Acceptance and commitment therapy for co-occurring gambling disorder and posttraumatic stress disorder in veterans: a narrative review

Figures & data

Figure 1. Flow chart of article screening process.

Table 1. Study characteristics.

First Author, Country, Setting	N	Age (Range, M (SD))	Gender (M/F)	Military Status	PTSD/GD diagnosis	Design, Context, Intervention, Control/Comparison, Duration	Time Point	ACT Elements	Reported Outcomes
Shirk et al. (2022), US, VA, mental health outpatient care	3	46–57	3/0	100% army, veterans. Persian Gulf and Vietnam era(s)	Not reported	Case series/feasibility study, group setting, manualised treatment, 9 weekly sessions, homework, duration 3 months.	Pre-test, post-test	Adapted MBRP	Reduced gambling behaviour (instances), cravings (impulsivity), emotional dysregulation Instances reduced from 21x – 3x per month across participants. Collectively impulsivity decreased from M = 50.7 to M = 44.3 and emotional dysregulation reduced from M = 56.3 to M = 40.0
Reyes et al. (2022), US, technology based	23	M 31.22 (5.53)	0/23	Veterans, Iraq/Afghanistan era	PTSD – DSM-5/ PCL-5	Quasi experiment, app-based delivery, daily/weekly activity engagement prompts, duration 1 month.	Pre-test, during, post-test	Mindfulness, ACT	Global PTSD scores, experiential avoidance, mindfulness PTSD – T1 to T2 M-11.61 (SD 12.71) and T3 M-27.78 (SD 14.22), p < .001. Experiential avoidance significantly improved at T3 M-7.71 (SD 6.97), p < .001 Mindfulness and PTSD symptoms were negatively significantly corelated (r = −.632)
Ramirez et al. (2021), US, trauma focused outpatient care	311	M 37.6 (8.06)	193/118	Active duty	PTSD – DSM-5/ PCL-5	Quasi experiment, group setting with 2 (60-90 min) one-to-one sessions, homework, duration 6 weeks.	Pre-test, during (weekly)	Exposure therapy combined with ACT	Global PTSD scores; PDS-5 and PCL-5, experiential avoidance. PTSD – PDS-5: M = −20.47 (SD 16.13), p < .000, d = 1.33. PCL-5: M = −18.12 (SD15.49), d = 1.19. 25.4%−28.3% (were below the PTSD clinical cut-off) Avoidance significantly reduced (M = −6.86, SD 9.30, d = 0.88)
Smith et al. (2021), US, technology based	1	Late 20s	1/0	Veteran	PTSD – DSM-5/ PCL-5	Single case study; individual ‘telehealth’ video conferencing setting, manualised treatment, 19 60-minute sessions, duration 5 months.	Pre-test, during, post-test, 1 month follow up	ACT	Global PTSD, experiential avoidance. PTSD reduced by 79%. Avoidance reduced (unreported)
Reyes et al. (2020a), US, VA, technology-based	23	M 31.22 (5.53)	0/23	Veterans, Iraq/Afghanistan era	PTSD – DSM-5/ PCL-5	Feasibility study, app-based delivery, daily/weekly activity engagement prompts, duration 4 weeks.	Pre-test, during and post-test; 4 weeks	Mindfulness, ACT	Global PTSD scores and app usability. PTSD reduced (−12.39, p < .001). App usability score – ‘excellent’ M 85.11 (SD 19.44)
Reyes et al. (2020b), US, technology-based	9	M 31.44 (not reported)	3/6	Veterans	Not reported	Feasibility study, mixed methods, daily/weekly activity app engagement prompts, in-person interviews conducted at the intention conclusion, duration 2 weeks.	Pre-test, during and post-test	Mindfulness, ACT	Global PTSD scores and app satisfaction. PTSD – deceased significantly (F = 5.08, p = .027). App satisfaction scores – ‘good’ (M 72.75) Qualitative themes elicited: instituting a sense of progression; integrating a sense of rhythm; inculcating a sense of contribution
Kelly et al. (2020), US, VA, post-service reintegration programme	1	50s	1/0	Veteran, Gulf era	PTSD – DSM-5/PCL-5 and SCID-5	Single case study, manualised treatment, 12 50-minute sessions, homework, duration 12 weeks.	Pre-test, during, post-test, 3 months follow up	Social support focused ACT (ACT-SS)	Global PTSD scores and negative thoughts PTSD – mean reduced 12.5% Cluster of negative thoughts reduced but unreported
