suspicions of research and the assumption that findings would be used to harm and humiliate Native Americans (Santos, 2008; Sahota, 2007).

Researchers interested in studying the impact of gambling on American Indian communities must understand the history this story illustrates, as well as the new research regulations some tribal governments have adopted to protect themselves by exerting more control over investigations conducted on their communities. We offer the following recommendations to researchers who are thinking about studying gambling and gambling disorders among American Indians.

Observe Proper Protocol

Issues of proper protocol can make or break a research project in Indian Country. As sovereign nations, American Indian tribal governments have the right and responsibility to regulate research on their lands, and some have created their own Institutional Review Boards (IRB) for the purpose of evaluating proposals for research on their communities (Sahota, 2007). Investigators should take care to follow the community’s research regulations when submitting the project to the tribe’s IRB.

We find that researchers are often reluctant to approach a tribal government about potential projects. One simple guideline for dealing with tribal leaders is to consider them as one would the President of the United States or a member of the U.S. Congress. Elected tribal chairs and members of tribal councils are the chosen representatives of sovereign peoples. They carry a heavy mantle of responsibility and should be accorded great respect. If the leaders and members believe that the concept of tribal sovereignty is understood and honored by researchers, they will be more cooperative and forthcoming and more likely to contribute their ideas and support to research among their community members.

Strive for Cultural Competence

The recommendation to develop a project that is culturally competent might sound like obvious advice. However, in our experience, researchers often fail to do their homework or invest time in trying to understand the community’s perspective on important issues. Learn as much as you can about the history, culture, traditions and circumstances of the community you would like to study. For example, try to understand the pace and rhythm of life in the community, which may not always proceed in accordance with your project’s timetable or deadlines. Ceremonies and rituals often take precedence, even over previously scheduled interviews with investigators.

In addition to examining your own personal preconceptions, take a critical look at the existing methodology for cultural bias. For example, current screening instruments for gambling problems have not been validated for use in American Indian populations. You might also consider how the view of gambling among Indian tribes might influence your investigation. Whereas the dominant American culture often seems ambivalent about gambling, despite the large percentage of Americans who gamble, many tribes view their own traditional gambling activities as an important and positive part of their history and culture. Additionally, for many tribal governments, gaming revenues provide the only source of governmental income and, therefore, tribal gaming’s political impacts are understood to outweigh any potential or actual social impacts.

Aim for a True Partnership

Most importantly, community leaders and tribal members should be involved from the inception of the research project as more than just human subjects to be studied. You should expect them to monitor your research project and to request continuous consultation and conversation. Be prepared to explain your project again and again to leaders, small groups and individuals and to incorporate feedback along the way.

Reciprocity should be the hallmark of research projects with American Indian communities. If investigators make use of the subjects’ time and participation, they should give back to the community by providing resources and skills and by focusing on projects that the community itself is seeking. Hiring tribal members to assist in research activities is a common practice that can benefit the tribe and also make it less likely that research participants will be exploited or exposed to unnecessary risk (Caldwell et al., 2005).

Conclusions

These are just a few of the many issues involved in the study of American Indian populations. Despite the many challenges, we are confident that researchers who make the effort to conduct community-based, collaborative research in Indian Country will succeed in producing enlightening studies that will benefit both the tribes and the gambling field.

About the Authors

Eileen Luna-Firebaugh(Choctaw/Cherokee), J.D., M.P.A., is associate head of American Indian Studies and associate professor of American Indian Studies at the University of Arizona and is a current member of the scientific advisory board of the Institute for Research on Gambling Disorders.

Katherine Spilde, M.B.A., Ph.D., is chair of theSycuan Institute on Tribal Gamingbased at San Diego State University (SDSU) and associate professor in the SDSU School of Hospitality & Tourism Management.

References

Caldwell, J.Y., Davis, J.D., Du Bois, B., Echo-Hawk, H., Erickson, J.S., Goins, R. T., Hill, C., Hillabrant, W., Johnson, S.R. et al. (2005).American Indian and Alaska Native Mental Health Research: The Journal of the National Center,12,(1), 1-21.

Legaspi, A., & Orr, E. (2007). Disseminating Research on Community Health and Well-being: A Collaboration between Alaska Native Villages and the Academe.American Indian and Alaska Native Mental Health Research, 14(1), 24-42.

Sahota, P. C. (2007). Research Regulation in American Indian/Alaska Native Communities: Policy and Practice Considerations.National Congress of American Indians (NCAI) Policy Research Center.

Santos, L. (2008). Genetic Research in Native Communities.Progress in Community Health Partnerships: Research, Education, and Action, 2(4), 321-326.

