The Effect of a Brief Intervention for Problem Gamblers - a Randomized Controlled
Phase: NA
Conditions: Gambling Problem
Sponsor: Karolinska Institutet

 
The Effect of a Brief Intervention for Problem Gamblers - a 
Randomized Controlled Pilot Trial 
 
Last updated: 20201006 
 
 
 

 
Study protocol 
Background 
 
The prevalence rates for problem gambling (PG) in Sweden remains the same despite the fact 
that the gambling participation declines. According to the latest prevalence survey on PG in 
Sweden, approximately 2% of the adult Swedish population suffer from PG. Further, 5% are 
at risk of developing PG (1,2). PG is hallmarked by an inability to stop or reduce gambling 
even though it affects several life domains, such as: personal finances, family relationships, 
the physical and mental health and work in a negative way (3). Despite the fact that there are 
treatments that work, only around 5% of the individuals in need of treatment seek help within 
the healthcare system (1). There is also an extensive overlap between PG and especially 
alcohol, depression and anxiety disorders (4–6). Given the fact that few gamblers in need of 
treatment actually seek help within the healthcare sector, it is urgent to develop and evaluate 
interventions with a low threshold to participate. 
 
Treatment outcome research 
 
Internationally, there is a growing body of research on psychological treatments for PG. To 
this date, cognitive behavioural therapy (CBT) delivered face-to-face, has yielded the 
strongest support, but the evidence level is still considered low (7). There is also some support 
for brief motivational enhancement interventions, usually delivered via telephone, consisting 
of an initial counselling session based on Motivational Interviewing (MI) aligned 
with additional support consisting of written self-help material and/or booster sessions via 
telephone (8–10). A few studies have evaluated the effects of online CBT for problem 
gamblers, showing promising results (11,12). Overall, there is a growing body of evidence 
supporting the effects of Internet delivered CBT-interventions (13). Further research on 
psychological treatments for PG is needed. 
 
Gambling helplines 
 
A natural entry point for individuals suffering from PG in Sweden is the Swedish National 
Gambling Helpline, the helpline. The helpline offers anonymous support and counselling to 
gamblers and concerned significant others (CSOs) via telephone, chat or email. The helpline 
also offers online screening of gambling habits with personalised feedback, and self-directed 
online help. On an annual basis about 1200 gamblers and 1000 CSOs contact the helpline for 
counselling and support. Approximately 3500 gamblers screen their gambling habits online 
and 1200 registers for the self-directed online help (14).  
 
In an international context, gambling helplines have been around for decades, but to our 
knowledge only one evaluation of its effectiveness has been conducted, compiled as a report 
to the New Zeeland Ministry of Health. At the New Zeeland gambling helpline, four different 
interventions were tested: 1) the regular counselling, 2) one MI-session, 3) one MI-session 
plus written self-help material, and 4) one MI-session, written self-help material and up 
to four booster counselling sessions. The authors were not able to show superiority of any 
intervention, but at a sub-group level they found that gamblers experiencing greater problem 

gambling severity, greater levels of depression and anxiety and who were consuming alcohol 
at an "at-risk"-level benefitted from the most extensive intervention (15).  
 
Given the fact that the Swedish gambling market has undergone a major transformation over 
the last decade - from being mainly a land-based market to predominantly being an online 
gambling market (16), and the fact that almost all Swedish citizens have access to the 
Internet, and the growing support for Internet delivered CBT-interventions - the natural 
development of offering written self-help materials and/or booster sessions in connection to 
an initial counselling session in a gambling helpline is to offer the extended contact as a brief 
online CBT-intervention. A study at the Australian gambling helpline discovered that the 
gamblers were primarily in need of practical tools on how to manage their gambling, rather 
than help enhancing their motivation to change (17). CBT provides concrete tools for 
changing the gambling habits. 
Aims  
The aim is to test the feasibility of a brief online CBT-intervention at the Swedish national 
gambling helpline's counselling service, more specifically: pilot-test of a short online CBT-
program in connection to an initial counselling session at the gambling helpline. 
Method and materials 
Design 
A pragmatic randomized controlled pilot trial examining feasibility of an additional brief 
online CBT-program in connection to an initial counselling session in the helpline. The study 
participants will, after an initial counselling session with the helpline, be randomized to either 
a brief online CBT-program or to log their gambling habits for six weeks.  
Outcomes 
 