Dindo et al. (2020), US, VA, polytrauma clinical care	42		42/0	Veterans	PTSD – DSM-IV/SCID-I	Pilot and follow-up RCT (ACT versus TAU), development and evaluation study, manualised treatment, homework, group-based, duration 3 months. TAU = psychoeducation	Pre-test, post-test, pilot measured at 2 weeks and 3 months, RCT measured at 3 months	ACT	Global PTSD scores, psychological flexibility PTSD and psychological flexibility saw non-signification reduction
Gobin et al. (2019), US, VA, multi-site clinical study	117	M 35.75 (8.1)	94/23	Veterans, Iraq/Afghanistan era	PTSD – DSM-IV/PCL-M	Secondary data study related to RTC by Lang et al. (2017) (see below). Data scrutinised for gender differences in intervention outcome.	Pre-test, post-test, 6, 9, 12 months follow up	Mindfulness, ACT	Global PTSD scores Gender difference over time (F(2,109.15) = 412, p < .05). Women had significant result (F(1,19.47) = 11.88, p < .01) PTSD – greater effect with ACT versus PCT (d = 1.20)
Wharton et al. (2019), US, VA, PTSD clinical care	21	M 54.5 (all >50)	21/0	Veterans, Vietnam era	PTSD – DSM-IV/ PCL-M	Pilot, quasi experiment, group therapy versus individual therapy, 12 weekly 60-minute sessions (individual therapy) or 90-minute session (group therapy), manualised ACT, duration 12 weeks.	Pre-test, post-test, 3 months follow up	ACT	Global PTSD scores, experiential avoidance, hyperarousal PTSD – group therapy (t(9) = 2.67, p < .05,g = 0.69). Individual therapy (t(7) = 2.42, p < .05, g = 1.24) Avoidance – group therapy (t(8) = 2.92, p < .05, g = 0.851), individual therapy (t(7) = 3.40, p < .05, g = 1.04) Hyperarousal – individual therapy (t(7) = 2.58, p < .05, g = 1.184)
Meyer et al. (2018), US, VA	43	M 45.26 (6.6)	38/5	Veterans	PTSD – DSM-5/PCL-5 and CAPS-5	Pilot, quasi experiment, 12 weekly sessions, manualised treatment, one-to-one setting, homework, duration 3 months.	Pre-test, post-test, 3 months follow up	ACT	Global PTSD, experiential avoidance PTSD – reduced (M −12.76, d = 0.96) at intervention end and at 3-month follow-up (M −12.34, d = 0.88) Experiential avoidance reduced (M −6.8, d = 0.62).
Lang et al. (2017), US, VA, multi-site clinical study	160	M 34 (8)	128/332	Veterans, Iraq/Afghanistan era	PTSD – DSM-IV/PCL-M	RCT of ACT versus PCT (person-centred treatment), manualised treatment, 12 60-minute one-to-one sessions, homework, duration 12 weeks.	Pre-test, post-test, 6, 9, 12 months follow up	ACT	Global PTSD scores. PTSD – reduced overall (d = 0.78) but no between condition differences
Shipherd et al. (2016), US, VA, mandatory post-deployment assessment/re-assessment	1524	M 28.65 (6.72)	1372/152	Activity duty	PTSD – DSM-IV/PCL-C NR	RCT comparing 4 conditions (TAU; PIT (psychoeducation)); ‘PIT + change’ (PIT + CBT); ‘PIT + acceptance’ (PIT + ACT), workshop/group face-to-face setting, 1 single session 50-60 min for ‘change’ or ‘acceptance’ or 20-30 min for PIT, duration 1 session.	Pre-test, post-test, 1 month follow up	Acceptance-based	Global PTSD scores PTSD – ‘reset’ condition outperformed TAU (p = .047, d = 0.09) and PIT (p = .021, d = 0.14). No significant difference between ‘reset’ and ‘control’
Blevins et al. (2011), US, military-base Guardsmen training	144	M 30 (9.70), control M 32.4 (8.70)	134/10	Guardsmen, Iraq/Afghanistan era	PTSD – DSM-IV/PCL	Quasi experiment, control versus ACT, workshop/group setting; 1 single two-hour session, duration 2-hours.	Pre-test, post-test, intervention group 2 months follow up, control group 4 months follow up	Acceptance-based	Global PTSD scores PTSD – reduced over time (M-4.561 (CI −8.05, −1.07), p < .05) but no significant between-group difference

