Psychological and psychosocial treatment of harmful gambling: Gambling-related harms: identification, assessment and management: Evidence review F

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ISBN-13: 978-1-4731-6806-0 Copyright and Permissions Copyright © NICE 2025. For more information, see the Bookshelf Copyright Notice . Psychological and psychosocial treatment of harmful gambling Review question What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? Introduction A number of approaches are currently used to reduce the severity and frequency of gambling, with the aim of reducing the harms that gambling causes. These range from self-help interventions and peer support groups to higher intensity pharmacological and psychological treatments within specialist gambling treatment settings. Several approaches may also be combined with the aim of improving outcomes. However, the relative effectiveness of these approaches is not known. The aim of this review is to determine the effectiveness and cost-effectiveness of different psychological and psychosocial treatments for people experiencing gambling-related harms. Summary of the protocol See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review. Table 1 Summary of the protocol (PICO table). For further details see the review protocol in appendix A . Methods and process This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual . Methods specific to this review question are described in the review protocol in appendix A , and methods specific to the NMA are summarised below and described in appendix L and in the methods document (Supplement 1: methods). Declarations of interest were recorded according to NICE’s conflicts of interest policy . Summary of methods Evidence synthesis Network meta-analysis (NMA) was the main method used to synthesise evidence on psychological and psychosocial interventions included in this review. NMA was employed to assess the following outcomes: Gambling symptom severity, reported in the included studies either as a score on a continuous severity scale or as the average number of diagnostic criteria met, and expressed as standardised mean difference (SMD) of gambling symptom change scores from baseline to treatment endpoint Gambling frequency The main (base-case) analyses for both gambling symptom severity and gambling frequency utilised intention-to-treat (ITT) data. In studies where ITT data were not available or possible to estimate, the NMA included imputed ITT data using completer case (CC) data and using the baseline observation carried forward (BOCF) method for imputation. Pairwise meta-analysis was undertaken to assess the following outcomes: Follow-up data on gambling symptom severity and frequency of gambling sessions Time spent gambling, gambling expenditure, and psychological wellbeing Personal, social, and life functioning Physical and mental health related quality of life Analysis for the outcomes of recovery capital and adverse events was also planned but no data for these outcomes were located. Class models Due to the large number of interventions included in this review, comparing all pairs of interventions individually within the NMA (and also in the pairwise meta-analysis) would require multiple comparisons and complex consideration and interpretation of the evidence. Moreover, some interventions included in the systematic review had been tested on small numbers of participants and their effects were characterised by considerable uncertainty. For these reasons, the NMAs utilised class models. Psychological therapies were grouped according to common theoretical structure and methodological approach, using relevant information extracted from the included studies. Interventions within a class were expected to have similar (but not necessarily identical) effects. The final grouping of interventions into classes was approved by the committee. Following appropriate tests of fit, fixed class effect models were used for both outcomes examined in the NMA, which assume that all interventions in a class share the class effect, due to lack of adequate data to allow estimation of individual intervention effects within each class. Bias adjustment NMA models and other sensitivity analysis As the NMAs included a significant number of small studies, a bias-adjusted analysis was carried out on each outcome (gambling symptom severity and gambling frequency), which adjusted for bias associated with small study size effects by including a covariate effect for 1/N for active vs control comparisons, where N is the sample size. The analysis was based on the assumption that the smaller the study the greater the bias. The analysis assumed possible bias in comparisons of active interventions versus inactive control; no bias was assumed between inactive control comparisons, and also no bias was assumed between active intervention comparisons. Moreover, analyses adjusting for potential bias associated with the source of funding were undertaken for the outcomes of gambling symptom severity and gambling frequency, by including a covariate effect if a study reported receiving industry funding or if industry funding was unclear, assuming bias favouring the active interventions versus inactive controls for trials with industry and unclear funding; no bias was assumed between inactive control comparisons, and also no bias was assumed between active intervention comparisons. In addition, a sensitivity analysis was conducted including only studies classified as not receiving industry funding. Finally, as the main (base-case) analyses for both gambling symptom severity and gambling frequency were conducted for the full dataset, including ITT data where available and imputed ITT data from studies reporting CC data using the BOCF method for imputation, sensitivity analysis were run using the following subsets of the full dataset: Studies reporting ITT only Studies reporting CC only (without imputation) Presentation of the NMA results For both outcomes (gambling symptom severity and gambling frequency), results of the NMAs are presented as the posterior mean SMD of change scores, with 95% Credible Intervals (CrI), for each treatment class compared with no treatment, which was selected as the reference treatment as it is considered to represent standard of care for the majority of people experiencing gambling-related harms in England. Results are provided for the base-case analysis of the full dataset as well as for sensitivity analyses. Results of bias-adjusted analyses are not presented, as the bias models did not indicate statistical evidence of bias associated with small study size or source of funding. Detailed methods and results of the NMA are provided in appendix L and supplement 4: NMA data and results. Presentation of the pairwise comparisons results For pairwise comparisons, meta-analyses using random-effects models were conducted to combine results from similar studies. An ITT approach was taken where possible. Continuous outcomes were assessed using SMD and dichotomous outcomes using relative risk (RR) (see the methods document - supplement 1: methods). Effectiveness evidence Included studies Forty-eight studies reported in 51 papers were included analysis for this review, 1 reporting a non-randomised controlled trial ( Zhuang 2018 ), and 50 papers reporting randomised controlled trials (RCTs: Abbott 2012 and Abbott 2018 , Armstrong 2020 , Bouchard 2017 , Boudreault 2018 , Bucker 2018 , Bucker 2021 , Campos 2016 , Carlbring 2008 , Cunningham 2019 , Cunningham 2012 , Cunningham 2009 , Diskin 2009 , Dowling 2007 , Dowling 2021 , Ede 2020 , Grant 2009 , Hodgins 2001 and Hodgins 2004 , Hodgins 2019 , Hodgins 2009 , Jonas 2020 , Korman 2008 , LaBrie 2012 , Ladouceur 2001 , Ladouceur 2003 , Larimer 2012 , Lee 2015 , Luquiens 2016 , Marceaux 2011 , Martens 2015 , McIntosh 2016 , Milton 2002 , Myrseth 2009 , Myrseth 2011 , Neighbors 2015 , Nilsson 2019 , Oei 2018 , Petry 2006 , Petry 2016 , Petry 2008 , Petry 2009 , Rodda 2018 , Smith 2015 , So 2020 , Thomas 2017 , Toneatto 2009 , Toneatto 2016 , Wittekind 2019 , and Wong 2015 ). Thirteen papers reported studies conducted in the USA ( Armstrong 2000 , Campos 2016 , Cunningham 2019 , Grant 2009 , LaBrie 2012 , Larimer 2012 , Marceaux 2011 , Martens 2015 , Neighbors 2015 , Petry 2006 , Petry 2016 , Petry 2008 , Petry 2009 ), 15 reported studies conducted in Canada ( Bouchard 2017 , Boudreault 2018 , Cunningham 2012 , Cunningham 2019 , Diskin 2009 , Hodgins 2001 , Hodgins 2004 , Hodgins 2019 , Hodgins 2009 , Korman 2008 , Ladouceur 2003 , Ladouceur 2001 , Lee 2015 , Toneatto 2009 and Toneatto 2016 ), 7 reported studies conducted in Australia ( Dowling 2007 , Dowling 2021 , McIntosh 2016 , Milton 2002 , Oei 2018 , Rodda 2018 , Smith 2015 ), 4 in Germany ( Bucker 2018 , Bucker 2021 , Jonas 2020 , Wittekind 2019 ), 2 reported studies conducted in Sweden ( Carlbring 2008 , Nilsson 2019 ), 2 reported studies conducted in Norway ( Myrseth 2009 , Myrseth 2011 ), 2 reported studies conducted in New Zealand ( Abbott 2012 and Abbott 2018 ), 1 reported a study conducted in Nigeria ( Ede 2020 ), 1 reported a study conducted in France ( Luquiens 2016 ), 1 reported a study conducted in Japan ( So 2020 ), and 2 reported studies conducted in Hong Kong ( Wong 2015 and Zhuang 2018 ). Four studies compared self-help interventions with guided self-help interventions ( Dowling 2021 , Hodgins 2001 , Hodgins 2004 and Hodgins 2019 ), while Hodgins 2001 and Hodgins 2004 also included a waitlist control and Hodgins 2019 another self-help and waitlist control group. Four studies compared self-help interventions with other self-help interventions with no or minimal support ( Cunningham 2012 , LaBrie 2012 , Luquiens 2016 and Martens 2015 ), while LaBrie 2012 and Cunningham 2012 also included a waitlist control group, Martens 2015 a no treatment group, and Luquiens 2016 a guided self-help group and waitlist control group. Four studies compared self-help interventions with a waitlist control ( Bucker 2018 , Bucker 2021 , Cunningham 2009 and Oei 2018 ). Three studies compared self-help interventions with an attention placebo ( Armstrong 2020 , Neighbors 2015 , Wittekind 2019 ) and 3 studies compared self-help interventions with no treatment or treatment as usual ( Cunningham 2019 , So 2020 and Rodda 2018 ). Seventeen studies reported in 18 papers compared individual CBT treatment with other treatments. Some studies included more than one comparison ( Thomas 2017 , Toneatto 2009 , Toneatto 2016 ). The comparisons included: other individual CBT treatment ( Bouchard 2017 , McIntosh 2016 and Milton 2002 ), group CBT and a waitlist control ( Dowling 2007 ) self-help ( Petry 2006 and Petry 2016 ), motivational interviewing, self-help and no treatment ( Petry 2008 and Petry 2009 ) individual behavioural therapy ( Smith 2015 , Thomas 2017 , Toneatto 2009 and Toneatto 2016 ) motivational interviewing and counselling ( Thomas 2017 ), motivational interviewing ( Toneatto 2009 and Toneatto 2016 ) a pharmacological intervention ( Myrseth 2011 ) the twelve-step programme ( Marceaux 2011 ) individual behavioural therapies ( Korman 2008 ) treatment as usual ( Grant 2009 ) a waitlist control group ( Ladouceur 2003 and Ladouceur 2001 ). Five studies compared guided self-help to other treatments. One compared to individual CBT treatment ( Boudreault 2018 ), 1 to a waitlist control ( Carlbring 2008 ), and 3 to guided self-help ( Hodgins 2009 , Jonas 2020 and Nilsson 2019 ), while Jonas 2020 also included a waitlist control group. Three studies compared group CBT treatment to a waitlist control ( Ede 2020 , Ladouceur 2003 and Myrseth 2009 ), 1 study compared group CBT combined with treatment as usual to treatment as usual ( Wong 2015 ) and 1 study compared group CBT treatment to an attention placebo (Zhuang 2019). One study compared motivational interviewing to guided self-help and treatment as usual ( Abbott 2012 / 2018 ), 1 study compared motivational interviewing to an attention placebo ( Diskin 2009 ) and 1 study compared motivational interviewing to group CBT ( Larimer 2012 ). Data for the following outcomes were identified through analysis of the included studies: gambling symptom severity frequency of gambling sessions time spent gambling gambling expenditure psychological wellbeing personal, social and life functioning physical and mental health related quality of life The included studies are summarised in Table 2 . See the literature search strategy in appendix B and study selection flow chart in appendix C . Excluded studies Studies not included in this review are listed, and reasons for their exclusion are provided in appendix J . Summary of included studies Summaries of the studies that were included in this review are presented in Table 2 . Table 2 Summary of included studies. See the full evidence tables in appendix D and the forest plots in appendix E . Summary of the evidence from the network meta-analysis The numbers of people tested on each treatment class and intervention (including relevant comparators) for each of the two outcomes (gambling symptom severity and gambling frequency) are shown in Table 3 . Psychological therapies were grouped according to common theoretical structure and methodological approach. For each outcome, we first present the evidence network plot and results (relative effects of each treatment versus no treatment) both in a forest-like plot and in tabulated form of the base-case analysis (full dataset). These are followed by the results of sensitivity analyses conducted using ITT