Pathological gambling is serious problem, with significant psychological, financial, and public health consequences. Nevertheless, controlled trials examining the efficacy of therapeutic interventions for pathological gamblers are sparse. Gambler's Anonymous (GA) is the most popular form of treatment, and GA participation may improve outcomes among patients who become actively involved in the fellowship. Results from our first cycle of funding indicate that cognitive-behavioral (CB) treatment in conjunction with GA is more efficacious in reducing gambling than referral to GA alone. However, only about 60% of patients assigned to the CB condition became actively involved in treatment, and only about a third attended GA even once during the 8-weeks of treatment. The purposes of the present study are two-fold. First, we will compare the efficacy of CB treatment to an active control condition to ascertain whether the beneficial effects are related specifically to CB therapy or to more general therapeutic processes. Second, we will evaluate the efficacy of CB therapy to an enhanced CB approach that utilizes contingency management (CM). CM treatments provide tangible rewards for objective behavior changes, and these procedures are highly efficacious in improving retention and reducing substance use in drug abusing patients. We have pilot data from pathological gamblers suggesting that we can enhance engagement in therapy to over 85% utilizing CM techniques, and patients receiving the CB-CM treatment are more likely to complete CB homework exercises and become engaged with GA. This study will assess whether these effects are associated with long-term improved outcomes. In total, 210 pathological gamblers will be randomized to one of three conditions: psychoeducation plus case management (an active control condition), CB therapy, or CB therapy plus CM. Patients in each group will receive 8 individual therapy sessions, and all will be referred to GA. Gambling and psychosocial problems will be assessed from both the patient and a collateral using standardized instruments at pre- and post-treatment, and at 6, 9, 12, 18, and 24-month follow-up evaluations. We expect that CB will improve outcomes relative to psychoeducation, and that CB-CM will reduce gambling to a greater extent than CB alone. We will also assess whether the interventions result in better psychosocial functioning during treatment and follow-up. Patient characteristics that may be associated with outcomes will be evaluated, and a cost-effectiveness evaluation of the interventions also will be conducted. ? ?
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