Note: US, United States; VA, Veteran Affairs Administration; M (SD), mean (standard deviation); OR, odds ratio; CI, confidence interval; RCT, randomised control trial; TAU, treatment as usual; ACT, acceptance and commitment therapy; ACT-SS, acceptance and commitment therapy for social support; PIT, psychoeducation; PCT, patient centred treatment; MBRP, mindfulness-based relapse prevention; DSM, Diagnostic and Statistical Manual; PTSD, post traumatic stress disorder; GD, gambling disorder; PCL, Patient Checklist; PCL-M Patient Checklist Military; PCL-C, Patient Checklist Civilian; PDS, post traumatic diagnostic scale; PSSI, post traumatic stress disorder symptom scale; SCID, I/5 – structured clinical interview for Axis I disorders/DSM; CAPS-5, clinically administered PTSD scale for DSM-5.

Table 2. Matrix of quality criteria scores for all articles based on JBI critical appraisal tools.

Article	Shirk et al. (2022)	Reyes et al. (2022)	Ramirez et al. (2021)	Smith et al. (2021)	Reyes et al. (2020a)	Reyes et al. (2020b)	Kelly et al. (2020)	Dindo et al. (2020)	Gobin et al. (2019)	Wharton et al. (2019)	Meyer et al. (2018)	Lang et al. (2017)	Shipherd et al. (2016)	Blevins et al. (2011)
Criteria
Demographics described	3	3	3	3	3	3	3	3	3	3	3	3	3	3
Participants history described	3	3	3	1	3	3	3	1	3	3	1	3	1	3
Clinical condition described	3	3	3	3	3	0	3	3	3	3	3	3	3	3
Randomisation of participants described	0	0	0	0	0	0	0	1	3	0	0	3	1	0
Randomisation of others described	0	0	0	0	0	0	0	1	1	0	0	1	1	0
Randomisation was ‘blind’	0	0	0	0	0	0	0	1	1	0	0	1	1	0
Groups similar at baseline	3	0	0	0	0	0	3	2	3	2	0	3	2	2
Interventions administered similarly across groups	0	0	0	0	0	0	0	3	3	3	0	3	3	3
Interventions described adequately	3	3	3	3	3	3	3	3	3	3	3	3	3	3
Control group included	0	0	0	0	0	0	0	3	3	0	0	3	3	3
Pre and post-tests described	3	3	3	3	3	3	3	3	3	3	3	3	3	3
All groups tested identically across timepoints	0	0	0	0	0	0	0	3	3	3	0	3	3	1
Follow up completed	1	1	1	3	1	1	3	3	3	3	3	3	3	3
Outcomes measured reliably	3	3	3	3	3	3	3	3	3	3	3	3	3	3
Appropriate statistical tests used	3	3	3	3	3	3	3	3	3	3	3	3	3	3
Adverse events described	3	0	0	0	0	0	0	0	0	0	0	0	0	0
Ethics approval obtained	2	3	2	2	2	2	2	3	2	2	3	2	2	3
Informed consent described	1	3	1	1	3	3	1	3	3	2	3	3	3	3
Score	31	28	25	25	27	24	30	42	46	36	28	46	41	39

Note: Scoring: 3 = Yes, 2 = Unclear, 1 = No, 0 = Not applicable.

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