data, CC data, and non-industry funded data. Bias-adjusted models did not show statistical evidence of bias due to small study size or source of funding, and therefore respective results of those analyses are not shown. In each network plot presented below, the width of lines is proportional to the number of trials that make each direct comparison; the size of each circle (treatment node) is proportional to the number of participants tested on each treatment class. Full results of the NMA including relative effects of all pairs of treatments for the full dataset and sensitivity analyses are reported in appendix L and supplement 4: NMA data and results. Table 3 Treatment classes, interventions and numbers of participants tested on each in the NMAs of gambling symptom severity and 1 gambling frequency in adults experiencing harmful gambling. Gambling symptom severity Base-case analysis (full dataset) The network plot at the treatment class level for the base-case analysis is shown in Figure 1 . The base-case relative effects (posterior mean SMD with 95% CrI) of all treatment classes versus no treatment (reference treatment) are illustrated in Figure 2 (forest plot) and reported in Table 4 . Treatment classes in the table have been ordered by effectiveness, based on their mean rankings in the NMA iterations. Figure 1 Gambling symptom severity network plot – full dataset containing 39 RCTs, 95 treatment arms, 14 treatment classes and 40 interventions, 4,996 participants. Figure 2 Gambling symptom severity forest plot – full dataset. Table 4 Gambling symptom severity results – full dataset: posterior standardised mean difference (SMD) of all treatments versus no treatment. Sensitivity analyses Table 5 shows the network plots and the NMA results of the base-case and all sensitivity analyses for the outcome of gambling symptom severity. Table 5 Gambling symptom severity - base-case and sensitivity analyses: network plots and results, all treatments versus no treatment. Gambling frequency Base-case analysis (full dataset) The network plot at the treatment class level for the base-case analysis is shown in Figure 3 . The base-case relative effects (posterior mean SMD with 95% CrI) of all treatment classes versus no treatment (reference treatment) are illustrated in Figure 4 (forest plot) and reported in CBT: cognitive behavioural therapy; TAU: treatment as usual Table 6 . Treatment classes in the table have been ordered by effectiveness, based on their mean rankings in the NMA iterations. Figure 3 Gambling frequency network plot – full dataset containing 62 treatment arms, 11 treatment classes and 25 interventions, 4,102 participants. Figure 4 Gambling frequency forest plot – full dataset. Standardised mean difference versus no treatment (N=592). Vertical axis shows effect of no treatment. Values on the left side of the vertical axis indicate better effect compared with no treatment. (more...) Table 6 Gambling frequency results – full dataset: posterior standardised mean difference (SMD) of all treatments versus no treatment. Sensitivity analyses Table 7 shows the network plots and the NMA results of the base-case and all sensitivity analyses for the outcome of gambling frequency. Table 7 Gambling frequency – base-case and sensitivity analyses: network plots and results, all treatments versus no treatment. Quality assessment of the NMA Threshold analysis was undertaken to test the robustness of treatment recommendations based on the NMA of gambling symptom severity, to potential biases or sampling variation in the included evidence. Full methods and results of threshold analysis are presented in appendix M . Summary of the evidence from the pairwise comparisons Across all the comparisons in the pairwise analysis, the majority showed no clinically important difference between the interventions compared (for example motivational interviewing versus individual counselling, self-help versus attention placebo, behavioural therapies versus motivational interviewing, and behavioural therapies versus individual counselling). These comparisons typically included only one study and often had serious to very serious imprecise findings. Exceptions were group CBT versus waitlist and behavioural therapies versus individual CBT where the interventions had an important benefit compared with the controls, in terms of gambling symptom severity. Important benefits were also shown for self-help (with no or minimal support) compared with no treatment in terms of gambling frequency. Important benefits were also shown for self-help versus waitlist, and group CBT plus treatment as usual compared with attention placebo in terms of abstinence and remission and money spent gambling respectively. Important benefits were also shown for expenditure. For example, self-help (with no or minimal support) versus waitlist, self-help (with no or minimal support) versus no treatment, guided self-help versus self-help (with no or minimal support), guided self-help versus waitlist, individual CBT versus waitlist, group CBT plus treatment as usual versus attention placebo, and behavioural therapies versus individual CBT where the intervention showed an important benefit over the comparator in terms of money spent gambling. Important benefits were also shown for gambling frequency. For example self-help (with no or minimal support) versus waitlist where the intervention showed important benefits. Important benefits were also shown for time spent gambling for group CBT plus treatment as usual versus attention placebo showed important benefits for the intervention. Important benefits were also shown for other non-gambling outcomes. For example, individual CBT versus treatment as usual showed important differences for the intervention in terms of depression and anxiety symptoms, functional impairment and quality of life. Group CBT plus treatment as usual versus attention placebo, and self-help (with no or minimal support) versus waitlist showed important differences for the intervention in terms of depression and anxiety symptoms and psychological distress. Guided self-help versus waitlist also showed important difference for the intervention in terms of depression and anxiety symptoms and quality of life. Typically, the comparisons where no difference between interventions were found included only one study and had serious to very serious imprecise findings, therefore they should not be taken as definitive evidence of no difference between the interventions. The overall quality of the outcomes for the pairwise comparisons ranged from very low to low. There was no evidence identified for the following interventions: trauma informed interventions, neurological and brain stimulation interventions and residential treatment. There was no evidence identified for the following outcomes recovery capital, and adverse life events, such as suicide, self-harm, or unplanned acute mental health hospital admission. See appendix F for full GRADE tables. Economic evidence Included studies A single economic search was undertaken for all topics included in the scope of this guideline. One economic study was identified which was relevant to this question ( Bellringer 2021 ). Moreover, three studies reporting utility data were included in the review, and these are described in Appendix I (Economic model), in the respective ‘Utility data’ section. See the literature search strategy in appendix B and economic study selection flow chart in appendix G . Excluded studies Economic studies not included in this review are listed, and reasons for their exclusion are provided in appendix J . Summary of included economic evidence See Table 8 for the economic evidence profile of the included study and of the economic analysis conducted for this guideline. Table 8 Economic evidence profile for psychological and psychosocial interventions for gambling-related harms. Economic model A decision-analytic model was developed to assess the relative cost effectiveness of psychological and psychosocial treatments for adults experiencing gambling-related harms. The objective of economic modelling, the methodology adopted, the results and the conclusions from this economic analysis are described in detail in appendix I . This section provides a summary of the methods employed and the results of the economic analysis. Overview of economic modelling methods A hybrid decision-analytic model consisting of a decision-tree followed by a three-state Markov model was constructed to evaluate the relative cost effectiveness of a number of psychological and psychosocial treatments for adults experiencing gambling-related harms. The time horizon of the analysis was 3 months of treatment (decision-tree) plus 2 years of follow-up (Markov model). The treatments assessed were determined by the availability of efficacy data obtained from the NMA that was conducted to inform this guideline. The economic analysis included only treatments with a higher mean effect on gambling symptom severity compared with no treatment. The following treatments were assessed: Individual cognitive behavioural therapy (CBT) Individual behavioural therapy Individual counselling Group CBT Motivational interviewing Guided self-help No treatment, which served as the reference treatment, and currently represents standard care for the majority of adults experiencing gambling-related harms in England. The model structure considered the health states of problem gambling (reflected in a PGSI score of 8 or above), no problem gambling, which consisted of the states of moderate risk of problem gambling (PGSI score of 3-7), low risk of problem gambling (PGSI score of 1-2) and no risk of problem gambling (PGSI score of 0), and death (due to suicide or other reasons). Efficacy data were derived from the guideline systematic review and NMA on gambling symptom severity. Other clinical inputs were estimated from longitudinal studies. The measure of outcome of the economic analysis was the number of QALYs gained. In a scenario analysis, lifetime QALY losses due to completed suicide were also considered. Utility data were derived from a systematic review of the literature. The analysis adopted two different perspectives: the NHS/PSS (personal social services) and a wider, public sector perspective. Intervention resource use was based on RCTs that informed the NMA, modified to reflect optimal routine delivery of the assessed interventions in the UK. Costs associated with problem gambling were taken from 2 recently published reports, and were considered in 2 separate analyses, respectively, to avoid possible double counting, as the reports estimated costs in overlapping areas. National UK unit costs were used. The cost year was 2022. Model input parameters were synthesised in a probabilistic analysis. This approach allowed more comprehensive consideration of the uncertainty characterising the input parameters and captured the non-linearity characterising the economic model structure. A number of one-way deterministic sensitivity analyses was also carried out. Overview of economic modelling results and conclusions Group CBT was the most cost-effective treatment and more cost-effective than no treatment under almost all perspectives, cost sets used, sensitivity and scenario analyses, with, a high probability of being the most cost-effective option that exceeded 0.60 under all perspectives and cost sets used. Motivational interviewing was the second most cost-effective treatment, following group CBT, and more cost-effective than no treatment in the majority of analyses. This result was sensitive to the initial PGSI score and the perspective and magnitude of the costs associated with gambling-related harms: a higher gambling symptom severity, represented by higher PGSI scores, and lower costs associated with gambling-related harms led to motivational interviewing becoming less cost-effective than no treatment. The other individual high intensity treatments (individual CBT, individual behavioural therapy, counselling) were less cost-effective than no treatment in all scenarios tested under a NHS/PSS perspective, apparently because their clinical effectiveness and the associated cost-savings resulting from a reduction in gambling symptom severity were not high enough to offset their higher intervention costs compared with other treatment options. However, they were more cost-effective than no treatment in several analyses conducted under a public sector perspective, which accounted for higher cost-savings to the public sector resulting from provision of these treatments that were adequate to offset their intervention costs. Guided self-help was not cost-effective relative to no treatment under any analysis (probabilistic or deterministic). Economic evidence statements Evidence from one study from New Zealand conducted alongside a RCT (N=227) suggested no differences in costs or outcomes between face-to-face low intensity combined cognitive behaviour + cue exposure therapy and face-to-face motivational interviewing combined with a self-help workbook and follow-up telephone booster sessions for adults experiencing gambling-related harms. The study is partially applicable to the UK and is characterised by potentially serious limitations. Evidence from the economic analysis conducted for this guideline indicated that group CBT was cost-effective versus no treatment and the most cost-effective treatment option among those assessed for adults experiencing gambling-related harms, followed by motivational interviewing. Individual behavioural therapy, individual CBT and