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mental health
and suicide
A literature review
mental health and suicide
A literature review
Lindsey L. Krawchuk, MEd, Research Services
Citation of this source is appreciated. Suggested citation:
Alberta Health Services. (2009). Problem gambling, mental health and suicide: A literature review. Edmonton, Alberta, Canada: Author.
Table of contents
Executive summary ...5
Introduction ...7
Methods ...8
Limitations ... 8
Understanding pathological or problem gambling ...9
Prevalence of adult problem gambling ... 10
Prevalence and patterns of youth gambling ...11
Gambling and mental health: Co-morbidity ...14
Suicide and mental health ...15
Defining suicide ... 15
Global and North American scope of suicide ... 16
Understanding suicide-related behaviour ... 17
Suicide and gender ... 19
Mood disorders, anxiety and suicidality among
adult gamblers ...20
Prevalence, co-morbidity and suicide among problem gamblers ... 21
Population-based rates ... 21
Treatment-based rates ... 24
Hospital admissions ... 27
Death by suicide ... 28
Gambling and suicide among youth ...30
Risk factors for suicide among problem gamblers ...34
Substance abuse and problem gambling ... 35
Gambling and personality disorders ... 36
Availability of gambling ... 37
Implications ...38
Prevention ... 38
Future directions ...39
List of tables
Table 1. Studies of the prevalence of adult problem gambling Table 2. Studies of the prevalence of youth problem gambling
Table 3. Suicidal behaviour among problem gamblers in treatment-based studies Table 4. Factors that may increase risk of suicide among problem gamblers
Executive summary
Thoughts of suicide or suicidal behaviour may arise when people face life stressors, psychological problems or substance use problems, and when they feel that they have few coping mechanisms. Problem gamblers often face significant life stressors such as financial strain, interpersonal problems and work-related difficulties. In addition, problem gamblers often have co-existing mental health or substance use problems.
The purpose of this literature review is to investigate mental health and suicidality among both adult and adolescent problem gamblers. This review begins by providing context from the relevant literature on problem gambling in adult and youth populations. The review then focuses more specifically on mental health, suicide and problem gambling and presents risk factors for both adult and youth populations. The following are highlights from the literature review:
• The estimated prevalence of adult problem gambling is between 1.6% and 4.8% lifetime pathological gambling, and between 3.9% and 4.2% lifetime at risk for pathological gambling. The estimated prevalence of previous-year adult pathological gambling ranges from 1.1% to 1.9%. The prevalence of previous-year at-risk gambling for adults is between 2.5% and 2.8%.
• Alberta prevalence statistics for adults (2002) indicate that 67.0% are non-problem gamblers, 9.8% are low-risk gamblers, 3.9% are moderately at-risk gamblers and 1.3% are considered problem gamblers.
• The estimated prevalence of lifetime pathological gambling by youth ranges from 3.9% to 7.4%. Prevalence of lifetime at-risk gambling ranges from 8.4% to 14.2%. Estimated rates of previous-year pathological gambling range from 2.1% to 5.8%, and rates of previous-year at-risk gambling among youth range from 6.5% to 14.8%.
• In a 2005 survey of Alberta youth, the majority of youth surveyed (87.6%) were found to be non-problem gamblers, 8.8% were found to be at risk for gambling problems, and 3.6% were considered to be problem gamblers.
• The World Health Organization (WHO) has indicated that over the next 20 years, it is expected that depression will become the second leading cause of disability worldwide.
• Suicide is one of the three leading causes of death among people aged 15 to 45 and has increased by 60% over the last 45 years.
• The WHO notes that psychological disorders (especially depression and substance abuse) are related to more than 90% of suicides.
• In Canada in 1998/1999, there were 22,887 hospitalizations for attempted suicide and 3,698 people died from suicide that same year.
• The research suggests that pathological gamblers are more likely to have a variety of mental health issues, including depression and anxiety disorders, and are at increased risk of suicide.
• Among youth, significantly more problem gamblers than social gamblers and non-gamblers report suicidal ideation.
• Pathological gamblers are also at greater risk of alcohol and other substance use disorders, which are key risk factors for suicidality. • People with personality disorders tend to have a higher risk of suicidal
ideation, attempts and death by suicide, as well as self-harm. Problem gamblers have been found to be more likely to have a co-existing personality disorder.
Introduction
Issues involving mental health and addiction present some of the most difficult challenges for health-care workers, families and communities. Even more troubling to both workers and families is losing a client or a loved one to suicide. The psychological cost to the loved ones of people who die by suicide is immeasurable. Suicide is an issue with many facets that are biological, psychological, cultural, sociological, personal and philosophical in nature (Leenaars et al., 1998). People who are suicidal will experience difficulties in these areas to varying degrees, and all of these areas must be considered when dealing with each person. Often, suicidal thoughts or behaviour may arise when there are significant life stressors, psychological or substance use problems, and when the person feels that he or she has few coping mechanisms. This may often be the case for problem gamblers (Ledgerwood, Steinberg, Wu, & Potenza, 2005; Newman & Thompson, 2007; Sullivan, 1994).
People who have difficulties with gambling may experience significant stressors such as financial or occupational issues, relationship strain, and isolation. They may also experience co-existing mental health and substance use issues. The stressors that often accompany problem gambling may increase the person’s risk of suicide or suicide attempts. It has been noted that, given the sometimes fatal consequences, practitioners feel that suicidal behaviour is the most fear-provoking behaviour that a client can present with (McGlothlin, 2008). Suicidality disclosed by clients can cause mental health workers to feel emotionally paralyzed and may even cause difficulties in making clinical judgments (McGlothlin, 2008). Part of relieving some of the anxieties that practitioners may feel in dealing with gamblers who present with suicidal ideation or suicidal behaviour is to understand suicide-related behaviour among problem gamblers. To gain understanding, it is important to explore some of the mental health issues affecting problem gamblers and to investigate the nature of the relationship between gambling, suicide and mental health in this potentially vulnerable population.
The purpose of this review is to investigate the relationship between gambling and mental health, with a specific focus on suicide. Most of the published literature focuses on adults and thus the review provides a more in-depth discussion of issues related to adults; however, topics related to youth are included where there is relevant literature. This review has several goals:
• Describe problem gambling and its prevalence in adult and youth populations. • Explore some of the issues regarding suicide-related ideation and behaviour. • Focus on mental health and problem gambling, with a primary focus
on the literature on gambling and suicidality.
• Look at co-morbid disorders related to gambling and mental health, such as depression, anxiety and substance use disorders.
• Note some of the risk factors associated with increased risk of suicidal-ity among problem gamblers.
• Discuss implications for treatment, prevention and research.
Methods
Resources were obtained from the PsycINFO® and MEDLINE® electronic databases. The literature search also included searches of government websites and community mental health organization websites, and a University of Alberta library book search. Keywords used in the search strategy were suicide, depression, anxiety, mental health, substance abuse, gambling or problem gambling, and adult, adolescent or youth. Articles published since January 1985 were considered for inclusion in this review.
Limitations
• The purpose of this review is to investigate gambling, mental health and suicide in order to gain an understanding of these issues and use this knowledge to benefit practitioners. Therefore, this review considers many of the current research studies in this area but may not be a systematic or exhaustive review of all the published literature on this topic.
