What are the first-line and best evidence treatments for gambling disorder in psychiatry?

First-Line and Best Evidence Treatments for Gambling Disorder

Cognitive Behavioral Therapy (CBT) combined with Motivational Interviewing (MI) represents the first-line psychological treatment for gambling disorder, with naltrexone as the primary evidence-based pharmacological option for reducing gambling urges and behavior. 1

Psychological Interventions (First-Line)

Cognitive Behavioral Therapy (CBT)

CBT has the strongest evidence base accumulated over 20 years and should be the initial treatment approach. 1 The therapy has demonstrated effectiveness across multiple delivery formats:

• Individual cognitive therapy targeting gambling-specific cognitive distortions (erroneous beliefs about probability, illusions of control, superstitious thinking) 1, 2
• Group CBT for peer support and shared learning 1
• Imaginal desensitization to address urges triggered by gambling cues 1, 2
• Brief interventions using bibliotherapy for less severe cases 1

The key innovation specific to gambling treatment is cognitive restructuring to address distortions about randomness, probability, and control. 2 These cognitive distortions are unique to gambling disorder and must be directly targeted, unlike traditional addiction treatments. 2

Motivational Interviewing (MI)

MI should be combined with CBT, particularly for patients ambivalent about change or not actively seeking treatment. 1, 3 This approach reduces barriers to engagement and can reach at-risk and problem gamblers before they develop severe disorder. 3

Exposure-Based Techniques

In vivo exposure and imaginal desensitization represent gambling-specific additions to standard addiction treatment. 2 These techniques help patients manage urges prompted by gambling-related cues in real-world settings. 2

Pharmacological Interventions

Opioid Antagonists (Primary Pharmacotherapy)

Naltrexone is the medication with the strongest evidence from double-blind, placebo-controlled studies for reducing gambling urges and behavior. 1, 4, 5

• Nalmefene also shows promising results as an alternative opioid antagonist 5
• These medications target the reward pathways (striatum) implicated in gambling disorder 1

Important caveat: Despite promising results, efficacy has varied across studies, and high placebo response rates complicate interpretation. 5 No medication is FDA-approved specifically for gambling disorder. 5

Other Pharmacological Options (Limited Evidence)

The following have been studied but lack the evidence strength of naltrexone:

• Glutamatergic agents (N-acetylcysteine, acamprosate, memantine) 5
• SSRIs (fluvoxamine, paroxetine, sertraline) - results inconsistent 5
• Mood stabilizers (topiramate, carbamazepine, lithium) 5

Treatment Sequencing and Integration

Pharmacotherapy should always be delivered as an adjunct to behavioral treatment, not as monotherapy. 1 The evidence shows:

• Structured CBT added to pharmacotherapy improves plateaued responses 1
• Nearly 50% abstinence rates when combining rTMS with nicotine replacement (extrapolated from smoking cessation, relevant to behavioral addictions) 1
• Behavioral modification framework is critical for sustained recovery 1

Common pitfall: Treating gambling disorder with medication alone without addressing cognitive distortions and behavioral patterns leads to poor outcomes. 1, 2

Self-Directed and Brief Interventions

Self-help interventions with therapist support (in-person or telephone) represent an important option for reducing treatment barriers. 3 These approaches:

• Reach gamblers not seeking formal treatment 3
• Show improved outcomes when minimal therapist contact is added 3
• Are particularly useful for at-risk and problem gamblers before severe disorder develops 3

Peer support programs (e.g., Gamblers Anonymous) are optimal when combined with professional treatment, though engagement and retention remain challenging. 3

Emerging and Adjunctive Approaches

While not yet first-line, the following show promise as adjuncts:

• Third-wave CBT interventions (mindfulness, acceptance-based approaches) 1
• Neurocognitive interventions targeting executive functioning deficits 1, 6
• Cognitive remediation to address impulsive, reflective, and interoceptive process abnormalities 6
• Non-invasive neuromodulation (rTMS, tDCS) to enhance DLPFC functioning and cognitive control 1

Critical limitation: Cognitive remediation has virtually no clinical studies in gambling disorder populations despite theoretical promise. 6 The single exception is the Playmancer serious videogame, tested in bulimia nervosa and gambling disorder. 6

Key Clinical Considerations

Address comorbidities systematically: Gambling disorder frequently co-occurs with ADHD, impulse control problems, compulsive symptoms, and substance use disorders. 1 These must be identified and treated concurrently.

Treatment duration and sequencing remain unclear: There are virtually no data on optimal therapy duration for individual patients or how treatments should be sequenced. 1 This represents a significant gap requiring clinical judgment based on response.

High dropout and relapse rates with CBT alone: 6 This may reflect resistance to changing core neurocognitive characteristics (executive functioning, attention, emotional regulation). 6 Consider adding cognitive remediation or pharmacotherapy for patients showing poor CBT response.

Parkinson's disease patients on dopaminergic medications: Be vigilant for gambling disorder development in this population, as there is evidence of comorbid overlap. 1 This has implications for understanding dopamine's role in gambling disorder generally. 1