counselling were likely to be cost-effective versus no treatment when a wider, public sector perspective was considered, especially considering that the public sector cost estimates utilised in the economic model conducted for this guideline were likely to be an underestimate of the true costs associated with gambling-related harms. Guided self-help was not cost-effective versus no treatment under any scenario tested. The study is directly applicable to the UK and is characterised by minor limitations, as results were robust under most alternative scenarios explored, despite the uncertainty characterising a number of input parameters. The committee’s discussion and interpretation of the evidence The outcomes that matter most Gambling symptom severity, frequency of gambling, time spent gambling, gambling expenditure, recovery capital, psychological wellbeing, and personal, social and life functioning, were prioritised by the committee as critical outcomes because changes in these would most accurately capture the clinical effectiveness of psychological and psychosocial interventions for gambling. The committee also discussed that the shame and distress caused by gambling often prevents people from seeking help when they experience it and can lead to a variety of adverse events such as self-harm and suicide or mental health crises, and so this was also included as a critical outcome. Physical and mental health related quality of life was also identified as an important outcome by the committee because people who gamble less or abstain from gambling are likely to have an improved quality of life, compared to people who gamble more frequently. The quality of the evidence NMA The quality of the individual studies included in the NMAs ranged from very low to low, mainly due to risk of bias stemming from lack of blinding, poor reporting of randomisation procedures, or high attrition rates. This impacted on the quality of the NMAs. The two NMAs on gambling symptom severity and gambling frequency allowed estimation of relative effects between all pairs of treatments for people experiencing harmful gambling, via direct and indirect comparisons, using available RCT evidence, without breaking the rules of randomisation. Due to the large number of interventions, class effects models were fitted. Following appropriate tests of fit, fixed class effect models were used for both outcomes examined in the NMA, which assume that all interventions in a class share the class effect, due to lack of adequate data to allow estimation of individual intervention effects within each class. For both outcomes, inconsistency between direct and indirect evidence was found only in the comparison between individual CBT versus waitlist: one study showed very strong effects for individual CBT versus waitlist, which were at odds with the rest of the studies included in the NMA, especially for the gambling frequency outcome. Heterogeneity was found to be moderate-to-high for gambling symptom severity (lower for the ITT analysis) and very low for gambling frequency (slightly higher for the ITT analysis). The committee attributed the moderate-to-high heterogeneity identified for gambling symptom severity to construct differences across gambling symptom scales and between gambling symptom scales and DSM criteria, which were synthesised in the analysis; in contrast, gambling frequency, which was straightforward to measure using very similar methods across studies, was characterised by very low heterogeneity. Bias adjustment analyses testing for bias resulting from small study size and bias associated with funding source (any industry / unclear funding) showed no statistical evidence of such bias. However, it is still possible that such bias exists, as the comparisons on which such bias could be tested were limited. Effects for a number of treatments included in the NMA (12 step group programme, couple interventions and SSRIs) were informed by very limited evidence on gambling symptom severity (each was tested on 15 people or fewer) and were characterised by particularly high uncertainty, whereas no evidence was identified on gambling frequency. These treatments were therefore not considered when formulating recommendations. Threshold analysis on the gambling symptom severity outcome ( appendix M ) suggested that conclusions of the NMA, which directly informed recommendations, were robust to potential changes in the evidence. Therefore, the committee was confident in the recommendations they made based on the NMA evidence. The committee noted the above information around the strengths and limitations of the NMAs when interpreting the results. They agreed to make strong recommendations where the clinical evidence was robust, as it was also supported by economic evidence and the committee’s clinical experience. They also decided to make weaker (‘consider’) recommendations on treatments that were supported by less robust evidence. Pairwise meta-analysis The quality of the evidence for quantitative outcomes assessed in pairwise meta-analysis was assessed with GRADE methodology and the overall confidence in the findings ranged from very low to low. Findings were downgraded due to risk of bias stemming from lack of blinding, poor reporting of randomisation procedures, or high rates of attrition from the study. Studies were also downgraded for imprecision when 95% confidence intervals crossed 1 or more decision-making thresholds. Some evidence was downgraded for inconsistency as heterogeneity could not be explained as no subgroup analysis was performed as per protocol. Evidence was not downgraded for indirectness. See appendix F for full GRADE tables with quality ratings of all outcomes. Benefits and harms Network meta-analysis The committee discussed the results of the NMAs on gambling symptom severity and gambling frequency. Results were interpreted in terms of ‘evidence of effect’, which was determined by 95% credible intervals (CrI) not crossing the line of no effect. The committee compared the results of the NMA base-case analyses, which used the full study dataset, and the results of sensitivity analyses, each of which was informed by more limited evidence. They agreed that results of the sensitivity analyses were overall consistent with those of the base-case analyses and decided to focus on the base-case results in order to make recommendations. The committee noted that, for the gambling symptom severity outcome, all active treatment classes except pure self-help showed evidence of benefit compared to no treatment, although for most treatment classes results were characterised by uncertainty as indicated by 95%CrI that crossed the line of no effect; moreover, all active treatment classes ranked in a higher position than treatment as usual (TAU) and waiting list. Waiting list showed evidence of leading to increased symptom severity compared with no treatment, with 95%CrI not crossing the line of no effect. For the gambling frequency outcome, the committee noted that all active treatment classes showed a benefit compared to no treatment, with evidence of efficacy (the 95%CrI that did not cross the line of no effect) for most treatment classes. Waiting list had practically the same effect as no treatment. However, all active treatment classes showed similar to lower effects compared to TAU. The committee’s interpretation of the results on gambling frequency was that any intervention (including TAU, which was described as ‘information and referral to face-to-face problem gambling counselling services or other services and websites and/or suggestions for self-care’ in the single TAU arm included in the gambling frequency NMA) reduces gambling frequency compared with no treatment, but all treatment classes have a similar effect, and it is not possible to differentiate from one another. The committee expressed the view that gambling frequency is only one aspect of gambling symptom severity, which may explain the low heterogeneity of this analysis. They noted the more limited evidence base for every treatment in the NMA of gambling frequency compared with the NMA of gambling symptom severity and decided to consider mainly the results on symptom severity when formulating recommendations. The committee noted that the results of the NMA base-case analysis on gambling symptom severity, which utilised the full study dataset, suggested that group CBT had the highest effect among all treatment classes, and was the only treatment class that showed evidence of effect compared with no treatment. This was followed by individual CBT, the 95% CrI of which only marginally crossed the line of no effect compared with no treatment. Based on these findings, which were supported by their own clinical experience, the committee decided to make a strong (‘offer’) recommendation for group CBT, and, where the person did not wish to join a group, or group therapy was not possible (for example, there were no other people available to form a suitable group) or was considered as not suitable for the person, individual CBT was recommended instead. The recommendation for offering individual CBT as an alternative treatment was further supported by the evidence of a negative effect for waiting list compared with no treatment in the NMA of gambling symptom severity, which suggested that people experiencing gambling that harms presenting to services should receive effective treatment rather than be placed on a waiting list. According to the committee’s expert advice, CBT needs to be offered by practitioners with gambling-specific training and competence, who can help to address the fact that people sometimes experience CBT as being stigmatising, and this was reflected in the related recommendations on the delivery of CBT. For group CBT it was agreed that it should be ideally delivered by 2 practitioners, at least 1 of whom should have appropriate gambling-specific training and competence. The committee looked at the evidence and considered their own experience and noted that currently CBT that showed important benefits was delivered using an evidence-based treatment protocol and included a relapse prevention component, and captured this information in recommendations. They also recommended the number of sessions for group and individual CBT based on the number of sessions that had been delivered in the evidence that had shown benefit, but acknowledged that in some cases more sessions might be needed or fewer sessions might be sufficient). The committee noted that individual behavioural therapy had similar effects with individual CBT in reducing gambling symptom severity, albeit with higher uncertainty (as indicated by 95% CrI that crossed the line of no effect) and a somewhat smaller evidence base. However, they noted that pure behavioural therapy is lacking the cognitive element that is part of CBT and that direct work on cognition, enabled with CBT (but not with behavioural therapy), is preferable, as cognitive errors are a maintaining factor in gambling disorder. Ultimately, they expressed the view that therapy for adults experiencing gambling that harms needs to include a cognitive element, which pure behavioural therapy is lacking, and therefore they decided not to recommend behavioural therapy. The committee did not wish to make a recommendation for counselling, as its effects in reducing gambling symptom severity were lower than other high intensity interventions, were characterised by high uncertainty and were based on more limited evidence. The committee discussed that motivational interviewing had beneficial effects on gambling symptom severity versus no treatment, that were lower than those of all other high intensity treatments and were also characterised by uncertainty. However, in the committee’s experience, the dynamic nature of motivational interviewing often encourages people to seek treatment when they initially feel ambivalent towards it. The committee also advised that motivational interviewing is the only approach that is appropriate to use in people undecided as to whether they want to reduce their gambling harms. They noted that some of the CBT interventions tested in the RCTs included in the NMA included an initial session of motivational interviewing. Based on the available evidence and their clinical considerations, they decided to make a weaker (‘consider’) recommendation for motivational interviewing, in order to strengthen people’s confidence and commitment to change, or encourage people who are unsure or have reservations about starting treatment for gambling that harms, but did not consider, based on the available evidence and their experience, that it would lead to the level of behavioural change required to treat gambling that harms as a standalone intervention. Pairwise meta-analysis The evidence for the outcomes of time spent gambling, gambling expenditure, psychological wellbeing, personal, social and life functioning, and physical and mental health related quality of life, and follow-up outcomes of gambling symptoms severity and frequency of gambling were presented as pairwise analyses. The committee reviewed the outcomes where clinically important and statistically significant difference has been identified but noted that the results were all from single studies, and more than half of the studies had fewer than 100 participants. In terms of money spent gambling there was some evidence of benefits for guided self-help compared to self-help, self-help compared to waitlist, guided self-help compared to waitlist, individual CBT compared to