• Some of the studies reviewed included limited sample sizes that may not be representative of larger populations.
• This review focuses mainly on gambling and suicide in a North American context, and may not accurately represent the situation in different countries or cultures.
Understanding pathological or problem gambling
Gambling can be defined as “any behaviour involving the risk of money or valuable possessions on the outcome of a game, contest, or other event in which the outcome is at least partially determined by chance” (Whelan, Steenbergh, & Meyers, 2007, p. 1). The Alberta Alcohol and Drug Abuse Commission (AADAC) has defined gambling as “any activity involving an element of chance where a person places a bet or wager. It can include purchasing lottery tickets, making speculative investments on the stock market, guessing the outcome of a sporting event, playing a casino game or betting on a horse race” (2003, p. 2). Most people can gamble recreationally and responsibly without developing gambling problems; however, for those who do develop problem or pathological gambling issues, the psychological, financial and social consequences can be devastating.
Shaffer, Hall, and Vander Bilt (1997, 1999) note that gambling-related behaviour exists on a continuum from abstinence from gambling, to severe problems, to pathological gambling. Shaffer et al. also note the number of terms used to describe the continuum of gambling problems, such as “pathological,” “probable pathological” or “compulsive” for severe problems, and “potential pathological,” “problem” or “at-risk” for less severe problems. To reduce confusion, Shaffer and his colleagues have proposed three levels of gambling behaviour. The first level includes not gambling at all, as well as recreational gambling. People in this category who gamble do so for social or recreational purposes and they do not usually exceed self-imposed monetary limits. When they choose to gamble, they usually experience little or no financial, psychological or interpersonal harm (Shaffer et al., 1997, 1999; Whelan et al., 2007).
Level 2 comprises problematic but sub-clinical levels of gambling behaviour. People at this level may be considered “problem,” “at-risk” or “potential pathological” gamblers (Shaffer et al., 1999). Whelan et al. note that people at Level 2 present with some of the markers of a gambling problem, but do not meet the full diagnostic criteria for pathological gambling as listed in the revised fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; 2000). Whelan et al. also note that Level 2 includes a wide range of people, from those who may indicate one gambling-related symptom or problem to those who have previously met the diagnostic criteria for pathological gambling but do not currently meet the diagnostic criteria. According to Whelan et al., this level encompasses people who could move to either end of the continuum or could maintain a moderate level of problematic gambling.
Level 3 gambling behaviour represents the end of the continuum (Shaffer et al., 1997, 1999). People at this level tend to have severe and persistent gambling symptoms that usually meet the DSM-IV-TR (2000) criteria for pathological gambling. People at Level 3 often have gambling problems that are chronic and that cause significant disruption to their daily functioning (Whelan et al., 2007). DSM-IV-TR (2000) diagnostic criteria for pathological gambling
involve “persistent and recurrent maladaptive gambling behaviour” (p. 674) as indicated by certain gambling-related behaviour such as being preoccupied with gambling; using increasing amounts of money for gambling to receive the same amount of enjoyment; gambling to escape personal difficulties or to reduce feelings of stress, irritability, anxiety or depression; “chasing” losses by trying to win back previously lost amounts; engaging in illegal activities to support gambling; lying to significant others about the degree of involvement in gambling; jeopardizing or losing significant aspects of the major life areas such as relationships or employment because of gambling; borrowing money from others due to financial hardships caused by gambling, or having difficulty controlling or stopping gambling.
For the purposes of this review, unless a specific reference is needed to describe a certain level of gambling, the term “problem gambling” is used as a general term to denote gambling that has gone beyond the recreational level and thus has potentially harmful consequences, whether or not the gambling has reached the pathological level. Therefore, the term problem gambling refers to any gambling behaviour that has gone beyond Level 1 or recreational gambling unless otherwise specified.
Prevalence of adult problem gambling
Several large reviews of the literature have been conducted to investigate prevalence of problem gambling among adults. There are two main ways in which rates of problem gambling are determined. The first method measures gambling behaviour in the previous year, whereas the second method measures levels of gambling behaviour over the lifetime.
Two large meta-analyses have been conducted to determine prevalence in Canada and the United States. The first was conducted by Shaffer, Hall, and Vander Bilt (1999) to estimate the prevalence of disordered gambling in North America based on the three levels listed above. The study yielded average rates of 1.1% for previous-year Level 3 gambling and 1.6% for lifetime Level 3 gambling, and 2.8% for previous-year Level 2 gambling and 3.9% lifetime Level 2 gambling. Furthermore, the researchers note that the rates had significantly increased over the 20 years prior to the study. In an update of the rates of disordered gambling in the United States and Canada, Shaffer and Hall (2001) found that the rates of Level 3 gambling among adults were 1.7% previous year and 1.9% lifetime. For Level 2, the rates of gambling were 2.5% for previous year and 4.2% for lifetime. From these two studies, it appears that there was an increase in Level 3 gambling, whereas Level 2 gambling remained relatively stable.
Welte, Barnes, Wieczorek, Tidwell, and Parker (2001) conducted a study in which 2,638 U.S. adults were surveyed regarding gambling and alcohol dependence. The prevalence of current pathological gambling was found to be 1.3% (4.8% lifetime pathological gambling) using the DSM-IV criteria and 1.9% (4.0% lifetime pathological gambling) using the South Oaks Gambling
Screen (SOGS) (Lesieur & Blume, 1987). This study demonstrates that measures used in the studies may yield different prevalence results. For instance, in one of the more recent studies, Stucki & Rihs-Middel (2007) reviewed the international research literature to determine prevalence. In addition, they compared three common ways of measuring gambling problems in adult populations—the SOGS, the Canadian Problem Gambling Index (CPGI) (Wynne, 2002), and
DSM-IV—to investigate whether prevalence differed significantly by measure. The weighted mean rates for problem gambling were 1.2% for the SOGS, 2.4% for the CPGI and 1.9 % for DSM-IV. For pathological gambling, the rates were 1.8% for the SOGS, 0.8% for the CPGI and 1.2% for DSM-IV
(Stucki & Rihs-Middel, 2007).
An Alberta prevalence study by Smith and Wynne (2002) indicated that 67.0% were non-problem gamblers, 9.8% were low-risk gamblers, 3.9% were moderately at-risk gamblers and 1.3% were considered problem gamblers. Whelan, Steenbergh, and Meyers (2007) summarized prevalence data on problem gambling among the overall North American adult population; they noted that about 5.4% (1 in 20) of the North American population had experienced gambling problems in their lifetime, and that about 4% (1 in 25) had experienced gambling problems in the previous year.
