INTRODUCTION

There is little research in the area of problem gambling and suicide. The research that has been undertaken has been from the perspective of screening those who present for treatment in respect of their gambling problem and identifying the proportion of these who have either considered suicide or made a suicide attempt. Studies investigating suicidality in treatment populations establish strong links. The Australian Productivity Commission (1999) in tabling evidence from the literature on suicide thoughts and attempts among problem gamblers report figures of between 4 percent to 31 percent attempted and 17 percent to 80 percent who had suicidal ideation.

While some general population studies have been undertaken investigating the links between reported suicidal thoughts and pathological gambling it would seem that no research has resolved to determine what part problem gambling plays for those presenting to hospital following deliberate self-harm.

Further to this a study by Ciarrocchi (1987) noted that clients dually addicted to gambling, alcohol and/or drugs were at a greater risk of suicide. He reported that 100 percent of chemically dependent pathological gamblers were diagnosed with major depression and of those 42 percent had made a serious suicide attempt. This was five times the frequency of the chemically dependent group alone. While this particular study was again undertaken within a treatment population it would seem important to investigate whether an alcohol and/or drug problem was likely to coexist when a gambling problem was identified in investigating a population who present to hospital following deliberate self harm. In addition the seriousness of the attempt requires investigation to determine the association between problem gambling, chemical dependence and deliberate self-harm.

New research is investigating the association between problem gambling and suicide attempts and the role of alcohol in this from the perspective of screening those who present at emergency departments following an episode of deliberate self-harm for problem gambling and alcohol misuse.

SUICIDE IN NEW ZEALAND

Suicide trends in New Zealand show an upward trend overall with an increase of 72% for the male suicide rate from 1978 to1998 although the female rate has in fact decreased by 14% over the same time period (NZHIS, 2001). This places New Zealand males with the second highest suicide rate in the world behind Finland. Deaths for Maori by suicide accounted for 18% of the total indicating an over representation. The most common method of suicide for both males and females is hanging with this accounting for over 40% of suicides in 1997 (NZHIS, 2001).

The statistics for suicide attempts or deliberate self-harm indicate that this is a different group. The most recent figures for hospitalisation for self-inflicted injury are 1999/2000 in which there were 1389 male hospitalisations in New Zealand and 2378 female hospitalisations, indicating a ratio of almost 1:2 male to female (NZHIS, 2002). It is important to note that there is not accurate data on all suicide attempts as records are only kept on those who are admitted to hospital or seen as day patients for longer than three hours.

SUICIDE AND PROBLEM GAMBLING

The research that has emerged in this area has spread across many layers, from a societal level, attempting to for example determine the impact of casinos on suicidality in a region, to general population studies, to studies of those in treatment and finally analysis of individual gambling related suicides. No previous research has attempted to identify the incidence of problem gambling in those who have either attempted or completed suicide.

The Australian Productivity Commission (1999) in their report on Australia’s Gambling Industries attempted to estimate gambling related suicides for the population of Australia and appear to have taken a considered approach to this. They investigated case studies of individual gamblers and surveys of problem gamblers both in treatment and as identified as part of a general population. It was commented that it is probable that a proportion of suicides of problem gamblers reflect wider problems and may have occurred anyway, but equally many suicides may be misdiagnosed as car accidents, drowning, or other forms of death. The Commission using epidemiological evidence determined a figure at around 400, but acknowledged that this was probably an overestimate and that the figure was probably between 40 and 400 a year. Their concluding comment was that there is little doubt that suicides are linked to gambling.

Studies investigating suicidality in treatment populations establish strong links, as would be expected. A study by Sullivan (1994) in New Zealand stated that over 80 percent of problem gamblers reported suicidal ideation as a solution to their gambling problems during the first twelve months operation of a Gambling Problem Hotline. While it might be expected that a new, potentially anonymous service may attract those with the most serious of problems in the initial phase it highlights the way in which those with serious gambling problems identify suicide as a solution.

A further way of approaching and understanding the link between gambling and suicide is by psychological autopsy. Blaszczynski and Farrell (1998) undertook an analysis of completed gambling related suicides and evidenced that almost a third had previously attempted suicide, and one in four had sought mental health assistance for their gambling problem. This descriptive study highlights the overlap between gambling, psychiatric disorders, as well as other life problems and suicide. It also may suggest that there is an important link between problem gambling and serious suicide attempts.