waitlist, group CBT plus treatment as usual compared to attention placebo, and behavioural therapy when compared to individual CBT. For time spent gambling there was some evidence of benefits for self-help compared to waitlist, and group CBT plus treatment as usual compared to attention placebo. The committee agreed that these interventions were successful in treating gambling that harms but that the limited evidence was not sufficient to use as a basis for a recommendation on its own. That said, the committee did note that there may be benefits in terms of money spent gambling from some of these treatments which also appeared to be effective based on outcomes shown in the NMA. Therefore, the committee used this evidence to support the recommendation on offering group CBT. For the other non-gambling outcomes such as depression, anxiety, psychological wellbeing and quality of life, there was some evidence of benefits for individual CBT compared to treatment as usual, group CBT plus treatment as usual compared to attention placebo, and self-help and guided self-help compared to waitlist. The committee agreed that this was insufficient evidence to make a recommendation but noted that these data supported the results of the NMA that showed benefits for group and individual CBT. Follow-up outcomes for gambling symptom severity and gambling frequency showed some evidence of benefits for self-help compared to no treatment or waitlist, and group CBT compared to waitlist. The committee noted that maximum follow-up time for the follow-up outcomes was only 12-months, therefore agreed not to make recommendations for specific interventions based on long-term outcomes. As there was limited evidence on the long-term effectiveness or the effect on increasing recovery capital for psychological interventions in treating gambling that harms, the committee agreed to make research recommendations on these 2 topics. Furthermore, the committee agreed that there was a lack of evidence for treatments for people who have experienced gambling that harms with co-morbid conditions and so made a research recommendation. Lastly, the committee agreed to make a further research recommendation as there was paucity of evidence of combinations of psychological or psychosocial treatments for gambling that harms. The descriptions of the 4 research recommendations can be found in appendix K . Cost effectiveness and resource use The systematic literature review identified one study conducted in New Zealand that compared low intensity combined cognitive behaviour + cue exposure therapy with motivational interviewing combined with a self-help workbook and follow-up telephone booster sessions for adults experiencing gambling that harms and found no differences in costs or outcomes. This evidence was very limited and did not capture the whole range of available treatment options for adults experiencing gambling that harms, was partially applicable to the UK context, and was characterised by potentially serious limitations. For these reasons it was not considered by the committee further, when making recommendations. The committee considered the results of the economic analysis conducted for this guideline. This was informed by the NMA on gambling symptom severity conducted for the guideline, because there is evidence that gambling symptom severity has an impact on the magnitude of gambling-related costs and utility values. In contrast, no evidence linking the frequency of gambling that harms with gambling-related costs and utility values is available. For this reason, data on the NMA on gambling frequency were not considered in the economic model. In any case, the committee noted that gambling frequency is an aspect of gambling symptom severity, and, in this sense, its impact on costs and utilities is likely to have been indirectly incorporated in the model. The strengths and limitations of the NMA on gambling symptom severity characterise the guideline economic analysis as well. Only treatment classes that showed a higher mean effect on gambling symptom severity compared with no treatment were included in the economic analysis; this meant that pure self-help was not included in the guideline economic model. Further to that, twelve-step group programme and couple therapies (and SSRIs, which were included in the NMA as a relevant comparator to psychological interventions that had been tested in RCTs) were not considered in the economic analysis due to very limited evidence base as they had been tested in study arms of 15 participants or fewer. Results of the guideline economic analysis were directly applicable to the NICE decision-making context, although QALY estimates were based on SF-6D ratings due to lack of evidence based on EQ-5D scores; however, evidence suggests that EQ-5D, which is the preferred measure by NICE, may be less sensitive in capturing changes in health-related quality of life of people experiencing gambling that harms. On the other hand, two sets of costs associated with gambling that harms were obtained from 2 UK studies, respectively, each with its own strengths and limitations, and are therefore directly relevant to the UK context. Intervention resource use was based on relevant information reported in the RCTs included in the NMA that informed the economic analysis, modified by the committee to reflect optimal routine delivery of these interventions in the UK. The economic analysis was undertaken from two separate perspectives, a narrower NHS and personal social services (PSS) perspective and a wider public sector perspective, as the committee advised that public sector beyond NHS/PSS bears the largest part of costs incurred by people experiencing gambling that harms (for example, costs relating to the criminal justice system, housing and unemployment). The committee agreed that economic results from a public sector perspective should be given a higher weight when formulating recommendations. They also commented that the total costs associated with gambling were likely underestimated in the economic analysis, due to lack of relevant data or because some costs lie outside the perspective of the analysis. For example, the economic analysis only partially considered costs associated with gambling-related crime and homelessness and did not consider costs associated with personal debt and bankruptcy, impact on education, as well as intangible costs associated with gambling-related harms, including, but not limited to, completed or attempted suicide, self-harm, emotional or physical distress, relationships breakdown, for the person, their family, friends and close others. The guideline economic analysis was overall characterised by minor limitations, as, despite the uncertainty around a number of input parameters, results were robust under most alternative scenarios explored. Therefore, the committee were confident to use the economic model’s findings to support recommendations. The results of the economic analysis suggested that group CBT, which had shown the highest effect on the NMA of gambling symptom severity, was also the most cost-effective treatment, and more cost-effective than no treatment, under any scenario and perspective explored (including all scenarios tested in sensitivity analysis with the exception of one extreme scenario testing a PGSI score of 27, that is, the highest possible, at treatment initiation). These findings supported a strong (‘offer’) recommendation on group CBT. The economic findings were based on group CBT being modelled as 9 x 90-minute sessions, delivered ideally by 2 appropriately trained therapists to a group of 8 people, according to RCT available information, modified to reflect optimal routine delivery of this intervention in England. Based on this modelled resource use, the committee recommended that group therapy be delivered ideally by 2 practitioners, at least one of whom has gambling-specific training and competence, usually within 8 to 10 sessions, although it was acknowledged that more sessions might be needed or fewer sessions might be sufficient. The committee agreed that appropriately trained and competent therapists would help to address that people sometimes experience CBT as being stigmatising. The committee noted the important role of the second practitioner (co-facilitator) in ensuring participants’ safety, that all participants are involved in the sessions, and in following up participants, and therefore recommended that group CBT be ideally delivered by 2 practitioners. However, they also acknowledged that workforce issues may sometimes be a barrier to this. Motivational interviewing was shown to be the second most cost-effective treatment option and more cost-effective than no treatment under most scenarios explored (including scenarios tested in sensitivity analysis), under either a NHS/PSS or a public sector perspective. The committee considered these results together with the relatively small and uncertain effects of motivational interviewing compared with no treatment in the NMA of gambling symptom severity and their own experience, and decided to make a weaker (‘consider’) recommendation for motivational interviewing, in order to strengthen people’s commitment to change or to encourage people who are unsure or have reservations about starting treatment. The committee noted that other individual face-to-face psychological treatment classes (individual CBT, individual behavioural therapy and counselling) appeared to be less cost-effective than no treatment when a narrow NHS/PSS perspective was adopted (including scenarios tested in sensitivity analysis), with the exception of the scenario analysis that included lifetime QALY losses due to suicide and was using the OHID cost set; in this scenario analysis, other individual face-to-face psychological treatment classes were more cost-effective than no treatment under an NHS/PSS perspective. The cost-effectiveness of other individual face-to-face treatments improved as costs associated with gambling-related harms increased under a public sector perspective, so that they were likely to be cost-effective compared with no treatment under this wider perspective. The committee also noted that gambling-related cost figures used in the economic analysis were underestimates of the true costs incurred by people experiencing gambling that harms, so the cost-effectiveness of interventions was likely to be higher than what was estimated in the economic analysis. Sensitivity analysis revealed that, under a public sector perspective, these treatment classes were also cost-effective relative to no treatment when a log-normal or gamma distribution was assumed for post-treatment PGSI scores (rather than a normal distribution, which was assumed in the base-case analysis). Based on these findings and the clinical considerations described above, the committee expressed the view that the overall clinical and economic evidence for individual CBT was adequate to support a recommendation for individual CBT when the person did not wish to join a group therapy, when group therapy was not possible or when it was considered not suitable for the person. Based on the estimated resource use for individual CBT in the economic analysis, comprising 8 x 1-hour sessions delivered by an appropriately trained therapist, the committee recommended that individual CBT be delivered by a practitioner with gambling-specific training and competence (who would help to address that people sometimes experience CBT as being stigmatising) in 6 to 8 sessions, although it was acknowledged that more sessions might be needed or fewer sessions might be sufficient. However, the committee did not wish to make a recommendation for behavioural therapy or counselling, as these had similar clinical and cost-effectiveness to individual CBT but their clinical effects were characterised by higher uncertainty and were based on a narrower evidence base; moreover, when considering the results for behavioural therapy, it was noted that this lacks the cognitive element of CBT which is considered important in treating people experiencing gambling-related harms. Other factors the committee took into account Funding sources The funding sources for the studies included in this evidence review were: Any industry funding: Bucker 2018 , Cunningham 2009 , Cunningham 2012 , Dowling 2021 , Korman 2008 , LaBrie 2012 , Ladouceur 2001 , Lee 2015 , Luquiens 2016 , Martens 2015 , McIntosh 2016 , Milton 2002 , Neighbors 2015 , Nilsson 2020, Rodda 2018 , Smith 2015 , Thomas 2017 , Toneatto 2009 / 2016 , Wittekind 2019 No-industry funding: Abbott 2012 / 2018 , Armstrong 2020 , Bouchard 2017 , Boudreault 2018 , Bucker 2021 , Campos 2016 , Carlbring 2008 , Cunningham 2019 , Ede 2020 , Grant 2009 , Hodgins 2001 / 2004 , Hodgins 2009 , Hodgins 2019 , Jonas 2020 , Larimer 2012 , Myrseth 2011 , Oei 2018 , Petry 2006 , Petry 2008 , Petry 2009 , So 2020 , Zhuang 2018 Unclear funding source: Diskin 2009 , Dowling 2007 , Ladouceur 2003 , Marceaux 2001, Myrseth 2009 , Petry 2016 , Wong 2015 The committee inspected the NMA base-case results as well as those of the sensitivity analyses that included only studies with no-industry funding. They noted that results were overall consistent between the two analyses, although the sensitivity analysis included a limited number of studies and comparisons. They also noted that bias adjustment analyses testing for bias associated with funding source (any industry / unclear funding) showed no statistical evidence of such bias, although they acknowledged that it is still possible