ABSTRACT

The coexistence of alcohol misuse and problem gambling is a common association, while alcohol misuse amongst those who attempt suicide is also high. This research involved 70 patients admitted to an Auckland (New Zealand) hospital immediately following a suicide attempt. The first paper in this study identified twelve (17.1%) of these patients as being positive on the Eight problem gambling screen. Of these, 75% were also positive on the CAGE alcohol screen, compared with 31% of these patients who were negative on the gambling screen. Problem gambling patients who had attempted suicide were also more likely to be Maori (indigenous New Zealanders). The severity of the suicide attempt between the patients screened as problem gambling and those who were not problem gambling did not differ.

INTRODUCTION

Over 5000 people were hospitalised in New Zealand (population 4.1 million) for deliberate self harm in the latest published records (Ministry of Health 2005). However this number probably considerably under-estimates the extent of those seeking help because of the design of data-collection processes at Emergency Departments. Those who are treated and released within a relatively brief period, including those who have self-harmed, may not be recorded as hospital admissions.

Alcohol misuse and problem gambling have been found to commonly co-exist amongst clinical populations. Between 10%-31% of alcohol and other drug treatment populations have also been diagnosed as meeting criteria for Pathological Gambling Disorder (Lesieur, Blume & Zoppa 1986; Shepherd 1996). Crockford & el-Guebaly (1998) identified from a literature review, that pathological gambling clients had a lifetime rate of substance abuse disorders ranging from 25%-63%, while in New Zealand, up to 35% of a problem gambling treatment population were also found to be currently harmfully using alcohol (Sullivan 1997).

Alcohol consumption has been found to precede 48% of self harm episodes (House, Owens & Storer 1992) although the contribution of an inebriated state to a suicide attempt is not well understood.

Problem gambling and attempted suicide have been found to be correlated, with between 4% and 31% of problem gamblers having attempted to take their own lives (APC 1999). In the first paper of this study (reference), 17.1% of 70 patients admitted following a suicide attempt were also positive on a problem gambling screen. A small amount of research into the effects of co-existing problem gambling and alcohol abuse on suicide attempts, suggest that problem gambling and alcohol abuse may significantly increase the risk of attempted suicide (Ciarrocchi 1987; Kausch 2003)

This paper reports upon the correlation of alcohol misuse, problem gambling and degree of suicidal intent amongst those individuals who have been admitted to a hospital Accident & Emergency Department following a suicide attempt.

METHODS

Patients admitted to an Auckland hospital following a suicide attempt were invited to complete a battery of three screens: a brief gambling screen (Eight Screen; Sullivan 1999), an alcohol abuse screen (CAGE; Mayfield, McLeod & Hall 1974) and a screen to measure the seriousness of the attempt (Beck Suicidal Intent Scale; Beck, Schuyler & Herman 1974). Only one of the three screens (the gambling screen) was not part of the usual information collected from such patients, and it was estimated that the additional screen would add approximately one minute to the process.

The Eight Screen is a brief gambling screen that was originally designed to identify problem gambling amongst a general practice doctor’s patient population. It comprises eight questions covering health, emotional, cognitive and behavioural dimensions, with a score of four or more out of a possible eight indicating significant gambling problems.

The CAGE alcohol screen is a brief (four questions) screen to detect alcohol abuse and alcohol dependence. It has been widely used by health professionals over the past thirty years. A positive response to two or more of the four questions indicates an assessment for alcohol abuse is warranted. Additional information recorded was whether alcohol consumption was included in the suicide attempt, whether the patient was currently attending, or had attended in the past, an alcohol and/or other drug treatment service.

The Beck Suicidal Intent Scale is designed to quantify the seriousness of the attempt taking into account the unexpected low correlation between the medical seriousness of suicide attempts and their intention to suicide. Some patients may not intend to end their lives but rather, may be seeking to draw attention to their distress, and may have chosen a particularly lethal mode in so doing. In contrast, others may have intended death as an outcome but may have chosen a relatively low-lethal means. Therefore the level of knowledge of the likely consequences of using the particular mode of self-harm may be important in drawing a conclusion that there has been an attempt to end their life. This two-part screen identifies the factual aspects of the ‘attempt’ (obtainable from the patient or others) and secondly, the patient’s thoughts and feelings after the event. This screen takes approximately 10 minutes to complete, with a maximum score of 30 from the 15 items, and higher scores indicating a greater suicidal intent. Additional information recorded was whether these patients had made any past suicide attempts.

RESULTS

Participants compared with non-participants
One hundred and eighty-nine patients were eligible to participate in the screening and seventy patients actually participated. Reasons for non-participation were largely because the patient presented out of hours and were not asked by the reduced numbers of staff, owing to insufficient time (n=95, 80%), or they refused (n=14, 12%). There were no statistically significant differences between those who completed the questionnaires and those who didn’t with regard to age, gender, ethnicity, living arrangements, past psychiatric history, method of attempt, involvement of alcohol, whether they were a current or past client of alcohol and drug services, or the number of their past suicide attempts.

Paper one in this research (Penfold, Hatcher, Sullivan & Collins, 2006) identified one in six of the participating patients admitted to an Auckland (New Zealand) hospital following a suicide attempt, were also positives on the Eight Gambling Screen (scored four or more out of a possible of eight), with high scores (six or more out of eight) predominating.

Gambling machines were the predominant mode of gambling for the 12 patients scoring as gambling screen positives, with 10 of the 12 using this mode of gambling. Three patients used gambling machines only, with the remaining seven using more than one mode of gambling.