Table 1. Studies of the prevalence of adult problem gambling
Study Location Research type
and participants Lifetime prevalence Previous-year prevalence Shaffer, Hall, & Vander Bilt
(1999) North America Meta-analysis n = 119*
1.6% Level 3
3.9% Level 2 1.1% Level 3 2.8% Level 2 Shaffer & Hall
(2001) North America Meta-analysis n = 146* 1.9% Level 3 4.2% Level 2 1.7% Level 3 2.5% Level 2 Welte, Barnes,
Wieczorek, Tidwell, & Parker (2001)
United States Survey n = 2,638
4.8% Level 3 (DSM-IV) 4.0% Level 3 (SOGS) 1.3% Level 3 (DSM-IV) 1.9% Level 3 (SOGS) Whelan, Steenbergh, &
Meyers (2007) North America
Summarized data from other sources
5.4% problem
gambling 4.0% problem gambling
Smith & Wynne (2002) Alberta n = 1,804 ----9.8% low risk 3.9% moderate risk 1.3% problem gamblers * number of studies rather than number of participants
Prevalence and patterns of youth gambling
Many people assume that because youth are under the legal age to enter gambling establishments, they are not as susceptible to gambling problems. However, the research literature indicates that youth may enter gambling establishments illegally or may gamble in places other than casinos, often
within their own homes. In fact, the literature to date seems to indicate that problem gambling is more prevalent among youth than it is among adults (e.g., Shaffer & Hall, 1996; Gupta & Derevensky, 1998).
In an early study, Arcuri, Lester, and Smith (1985) found that 64% of high school students had gambled in an Atlantic City casino, even though they were under the legal age to do so. In addition, 79% of the students reported that their parents knew that they had gambled. In a 2005 survey of youth in Alberta (AADAC, 2007), it was found that among youth who reported gambling in the previous year (62.6%), the most common types of gambling reported were playing cards for money (41.3%), playing scratch tickets (35.0%), betting on sporting events (28.4%), playing bingo (19.8%) and playing other types of lotteries (13.5%). Despite the age restrictions placed on gambling, a high percentage of youth report engaging in gambling, and their choices of gambling activities are not as susceptible to age-restriction enforcement.
As with adult gambling, there have been several meta-analyses conducted to try to determine the prevalence of youth gambling. Despite the number of studies, there is some controversy about measuring prevalence of gambling in adolescents (Derevensky, Gupta, & Winters, 2003; Shaffer & Hall, 1996), particularly with regard to using criteria or measurement instruments that were designed for use with adults to evaluate problem gambling by youth. Nevertheless, efforts are made to determine rates of youth problem gambling. Shaffer and Hall (1996) conducted a meta-analysis of studies that were carried out in Canada and the United States. These studies involved about 7,770 adolescents. Shaffer and Hall attempted to determine the rates of gambling by adolescents that would correspond to the three gambling levels mentioned above: Level 1 (“non-problem” gambling), Level 2 (“at-risk” or “in-transition” gambling), and Level 3 (“pathological” or “compulsive” gambling). They found that between 77.9% and 83.0% of adolescents were at Level 1, between 9.9% and 14.2% were at Level 2 and between 4.4% and 7.4% were at Level 3. Shaffer et al. (1999) conducted a meta-analysis and found that in terms of lifetime gambling problems, adolescents had rates of 3.9% (Level 3) and 9.5% (Level 2). For previous-year gambling, the rates were 5.8% (Level 3) and 14.8% (Level 2). In an update of these figures, Shaffer and Hall (2001) conducted a meta-analysis and determined the following rates among adolescents: 3.4% (Level 3 lifetime), 8.4% (Level 2 lifetime), 4.8% (Level 3 previous year), 14.6% (Level 2 previous year), and 82.7% (Level 1 previous year). In a more recent study, Welte, Barnes, Tidwell, and Hoffman (2008) conducted a prevalence study with a sample of 2,274 youth aged 14 to 21, using an instrument modified for use with adolescents. They found the prevalence of previous-year gambling problems to be 2.1%, with another 6.5% at risk for gambling problems. In addition, they noted that 68.0% of the youth included in the study reported gambling in the previous year, and that 11.0% had gambled more often than two times per week.
In a 2005 survey of Alberta youth (AADAC, 2007) using the South Oaks Gambling Screen–Revised for Adolescents (SOGS–RA), the majority of youth surveyed (87.6%) were found to be non-problem gamblers. In addition, 8.8% were found to be at risk for gambling problems, and 3.6% were considered to be problem gamblers.
Because of the controversy in determining the prevalence of Level 3 problem gambling among youth, some have argued that the prevalence of problem gambling among youth is inflated (e.g., Ladouceur et al., 2000). Despite these potential measurement issues, the research literature indicates that youth remain at considerable risk for gambling problems (Shaffer & Hall, 1996). Whether actual rates of youth gambling are inflated or not, the prevalence of gambling behaviour among youth must be monitored closely given the potential for severe consequences.
Table 2. Studies of the prevalence of youth problem gambling
Study Location Research type
and participants
Lifetime prevalence
Previous-year prevalence
Shaffer & Hall
(1996)* North America Meta-analysis n = 7,770
4.4% to 7.4% Level 3 9.9% to 14.2% Level 2 ---Shaffer, Hall,
& Vander Bilt
(1999) North America
Meta-analysis
n = 22** 3.9% Level 3 9.5% Level 2 5.8% Level 3 14.8% Level 2 Shaffer & Hall
(2001) North America Meta-analysis n = 32** 3.4% Level 3 8.4% Level 2 4.8% Level 3 14.6% Level 2 AADAC (2007) Alberta Survey n = 3,915 --- 3.6% Level 3 8.8% Level 2 Welte, Barnes,
Tidwell, &
Hoff-man (2008) United States
Survey
n = 2,274 --- 2.1% Level 3 6.5% Level 2 * Lifetime and previous-year estimates are pooled.
Gambling and mental health: Co-morbidity
In addition to the problems directly associated with gambling, many problem gamblers often have co-existing mental health or substance use issues. When a person has two or more disorders, this is called co-morbidity (Petry, 2005). The disorders may occur independently, which would be considered lifetime co-morbidity, or they may occur at the same time, which is known as current co-morbidity (Petry, 2005). Co-morbidity is often considered to be a more general term that is used in the medical field, whereas the term concurrent disorder has been primarily used by psychiatrists to specifically refer to the co-existence of a mental disorder and an addiction problem related to substance use or gambling (Currie, n.d.). It has been suggested that “co-morbidity” be used to describe co-occurring non-addictive mental health disorders (e.g., depression and panic disorder), whereas “concurrent disorder” would refer to a mental health and addiction problem (e.g., depression and gambling) (Currie, n.d.). When the disorders co-occur, it is often difficult to understand which problem came first, and whether one caused the other. It is also often difficult to ascertain whether providing treatment for one condition would subsequently cause improvements in the co-existing condition. These are important questions that have yet to be fully answered in the research literature.
Suicide and mental health
Defining suicide
Many terms are used to describe suicide and associated behaviour. The following terms were adopted by the American Psychiatric Association (2003) and are listed in McGlothlin (2008, p. 5):
Suicide: A death that was self-inflicted and there was intent to die. The term completed suicide can be used interchangeably with suicide.1
Suicide attempt: A potentially self-injurious behaviour with a non-fatal outcome and there was intent to die. A suicide attempt may or may not result in injuries.
Aborted suicide attempt: A potentially self-injurious behaviour with non-fatal outcome and there was intent to die. The person stopped the attempt before any physical damage could occur.