that such bias exists, as the comparisons on which such bias could be tested were limited. Following these observations, the committee agreed to focus on the base-case NMA results in order to make recommendations. Recommendations supported by this evidence review This evidence review supports recommendations 1.5.12 to 1.5.15 and the research recommendations on long-term effectiveness of psychological treatments, effectiveness of psychological treatments in people with comorbidities, effectiveness of combination psychological treatments and effectiveness at increasing recovery capital. References – included studies Effectiveness Abbott 2012 Abbott M, Bellringer M, Vandal A et al. (2012) Effectiveness of problem gambling brief telephone interventions: A randomised controlled trial. Abbott 2018 Abbott, Max, Hodgins, David C, Bellringer, Maria et al. (2018) Brief telephone interventions for problem gambling: a randomized controlled trial. Addiction (Abingdon, England) 113(5): 883–895 [ PubMed : 29274179 ] Armstrong 2020 Armstrong, Tess, Rockloff, Matthew, Browne, Matthew et al. (2020) Training gamblers to re-think their gambling choices: How contextual analytical thinking may be useful in promoting safer gambling. Journal of Behavioral addictions 9(3): 766–784 [ PMC free article : PMC8943676 ] [ PubMed : 33011715 ] Bouchard 2017 Bouchard, Stephane, Robillard, Genevieve, Giroux, Isabelle et al. (2017) Using Virtual Reality in the Treatment of Gambling Disorder: The Development of a New Tool for Cognitive Behavior Therapy. Frontiers in psychiatry 8: 27 [ PMC free article : PMC5324022 ] [ PubMed : 28286486 ] Boudreault 2018 Boudreault, Catherine, Giroux, Isabelle, Jacques, Christian et al. (2018) Efficacy of a Self-Help Treatment for At-Risk and Pathological Gamblers. Journal of gambling studies 34(2): 561–580 [ PubMed : 28905166 ] Bucker 2018 Bucker, Lara, Bierbrodt, Julia, Hand, Iver et al. (2018) Effects of a depression-focused internet intervention in slot machine gamblers: A randomized controlled trial. PloS one 13(6): e0198859 [ PMC free article : PMC5993308 ] [ PubMed : 29883479 ] Bucker 2021 Bucker, Lara, Gehlenborg, Josefine, Moritz, Steffen et al. (2021) A randomized controlled trial on a self-guided Internet-based intervention for gambling problems. Scientific reports 11(1): 13033 [ PMC free article : PMC8219798 ] [ PubMed : 34158553 ] Campos 2016 Campos, Michael D, Rosenthal, Richard J, Chen, Qiaolin et al. (2016) A self-help manual for problem gamblers: The impact of minimal therapist guidance on outcome. International Journal of Mental Health and Addiction 14(4): 579–596 Carlbring 2008 Carlbring, Per and Smit, Filip (2008) Randomized trial of internet-delivered self-help with telephone support for pathological gamblers. Journal of consulting and clinical psychology 76(6): 1090–4 [ PubMed : 19045977 ] Cunningham 2019 Cunningham, John A, Godinho, Alexandra, Hodgins, David C (2019) Pilot randomized controlled trial of an online intervention for problem gamblers. Addictive Behaviors reports 9: 100175 [ PMC free article : PMC6542746 ] [ PubMed : 31193792 ] Cunningham 2012 Cunningham, John A, Hodgins, David C, Toneatto, Tony et al. (2012) A randomized controlled trial of a personalized feedback intervention for problem gamblers. PloS one 7(2): e31586 [ PMC free article : PMC3279405 ] [ PubMed : 22348112 ] Cunningham 2009 Cunningham, John A, Hodgins, David C, Toneatto, Tony et al. (2009) Pilot study of a personalized feedback intervention for problem gamblers. Behavior therapy 40(3): 219–24 [ PubMed : 19647523 ] Diskin 2009 Diskin, Katherine M and Hodgins, David C (2009) A randomized controlled trial of a single session motivational intervention for concerned gamblers. Behaviour research and therapy 47(5): 382–8 [ PubMed : 19249015 ] Dowling 2007 Dowling, Nicki; Smith, David; Thomas, Trang (2007) A comparison of individual and group cognitive-behavioural treatment for female pathological gambling. Behaviour research and therapy 45(9): 2192–202 [ PubMed : 17196159 ] Dowling 2021 Dowling, Nicki A, Merkouris, Stephanie S, Rodda, Simone N et al. (2021) GamblingLess: A Randomised Trial Comparing Guided and Unguided Internet-Based Gambling Interventions. Journal of clinical medicine 10(11) [ PMC free article : PMC8196610 ] [ PubMed : 34063826 ] Ede 2020 Ede, Moses Onyemaechi, Omeje, Joachim C, Ncheke, Damian Chijioke et al. (2020) Assessment of the Effectiveness of Group Cognitive Behavioural Therapy in Reducing Pathological Gambling. Journal of gambling studies 36(4): 1325–1339 [ PubMed : 33037961 ] Grant 2009 Grant, Jon E, Donahue, Christopher B, Odlaug, Brian L et al. (2009) Imaginal desensitisation plus motivational interviewing for pathological gambling: randomised controlled trial. The British journal of psychiatry : the journal of mental science 195(3): 266–7 [ PMC free article : PMC2801822 ] [ PubMed : 19721120 ] Hodgins 2019 Hodgins, David C, Cunningham, John A, Murray, Robert et al. (2019) Online Self-Directed Interventions for Gambling Disorder: Randomized Controlled Trial. Journal of gambling studies 35(2): 635–651 [ PubMed : 30701377 ] Hodgins 2001 Hodgins, D C; Currie, S R; el-Guebaly, N (2001) Motivational enhancement and self-help treatments for problem gambling. 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(2008) Randomized control trial of an integrated therapy for comorbid anger and gambling. Psychotherapy research: journal of the Society for Psychotherapy Research 18(4): 454–65 [ PubMed : 18815997 ] Labrie 2012 Labrie, Richard A, Peller, Allyson J, Laplante, Debi A et al. (2012) A brief self-help toolkit intervention for gambling problems: a randomized multisite trial. The American journal of orthopsychiatry 82(2): 278–89 [ PubMed : 22506530 ] Ladouceur 2001 Ladouceur, R, Sylvain, C, Boutin, C et al. (2001) Cognitive treatment of pathological gambling. The Journal of nervous and mental disease 189(11): 774–80 [ PubMed : 11758661 ] Ladouceur 2003 Ladouceur, R, Sylvain, C, Boutin, C et al. (2003) Group therapy for pathological gamblers: a cognitive approach. Behaviour research and therapy 41(5): 587–96 [ PubMed : 12711266 ] Larimer 2012 Larimer, Mary E, Neighbors, Clayton, Lostutter, Ty W et al. (2012) Brief motivational feedback and cognitive behavioral interventions for prevention of disordered gambling: a randomized clinical trial. Addiction (Abingdon, England) 107(6): 1148–58 [ PMC free article : PMC3528181 ] [ PubMed : 22188239 ] Lee 2015 Lee, Bonnie K and Awosoga, Olu (2015) Congruence Couple Therapy for Pathological Gambling: A Pilot Randomized Controlled Trial. Journal of gambling studies 31(3): 1047–68 [ PubMed : 24838782 ] Luquiens 2016 Luquiens, Amandine, Tanguy, Marie-Laure, Lagadec, Marthylle et al. (2016) The Efficacy of Three Modalities of Internet-Based Psychotherapy for Non-Treatment-Seeking Online Problem Gamblers: A Randomized Controlled Trial. Journal of medical Internet research 18(2): e36 [ PMC free article : PMC4771930 ] [ PubMed : 26878894 ] Marceaux 2011 Marceaux, Janice C and Melville, Cameron L (2011) Twelve-step facilitated versus mapping-enhanced cognitive-behavioral therapy for pathological gambling: a controlled study. Journal of gambling studies 27(1): 171–90 [ PubMed : 20490632 ] Martens 2015 Martens, Matthew P, Arterberry, Brooke J, Takamatsu, Stephanie K et al. (2015) The efficacy of a personalized feedback-only intervention for at-risk college gamblers. Journal of consulting and clinical psychology 83(3): 494–9 [ PubMed : 25664642 ] McIntosh 2016 McIntosh, C C; Crino, R D; O’Neill, K (2016) Treating Problem Gambling Samples with Cognitive Behavioural Therapy and Mindfulness-Based Interventions: A Clinical Trial. Journal of gambling studies 32(4): 1305–1325 [ PubMed : 27040973 ] Milton 2002 Milton, Simon, Crino, Rocco, Hunt, Caroline et al. (2002) The effect of compliance-improving interventions on the cognitive-behavioural treatment of pathological gambling. Journal of gambling studies 18(2): 207–29 [ PubMed : 12096449 ] Myrseth 2009 Myrseth, Helga, Litlere, Irene, Stoylen, Inge Jarl et al. (2009) A controlled study of the effect of cognitive-behavioural group therapy for pathological gamblers. Nordic journal of psychiatry 63(1): 22–31 [ PubMed : 18991158 ] Myrseth 2011 Myrseth, Helga, Molde, Helge, Stoylen, Inge Jarl et al. (2011) A pilot study of CBT versus escitalopram combined with CBT in the treatment of pathological gamblers. International Gambling Studies 11(1): 121–141 Neighbors 2015 Neighbors, Clayton, Rodriguez, Lindsey M, Rinker, Dipali V et al. (2015) Efficacy of personalized normative feedback as a brief intervention for college student gambling: a randomized controlled trial. Journal of consulting and clinical psychology 83(3): 500–11 [ PMC free article : PMC4939822 ] [ PubMed : 26009785 ] Nilsson 2019 Nilsson, A., Magnusson, K., Carlbring, P. et al. (2019) Behavioral couples therapy versus cognitive behavioral therapy for problem gambling: a randomized controlled trial. Addiction [ PMC free article : PMC7317433 ] [ PubMed : 31746075 ] Oei 2018 Oei, T P S; Raylu, N; Lai, W W (2018) Effectiveness of a Self Help Cognitive Behavioural Treatment Program for Problem Gamblers: A Randomised Controlled Trial. Journal of gambling studies 34(2): 581–595 [ PubMed : 29032449 ] Petry 2006 Petry, Nancy M, Ammerman, Yola, Bohl, Jaime et al. (2006) Cognitive-behavioral therapy for pathological gamblers. Journal of consulting and clinical psychology 74(3): 555–67 [ PubMed : 16822112 ] Petry 2016 Petry, Nancy M; Rash, Carla J; Alessi, Sheila M (2016) A randomized controlled trial of brief interventions for problem gambling in substance abuse treatment patients. Journal of consulting and clinical psychology 84(10): 874–86 [ PMC free article : PMC5036993 ] [ PubMed : 27398781 ] Petry 2008 Petry, Nancy M, Weinstock, Jeremiah, Ledgerwood, David M et al. (2008) A randomized trial of brief interventions for problem and pathological gamblers. Journal of consulting and clinical psychology 76(2): 318–28 [ PMC free article : PMC2738749 ] [ PubMed : 18377127 ] Petry 2009 Petry, Nancy M, Weinstock, Jeremiah, Morasco, Benjamin J et al. (2009) Brief motivational interventions for college student problem gamblers. Addiction (Abingdon, England) 104(9): 1569–78 [ PMC free article : PMC2758481 ] [ PubMed : 19686527 ] Rodda 2018 Rodda, S. N, Dowling, N. A, Knaebe, B et al. (2018) Does SMS improve gambling outcomes over and above access to other e-mental health supports? A feasibility study. International Gambling Studies 18(2): 343–357 Smith 2015 Smith, David P, Battersby, Malcolm W, Harvey, Peter W et al. (2015) Cognitive versus exposure therapy for problem gambling: Randomised controlled trial. Behaviour research and therapy 69: 100–10 [ PubMed : 25917008 ] So 2020 So, Ryuhei, Furukawa, Toshi A, Matsushita, Sachio et al. (2020) Unguided Chatbot-Delivered Cognitive Behavioural Intervention for Problem Gamblers Through Messaging App: A Randomised Controlled Trial. Journal of gambling studies 36(4): 1391–1407 [ PubMed : 32162075 ] Thomas 2017 Thomas S, Jackson A, Browning C et al. (2017) Psychological treatments for problem gambling (PROGRESS) study final report. Toneatto 2009 Toneatto, T. and Gunaratne, M. (2009) Does the treatment of cognitive distortions improve clinical outcomes for problem gambling?. Journal of Contemporary Psychotherapy 39(4): 221–229 Toneatto 2016 Toneatto, Tony (2016) Single-session interventions for problem gambling may be as effective as longer treatments: Results of a randomized control trial. Addictive behaviors 52: 58–65 [ PubMed : 26363305 ] Wittekind 2019 Wittekind, Charlotte E, Bierbrodt, Julia, Ludecke, Daniel et al. (2019) Cognitive bias modification in problem and pathological gambling using a web-based approach-avoidance task: A pilot trial. Psychiatry research 272: 171–181 [ PubMed : 30583260 ] Wong 2015 Wong, Daniel Fu Keung, Chung, Catherine Lai Ping, Wu, Janet et al. (2015) A Preliminary Study of an Integrated and Culturally Attuned Cognitive Behavioral Group Treatment for Chinese Problem Gamblers in Hong Kong. Journal of gambling studies 31(3): 1015–27 [ PubMed : 24699943 ] Zhuang 2018 Zhuang, X.Y., Wong, D.F.K., Ng, T.K. et al. (2018) Evaluating the Effectiveness of an Integrated Cognitive-Behavioural Intervention (CBI) Model for Male Problem Gamblers in Hong Kong: A Matched-Pair Comparison Design. Journal of gambling studies 34(3): 969–985 [ PubMed : 29357020 ] Economic Bellringer 2021 Bellringer ME, Palmer du Preez K, Vandal AC, Janicot S, Ikeda T, Hodgins DC, Battersby M, van Kessel K, Sullivan S, Riley B, Te Ao B, Henry N, Mauchline L, Landon J (2021). Effectiveness of face-to-face gambling interventions: A randomised controlled trial. Auckland: Auckland University of Technology, Gambling and Addictions Research Centre. Appendices Appendix A. Review protocols Review protocol for review question: What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? (PDF, 253K) Appendix B. Literature search strategies Literature search strategies for review question: What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? Effectiveness searches (PDF, 404K) Economics searches (PDF, 237K) Appendix C. Effectiveness evidence study selection Study selection for: What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? (PDF, 168K) Appendix D. Evidence tables Evidence tables for review question: What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? Please refer to the evidence tables in supplement 3: psychological treatment evidence tables. Appendix E. Forest plots Forest plots for review question: What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? (PDF, 