Gambling screen positives compared with screen negatives
Demographics and Histories
There were no differences in age, gender, living arrangements, past psychiatric history, past suicide attempts, involvement of alcohol in the attempt, and being a client with alcohol or other drug services, between those who scored positive and those who scored negative on the gambling screen.

Alcohol abuse
Those who scored as positives on the Eight Gambling Screen were more likely to be abusing alcohol, as identified by the CAGE alcohol abuse screen (logistic regression; p=.01).

However, those who were positive on the gambling screen were no more likely to be current or past clients of alcohol treatment services than gambling screen negatives, neither was there more likelihood of alcohol being involved in their current attempt (table 1).

Referral
Hospital management could refer patients to other services in order to address issues that may have contributed to their suicide attempt.

Following a review of case notes of the 12 participants who scored as positive on the gambling screen, it was noted that in only two cases was the presence of a gambling problem identified. No participant who scored as positive on the gambling screen was referred to problem gambling treatment services.

Ethnicity
The three ethnicity categories of participants who were positives and negatives on the gambling screen were compared.

Patients who identified as Maori were more likely to score as positives on the Eight Gambling Screen. In addition Maori participants were more likely to be positive on the gambling screen and be abusing alcohol.

Intent to suicide
The Beck Suicidal Intent Scale provided a measure of the seriousness of the current attempt. The level of intent to commit suicide was moderate, with no differences between gambling screen positives and negatives.

DISCUSSION

The findings that a significant proportion of individuals who present to hospital after self-harm was discussed in paper one of this project (Penfold, Hatcher, Sullivan & Collins 2006).

The role of alcohol in the suicide attempts of those with gambling problems is an important factor in both understanding processes and developing strategies to reduce risk for self-harm. Those who were problem gambling were more likely to be abusing alcohol, although no more likely to be using alcohol as part of the suicide attempt process. The high numbers identified in the study as affected by gambling combined with higher alcohol abuse suggests a possible influencing factor could exist, although no causative conclusion could be drawn from this study. The finding that problem gamblers are more common amongst those who intentionally self-harm is consistent with other studies that suggest that people who self-harm are poor at solving problems, often having run out of solutions (Pollock & Williams, 2004).

Maori who had attempted suicide were found to be more likely to be problem gamblers, and were more likely to have abused alcohol. Nearly half of those who had attempted suicide and were experiencing gambling problems identified as Maori, supporting other findings that Maori are more at risk for gambling problems (Abbott & Volberg 2000; Dyall & Hand 2003). The additional finding in this study that alcohol may be a factor in increasing the risk for attempted suicide provides support for identifying problem gambling issues in alcohol treatment services, and alcohol abuse in problem gambling treatment services, in order to reduce the risk for suicide amongst Maori seeking help from those services.

There appeared to be no relationship between the seriousness of the attempt and the presence of gambling problems. This may have been an influencing factor in the absence of notes in the clinical record of the problem gambling patients who had attempted suicide. However, the higher likelihood of gambling problems suggests it may be important to both screen for and note the presence of gambling problems as a possible factor that may influence future suicide attempts, if not the seriousness of these attempts.

The main strength of this study is that it is the first to survey a group of well-described people who present to a hospital emergency department following intentional self-harm. Research to date has been obtained from people who have accessed treatment services for gambling and who have attempted suicide (Sullivan 1994; Petry & Kiluk 2002), from analysis of general populations (National Research Council 1999) or historical autopsies of those who completed suicide, possibly influenced by their problem gambling (Blaszczynski & Farrell 1998). This research enabled information on problem gambling, alcohol misuse, and seriousness of an attempt to be obtained from people who have recently attempted suicide, and who may never seek help for gambling. These findings may therefore be more representative of those affected by gambling who attempt to end their lives than studies to date.

The fact that less than half of those who may have been eligible to participate did participate, may appear to weaken these findings. However the low completion rate may not be a major threat to the findings. There appeared to be no systematic selection of participants that would result in problem gamblers, or those who were abusing alcohol and problem gambling, or who were Maori, as being more likely to participate.

Future studies could identify the level of problem gambling in alcohol treatment services, and the proportion of these dually affected individuals who have attempted suicide. Further enquiry could be made as to whether these people were admitted to hospital as a consequence of their attempt. This alternative setting may serve to confirm the association between attempted suicide and problem gambling, for those also affected by alcohol abuse. In addition, the individual’s perception of the role or influence that the gambling problems, and their relation to alcohol abuse, would provide further important information upon which to establish strategies to reduce risk. In these proposed studies, the existence of clinical depression could be ascertained (rather than assumed) to ensure that the known correlation between depression and suicide did not confound the conclusions (The Wager 2005).

CONCLUSIONS

This study identified the high presence of problem gambling amongst people admitted to an Auckland hospital following a suicide attempt. It raises the need for screening for problem gambling at Accident & Emergency settings and the providing of options to these at-risk people to address their gambling. It also may provide evidence to hospital staff of increased risk for further suicide attempts by these people, especially if alcohol abuse is a factor. Maori, in particular, are found to have higher risk for admission to a hospital following a suicide attempt, and this higher risk may need to be addressed at other opportunities through appropriate resourcing. Further research is needed in other settings, to confirm whether these hospital-based findings generalise, and, if that is the case, to enable appropriate resources to be allocated, to assist in minimising the increased risk for self-harm.

The intensity of the suicide attempt appears not to be increased through the presence of problem gambling, however the considerably higher likelihood of attempted suicide, and also the role of alcohol abuse, are important factors to consider regarding future attempts, especially as past attempts are a strong indicator for suicide completion.

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