Internet-based cognitive behavior therapy for problem gambling in routine care: protocol for a non-randomized pilot and feasibility trial

Background Problem gambling and gambling disorder are major public health concerns worldwide, and awareness of associated negative consequences is rising. In parallel, treatment demand has increased, and Internet interventions offer a promising alternative for providing evidence-based treatment at scale to a low cost. Method We developed a novel Internet-delivered cognitive behavioral treatment for gambling, based on qualitative interviews with treatment-seeking gamblers, behavioral research on gambling behavior, and the pathway model for problem gambling. This research protocol describes a non-randomized pilot and feasibility trial conducted in routine addiction care with adult treatment-seeking patients (max N = 25) with problem gambling. The primary aim is to ensure acceptability and safety, measured by satisfaction, credibility, working alliance, and possible negative effects. Secondary aims are feasibility of study procedures in terms of recruitment and measurement procedures as well as potential effectiveness measured weekly by gambling symptoms as primary outcome and gambling behavior, quality of life, symptoms of depression and anxiety, alcohol, and drug use as secondary outcomes. Potential mediators measured weekly are loss of control, verbal rules, and well-being. Discussion This study is innovative in several respects, regarding both treatment development and implementation. The results of the study will guide a future randomized controlled trial, as well as the development of the intervention and intervention implementation within ordinary addiction care. Trial registration Clinical trials.gov, NCT ID: NCT03946098. Registered 10 May 2019


Internet-based Cognitive Behavior Therapy for Problem Gambling
Internet-based Cognitive Behavior Therapy for Problem Gambling

Why:
We have used a bottom-up approach in the treatment development process. This includes deriving the treatment content from in-depth clinical interviews with treatment-seeking gamblers, research on the learning and maintenance processes of gambling behavior, as well as the Pathway model for problem gambling. Also, we designed the treatment protocol to build on a simple, delimited set of interventions of presumed greatest importance. This is contrary to typical addiction treatments that o er a smorgasbord of exercises and treatment rationales in an attempt to capture all relevant aspects that may apply di erently to di erent patients. As a research field, the study of treatment for problem gambling is still in its infancy. Current cognitive behavior therapy (CBT) protocols for problem gambling are seldom based on a functional analysis on why problem gambling behavior persists over time despite negative consequences. This is so, despite the fact that problem gambling is a phenomenon that has generated basic research on the learning processes involved. In general, a broad mixture of general CBT components, which have been found e ective for other conditions such as depression, anxiety or alcohol problems, have o en been arbitrarily combined into treatment protocols, while interventions targeting key gambling processes such as "chasing losses", or "loss of control" have been lacking. In contrast, utilizing a few, carefully selected treatment components, will hopefully enable a more clear definition of what to prioritize in treatment, opportunities for continuous applied behavior change, as well as better controlled studies in terms of mediating and moderating factors.

What (material):
Treatment will be delivered using the recently introduced and nationally available Swedish Stöd och Behandling (Support and Treatment, SaT) platform for internet-delivered treatments within routine care, both psychiatric and somatic. Usage is not anonymous and requires login using a secure, bank-issued national e-identification solution. The same platform, with di erent interfaces, is used by patients and health care professionals. This is typically done through asynchronous messages within the SaT platform, complemented as needed by telephone calls. Established clinical procedure will be followed, including telephone calls at specific timepoints in case of poor compliance (no logins or progress) or indications of suicidality.

What (procedures):
The treatment consist of CBT based content in the form of text and images (se below for treatment components). The full treatment protocol is in Swedish and is not yet published.

How (mode of delivery; individual or group):
The internet based CBT will be delivered individually. Regular licenced clinical psychologists at the eClinic will serve as therapists, involving monitoring, encouraging and praising compliance and progress, unlocking modules, and answering questions. During treatment, participants will have online contact via asynchronous secure messages with an assigned clinical psychologist at the Addiction eClinic.
Where: Participants will be recruited among patients at one of eight outpatient clinics belonging to the publicly operated Stockholm Center for Dependency Disorders. Patients will be informed during a ordinary visit with a physician, nurse or psychologist that available treatments include iCBT. Written information will be supplied in the form of a pamphlet, and the clinician will be able to answer any question. The recruiting clinician will make a preliminary assessment of eligibility, i.e. PGSI score, and make a formal clinical referral to the Addiction eClinic, a specialized clinic that is part of the Stockholm Center for Dependency Disorders, which will make the final decision as to whether iCBT is suitable. Since this trial is conducted within ordinary care, all patients referred to the eClinic will be o ered the treatment regardless of study participation. Informed consent will be collected digitally in the first, introductory module of the online program. Only patients who consent will be included in this study; those who decline will nonetheless be o ered the exact same treatment, but excluded from studyrelated data collection and analysis.
When and how much: Treatment will consist of a 1+10 module iCBT program targeting problem gambling. The preprogram module will contain an introduction to online treatment as well as collection of pretreatment measures within the SaT platform. A er that, participants will complete the 10 treatment modules at a pace of once a week, completing homework assignments facilitating behavior change during each week. The authors' experience of iCBT delivery for addictive disorders in a clinical setting is that participants work at a slower pace than one module per week and are likely to need longer to complete the treatment. Hence, participants will be