SSRI Plus Cognitive Behavioral Therapy Effective for Pathological Gambling

Louise Gagnon

November 13, 2006

November 13, 2006 (Toronto) — The combination of a selective serotonin reuptake inhibitor (SSRI) and cognitive behavioral therapy (CBT) resulted in remission of pathological gambling for gamblers who had no other comorbidities.

Presented here at the annual meeting of the Canadian Psychiatric Association, researchers recruited 34 patients who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for pathological gambling. They were randomized to 1 of 3 study groups: paroxetine alone, at a dose range of 10 to 40 mg daily; combination therapy consisting of CBT and paroxetine; and CBT with placebo, all for 16 weeks.

Arun Ravindran, MD, PhD, the study's principal investigator and a professor of psychiatry at the University of Toronto in Ontario, Canada, said that the prevalence of gambling in Canada is climbing with the explosion of Internet gambling and the growth of casinos.

"It is a heterogeneous population because we find other comorbidities in this population," said Dr. Ravindran, who is also clinical director for the mood and anxiety program at the Centre for Addiction and Mental Health in Toronto.

He added that one of the specific comorbidities that presents with pathological gambling is depression, which has prompted clinicians to use SSRIs as a therapy for some pathological gamblers.

Dr. Ravindran said it would seem intuitive that the combination of CBT and medication would prove most effective, but studies have not clearly demonstrated the benefit of combination therapy.

The investigators employed the Pathological Gambling–Yale Brown Obsessive-Compulsive Scale (PG-YBOCS) as the primary measure of efficacy, and they also used other scales such as the Gambling Symptoms Assessment Scale (GSAS) and the Clinical Global Impression (CGI) scale.

Remission was defined as a score of 2 or lower on the CGI, meaning very much or much improved, and a score of 11 or lower on the PG-YBOCS.

At 8 weeks, 27 participants had completed treatment and were assessed. A total of 9 patients were receiving paroxetine alone; 8 were receiving paroxetine and CBT; and 10 were receiving CBT plus placebo. Of the patients in the paroxetine group, 3 experienced remission compared with 7 each in the combination group and the CBT plus placebo group.

At 16 weeks, 19 subjects had completed therapy, with no significant difference in the 3 groups on the PG-YBOCS. Patients who received the dual therapy of paroxetine and CBT had the fastest decrease in gambling symptoms, using the GSAS (P < .05). Using the CGI scale, patients rated the combination therapy superior (P < .05).

Sex, age, and severity did not predict response to therapy, the researchers found.

"There was an improvement in all 3 groups, but the combination of CBT and medication is likely to act quicker than CBT alone or medication alone," Dr. Ravindran told Medscape. "I think both CBT and medications are definitely helpful together and independently."

Because study subjects were followed for a short period of time, longer-term outcomes may prove one type of therapy to be of greater benefit than another, said Dr. Ravindran.

The lack of a placebo group may confound the ability to determine the effect of the drug in combination therapy, added Dr. Ravindran.

Mel Vincent, MD, MSc, a psychiatrist and clinical instructor in the Department of Psychiatry at the University of British Columbia in Vancouver, and director of psychiatricservices at Edgewood Treatment Centre in Nanaimo, British Columbia, Canada, noted the study's weaknesses.

"The study has significant limitations," said Dr. Vincent. "Ideally, you would want to have a placebo group because there may be a high response to placebo itself. It is a small sample size, so it's fairly difficult to show a [drug] effect with those numbers.

Dr. Vincent added that it is an interesting question to explore the effects of individual elements of therapy, noting CBT to be a mainstay in addiction treatment and drug therapy to be a newer approach to treat pathological gambling.

The Ontario Problem Gambling Research Centre supported the study. Dr. Ravindran is an investigator for Janssen-Ortho and has received research funding from AstraZeneca. Dr. Vincent is a member of the speaker's bureau for Wyeth Pharmaceuticals and AstraZeneca.

CPA 2006 Annual Meeting: Abstract PS9D. Presented November 11, 2006.

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