Suicidal act: A potentially self-injurious behaviour with a fatal outcome and there was intent to die.
Suicide-related behaviour: Potentially self-injurious behaviour for which there is evidence that there was intent to die or a wish to use the appearance of intending to die to attain some other end. Suicide-related behaviour comprises “suicide acts.”2
Suicide threat: Any interpersonal action, verbal or non-verbal, stopping short of a directly self-harming act, which communicates or suggests that a suicidal act or other suicide-related behaviour might occur in the near future.
Suicidal ideation: Any self-reported thought of engaging in suicide-related behaviour.3
Suicidal intent: Subjective expectation and desire for a self-destructive act to end in death.
Note: From Developing Clinical Skills in Suicide Assessment, Prevention, and Treatment
(p. 5), by J. M. McGlothlin, 2008, Alexandria, VA: American Counseling Association. Copyright 2008 by American Counseling Association. Reprinted with permission.
McGlothlin (2008) notes that the more recent term “parasuicide” has gained increasing use in the literature. He indicates that this term reflects the terms “suicide attempt,” “aborted suicide attempt” or “suicide-related behaviour.” Essentially, parasuicide refers to “non-lethal yet intentional self-harm” (p. 5).
1 The terms death by suicide, died by suicide or suicide are often preferred to the term completed suicide. 2 An important addition to this definition comes from McLaughlin (2007), who notes that this is a “general term that
includes all self-inflicted life-threatening behaviour including verbal comments in which there is either clear or implied evidence that a person intended or intends to either harm or kill him or herself and which could, whether intentional or not, result in the person’s death” (p. 51).
3 McLaughlin (2007) indicates that suicide-related ideation also includes “any behaviour, whether verbal or non-verbal,
Research has indicated that a non-fatal suicide attempt is one of the strongest predictors of a fatal suicide attempt (Hirschfeld & Russell, 1997). However, McLaughlin (2007) indicates that self-harm is not the same as attempted suicide, but that those who self-harm are at a very high risk of suicide and that self-harm often follows a psychological crisis. Therefore, all self-harm should not necessarily be seen as a suicide attempt, but as an indicator that the person is experiencing extreme distress and that they are at a greater risk for suicide. Given how sensitive the topic of suicide is to family members and to suicidal people themselves, it is important that the terminology people use be as free of judgment as possible, and that it demonstrate a level of respect and understanding The term “commit suicide” is fairly common and may seem benign to most people. However, McLaughlin (2007) suggests that to loved ones of a person who has died from suicide, the term “commit” may come with connotations similar to those of “committing” a crime. In relation to self-harm, McLaughlin also recommends that the terms “deliberate” or “intentional” be used with care because they give the impression that the person should be blamed for the act. McLaughlin suggests that practitioners’ intentions are not to demonstrate a blaming attitude, but to find out why the person feels suicidal or has carried out the suicide-related behaviour. It is suggested that these terms be used with caution, care and respect.
Global and North American scope of suicide
Prior to understanding how mental health issues and suicide affect problem gamblers in particular, it is important to understand the scope of suicide and mental health issues in general. The World Health Organization indicates that five of the 10 leading causes of disabilities are related to psychological difficulties. The WHO indicates that, over the next 20 years, it is expected that depression will become the second leading cause of disability worldwide (Statistics Canada, 2003). In terms of years lost due to disability, the WHO indicates that depression is the single most important cause of disability. In addition, it is the mood disorders (e.g., depression and bipolar disorder) that are most often associated with suicide (as cited by McLean & Taylor, 1998). McLean and Taylor (1998) indicate that the most common precipitating factor for suicide is depression, which can be brought on or exacerbated by circumstances that the person finds aversive, disabling and unrelenting. Such is the situation that often arises when people experience problems with addiction, including pathological gambling.
Suicide is not a small problem. According to the WHO, approximately one million people, or 16 per 100,000, die by suicide each year worldwide. The WHO estimates that there may be as many as 20 attempts for every death from suicide (Langlois & Morrison, 2002). Suicide is one of the three leading causes of death among people aged 15 to 45, and has increased by 60% over the last 45 years (Langlois & Morrison, 2002; Statistics Canada, 2003). The WHO notes that psychological disorders (especially depression and substance abuse) are related to more than 90% of suicides (Langlois & Morrison,
2002; Statistics Canada, 2003). In Canada in 1998/1999, there were 22,887 hospitalizations for attempted suicide, and 3,698 people died from suicide that same year (Langlois & Morrison, 2002; Statistics Canada, 2003). In 2005, more than 3,700 people in Canada died from suicide (Statistics Canada, 2009). In the United States, an estimated 816,000 people attempt suicide each year, and 32,637 people died from suicide in 2005 (Kung, Hoyert, Xu, & Murphy, 2008). Given the taboo nature of suicide and mental health issues, the number of people who contemplate, attempt and die by suicide is likely to be significantly underestimated. The Canadian Association for Suicide Prevention (CASP) estimates that over 400,000 people harm themselves every year, and that the annual economic cost of suicide and suicide attempts is approximately $14.7 million (CASP, 2008). In 1998, mental disorders were the third highest source of health-care costs in Canada at $4.7 billion (Statistics Canada, 2003). The emotional cost to family and friends of a person lost to suicide is immeasurable.
Understanding suicide-related behaviour
Two critical concepts noted by McLaughlin (2007) underlie and define all suicide-related behaviour. The first is the person’s intention to die and the second is the lethality of the behaviour. Suicidal intent refers to whether or not a person intends to die at the time of the behaviour related to suicide or self-harm. McLaughlin indicates that it is often difficult for practitioners to determine the actual degree of suicidal intent because suicidal people may try to minimize the degree of the intent or may claim more intent than is actually true. Knowing the intention often helps practitioners to determine the amount of risk, but accurately determining the risk can be a challenging task (McLaughlin, 2007). In addition, people displaying suicidal behaviour may be experiencing ambivalence, which is a fairly common mind state among people experiencing suicidal ideation. The ambivalent person experiences contradictory feelings towards wanting to live or die (McLaughlin, 2007). It may be the case that people feel like they want to die to alleviate their problems or distress, but may also want to seek help for the distressing issues. People experiencing ambivalence may indicate that they do not care whether they live or die (McLaughlin, 2007). People showing ambivalence should be taken seriously because being ambivalent about life and death demonstrates that the person has at least some degree of suicidal intent; thus, ambivalence should be considered a serious type of suicidal thinking (McLaughlin, 2007). It also should be noted that a person demonstrating ambivalence about life and death is not necessarily leaning more towards death, given that the person is also likely to accept help (McLaughlin, 2007). The notion of ambivalence is an important concept for practitioners because it may offer an opportunity to assist a client in moving from a death-oriented frame of mind to a life-oriented frame of mind (McLaughlin, 2007).
The second critical concept that defines suicide-related behaviour is lethality. McLaughlin (2007) notes that unless a suicide attempt is extremely dramatic (e.g., gunshot wound), it is often difficult for practitioners to determine the lethality of a method. Therefore, regardless of the methods the person indicates
that he or she intends to use, or has used (if the person has already attempted), the health-care practitioner should attempt to determine whether the person intends (or intended) for the method to be lethal. McLaughlin suggests that any methods used (e.g., hanging, cutting, overdose) should be regarded as potentially lethal whether or not there is a greater chance of survival associated with one method than with another. Although the method someone chooses is important, it is the intention to kill themselves that should be considered of utmost importance, and any method the person indicates should be regarded as potentially lethal (McLaughlin, 2007).