198K) Appendix F. GRADE tables GRADE tables for review question: What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? (PDF, 1.0M) Appendix G. Economic evidence study selection Study selection for: What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? (PDF, 104K) Appendix H. Economic evidence tables Economic evidence tables for review question: What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? (PDF, 109K) Appendix I. Economic model Economic model for review question: What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? (PDF, 797K) Appendix J. Excluded studies Excluded studies for review question: What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? Excluded effectiveness studies Table 99 Excluded effectiveness studies and reasons for their exclusion View in own window Study Reason for exclusion Actrn (2017) Comparison of two versions of psychological therapy for gambling disorder. https://trialsearch ​.who ​.int/Trial2.aspx?TrialID ​=ACTRN12617000646347 - Publication type Clinical trial record Actrn (2010) ‘XGAMBLE’- The effect of counselling on gambling behaviours in four New Zealand population groups. https://trialsearch ​.who ​.int/Trial2.aspx?TrialID ​=ACTRN12610000826044 - Publication type Clinical trial record Actrn (2020) A randomised control trial comparing face-to-face with online problem gambling treatment. https://trialsearch ​.who ​.int/Trial2.aspx?TrialID ​=ACTRN12620000279921 - Publication type Clinical trial record Amandine, L.; Marie-Laure, T.; Henri-Jean, A. (2017) Online psychotherapy among problem poker gamblers: 3 years of follow up. Journal of Behavioral Addictions 6(fusupplement1): 3 - Publication type Conference abstract only Andersson, Gerhard, Rozental, Alexander, Shafran, Roz et al. (2018) Long-term effects of internet-supported cognitive behaviour therapy. Expert review of neurotherapeutics 18(1): 21–28 [ PubMed : 29094622 ] - Study design Narrative review, not a systematic review Auer, Michael M and Griffiths, Mark D (2016) Personalized behavioral feedback for online gamblers: A real world empirical study. Frontiers in Psychology 7 [ PMC free article : PMC5124696 ] [ PubMed : 27965611 ] - Outcome No protocol outcomes reported Auer, Michael M and Griffiths, Mark D (2015) The use of personalized behavioral feedback for online gamblers: an empirical study. Frontiers in psychology 6: 1406 [ PMC free article : PMC4585278 ] [ PubMed : 26441779 ] - Outcome No protocol outcomes reported Augner, Christoph, Vlasak, Thomas, Aichhorn, Wolfgang et al. (2022) Psychological online interventions for problem gambling and gambling disorder – A meta-analytic approach. Journal of psychiatric research 151: 86–94 [ PubMed : 35472684 ] - Population Includes studies with population of <18 years old. Other included studies checked for possible inclusions. Battersby, M. (2015) Cognitive versus exposure therapy for problem gambling: a randomised controlled trial. Australian and New Zealand journal of psychiatry 49: 76 [ PubMed : 25917008 ] - Publication type Abstract only Bellringer ME; Palmer du Preez K; Vandal A (2022) Effectiveness of face-to-face gambling interventions: two years later. - Outcome Data could not be extracted Bergeron, P.-Y., Giroux, I., Chretien, M. et al. (2022) Exposure Therapy for Gambling Disorder: Systematic Review and Meta-analysis. Current Addiction Reports 9(3): 179–194 - Duplicate Individual papers have of this systematic review have been checked and included if they meet protocol criteria. Bouchard, Amy E, Dickler, Maya, Renauld, Emmanuelle et al. (2021) Concurrent Transcranial Direct Current Stimulation and Resting-State Functional Magnetic Resonance Imaging in Patients with Gambling Disorder. Brain connectivity 11(10): 815–821 [ PubMed : 34128386 ] - Outcome No protocol outcomes reported Boughton, Roberta R; Jindani, Farah; Turner, Nigel E (2016) Group Treatment for Women Gamblers Using Web, Teleconference and Workbook: Effectiveness Pilot. International journal of mental health and addiction 14(6): 1074–1095 [ PMC free article : PMC5120056 ] [ PubMed : 27942254 ] - Comparator No comparator Boughton, Roberta, Jindani, Farah, Turner, Nigel E et al. (2017) Closing a treatment gap in Ontario: Pilot of a Tutorial Workbook for women gamblers. Journal of Gambling Issues 36: 199–231 - Comparator No comparator Boumparis, N., Haugorcid, S., Abend, S. et al. (2022) Internet-based interventions for behavioral addictions: A systematic review. Journal of Behavioral Addictions 11(3): 620–642 [ PMC free article : PMC9872535 ] [ PubMed : 36495471 ] - Duplicate Individual papers included in this review have been checked and included if they meet protocol criteria. Canale, N., Vieno, A., Griffiths, M.D. et al. (2016) The efficacy of a web-based gambling intervention program for high school students: A preliminary randomized study. Computers in Human Behavior 55: 946–954 - Population Participants less than 18 years of age Carlbring, Per, Jonsson, Jakob, Josephson, Henrik et al. (2010) Motivational interviewing versus cognitive behavioral group therapy in the treatment of problem and pathological gambling: a randomized controlled trial. Cognitive behaviour therapy 39(2): 92–103 [ PMC free article : PMC2882846 ] [ PubMed : 19967577 ] - Outcome Data cannot be extracted (data not presented per arm) Casey, Leanne M, Oei, Tian P S, Raylu, Namrata et al. (2017) Internet-Based Delivery of Cognitive Behaviour Therapy Compared to Monitoring, Feedback and Support for Problem Gambling: A Randomised Controlled Trial. Journal of gambling studies 33(3): 993–1010 [ PubMed : 28124288 ] - Outcome Data cannot be extracted (Ns not reported ‘Available data at post ranged between n = 18–27 for I-CBT, n = 18–30 for I-MFS, and n = 38–44 for Waitlist’) Chebli, Jaymee-Lee; Blaszczynski, Alexander; Gainsbury, Sally M (2016) Internet-Based Interventions for Addictive Behaviours: A Systematic Review. Journal of gambling studies 32(4): 1279–1304 [ PubMed : 27002522 ] - Population Studies included in this review included populations with other addictive behaviours Other included studies checked for possible inclusions. Choi, Y.S. (2010) Effectiveness of psychosocial rehabilitation program for the pathologic gamblers in Korea. International Journal of Neuropsychopharmacology 13(suppl1): 48 - Publication type Abstract only Christensen, D. R., Dowling, N. A., Jackson, A. C. et al. (2013) A Proof of Concept for Using Brief Dialectical Behavior Therapy as a Treatment for Problem Gambling. Behaviour Change 30(2): 117–137 - Comparator No comparator Clarke, Ciaran and Skokauskas, Norbertas (2009) CBT for adolescent pathological gambling – lessons from adult research. Irish journal of psychological medicine 26(3): 140–146 [ PubMed : 30282309 ] - Study design Not a systematic review. Cowlishaw, S, Merkouris, S, Dowling, N et al. (2012) Psychological therapies for pathological and problem gambling. Cochrane Database of Systematic Reviews [ PubMed : 23152266 ] - Duplicate Excluded based on duplicates. Individual studies within this review have been checked and included if they meet our protocol criteria Danielsson, Anna-Karin; Eriksson, Anna-Karin; Allebeck, Peter (2014) Technology-based support via telephone or web: a systematic review of the effects on smoking, alcohol use and gambling. Addictive behaviors 39(12): 1846–68 [ PubMed : 25128637 ] - Population Studies included in the review included population with different substance abuse disorders Di Nicola, Marco, De Crescenzo, Franco, D’Alo, Gian Loreto et al. (2020) Pharmacological and Psychosocial Treatment of Adults With Gambling Disorder: A Meta-Review. Journal of addiction medicine 14(4): e15–e23 [ PubMed : 31651561 ] - Duplicate Includes duplicates. Individual reviews and studies included in this review have been checked and included if they meet our protocol criteria. Dickinson, Patrick, Gerling, Kathrin, Wilson, Liam et al. (2020) Virtual reality as a platform for research in gambling behaviour. Computers in Human Behavior 107: npag–npag - Population Study excluded participants who currently engage in harmful gambling DiClemente, Carlo C, Corno, Catherine M, Graydon, Meagan M et al. (2017) Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors 31(8): 862–887 [ PubMed : 29199843 ] - Outcome Outcomes reported qualitatively. Donati, M.A., Iozzi, A., Fusi, G. et al. (2022) A cognitive group therapy for patients in case of Gambling Disorder: The utility of the dual-process model. Journal of Behavioral Addictions 11(supplement1): 259 - Publication type Abstract only Dowling N, Merkouris S, Rodda S et al. (2018) Development and evaluation of an online gambling self-directed program: effective integration into existing services. - Other protocol criteria Protocol summary only Dowling, N.; Smith, D.; Thomas, T. (2004) Efficacy of a cognitive-behavioural approach in the treatment of female pathological gambling. Australian Journal of Psychology 56: 179–179 - Publication type Abstract only Dowling, N; Jackson, AC; Thomas, SA (2008) Behavioral interventions in the treatment of pathological gambling: A review of activity scheduling and desensitization. International Journal of Behavioral Consultation & Therapy 4(2): 172–187 - Study design Not a systematic review Dowling, Nicki; Smith, David; Thomas, Trang (2006) Treatment of female pathological gambling: the efficacy of a cognitive-behavioural approach. Journal of gambling studies 22(4): 355–72 [ PubMed : 16924426 ] - Outcome Data cannot be extracted (Ns not reported, data for all treated participants combined for intervention group [including those initially on waitlist], also only includes participants who selected abstinence as treatment goal) Drks (2021) Further development of the Internet-based self-help program “Restart” for individuals with gambling problems: a randomized controlled trial. https://trialsearch ​.who ​.int/Trial2.aspx?TrialID=DRKS00024840 - Publication type Clinical trial record Drks (2017) Evaluation of the effectiveness of “Check dein Spiel” (CDS), an Internet-based intervention for pathological gambling. https://trialsearch ​.who ​.int/Trial2.aspx?TrialID=DRKS00011569 - Publication type Clinical trial record Echeburua, Enrique; Gomez, Montserrat; Freixa, Montserrat (2011) Cognitive-behavioural treatment of pathological gambling in individuals with chronic schizophrenia: a pilot study. Behaviour research and therapy 49(11): 808–14 [ PubMed : 21920501 ] - Study design Experimental study using a non-randomly assigned control group with no controls for confounding. Drks (2018) Efficacy of a depression-focused internet intervention in slot machine gamblers: A randomized controlled trial. https://trialsearch ​.who ​.int/Trial2.aspx?TrialID=DRKS00013888 [ PMC free article : PMC5993308 ] [ PubMed : 29883479 ] - Publication type Clinical trial record Fiskaali, A., Stenbro, A.W., Marcussen, T. et al. (2022) Preventive Interventions and Harm Reduction in Online and Electronic Gambling: A Systematic Review. Journal of gambling studies [ PubMed : 35999322 ] - Population Includes interventions other than psychological and/or psychosocial. Individual studies have been checked and included if they meet protocol criteria. Ghosh, A.; Dhawan, L.; Basu, D. (2015) Treating Gambling disorder (GD): a biofeedback based exposure therapy. Indian Journal of Psychiatry 57(5): S139–S140 - Publication type Abstract only Giroux, Isabelle, Faucher-Gravel, Andreanne, St-Hilaire, Alexandre et al. (2013) Gambling exposure in virtual reality and modification of urge to gamble. Cyberpsychology, behavior and social networking 16(3): 224–31 [ PubMed : 23496679 ] - Comparator No comparator Gooding, Patricia and Tarrier, Nicholas (2009) A systematic review and meta-analysis of cognitive-behavioural interventions to reduce problem gambling: hedging our bets?. Behaviour research and therapy 47(7): 592–607 [ PubMed : 19446287 ] - Duplicate Includes duplicates. Individual studies included in this review have been checked and included if they meet our protocol criteria. Goslar, Martina, Leibetseder, Max, Muench, Hannah M et al. (2017) Efficacy of face-to-face versus self-guided treatments for disordered gambling: A meta-analysis. Journal of behavioral addictions 6(2): 142–162 [ PMC free article : PMC5520130 ] [ PubMed : 28662618 ] - Duplicate Excluded based on duplicates. Individual studies within this review have been checked and included if they meet our protocol criteria Grande-Gosende, Aris, Lopez-Nunez, Carla, Garcia-Fernandez, Gloria et al. (2020) Systematic Review of Preventive Programs for Reducing Problem Gambling Behaviors Among Young Adults. Journal of gambling studies 36(1): 1–22 [ PubMed : 31168687 ] - Duplicate Includes duplicates. Individual studies included in this review have been checked and included if they meet our protocol criteria. Grant, Jon E, Donahue, Christopher B, Odlaug, Brian L et al. (2011) A 6-month follow-up of imaginal desensitization plus motivational interviewing in the treatment of pathological gambling. Annals of clinical psychiatry : official journal of the American Academy of Clinical Psychiatrists 23(1): 3–10 [ PMC free article : PMC3465840 ] [ PubMed : 21318190 ] - Outcome Follow-up data for Grant 2009 but only for intervention arm (so no comparator) as waitlist arm received intervention after endpoint Harris, Nicholas and Mazmanian, Dwight (2016) Cognitive behavioural group therapy for problem gamblers who gamble over the internet: A controlled study. Journal of Gambling Issues 33: 170–188 - Study design Non-randomised and there is no control for