Eileen Luna-Firebaugh, J.D., M.P.A. and Katherine Spilde, M.B.A., Ph.D.Issues & InsightsAmerican Indiandisordered gamblingresearch challengestribal gaming

As the body of research on gambling disorders continues to grow, scientific evidence is beginning to show that some vulnerable and special needs populations appear to be at a higher risk for developing gambling disorders than the general population. The National Center for Responsible Gaming (NCRG) and the Institute for Research on Gambling Disorders have made research on these groups a priority, supporting investigations of gambling problems among young people, women, homeless individuals and African-American adolescents.

Psychiatric patients constitute another population that has been identified by several studies as more vulnerable to excessive gambling. Numerous studies have documented the high rate of co-occurring psychiatric and addictive disorders among individuals with gambling problems.^{1, 2}However, to date, there has been no systematic examination of gambling behaviors in individuals in outpatient treatment for psychotic disorders.

A new study by Yale University researchers Rani Desai, PhD, MPH and Marc Potenza, MD, PhD has filled this gap. The results of their study were recently published online in theJournal of Clinical Psychiatry, the third most cited psychiatric journal in the world,³in the article “A Cross-Sectional Study of Problem and Pathological Gambling in Patients with Schizophrenia/Schizoaffective Disorder.”⁴The study was funded by the NCRG.

The researchers interviewed a sample of 337 patients diagnosed with and in outpatient treatment for schizophrenia/schizoaffective disorder. Using the DSM-IV criteria for pathological gambling and structured psychiatric assessments, the researchers found that these patients may be at a particularly high risk for gambling disorders. While 46 percent of the participants were categorized as non-gamblers and 34.7 percent as recreational gamblers (i.e., those who gamble and are able to do so without adverse consequences), 19.3 percent were classified as either problem or pathological gamblers.⁴Of the group with gambling problems, 9.8 percent met the threshold for pathological gambling, the most severe form of the disorder.⁴Recent national studies have estimated the rate of pathological gambling among the general adult population at one percent and lower.^{5, 6}

Desai and Potenza conjecture that several reasons might predispose this population to gambling problems. First, the cognitive disturbances associated with psychotic disorders may make it difficult for these patients to control their gambling or understand the risks of excessive gambling. Second, both schizophrenia/schizoaffective disorder and pathological gambling show evidence of impaired impulse control. The authors note that, “Clinically, this finding is important, because co-occurring addictions can complicate treatment of schizophrenia/schizoaffective disorder itself, and because even if patients are in recovery from one addictive behavior (eg, alcoholism), they may be vulnerable to substituting another (eg, problem gambling).”⁴

They also note that clinicians should be aware of the potential for excessive gambling in patients with schizophrenia/schizoaffective disorder and screen such patients for gambling problems, especially those who are either in recovery or actively abusing drugs or alcohol.

Third, the study showed significantly higher scores for depression among the patients with gambling problems, which can increase vulnerability to excessive gambling. The authors also note that depressive symptoms can be a response to the typical consequences of pathological gambling, such as financial stress.

This study represents a great advance as one of the largest to directly examine gambling patterns in a sample of people with schizophrenia/schizoaffective disorder. It demonstrates the importance of screening patients with psychotic disorders for gambling problems. These findings also provide a roadmap for future research, suggesting that future investigations should identify the factors that place these patients at risk for developing a gambling disorder. Finding effective therapies for this population is another priority for future investigations because current clinical trials for treatment of gambling disorders typically exclude subjects with psychotic disorders.

References

1.Cunningham-Williams RM, Cottler LB, Compton WM, 3rd, Spitznagel EL. Taking chances: problem gamblers and mental health disorders–results from the St. Louis Epidemiologic Catchment Area Study.Am J Public Health.Jul 1998;88(7):1093-1096.

2.Grant JE, Levine L, Kim D, Potenza MN. Impulse control disorders in adult psychiatric inpatients.Am J Psychiatry.Nov 2005;162(11):2184-2188.

3.ISI Web of Knowledge.Journal of Citation Reports: Thomas Reuters; 2008. Available athttp://thomsonreuters.com/products_services/science/science_products/scholarly_research_analysis/research_evaluation/journal_citation_repoAccessed September 4, 2009.

4.Desai RA, Potenza MN. A cross-sectional study of problem and pathological gambling in patients with schizophrenia/schizoaffective disorder.J Clin Psychiatry.Jun 16 2009.

5.Petry NM, Stinson FS, Grant BF. Comorbidity of DSM-IV pathological gambling and other psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions.J Clin Psychiatry.May 2005;66(5):564-574.

6.Kessler RC, Hwang I, LaBrie R, et al. DSM-IV pathological gambling in the National Comorbidity Survey Replication.Psychol Med.Sep 2008;38(9):1351-1360.

Christine Reilly Executive Director, Institute for Research on Gambling DisordersIssues & Insightscomorbiditynew research