Farberow and Litman (1970, as cited in De Man, 1998) indicate that suicidal people fall into three major categories. People fall into the first category of suicidal behaviour relatively rarely. These people do not explicitly share the extent of their distress to others and generally do not give warning of the intention to end their lives. These people are more likely to choose a method that is more lethal and to prepare a plan for which the possibility of intervention may be minimal. The second category is said to be far more common than the first, and involves people who are ambivalent about death. These people likely do not wish to die, but are having conflicts or difficulties they wish to settle. They may leave possibility of life or death to chance by choosing methods that are potentially lethal, but offer at least some possibility of intervention. These people generally discuss their difficulties and distress with others (Farberow and Litman, 1970, as cited in De Man, 1998). These people may not actually want to die, but feel that there may be few other options to end their troubles. In the third category is the largest group: those who do not want to die, but are in severe distress and demonstrate it through a suicidal attempt or harm to themselves. These people may choose less lethal methods, and are likely to communicate distress to others (Farberow and Litman, 1970, as cited in De Man, 1998). However, as previously mentioned, all methods are to be considered potentially lethal.
The fact that most people likely do not want to die, and indeed attempt to reach out to others, offers much hope for practitioners to make a significant impact if they implement suicide prevention strategies. It may be the case that suicidal people want to end the pain related to the negative consequences of addiction, rather than to actually end their life. People with addictions may become overwhelmed with the financial burdens or the physical and mental toll, and may feel they have little support because of relational strain or isolation associated with addiction. In addition, they may feel that they have few coping strategies to deal with stressors. Sullivan (1994) indicates that problem or pathological gambling can be isolating and can have negative effects on self-esteem, but it also has the potential to cause the development of narcis-sistic traits, which may lead gamblers to remain silent about suicide attempts for fear that the attempts may make them appear weak. As previously noted, people who do not make their suicidal intentions known are the most difficult to reach and are those who may be at highest risk for dying by suicide. It is logical to assume that a person who has attempted or died by suicide had
predict suicidal ideation may be a good approach to understanding suicide risk (De Man, 1998). Although there are likely many factors associated with suicide among problem gamblers (e.g., financial difficulties), the focus of this review is on the relationship between problem gambling, suicide risk and mental health issues.
Suicide and gender
Research suggests that boys tend to begin gambling earlier, tend to gamble more often, and are often at greater risk of developing a gambling addiction than girls (Valentine, 2008). This is particularly important because men are generally more likely than women to die by suicide (McGirr et al., 2006), but women are more likely to attempt suicide or self-harm (Kposowa & McElvain, 2006). However, male self-harm is often associated with greater suicide risk (Hawton, 2000). In addition, males tend to use more violent means of both self-harm and suicide (Hawton, 2000; Kposowa & McElvain, 2006; McGirr et al., 2006). However, teenaged girls are said to be the group most likely to be hospitalized for attempted suicide (Langlois & Morrison, 2002). Mental health issues are a significant risk factor for suicidal behaviour in both genders, but females may have a higher risk than males (Hawton, 2000; Qin, Agerbo, Westergard-Nielsen, Eriksson, & Mortensen, 2000). Females tend to be more likely to seek help for mental health issues (Hawton, 2000), which may explain why males may be more likely to die by suicide. Males tend to report more acute episodes of suicide ideation, whereas females tend to report more chronic or longer-lasting suicide ideation (MacCallum & Blaszczynski, 2003). In an investigation of individuals who died by suicide in Quebec, McGirr et al. (2006) found that females were more likely than men to have higher levels of anxiety and depressive disorders, whereas males were more likely to have current or past alcohol abuse. Women who reported abusing alcohol were less likely than males who reported abusing alcohol to meet the criteria for a depressive disorder. However, McGirr et al. note that despite the lower prevalence of substance abuse among women than among men, alcohol abuse among women should be considered a significant risk factor for suicide. Some research suggests that women with pathological gambling problems tend to be more likely to have emotional difficulties related to interpersonal relationships and are more likely to experience loneliness, depression or a history of physical abuse (Petry & Ladd, as cited in Valentine, 2008). On the other hand, men may have a greater tendency towards sensation-seeking and impulsivity, and may be more likely to have a history of alcoholism or to resort to criminal behaviour to support gambling (Petry & Ladd, as cited in Valentine, 2008).
Although men and women display differing patterns and frequency of gambling behaviour, suicide and suicide attempts, and differing levels of treatment-seeking behaviour, the distress behind any suicide ideation or attempt is likely to be profound. Thus, any suicidal behaviour by either gender should be seen as serious and potentially lethal.
Mood disorders, anxiety and suicidality among
adult gamblers
One of the most dire consequences of addiction for clients, families and prac-titioners is when a person feels like the only escape is to take his or her own life. The two most common co-morbid disorders associated with pathological gambling are depression and substance abuse (Battersby, Tolchard, Scurrah, & Thomas, 2006). As noted previously, the presence of a clinical depressive disorder is one of the most important predictors of suicide risk (McLean & Taylor, 1998). Hodgins, Mansley, and Thygesen (2006) found that when the problem gamblers in their sample reported a suicide attempt, 97.0% of the attempts were made while feeling depressed. Depression, other mental health issues and substance abuse are related to increased suicide risk even without the presence of gambling problems (Langlois & Morrison, 2002). Much of the research literature supports the notion that gambling problems often coexist with other conditions, such as substance abuse or mental health problems. For example, a study of 40 inpatient problem gamblers in Minnesota showed that 92.0% had lifetime co-morbidity of a psychiatric condition, with 54.0% listing the psychiatric condition as being current. This proportion was significantly greater than that among the control group in this study (Specker, Carlson, Edmonson, Johnson, & Marcotte, 1996). Twenty-five per cent of the problem gambling group were diagnosed with a personality disorder, but this proportion was not significantly greater than that in the control group (9.4%). Among gamblers who had major depression as well as a substance use disorder, 50.0% indicated that the substance use occurred prior to the depression. Overall, 80.0% of female gamblers and 64.0% of male gamblers had major depression, and 73.0% of women and 16.0% of men had an anxiety disorder (Specker et al., 1996). The researchers found that rates of depression in their problem gambling sample were higher than the reported rates among substance abusers (Specker et al., 1996). In this sample it was also found that 32.5% had suffered from childhood physical or sexual abuse (Specker et al., 1996). The authors suggest that physical and sexual abuse may be yet another precipitating factor in pathological gambling (Specker et al., 1996).
