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1 Copyright Notice This document is the property of Alberta Health Services (AHS). On April 1, 2009, AHS brought together 12 formerly separate health entities in the province: nine geographically based health authorities (Chinook Health, Palliser Health Region, Calgary Health Region, David Thompson Health Region, East Central Health, Capital Health, Aspen Regional Health, Peace Country Health and Northern Lights Health Region) and three provincial entities working specifically in the areas of mental health (Alberta Mental Health Board), addiction (Alberta Alcohol and Drug Abuse Commission) and cancer (Alberta Cancer Board).

2 Problem gambling, mental health and suicide A literature review August 2009

3 Problem gambling, mental health and suicide A literature review August 2009

4 Alberta Health Services Addiction and Mental Health Prepared by 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.

5 Table of contents Executive summary...5 Introduction...7 Methods...8 Limitations... 8 Understanding pathological or problem gambling...9 Prevalence of adult problem gambling Prevalence and patterns of youth gambling...11 Gambling and mental health: Co-morbidity...14 Suicide and mental health...15 Defining suicide Global and North American scope of suicide Understanding suicide-related behaviour Suicide and gender Mood disorders, anxiety and suicidality among adult gamblers...20 Prevalence, co-morbidity and suicide among problem gamblers Population-based rates Treatment-based rates Hospital admissions Death by suicide Gambling and suicide among youth...30 Risk factors for suicide among problem gamblers...34 Substance abuse and problem gambling Gambling and personality disorders Availability of gambling Implications...38 Prevention Future directions...39 References...40

6 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

7 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. 5

8 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. 6

9 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. 7

10 Note some of the risk factors associated with increased risk of suicidality 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. 8

11 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 9

12 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 10

13 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 Shaffer, Hall, & Vander Bilt (1999) Shaffer & Hall (2001) Welte, Barnes, Wieczorek, Tidwell, & Parker (2001) Whelan, Steenbergh, & Meyers (2007) Smith & Wynne (2002) Location North America North America United States North America Research type and participants Meta-analysis n = 119* Meta-analysis n = 146* Survey n = 2,638 Summarized data from other sources Lifetime prevalence 1.6% Level 3 3.9% Level 2 1.9% Level 3 4.2% Level 2 4.8% Level 3 (DSM-IV) 4.0% Level 3 (SOGS) 5.4% problem gambling Alberta n = 1, Previous-year prevalence 1.1% Level 3 2.8% Level 2 1.7% Level 3 2.5% Level 2 1.3% Level 3 (DSM-IV) 1.9% Level 3 (SOGS) 4.0% problem gambling 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 11

14 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. 12

15 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, % to 7.4% Level 3 9.9% to 14.2% Level Shaffer, Hall, & Vander Bilt (1999) North America Meta-analysis n = 22** 3.9% Level 3 9.5% Level 2 5.8% Level % Level 2 Shaffer & Hall (2001) North America Meta-analysis n = 32** 3.4% Level 3 8.4% Level 2 4.8% Level % Level 2 AADAC (2007) Alberta Survey n = 3, % Level 3 8.8% Level 2 Welte, Barnes, Tidwell, & Hoffman (2008) United States Survey n = 2, % Level 3 6.5% Level 2 * Lifetime and previous-year estimates are pooled. ** number of studies rather than number of participants 13

16 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. 14

17 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, that could be interpreted as communicating or suggesting that a suicide-related behaviour may occur (p. 51). 15

18 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, 16

19 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 17

20 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 narcissistic 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 experienced ideation prior to doing so. Therefore, focusing on factors that 18

21 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. 19

22 Mood disorders, anxiety and suicidality among adult gamblers One of the most dire consequences of addiction for clients, families and practitioners 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, 20

23 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, 21

24 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 22

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