First-Line Treatment for Gambling Disorder
Cognitive Behavioral Therapy (CBT) is the first-line treatment for gambling disorder, with the strongest evidence base for reducing gambling behavior and improving quality of life. 1
Primary Treatment Recommendation
- CBT should be the initial treatment approach, specifically targeting gambling-specific cognitive distortions through individual, group, or imaginal desensitization formats 1
- The mechanism of action involves improving coping skills, which mediates reductions in gambling behavior, with larger improvements in coping strategies directly correlating with decreased gambling at 2-month follow-up 2
- CBT demonstrates efficacy in reducing gambling symptoms, depression, anxiety, cognitive distortions, and improving quality of life 3, 4
Enhancing CBT Effectiveness
Motivational Interviewing (MI) should be combined with CBT, particularly for patients who are ambivalent about change 1. However, the choice between CBT and MI may depend on comorbidities:
- Screen for risky alcohol use with the AUDIT before treatment selection 5
- Patients with gambling disorder AND risky alcohol habits benefit more from MI 5
- Patients without risky alcohol habits respond better to cognitive behavioral group therapy (CBGT) 5
Treatment Delivery Formats
- Internet-delivered CBT with therapist guidance via telephone is effective, with 80% treatment retention and elimination of clinical gambling symptoms post-treatment 3
- Both internet-delivered CBT and motivational enhancement with telephone support showed equivalent efficacy, suggesting low-intensity interventions can reach more patients cost-effectively 3
- Manual-supported CBT or CBT combined with Mindfulness or Gamblers Anonymous sessions produces better long-term results 4
Critical Treatment Framework
Pharmacotherapy should always be delivered as an adjunct to behavioral treatment, never as monotherapy 1. Naltrexone has the strongest pharmacological evidence for reducing gambling urges when combined with structured CBT 1.
Essential Clinical Considerations
- Address comorbidities systematically, as 75% of treatment-seeking patients have one or more comorbid conditions including ADHD, impulse control disorders, depression, anxiety, and substance use disorders 6, 1
- The largest reduction in gambling symptoms often occurs between initial assessment and treatment baseline, suggesting that low-intensity interventions and the assessment process itself may initiate change 3
- Some symptom deterioration may occur between post-treatment and 6-month follow-up, indicating the need for maintenance strategies 3
Common Pitfalls to Avoid
- Do not offer pharmacotherapy alone without structured behavioral treatment, as outcomes are suboptimal 1
- Do not ignore alcohol screening, as it significantly impacts treatment selection and outcomes 5
- Do not overlook the high rate of undetected comorbid mental health conditions that require concurrent treatment 6