It is important to note that there may be a certain degree of diagnostic overlap between pathological gambling and substance, mood, anxiety and personality disorders that may account for some of the associations between disorders (Petry, Stinson, & Grant, 2005). For instance, Petry et al. (2005) present the common characteristics between substance use disorders and problem gambling. They note that the two disorders share certain features, such as impaired control, compulsivity, tolerance, and interpersonal problems. Shared characteristics can also be seen between other psychological conditions and problem gambling that may account for some of the relationships found in research. In addition, most of the data presented cannot adequately describe whether mental health issues occur prior to or as a result of gambling problems. Few studies have investigated the issue; however, one study showed that depression preceded gambling in 86.0% of the cases (McCormick, Russo, Ramirez, & Taber,
1984). Beaudoin and Cox (1999) note that some pathological gamblers report that gambling is a tactic used to alleviate a depressed mood.
As will be discussed in the next section, problem gamblers also tend to have higher rates of other psychiatric disorders such as anxiety or personality disorders. The high rates of depression and other psychiatric difficulties among problem gamblers, coupled with the detrimental effect gambling and mental illness have on financial stability and the stability of interpersonal relationships, may contribute to the risk of suicide among problem gamblers.
Prevalence, co-morbidity and suicide among
problem gamblers
There are two ways to look at the rates of co-morbid psychiatric problems among gamblers. The first is to look at how the two disorders occur in a survey of the general population (population-based). The second is to look at the co-occurrence among people who seek treatment for their problem gambling (treatment-based). Not all psychological difficulties are approached from both perspectives; thus, only data currently available can be presented. There are a limited number of studies that have investigated the relationship between youth gambling, mental health and suicide, but the few that have been conducted will be discussed.
Population-based rates
Several population-based studies have been conducted to determine the prevalence of psychiatric co-morbidity and suicidality among problem gamblers. Bland, Newman, Orn, and Stebelsky (1993) used data from 7,214 people from Edmonton, Alberta, to investigate pathological gambling and co-morbid psychiatric disorders. It was found that there was a lifetime prevalence of pathological gambling of 0.42% and the median age to begin heavy betting was 25 years (Bland et al.). For any psychological disorder (e.g., depression, anxiety, substance abuse, anti-social personality disorder), problem gamblers were 2.5 times more likely than non-gamblers to have a disorder. In this sample, 33.0% of problem gamblers met the criteria for a mood disorder (dysthymia, a milder but longer-lasting form of depression); this rate was significantly higher than that in the non-gambler comparison group (14.2%). Bland et al. also found that among the problem gamblers in their sample, 26.7% had an anxiety disorder in their lifetime, which was significantly higher than the rate among non-gamblers (9.2%). Problem gamblers were also significantly more likely than non-gamblers to have a substance use disorder (63.3% versus 19.0%), obsessive-compulsive disorder (16.7% versus 2.3%) and anti-social personality disorder (40.0% versus 3.1%). In addition, of those who met the criteria for pathological gambling, 13.3% reported attempting suicide (Bland et al.).
Using the same sample data as Bland et al., Newman and Thompson (2003) found that pathological gambling was also related to attempted suicide,
substance abuse and anti-social personality disorders, but not to major depression or panic disorder. They found that those who had attempted suicide were more likely to be female, to be relatively younger, and to have a mental disorder. However, using a regression model, Newman and Thompson found that pathological gambling was not a significant predictor of attempted suicide when they controlled for mental disorders. Their conclusion was that pathological gambling is associated with attempted suicide, but the association may be due to the common factor of mental disorders.
Cunningham-Williams, Cottler, Compton, and Spitznagel (1998) conducted a study with 3,004 adults in the United States. The researchers separated their sample into three groups: non-gamblers, recreational gamblers and problem/ pathological gamblers (Level 2–3). They found the prevalence of lifetime pathological gambling to be 0.9% with an average age of beginning to bet heavily of 21.8 years. The authors found that an increase in gambling severity was associated with an increase in the likelihood that one would meet the criteria for a psychological disorder. Specifically, they found that recreational gamblers and problem gamblers were at significantly greater risk of major depression than were non-gamblers (odds ratio 1.7 and 3.3 respectively), and that recreational gamblers were at significantly greater risk of dysthymic disorder (odds ratio 1.8). These results indicate that even if one gambles and does not experience any real consequences related to their gambling, there is still a greater associated risk for a depressive disorder. The researchers also note that, based on the age of onset of gambling problems and depression, it appears that the depression was more likely to precede problem gambling. Despite the increased risk of depression, gamblers in this study were not found to be at increased risk of suicidality.
More recently, there have been several large population-based studies to examine the relationship between gambling and suicidality. Petry et al. (2005) and Desai and Potenza (2008) analyzed data from 43,093 respondents within the United States who participated in the National Epidemiological Survey of Alcoholism and Related Conditions. Petry et al. focused on lifetime pathological gambling and its relationship to psychiatric disorders, whereas Desai and Potenza looked at previous-year less severe problem gambling, gender differences and co-morbid psychiatric disorders. Like the study by Bland et al. (1993), both studies showed the prevalence of lifetime pathological gambling to be 0.42% (Petry et al.; Desai & Potenza). Petry et al. note that although this estimate seems low as a percentage, it indicates that there are about 881,751 adults with pathological gambling problems in the United States. The extrapolated data also indicate that about 437,494 pathological gamblers will have a lifetime mood disorder, and 536,276 will have a lifetime personality disorder. With hundreds of thousands of people affected by or at risk of problems related to mental health, gambling and suicide, the strain on families, health-care systems and communities is likely to be far-reaching.
Petry et al. (2005) found that both mood disorders and anxiety disorders were prevalent among problem gamblers (49.6% and 41.3% respectively). After
controlling for socio-demographic and socio-economic characteristics, Petry et al. found that almost all mood and anxiety disorders were related to problem gambling (hypomania was the exception). Of considerable importance was the finding that pathological gamblers were eight times more likely to have experienced a manic episode in their lifetime. In terms of depression, pathological gamblers were about three times more likely to have a lifetime prevalence of either dysthymic disorder or major depression. Pathological gamblers in this study were also about four times more likely to have an anxiety disorder, with panic disorder (with and without agoraphobia) being the most strongly related to pathological gambling (Petry et al.). Desai and Potenza (2008) found that there was co-occurrence of gambling problems and depression, dysthymia, panic disorder, social phobia and generalized anxiety disorder in women but not in men. The authors found that for both sexes, mania, phobias and substance use problems occurred at significant rates among problem gamblers. Importantly, Desai and Potenza found that women who were only “at risk” for problem gambling (i.e., they met only one or two criteria for problem gambling) were more likely than men to demonstrate major depression, dysthymia, panic disorder and nicotine dependence. The authors note that these relationships cannot be interpreted as causal, but the findings may suggest that gambling problems in women may have different risks or effects than they do in men, and that different treatment considerations or approaches may therefore be needed depending on the clients’gender.
In a recent study, Newman and Thompson (2007) used data from the population-based Canadian Community Health Survey to investigate the association between problem gambling, major depression, alcohol and drug dependence, mental health care and suicide attempts within the previous year. They found the overall rate of attempted suicide to be 0.5% among this sample of Canadians. In addition, 4.3% of people who reported gambling problems within the previous year indicated a past suicide attempt. Previous-year problem gamblers were almost 3.4 times more likely to have made a suicide attempt than those who did not report previous-year gambling problems. There were other significant findings: people with major depression were 8.6 times more likely to have made a suicide attempt in the previous year than were those who did not report major depression, and people with alcohol dependence were 2.3 times more likely to have attempted suicide in the previous year.