confounding Hodgins, David C, Toneatto, Tony, Makarchuk, Karyn et al. (2007) Minimal treatment approaches for concerned significant others of problem gamblers: a randomized controlled trial. Journal of gambling studies 23(2): 215–30 [ PubMed : 17245662 ] - Intervention Intervention and outcomes are aimed at concerned significant others and not people who participate in harmful gambling. Humphreys, Gabrielle, Evans, Rebecca, Makin, Harriet et al. (2021) Identification of Behavior Change Techniques From Successful Web-Based Interventions Targeting Alcohol Consumption, Binge Eating, and Gambling: Systematic Review. Journal of medical Internet research 23(2): e22694 [ PMC free article : PMC7902193 ] [ PubMed : 33560243 ] - Outcome Outcomes reported qualitatively. Hutchison, P.; Cox, S.; Frings, D. (2018) Helping you helps me: Giving and receiving social support in recovery groups for problem gamblers. Group Dynamics 22(4): 187–199 - Comparator No comparator Iriki, A. (2019) Our group therapy session has helped the people with gambling disorder. Journal of Behavioral Addictions 8(supplement1): 120–121 - Publication type Abstract only Isrctn (2008) Is motivational interviewing and/or cognitive behavioural group therapy an effective treatment for pathological gambling?. https://trialsearch ​.who ​.int/Trial2.aspx?TrialID ​=ISRCTN92322614 - Publication type Clinical trial record Isrctn (2019) A randomized controlled trial of an Internet-based psychological treatment for disordered gambling. https://trialsearch ​.who ​.int/Trial2.aspx?TrialID ​=ISRCTN38692394 - Publication type Clinical trial record Jimenez-Murcia, S., Aymami, N., Gomez-Pena, M. et al. (2012) Does exposure and response prevention improve the results of group cognitive-behavioural therapy for male slot machine pathological gamblers?. The British journal of clinical psychology / the British Psychological Society 51(1): 54–71 [ PubMed : 22268541 ] - Study design Non-randomised and there is no control for confounding Jimenez-Murcia, Susana, Tremblay, Joel, Stinchfield, Randy et al. (2017) The Involvement of a Concerned Significant Other in Gambling Disorder Treatment Outcome. Journal of gambling studies 33(3): 937–953 [ PubMed : 27858265 ] - Study design Non-randomised and there is no control for confounding Jonsson, Jakob, Hodgins, David C, Munck, Ingrid et al. (2020) Reaching out to big losers leads to sustained reductions in gambling over 1 year: a randomized controlled trial of brief motivational contact. Addiction (Abingdon, England) 115(8): 1522–1531 [ PubMed : 31977104 ] - Outcome Data cannot be extracted (Unclear if reported data is ITT or completer analysis) Josephson, Henrik, Carlbring, Per, Forsberg, Lars et al. (2016) People with gambling disorder and risky alcohol habits benefit more from motivational interviewing than from cognitive behavioral group therapy. PeerJ 4: e1899 [ PMC free article : PMC4824888 ] [ PubMed : 27069823 ] - Study design Secondary analysis study with non-relevant data Kotter, Roxana, Kraplin, Anja, Pittig, Andre et al. (2019) A Systematic Review of Land-Based Self-Exclusion Programs: Demographics, Gambling Behavior, Gambling Problems, Mental Symptoms, and Mental Health. Journal of gambling studies 35(2): 367–394 [ PubMed : 29721719 ] - Comparator Did not include comparators Ladouceur, Robert; Sylvain, Caroline; Gosselin, Patrick (2007) Self-exclusion program: a longitudinal evaluation study. Journal of gambling studies 23(1): 85–94 [ PubMed : 17165137 ] - Intervention Not a psychological or psychosocial treatment. Lee, B.K., Ofori Dei, S.M., Brown, M.M.R. et al. (2022) Congruence couple therapy for alcohol use and gambling disorders with comorbidities (part I): Outcomes from a randomized controlled trial. Family process [ PubMed : 36217243 ] - Outcome Data not reported separately for those that have gambling disorder Lee, B.K.; Ofori Dei, S.M.; Isik, E. (2022) Congruence couple therapy for alcohol use and gambling disorders with comorbidities (part II): Targeted areas and mechanisms of change. Family process: e12816 [ PubMed : 36245316 ] - Outcome Data cannot be extracted as no means (SD) reported. Leibetseder, M., Laireiter, A.-R., Vierhauser, M. et al. (2011) Efficacy and effectiveness of psychological and psychopharmacological treatments in pathological gambling - A meta-analysis. Sucht 57(4): 275–285 - Other protocol criteria Non-English language article Linardatou, C., Parios, A., Varvogli, L. et al. (2014) An 8-week stress management program in pathological gamblers: Apilot randomized controlled trial. Journal of Psychiatric Research 56(1): 137–143 [ PubMed : 24912736 ] - Intervention Intervention not targeted at gambling and no relevant gambling outcomes Luquiens, A. (2018) Big data to track and treat? Proposing online therapy to problem gamblers: A randomized clinical trial. European Psychiatry 48(supplement1): 19–s20 - Publication type Conference abstract only Luquiens, A., Lagadec, M., Tanguy, M. L. et al. (2015) Efficacy of online psychotherapies in poker gambling disorder: an online randomized clinical trial. Journal of behavioral addictions 4: 27–28 [ PubMed : 25786497 ] - Publication type Abstract only Luquiens, A., Lagadec, M., Tanguy, M.-L. et al. (2015) Efficacy of online psychotherapies in poker gambling disorder: An online randomized clinical trial. Journal of Behavioral Addictions 4(supplement1): 27–28 [ PubMed : 25786497 ] - Publication type Abstract only Luquiens, A., Lagadec, M., Tanguy, M. et al. (2015) Efficacy of online psychotherapies in poker gambling disorder: An online randomized clinical trial. European Psychiatry 30(suppl1): 1053 - Publication type Conference abstract only Luquiens, Amandine, Tanguy, Marie-Laure, Lagadec, Marthylle et al. (2016) The Efficacy of Three Modalities of Internet-Based Psychotherapy for Non-Treatment-Seeking Online Problem Gamblers: A Randomized Controlled Trial. Journal of medical Internet research 18(2): e36 [ PMC free article : PMC4771930 ] [ PubMed : 26878894 ] - Intervention Intervention is self-exclusion (from gambling); neither a psychological nor a psychological intervention Makani, Ramkrishna, Pradhan, Basant, Shah, Umang et al. (2017) Role of Repetitive Transcranial Magnetic Stimulation (rTMS) in Treatment of Addiction and Related Disorders: A Systematic Review. Current drug abuse reviews 10(1): 31–43 [ PubMed : 29189190 ] - Population Studies included in this review included populations of different substance abuse disorders Marchica, Loredana and Derevensky, Jeffrey L (2016) Examining personalized feedback interventions for gambling disorders: A systematic review. Journal of behavioral addictions 5(1): 1–10 [ PMC free article : PMC5322985 ] [ PubMed : 28092190 ] - Duplicate Excluded as duplicate. Individual studies in this review have been checked and included if they meet our protocol criteria. Martinotti, G. and Pettorruso, M. (2018) Brain stimulation and gambling disorder: New therapeutic perspectives. Journal of Behavioral Addictions 7(supplement1): 111 [ PMC free article : PMC6426396 ] [ PubMed : 30264605 ] - Publication type Abstract only Martinotti, Giovanni, Lupi, Matteo, Montemitro, Chiara et al. (2019) Transcranial Direct Current Stimulation Reduces Craving in Substance Use Disorders: A Double-blind, Placebo-Controlled Study. The journal of ECT 35(3): 207–211 [ PubMed : 30844881 ] - Population Results did not differentiate participants for their substance us disorder. Matsuzaki, T., Matsushita, S., Nishimura, K. et al. (2019) Effectiveness of CBT-based outpatient treatment program for gambling disorder: multi-study site randomized control trial in Japan. Journal of behavioral addictions 8: 68 - Publication type Abstract only Maynard, B.R., Wilson, A.N., Labuzienski, E. et al. (2018) Mindfulness-Based Approaches in the Treatment of Disordered Gambling: A Systematic Review and Meta-Analysis. Research on Social Work Practice 28(3): 348–362 - Duplicate Includes duplicates. Individual studies included in this review have been checked and included if they meet our protocol criteria McCormick, Amanda V; Cohen, Irwin M; Davies, Garth (2018) Differential Effects of Formal and Informal Gambling on Symptoms of Problem Gambling During Voluntary Self-Exclusion. Journal of gambling studies 34(3): 1013–1031 [ PubMed : 29349720 ] - Comparator No comparator McMahon, Naoimh, Thomson, Katie, Kaner, Eileen et al. (2019) Effects of prevention and harm reduction interventions on gambling behaviours and gambling related harm: An umbrella review. Addictive behaviors 90: 380–388 [ PubMed : 30529994 ] - Population Studies included children. Included studies checked for possible inclusions. Melville, Cam L, Davis, Carolyn S, Matzenbacher, Dena L et al. (2004) Node-link-mapping-enhanced group treatment for pathological gambling. Addictive behaviors 29(1): 73–87 [ PubMed : 14667422 ] - Outcome Data cannot be extracted (no measure of variance reported) Morefield, Kate, Walker, Claire, Smith, David et al. (2014) An inpatient treatment program for people with gambling problems: Synopsis and early outcomes. International Journal of Mental Health and Addiction 12(3): 367–379 - Comparator No comparator Muller, K., Koch, A., Dickenhorst, U. et al. (2015) Effects of inpatient treatment of pathological gamblers: First results of a multicenter follow-up study. Journal of Behavioral Addictions 4(supplement1): 29 - Publication type Abstract only Myrseth, Helga, Brunborg, Geir Scott, Eidem, Magnus et al. (2013) Description and pre-post evaluation of a telephone and internet based treatment programme for pathological gambling in Norway: A pilot study. International Gambling Studies 13(2): 205–220 - Comparator No comparator Naish, Katherine R, Vedelago, Lana, MacKillop, James et al. (2018) Effects of neuromodulation on cognitive performance in individuals exhibiting addictive behaviors: A systematic review. Drug and alcohol dependence 192: 338–351 [ PMC free article : PMC8995136 ] [ PubMed : 30317162 ] - Population Population included substance use disorders Nct (2005) Cognitive Behavioral Therapy for Treatment of Pathological Gambling. https://clinicaltrials.gov/show/NCT00158314 - Publication type Clinical trial record Nct (2006) A Randomized Control Trial Examining Two Treatments for Problem Gambling. https://clinicaltrials.gov/show/NCT00345527 - Publication type Clinical trial record Nct (2016) Contingency Management as an Adjunct Treatment for Rural and Remote Disordered Gamblers. https://clinicaltrials.gov/show/NCT02953899 [ PMC free article : PMC5892741 ] [ PubMed : 29615445 ] - Publication type Clinical trial record Nct (2007) A Personalized Feedback Intervention for Problem Gamblers. https://clinicaltrials.gov/show/NCT00578357 - Publication type Clinical trial record Nct (2008) Brief Therapies for Problem Gambling Substance Abusers. https://clinicaltrials.gov/show/NCT00685048 - Publication type Clinical trial record Nct (2010) Deep Low-Frequency Repetitive Transcranial Magnetic Stimulation for Cessation of Pathological Gambling. https://clinicaltrials.gov/show/NCT01154712 - Publication type Clinical trial record Nct (2017) SBIRT Intervention for Gambling Behaviors. https://clinicaltrials.gov/show/NCT03287583 - Publication type Clinical trial record Nct (2018) Effects of Transcranial Direct Current Stimulation (tDCS) in Disordered Gambling. https://clinicaltrials.gov/show/NCT03464838 - Publication type Clinical trial record Nct (2018) Mindfulness-Based Cognitive-Behavioral Therapy for Gambling Disorder. https://clinicaltrials.gov/show/NCT03497247 - Publication type Clinical trial record Nilsson, Anders, Magnusson, Kristoffer, Carlbring, Per et al. (2018) The Development of an Internet-Based Treatment for Problem Gamblers and Concerned Significant Others: A Pilot Randomized Controlled Trial. Journal of gambling studies 34(2): 539–559 [ PMC free article : PMC5938305 ] [ PubMed : 28699054 ] - Outcome Data cannot be extracted for inclusion in the NMA, and pairwise not performed as within -class comparison Oakley-Browne, M A; Adams, P; Mobberley, P M (2000) Interventions for pathological gambling. The Cochrane database of systematic reviews: cd001521 [ PubMed : 10796802 ] - Publication date Studies included in this review were prior 2000 Oei, Tian P S; Raylu, Namrata; Casey, Leanne M (2010) Effectiveness of group and individual formats of a combined motivational interviewing and cognitive behavioral treatment program for problem gambling: a randomized controlled trial. Behavioural and cognitive psychotherapy 38(2): 233–8 [ PubMed : 20152065 ] - Outcome Data could not be extracted Pallesen, Stale, Mitsem, Morten, Kvale, Gerd et al. (2005) Outcome of psychological treatments of pathological gambling: a review and meta-analysis. Addiction (Abingdon, England) 100(10): 1412–22 [ PubMed : 16185203 ] - Duplicate Includes duplicates. Individual studies included in this review have been checked and included if they meet our protocol criteria. Park, J.J., King, D.L., Wilkinson-Meyers, L. et al. (2022) Content and Effectiveness of Web-Based Treatments for Online Behavioral Addictions: Systematic Review. JMIR Mental Health 9(9): e36662 [ PMC free article : PMC9508667 ] [ PubMed : 36083612 ] - Population SR had 3 studies which included participants with harmful gambling. These studies have been checked and included if they meet protocol criteria. Peter, Samuel C, Brett, Emma I, Suda, Matthew T et al. (2019) A Meta-analysis of Brief Personalized Feedback Interventions for Problematic Gambling. Journal of gambling studies 35(2): 447–464 [ PubMed : 30610506 ] - Duplicate Individual papers included in this paper are included in the review if they meet protocol criteria. Petry, Nancy M; Ginley, Meredith K; Rash, Carla J (2017) A systematic review of treatments for problem gambling. