Gambling-related suicidality: stigma, shame, and neglect

The relationship between gambling and suicidality is now more apparent than ever. In The Lancet Public Health, Heather Wardle and Sally McManus1Wardle H McManus S Suicidality and gambling among young adults in Great Britain: results from a cross-sectional online survey.Lancet Public Health. 2021; 6: e39-e49Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar provide an important addition to a growing body of literature on this important and greatly worrying issue. The factors that might lead many people to gamble are also likely to have been exacerbated this year by the COVID-19 pandemic and consequent economic recession, with further possible consequences for public health. Gambling has been shown to be strongly associated with comorbid mental health issues, particularly among young people who gamble on the internet.2Petry NM Weinstock J Internet gambling is common in college students and associated with poor mental health.Am J Addict. 2007; 16: 325-330Crossref PubMed Scopus (98) Google Scholar The extent to which comorbid mental health problems are caused by harmful gambling, or vice versa, is not entirely clear, although such associations are broadly evident.3Cook S Turner NE Ballon B et al.Problem gambling among Ontario students: associations with substance abuse, mental health problems, suicide attempts, and delinquent behaviours.J Gambl Stud. 2015; 31: 1121-1134Crossref PubMed Scopus (47) Google Scholar, 4Erickson L Molina CA Ladd GT Pietrzak RH Petry NM Problem and pathological gambling are associated with poorer mental and physical health in older adults.Int J Geriatr Psychiatry. 2005; 20: 754-759Crossref PubMed Scopus (78) Google Scholar However, it now appears that gamblers who report high-risk gambling behaviours are at increased risk of suicidality.1Wardle H McManus S Suicidality and gambling among young adults in Great Britain: results from a cross-sectional online survey.Lancet Public Health. 2021; 6: e39-e49Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar Despite the scarcity of data related to the role of gambling in suicides in most countries, available research now shows that the odds ratio for suicide among high-risk gamblers is substantial. A Swedish study, for example, reported a standardised mortality ratio of 15·1 for suicide among a cohort of more than 2000 people with diagnosed gambling disorder compared with the general population.5Karlsson A Håkansson A Gambling disorder, increased mortality, suicidality, and associated comorbidity: a longitudinal nationwide register study.J Behav Addict. 2018; 7: 1091-1099Crossref PubMed Scopus (45) Google Scholar Cowlishaw and Kessler6Cowlishaw S Kessler D Problem gambling in the UK: implications for health, psychosocial adjustment and health care utilization.Eur Addict Res. 2016; 22: 90-98Crossref PubMed Scopus (56) Google Scholar reported odds ratios of 4·2 for suicidal ideation, and 5·5 for suicide attempts, among high-risk gamblers in health-care settings. Importantly, recent activity by groups of experts by experience, such as Gambling With Lives, shows the widespread and devastating impact of gambling-related suicides, and the lack of effective responses from government, regulators, and industry. Although additional research is warranted, particularly involving coronial records and police reports of suicide, high-risk gambling behaviour is associated with increased risk of suicide. Although Wardle and McManus focus on a sample of young people, it is likely to also be a problem among other age groups, as has been shown previously.7Wardle H John A Dymond S McManus S Problem gambling and suicidality in England: secondary analysis of a representative cross-sectional survey.Public Health. 2020; 184: 11-16Crossref PubMed Scopus (13) Google Scholar In view of these data, it is crucial to improve screening and support services for people with gambling problems, either within primary care or in addiction treatment settings,8Dowling NA Merkouris SS Manning V et al.Screening for problem gambling within mental health services: a comparison of the classification accuracy of brief instruments.Addiction. 2018; 113: 1088-1104Crossref PubMed Scopus (28) Google Scholar and to glean a better understanding of what causes this association, including through the improvement of death-investigation systems to capture gambling-related suicides. Gambling is highly accessible in many countries, despite having previously been an activity regarded as problematic, if not unlawful. However, by the end of the 20th century, gambling had been legalised and legitimated across many high-income (and, increasingly, low-income and middle-income) countries. Legitimation of lawful gambling activity has arguably been achieved by the development of the so-called responsible gambling mantra, which has been successfully adapted in many countries to provide cover for the harm gambling imposes on communities, including in particular, disadvantaged communities. As we have argued elsewhere,9Livingstone C Rintoul A Moving on from responsible gambling: a new discourse is needed to prevent and minimise harm from gambling.Public Health. 2020; 184: 107-112Crossref PubMed Scopus (13) Google Scholar responsible gambling is not fit for purpose, given that it carries with it a message of irresponsibility and shame for those who supposedly cannot control their gambling. The idea that most people can walk away from gambling once they have spent their allotted money is pervasive in the language of so-called responsible gambling. This idea is further conveyed by the use of terminology such as so-called problem gamblers. Language is obviously among the most powerful ways in which we convey meaning. Thus, to consistently describe those experiencing high levels of harm from gambling as problem gamblers carries with it an implication of irresponsibility and social shame. It might readily be argued that the label of problem gambler is an effective and highly damaging form of stigma, which alienates those described as such, and leads to their internalisation of dangerous and unhelpful self-blame, and deep shame. If this labelling could be shown to assist in recovery from the harms of gambling, it might, conceivably, be of assistance. Sadly, it does not appear to aid recovery in this way.10Miller HE Thomas SL The problem with ‘responsible gambling’: impact of government and industry discourses on feelings of felt and enacted stigma in people who experience problems with gambling.Addict Res Theory. 2018; 26: 85-94Crossref Scopus (21) Google Scholar The normalisation of gambling, its widespread promotion, and easy accessibility, has led to substantial increases in gambling. The attendant use by governments, industry, and some researchers of concepts such as responsible gambling, and problem gamblers, could enable the avoidance of effective harm-prevention or harm-minimisation measures derived from public health principles,11Livingstone C Rintoul A de Lacy-Vawdon C et al.Identifying effective policy interventions to prevent gambling-related harm. Victorian Responsible Gambling Foundation, 2019https://responsiblegambling.vic.gov.au/resources/publications/identifying-effective-policy-interventions-to-prevent-gambling-related-harm-640Date accessed: October 13, 2020Google Scholar with revenue to gambling businesses and governments not disrupted, but substantial levels of harm externalised to populations. The consequences of not applying a public health approach are widespread, and clearly include impoverishment, entrenchment of disadvantage, relationship issues, increased criminality, exacerbation or establishment of mental health problems, and many other sequelae, including suicidality. Researchers and clinicians have an important part in modifying approaches to prevent and reduce harm from gambling. Avoiding industry-developed concepts such as responsible gambling, and not labelling people as problem gamblers, is a good start. Neither of these concepts are naturally occurring; both are artefacts of a highly effective system of stigmatisation that has provided cover for the massive profitability of industries that, as currently regulated and licensed, impose substantial harm on vulnerable populations. Those of us who work in public health have a duty to identify issues undermining public health, and to develop effective preventive measures that will address these issues. Wardle and McManus have contributed towards the first of those duties. Changing the way we conceive and speak of the harms of gambling should be our next priority. We declare no competing interests. Suicidality and gambling among young adults in Great Britain: results from a cross-sectional online surveyProblem gambling appears to be associated with suicide attempts in both young men and young women. This association persisted after adjusting for anxiety, impulsivity, life satisfaction, and other factors, which suggests that other mechanisms, such as the severity and multiplicity of harms experienced, or gambling to cope with life stressors, might underpin this relationship. Young people with problem-gambling behaviours should be considered at risk for suicidality. Full-Text PDF Open Access

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