The main outcome is feasibility of conducting the study, secondary outcomes are net losses to 
gambling, days gambling, problem gambling severity level, gambling urges, self-efficacy in 
gambling situations, psychosocial health and general social functioning. 
Participants 
 
Study participants will be recruited from the helpline's counselling service and webpage. 
Gamblers' scoring above 3 points on the PGSI scale are eligible for inclusion. Other inclusion 
criteria are:  
• 
Aged over 18 years 
• 
Good enough skills in the Swedish language 
• 
Access to the Internet 
Exclusion criteria are: 
• 
Being involved in a treatment research study the previous 3 months 

• 
Receiving other treatment for PG 
• 
Being on a non-stable drug treatment for any psychiatric disorder 
• 
Showing signs of severe depression 
 
 
Randomization 
Participants will be randomized using block randomization with varying block sizes (ranging 
between 2 to 8 participants per block) to ensure balanced groups.  
Data collection 
 
Data will be collected at baseline, weekly during the treatment, after the treatment, and 6 
weeks after the end of treatment.  
Intervention 
 
The internet-based CBT program that is the intervention in the study is developed by the 
research group and is based on CBT treatment for problematic gambling (see 18). The 
program have elements of psycho-education, functional analysis on gambling situations, 
behavioural activation, reflections on thoughts about gambling and relapse prevention, and 
basically the same motivational increasing principals that is used in the Motivation 
Interviewing (MI) method. The program consists of four modules that are given during six 
weeks (week 1, 2, 4, and 6 after randomization). Each module has its own team with text to 
read and exercises. When a module is completed, the participants receive feedback from a 
counsellor via a messaging system in the web platform. The feedback aims to highlight and 
strengthen the client’s self-determination and own ability to change their behaviour. In the last 
module, the progress made and tips for further support are summarized. Themes for the four 
treatment modules are as follows:  
Week 1: Objective of treatment, psycho-education, functional analysis on gambling 
Week 2: Functional analysis on gambling situations, thoughts on gambling and behavioral 
activation 
Week 4: Behavioural activation and functional analysis on gambling-free activities 
Week 6: Relapse plane: to maintain a gambling-free life with focus on handling risk situations 
and engage in gambling-free activities. 
The ordinary counsellors at the helpline will be the counsellors in the study and will be 
educated in the CBT method before the study starts. They all have a long experience to work 
with persons who are problematic gamblers and they will receive continuous supervision by a 
certified psychologist. The written feedback given to the counsellors will be reviewed to 
ensure that the treatment is given according to the CBT method. 

Statistical analyses plan (SAP) 
Feasibility will be analysed using mainly descriptive statistics. To analyse the longitudinal 
data a three-level regression model will be used. The highest level in the hierarchy consists of 
the therapist, the second level is the client and at the lowest level are the repeated 
measurements made on the clients. The main outcome in the longitudinal part of the study 
will be net losses, and based on earlier knowledge it is known that this outcome have a 
distribution that is far from a normal distribution. It has a distribution with high peaks at both 
ends of the measured values. Therefore, the regression models used to analyse the 
longitudinal data will not be linear models but rather zero-inflated or alternatively hurdle 
models based on either a Poisson distribution or a negative binomial distribution. 
Ethical considerations 
 
Since the patient group is fairly new and society’s help is limited, there is a risk that patients 
with too extensive need of support apply to participate in the intervention study. To make sure 
that no one is left without help, participants who for any reason are excluded from the study 
will be referred to help in their vicinity. The helpline has a record of addiction and psychiatric 
care to all of Sweden’s municipalities and county councils.  
 
Further, participants will be systematically followed up within the study, which enables the 
research group to have a constant supervision of the treatment process. Participants who are 
still experiencing problems after intervention termination will be referred to help in their 
vicinity.  
 
Participants who end the intervention without telling, will be contacted via telephone up to 3 
times to check further participation, and will, if necessary, be offered a referral to further 
treatment. Deviations will be reported in the participant’s paper journal. Personal data will be 
handled according to the Swedish Data Protection Act.  
 
In previous outcome studies participants have benefitted from the treatment they have 
received. It is likely to believe that those who participate in the study will benefit from the 
intervention. It is also likely to believe that future problem gamblers will benefit from the 
study.  
 
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