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors 31(8): 951–961 [ PMC free article : PMC5714688 ] [ PubMed : 28639817 ] - Duplicate Includes duplicates. Individual studies have been checked and included if they meet our protocol criteria. Pfund, Rory A, Peter, Samuel C, Whelan, James P et al. (2020) Is more better? A meta-analysis of dose and efficacy in face-to-face psychological treatments for problem and disordered gambling. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors 34(5): 557–568 [ PubMed : 32105113 ] - Duplicate Systematic review. Individual papers included in this paper are included in the review if they meet protocol criteria. Protasio, M.I.B., da Silva, J.P.L., Arias-Carrion, O. et al. (2015) Repetitive transcranial magnetic stimulation to treat substance use disorders and compulsive behavior. CNS and Neurological Disorders - Drug Targets 14(3): 331–340 [ PubMed : 25801835 ] - Study design Review is not systematic. Quilty, Lena C, Wardell, Jeffrey D, Thiruchselvam, Thulasi et al. (2019) Brief interventions for problem gambling: A meta-analysis. PloS one 14(4): e0214502 [ PMC free article : PMC6469774 ] [ PubMed : 30995229 ] - Duplicate Duplicate studies with Pfund - 2020 and Peter-2019 Ranta, Jussi, Bellringer, Maria, Garrett, Nick et al. (2019) Can a Brief Telephone Intervention for Problem Gambling Help to Reduce Co-existing Depression? A Three-Year Prospective Study in New Zealand. Journal of gambling studies 35(2): 617–633 [ PubMed : 29956059 ] - Comparator No comparator Ribeiro, Eliana O; Afonso, Nuno H; Morgado, Pedro (2021) Non-pharmacological treatment of gambling disorder: a systematic review of randomized controlled trials. BMC psychiatry 21(1): 105 [ PMC free article : PMC7888125 ] [ PubMed : 33596853 ] - Publication date Mixed publication date included in systematic review (3/22 pre-2000). Results not presented separately for target publication years. Included studies checked for possible inclusions. Robillard, G., Bouchard, S., Boutin, C. et al. (2016) Effectiveness of a revised virtual reality program for pathological gambling. Journal of Cyber Therapy and Rehabilitation 9(1): 55 - Publication type Abstract only Rodda, Simone N (2021) A Systematic Review of Internet Delivered Interventions for Gambling: Prevention, Harm Reduction and Early Intervention. Journal of gambling studies [ PubMed : 34515903 ] - Duplicate Includes duplicates. Individual studies have been checked and included if they meet our protocol criteria. Rogers, RD (2006) Review: psychological treatments improve pathological gambling in the short and long term. Evidence-based Mental Health 9(2): 44–44 [ PubMed : 16638893 ] - Other protocol criteria Abstract only Sagoe, Dominic, Griffiths, Mark D, Erevik, Eilin Kristine et al. (2021) Internet-based treatment of gambling problems: A systematic review and meta-analysis of randomized controlled trials. Journal of behavioral addictions 10(3): 546–565 [ PMC free article : PMC8997228 ] [ PubMed : 34546971 ] - Comparator Mixed comparators included in systematic review (wait-list control or no treatment [5/13 studies], sham (1/13 studies], referral to treatment [1/13 studies], assessment only [1/13 studies] , active treatment, not usual care [5/13 studies]). Results not presented separately for comparator of interest. Included studies checked for potential includes. Sauvaget, Anne, Bulteau, Samuel, Guilleux, Alice et al. (2018) Both active and sham low-frequency rTMS single sessions over the right DLPFC decrease cue-induced cravings among pathological gamblers seeking treatment: A randomized, double-blind, sham-controlled crossover trial. Journal of behavioral addictions 7(1): 126–136 [ PMC free article : PMC6035030 ] [ PubMed : 29463098 ] - Outcome No relevant outcome data reported. No data available for end of first phase (pre-crossover). Savron, G.; De Luca, R.; Pitti, P. (2007) Group therapy with Pathological Gamblers: results after 6, 12 and 18 months of treatment. Rivista Di Psichiatria 42(3): 189–204 - Other protocol criteria Non-English language article Saxton, Jenny, Rodda, Simone N, Booth, Natalia et al. (2021) The efficacy of Personalized Normative Feedback interventions across addictions: A systematic review and meta-analysis. PloS one 16(4): e0248262 [ PMC free article : PMC8016245 ] [ PubMed : 33793583 ] - Population Studies included in this review included populations with other addictions. Schuler, Andree, Ferentzy, Peter, Turner, Nigel E et al. (2016) Gamblers Anonymous as a Recovery Pathway: A Scoping Review. Journal of gambling studies 32(4): 1261–1278 [ PMC free article : PMC5101261 ] [ PubMed : 27040972 ] - Other protocol criteria Review that uses mixed methodologies (scoping review). Segawa, Tomoyuki, Baudry, Thomas, Bourla, Alexis et al. (2019) Virtual Reality (VR) in Assessment and Treatment of Addictive Disorders: A Systematic Review. Frontiers in neuroscience 13: 1409 [ PMC free article : PMC6965009 ] [ PubMed : 31998066 ] - Population Studies included in this review included populations with other addictions. Smith, D.P., Dunn, K.I., Harvey, P.W. et al. (2013) Assessing Randomised Clinical Trials of Cognitive and Exposure Therapies for Gambling Disorders: A Systematic Review. Behaviour Change 30(3): 139–158 - Publication date Studies included in the review were prior 2000 Smith, David P, Fairweather-Schmidt, A Kate, Harvey, Peter W et al. (2018) How does routinely delivered cognitive-behavioural therapy for gambling disorder compare to “gold standard” clinical trial?. Clinical psychology & psychotherapy 25(2): 302–310 [ PubMed : 29226494 ] - Study design Not a systematic review Soyata, Ahmet Zihni, Aksu, Serkan, Woods, Adam J et al. (2019) Effect of transcranial direct current stimulation on decision making and cognitive flexibility in gambling disorder. European archives of psychiatry and clinical neuroscience 269(3): 275–284 [ PubMed : 30367243 ] - Outcome No relevant outcome data reported Tavares, Hermano; Zilberman, Monica L; el-Guebaly, Nady (2003) Are there cognitive and behavioural approaches specific to the treatment of pathological gambling?. Canadian journal of psychiatry. Revue canadienne de psychiatrie 48(1): 22–7 [ PubMed : 12635560 ] - Study design Not a systematic review Toneatto, T. and Ladouceur, R. (2003) Treatment of Pathological Gambling: A Critical Review of the Literature. Psychology of Addictive Behaviors 17(4): 284–292 [ PubMed : 14640824 ] - Study design Not a systematic review Toneatto, Tony and Dragonetti, Rosa (2008) Effectiveness of community-based treatment for problem gambling: a quasi-experimental evaluation of cognitive-behavioral vs. twelve-step therapy. The American journal on addictions 17(4): 298–303 [ PubMed : 18612885 ] - Study design Non-randomised and there is no control for confounding Toneatto, Tony, Pillai, Sabina, Courtice, Erin Leigh et al. (2014) Mindfulness-enhanced cognitive behavior therapy for problem gambling: A controlled pilot study. International Journal of Mental Health and Addiction 12(2): 197–205 - Study design Non-randomised and there is no control for confounding Tse, S., Campbell, L., Rossen, F. et al. (2013) Face-to-Face and Telephone Counseling for Problem Gambling: A Pragmatic Multisite Randomized Study. Research on Social Work Practice 23(1): 57–65 - Population Included people aged <18 years of age. Yakovenko, Igor and Hodgins, David C (2021) Effectiveness of a voluntary casino self-exclusion online self-management program. Internet interventions 23: 100354 [ PMC free article : PMC7779774 ] [ PubMed : 33425687 ] - Outcome No raw data presented, only results of statistical analysis. Yakovenko, Igor, Quigley, Leanne, Hemmelgarn, Brenda R et al. (2015) The efficacy of motivational interviewing for disordered gambling: systematic review and meta-analysis. Addictive behaviors 43: 72–82 [ PubMed : 25577724 ] - Duplicate Includes duplicates. Individual studies included in this review have been checked and included if they meet our protocol criteria. Zack, Martin, Cho, Sang Soo, Parlee, Jennifer et al. (2016) Effects of High Frequency Repeated Transcranial Magnetic Stimulation and Continuous Theta Burst Stimulation on Gambling Reinforcement, Delay Discounting, and Stroop Interference in Men with Pathological Gambling. Brain stimulation 9(6): 867–875 [ PubMed : 27350401 ] - Comparator No comparator Zucchella, Chiara, Mantovani, Elisa, Federico, Angela et al. (2020) Non-invasive Brain Stimulation for Gambling Disorder: A Systematic Review. Frontiers in neuroscience 14: 729 [ PMC free article : PMC7461832 ] [ PubMed : 33013280 ] - Study design Mixed study design included in systematic review [cross-over studies [6/11 studies], observational studies [5/11 studies]). For cross-over studies, results not presented separately for initial experimental stage. Excluded economic and utility studies Table 100 Excluded economic and utility studies and reasons for their exclusion View in own window Study Code [Reason] Economic studies ACTRN12620000279921 (2020) A randomised control trial comparing face-to-face with online problem gambling treatment. https://trialsearch ​.who ​.int/Trial2.aspx?TrialID ​=ACTRN12620000279921 - Economic study protocol DRKS00015314 (2018) Efficacy and cost-effectiveness of an internet intervention for internet use disorder: a randomized controlled trial. https://trialsearch ​.who ​.int/Trial2.aspx?TrialID=DRKS00015314 - Economic study protocol Utility studies Bonfils, Nicolas A, Aubin, Henri-Jean, Benyamina, Amine et al. (2019) Quality of life instruments used in problem gambling studies: A systematic review and a meta-analysis. Neuroscience and biobehavioral reviews 104: 58–72 [ PubMed : 31271803 ] - Systematic review of HRQoL studies - primary studies checked for eligibility for utility review Browne M, Greer N, Rawat V, Rockloff M (2017) A population-level metric for gambling-related harm. International Gambling Studies 17(2): 163–175 - No preference-based measure used directly or via mapping; health states described using vignettes. Disability weights reported Browne, Matthew, Rawat, Vijay, Newall, Philip et al. (2020) A framework for indirect elicitation of the public health impact of gambling problems. BMC public health 20(1): 1717 [ PMC free article : PMC7670710 ] [ PubMed : 33198709 ] - Methodological paper - no utility data reported Kohler, D. (2011) Assessing the intangible costs of gambling addiction using a health utility index. Journal of Mental Health Policy and Economics 14(suppl1): 15–s16 - Utility study - abstract only. Full study reported in Kohler et al., 2014, which has been included in the review Appendix K. Research recommendations – full details Research recommendations for review question: What is the effectiveness of psychological and psychosocial interventions for people who participate in harmful gambling (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? K.1. Research recommendation (PDF, 147K) K.2. Research recommendation (PDF, 150K) K.3. Research recommendation (PDF, 184K) K.4. Research recommendation (PDF, 182K) Appendix L. Network meta-analysis report from the NICE Guidelines Technical Support Unit (TSU) Network meta-analysis report from the NICE Guidelines TSU for review question: What is the effectiveness of psychological and psychosocial interventions for people who participate in gambling that harms (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? (PDF, 925K) Appendix M. Threshold analysis report from the NICE Guidelines Technical Support Unit (TSU) Threshold analysis report from the NICE Guidelines TSU for review question: What is the effectiveness of psychological and psychosocial interventions for people who participate in gambling that harms (including those with comorbid conditions such as depression, anxiety and other substance-use disorders)? (PDF, 384K) Final Evidence review underpinning recommendations 1.5.12 to 1.5.15 and recommendations for research in the NICE guideline Developed by NICE Disclaimer : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties. NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government , Scottish Government , and Northern Ireland Executive . All NICE guidance is subject to regular review and may be updated or withdrawn. Copyright © NICE 2025. Bookshelf ID: NBK612822 PMID: 40127168 Share Views PubReader Print View Cite this Page Psychological and psychosocial treatment of harmful gambling: Gambling-related harms: identification, assessment and management: Evidence review F. London: National Institute for Health and Care Excellence (NICE); 2025 Jan. (NICE Guideline, No. 248.) PDF version of this title (4.8M) In this Page Psychological and psychosocial treatment of harmful gambling Appendices Other titles in this collection NICE Evidence Reviews Collection Related NICE Guideline NICE NG248: Gambling-related harms: identification, assessment and management Supplemental NICE documents Methods (PDF) Glossary and abbreviations (PDF) Related information PMC PubMed Central citations PubMed Links to PubMed Similar articles in PubMed Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. [Health Technol Assess. 2020] Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Leaviss J, Davis S, Ren S, Hamilton J, Scope A, Booth A, Sutton A, Parry G, Buszewicz M, Moss-Morris R, et al. Health Technol Assess. 2020 Sep; 24(46):1-490. 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