Although the nature of the data listed above does not allow for causal conclusions or lead to greater understanding of whether mental health issues and suicidality arise before or after the onset of gambling problems, it is apparent that there is a relationship worth investigating. Kessler et al. (2008) attempted to determine whether problem gambling preceded mental health issues or arose after the development of a gambling disorder by using age-of-onset data. In their sample they found that 96.3% of people with a lifetime history of problem gambling also met the criteria for another psychological disorder within their lifetime. Anxiety disorders (with the exception of post-traumatic stress disorder), major depressive disorders, and substance abuse disorders all had
an earlier age of onset than problem gambling. Among respondents who had problem gambling coupled with another lifetime disorder, in 74.3% of cases the other disorder preceded the onset of problem gambling. The authors suggest that this pattern of problem gambling indicates that some mental disorders may be risk factors for problem gambling, and at other times may arise as a consequence of problem gambling.
Another interesting finding from this study (Kessler et al., 2008) is that 49.0% of people with a lifetime history of problem gambling indicated that they had previously received treatment for mental health or substance use problems, but none indicated that they had received treatment to address their gambling problems. These results are important for several reasons. First, it appears that mental health issues such as depression often appear prior to gambling problems, which signifies that psychological issues may be a risk factor for problem gambling or may be exacerbated by gambling. The results also indicate that people may seek assistance for mental health issues rather than for gambling problems; therefore, mental health practitioners may need to be vigilant in recognizing the warning signs of a gambling problem. Population-based surveys give an idea of the global scope of the problem, but the connections between mental health, problem gambling and suicide become even more apparent, and are perhaps more relevant to direct service providers, when these difficulties are looked at in treatment-seeking gamblers.
Treatment-based rates
Results from treatment-based studies are probably the most useful for service providers working with clients who have gambling problems. These studies demonstrate how issues of mental health operate in treatment settings and may offer the best insights on how frequently treatment clients present with mental health issues, including suicidal feelings. Awareness of the prevalence of suicidal ideation or attempts among treatment-seeking gamblers may help practitioners to be attentive to some of the warning signs or risk factors among their clients.
In general, studies of treatment-seeking gamblers demonstrate that suicidality is fairly prevalent. In a study of callers to a gambling crisis hotline in New Zealand, 80.0% reported thinking that suicide was a possible solution to their gambling problem; 17.0% of these reported that they had a suicide plan and 4.0% reported a recent attempt at suicide (Sullivan, 1994). In a similar, more recent study, Ledgerwood et al. (2005) analyzed the data from 986 gamblers who called a U.S. helpline. Of the gamblers calling the helpline, 25.6% indicated gambling-related suicidality. Of the gamblers who reported previous gambling-related suicidality, 21.5% reported that they had made a previous suicide attempt related to their gambling. Callers with a history of suicidality were more likely to be in financial debt, including credit debt and debt to friends and family. They were also more likely to report family problems, financial problems, legal problems, and depression or anxiety than were those with no
history of suicidality. The gamblers with a previous history of suicidality were also more likely to have previously attempted treatment for alcohol or mental health issues. Among the gamblers calling the helpline, those who reported a suicide attempt related to their gambling were more likely than suicidal callers who had not previously attempted suicide to report problems with lottery gambling, gambling-related arrests or illegal behaviour, and alcohol or other drugs. They were also more likely to have sought treatment for substance use or mental health problems (Ledgerwood et al.).
Frank, Lester, and Wexler (1991) surveyed people attending Gamblers Anonymous and found that 48.0% of their sample had contemplated suicide and that 13.0% had previously attempted suicide. In their sample, gamblers who reported having been suicidal also tended to report that they had gambled at an earlier age, were more likely to be divorced or separated, and were more likely to have stolen money because of gambling. Frank et al. also found that the gamblers were more likely to have family members with substance use disorders. A promising finding of this study was that gamblers who had been suicidal were more likely to seek help at an earlier age than were those who indicated no previous history of suicidality.
In a study by Beaudoin & Cox (1999) of treatment-seeking gamblers, 50.9% had contemplated suicide in the year prior to the study. Of those who had suicidal ideation, 15.8% had made a suicide attempt within their lifetime and 5.3% had made a suicide attempt in the previous year. Among the gamblers in this study who reported that they had been suicidal, 68.6% reported that the suicidal ideation was caused by gambling related-problems.
Petry and Kiluk (2002) attempted to investigate the differences between outpatient treatment-seeking gamblers who had no suicide ideation, those who had suicidal ideation alone, and those who had attempted suicide. Gamblers with suicidal ideation or suicide attempts were more likely to have received treatment for alcohol or other drug problems. Those without suicide ideation had spent less money in the 30 days prior to treatment entry and had lower bankruptcy rates than the suicidal individuals did. Cravings or urges to gamble were significantly higher for suicidal gamblers, and these gamblers were more likely to have previously obtained treatment for their gambling problems. In terms of psychiatric difficulties, Petry and Kiluk found that suicidal gamblers were less likely to be satisfied with their current marital or living situations, had more days in conflict and had more days with psychiatric problems over the previous month. Those who had suicidal ideation or suicide attempts were more likely to have experienced problems with depression, anxiety, understanding or memory, and violent behaviour, and were more likely to have had suicidal ideation or an attempt within the previous month. Petry and Kiluk note that of 75 clients for whom they had data on the dates that the suicidal ideation occurred, all but one indicated that the suicidality came after the onset of their gambling problems.
MacCallum and Blaszczynski (2003) conducted interviews with 85 gambling treatment inpatients in Australia and found that 36% indicated a history of suicidal ideation that was associated with their gambling. The researchers found that the best predictors of a suicide attempt were anxiety, depression, loss of an interpersonal relationship, alcohol or other drug abuse, or difficulty maintaining employment. Gamblers experiencing suicidality also had higher scores on measures of depression. Forty-two percent of the gamblers who reported suicidal ideation also reported that they had a specific suicide plan. Males were more likely to choose more lethal methods, whereas females tended to choose less violent means. Those who had a suicide plan had a stronger ideation than did those without a plan. About one-third (35%) of the people who reported suicidal ideation had prepared materials such as arranging caregivers for their children or writing a suicide note. Four of the participants in this study had a previous gambling-related suicide attempt: three of these individuals’ injuries were severe enough to require medical assistance, and the other sought psychological assistance. Overall, the researchers found that depression and self-control were predictive of suicidal ideation, and that depression, martial discord and legal problems were predictive of suicidal behaviour.
Kausch (2003) conducted a study with gamblers attending a treatment centre for veterans in the United States. Of these gamblers, 39.5% indicated that they had made an suicide attempt in their lives; the most common methods used in the attempts were overdose followed by carbon monoxide poisoning. Of those who reported a suicide attempt, 64.0% indicated that the attempt was related to their gambling. In this study, 60.0% of the gamblers had a history of alcohol abuse and 39.0% had a history of other drug abuse. Of the gamblers who reported that their suicide attempt was related to gambling, 63.0% had a history of alcohol or other drug abuse. Those with drug dependence were more likely than those without to report a suicide attempt. Interestingly, 93.0% of those who reported that their suicide attempt was not related to gambling had a history of alcohol or other drug abuse. In addition, all (100%) of the gamblers in this study who had attempted suicide had a psychiatric diagnosis, and 73.0% had a history of substance abuse problems. Although the findings demonstrated that suicide attempters were more likely than non-attempters to have a psychiatric diagnosis, there was no specific diagnostic category (including depression) that was more common in suicide attempters than in non-attempters. Suicide attempts were found to be significantly related to severity of psychiatric problems and also to family problems. These findings demonstrate that although depression is often hypothesized to be a major contributor to suicidality, other mental health conditions are often significant contributors to suicidality among gamblers. Similarly, Battersby et al. (2006) found that 30.0% of their sample of pathological gamblers had previously attempted suicide. Of all the gamblers in this sample, 49% had clinical depression. Gambling severity, higher debt and alcohol dependence were predictive of a greater tendency towards suicidality in this study. Battersby et al. indicate that “the suicidal ideation and behaviour of
people with pathological gambling appears to be of the magnitude of depression and schizophrenia” (p. 242).
Table 3. Suicidal behaviour among problem gamblers in treatment-based studies
Study Location and participants Suicidal ideation Suicide attempt
Sullivan (1994) callers to a gambling hotline in New
Zealand 80.0% 4.0%
Ledgerwood, Steinberg, Wu, & Potenza (2005)
986 callers to a gambling hotline
in the U.S. 25.6% 21.5%
Frank, Lester, & Wexler (1991) 500 members of Gamblers Anonymous in the U.S. 48.0% 13.0%
Beaudoin & Cox
(1999) 57 treatment-seeking gamblers in Manitoba 50.9% 5.3% Petry & Kiluk
(2002) 342 treatment-seeking gamblers in the U.S. 32.0% 17.0% MacCallum &
Blaszczynski
(2003) 85 inpatient gamblers 36.0% 5.0%
Kausch (2003) 114 gamblers attendinga veterans’ treatment
centre --- 39.5%
Battersby, Tolchard, Scurrah, & Thomas (2006)
43 gamblers attending a treatment centre
in Australia 81.4% 30.2%
Hospital admissions
Another important way to study gambling and suicide is by investigating all hospital admissions for suicide attempts and determining how many patients screen positive for gambling problems.
Penfold, Hatcher, Sullivan, and Collins (2006a) administered a gambling screen to 70 people admitted to hospital after a suicide attempt. This sample consisted of 64% females and 36% males. It was reported that 39% of these people had attempted suicide more than once in the past. The results of the problem gambling screen indicated that 17.0% of these people met the criteria for a potential gambling problem, with 75.0% of these having scores that would be considered indicative of pathological gambling. This study also showed that 50.0% of those who were found to have potential gambling problems had a previous suicide attempt, and that 91.0% of those attempts were related to drug overdose. Also, 58.0% of those who screened positive for problem gambling had been treated for psychiatric problems. The results of this study cannot be used to determine with any certainty that gambling is a predominant factor in suicide attempts, but the finding that one in six suicide attempters screened positive for gambling problems does offer important information for hospital workers and other health-care staff treating problem
In a second part to this study, Penfold et al. (2006b) investigated data collected from 70 people hospitalized for suicide attempts, including the gambling screen results (described above), the seriousness of the suicide attempt, and results from an alcohol abuse screen. Those who had screened positive for gambling problems were significantly more likely to be abusing alcohol than were those who screened negative, but they were not more likely to have alcohol involved in their current suicide attempt or to have obtained alcohol treatment services in the past. An important finding was that although the people had been referred to other services to address specific needs related to the suicide attempt, none of those who screened positive for gambling problems was referred for gambling treatment.
Death by suicide
In a unique study of suicides among gamblers, Blaszczynski and Farrell (1998) investigated the case records of people who died by gambling-related suicide. This study is important because it provides insight into the lives of gamblers who actually come to a point at which they decide to escape the pain and consequences of their addiction by taking their own lives. Because of the rarity of this type of study and the potential insights it can provide, it will be presented in greater depth.
This study is rare because often when a coroner investigates suicides, the motivation leading to the suicide is not always known or recorded (Blaszczynski & Farrell, 1998). Blaszczynski & Farrell analyzed 44 deaths by suicide (comprising 39 males and five females) in which the coroner noted that the person had a gambling problem. This study offers insights into the types of behaviour that are both risk factors for suicide and characteristics of suicidal gamblers. The authors note that loss of control and chasing losses are likely to lead gamblers to experience repetitive stressors, which in turn may lead to or exacerbate feelings of depression and suicide. It is important, however, to note that problem gambling was listed only as a factor that was present in the lives of these people who died by suicide. The authors note that the conclusion should not be drawn that gambling was the only, or even the strongest, contributing factor to the suicide.
Blaszczynski & Farrell found that 16% of the suicide notes left by the people mentioned specifically that there was a difficulty with pathological gambling. (An additional suicide note mentioned that financial problems related to gambling were a factor leading to the suicide.) In the other cases, a relative or mental health professional indicated that gambling was a significant problem in the person’s life. It was also apparent from the coroner’s report that several |of the people (31.8%) had pre-morbid mental health or substance abuse problems. Blaszczynski & Farrell found that 13.6% of the individuals had been described as heavy drinkers, 6.8% were reported to have had alcohol and other drug problems in the past, and 4.5% were reported to be current drug users at the time of their death. Blaszczynski and Farrell also note that seven (15.0%) of the people were found to have elevated blood alcohol levels at the time of
death. The authors concluded that although alcohol use was a risk factor for dying by suicide, it appears that it is only a factor in a small number of these gambling-related suicides.
Suicide attempters are often at greater risk for death by suicide. In the study by Blaszczynski & Farrell, approximately 32% of the people who died by suicide had previously attempted suicide, many with repeated attempts. Three of the people had indicated suicide ideation to another person before their death. From the coroners’ reports in this study, indications emerge about some of the stressors that may have been present for the gamblers in the time leading up to their deaths. For example, the coroners’ reports for all the people indicated that each had at least some degree of financial difficulty. An exact amount of debt was not listed in all cases, but some of the reported losses were $13,000 over nine months, $30,000 over several years and $50,000 in a single year. One person appeared to have withdrawn about $10,000 within the previous few weeks, and individuals close to this person reported that he often lost about $1,000 per day. It was also reported that three people had declared bankruptcy, and two had to sell their houses as a result of the gambling behaviour (Blaszczynski & Farrell). Other stressors present prior to the suicides were relationship difficulties (34%) and work-related issues (9%). Three people had recently experienced the death of a loved one. Eight people had previous difficulties with illegal behaviour to support gambling habits, including stealing from a partner or employer, or committing fraud. Some of the deceased people’s relatives and friends described them as having a tendency to experience loneliness, depression, introversion and low self-esteem (Blaszczynski & Farrell). The authors indicate that perhaps the greatest risk for suicide may be after a serious loss, and when there may be a revelation of the extent of debt or of a criminal offense that was committed.