SUICIDE, PROBLEM GAMBLING AND ALCOHOL MISUSE

While the exact role of alcohol in suicide is also unclear, a strong association certainly exists. Welte et al (1988) and Berkelman et al (1985) report that between 18% and 66% of suicide victims have alcohol in their blood at the time of death. A clear connection also exists between alcohol and gambling problems with Crockford and el-Guebaly (1998) finding in a review of the literature that rates of lifetime substance abuse disorders among pathological gamblers ranged from 25-63 percent. The connection of both of these together with suicide has however not been clearly investigated.

Beautrais et al (1996) determined in their study that the risk of a suicide attempt increased with increasing psychiatric morbidity, and that subjects with two or more disorders had odds of serious suicide attempts that were 89.7 times the odds of those with no psychiatric disorder. Pathological gambling, a diagnosable psychiatric disorder under DSM-IV in itself is often seen with other psychiatric disorders, notably depression and substance misuse. This indicates therefore that this is a group of clients who are significantly at risk. Blaszczynski and Farrell (1998) comment that given that these variables of major depression, alcohol and substance abuse, and marital dysfunction which are considered risk factors for suicide in both the general population and among psychiatric patients, it is surprising that only a few studies have investigated risk factors associated with suicide in populations of pathological gamblers.

While there has been research undertaken as outlined previously, attempting to understand the connection between problem gambling and suicidality this has not been from the perspective of identifying problem gambling as a factor in either those who have attempted suicide or those who have completed. Further, while there has been a considerable body of work on the connection between alcohol and suicidality, problem gambling has never been taken in to account as a part of the equation that may contribute to a suicide attempt and particularly the seriousness of a suicide attempt.

THE AIMS

• To investigate the incidence of gambling problems in a population who have presented to hospital following an episode of deliberate self-harm
• To compare the prevalence rate of problem gambling identified in the study to the general population using currently available statistics in sub-groups of age, gender and ethnicity
• To investigate the affect of alcohol and gambling on the seriousness of suicide attempts

THE PROCESS

Participants in a survey to investigate the aims will be drawn from patients who present at Auckland and North Shore hospitals following an episode of deliberate self-harm. The expected number of participants is approximately 400.The gambling eight (early intervention gambling health test) screen (Sullivan, 1999) used to identify problem gamblers will be administered along with the CAGE alcohol screen and the Beck Suicidal Intent Scale (Beck et al, 1974). This information will be collected along with demographics including the preferred form of gambling.

The information accessed in this survey will enable the prevalence of gambling problems within the population of those who present to hospital following self-harm to be identified. Further to this, it will be possible to establish whether an alcohol problem has been a contributing factor in association with this. The Beck Suicidal Intent scale will also allow for the investigation of the relationship between the seriousness of the attempt and whether a gambling problem has been identified. It is expected from anecdotal evidence from counselling within the problem gambling field that this will be the case. It could in fact be deduced that those who complete suicide match well the profile of problem gamblers who present for treatment indicating that problem gambling does indeed impact upon the seriousness of the attempt. This may particularly be the case up until 1998, which are the most recent suicide statistics available, when males were also over-represented in problem gambling statistics. This picture has changed with the number of females receiving personal counselling almost quadrupling since 1997 (Paton-Simpson et al, 2001). The association of this in connection with more recent suicide statistics as they become available will require further investigation.

References

Beautrais, A., Joyce, P., Mulder, R., Fergusson, D., Deavoll, B. and Nightingale, S. (1996). Prevalence of Comorbidity of mental Disorders in Persons Making Serious Suicide Attempts: A Case-Control Study. Am J Psychiatry 153 : 8

Beck, A., Schuyler, D. and Herman, J. (1974). Development of Suicidal Intent Scales. In: The Prediction of Suicide (Beck, A., Resnik, H and Lettieri, D., eds), Charles Press, Maryland

Berkelman, R., Herndon, J., Callaway, J., Stivers, R., Howard, L., Bezjak, A. and Sikes, R. (1985). Fatal Injuries and Alcohol. American Journal of Preventive Medicine 1 () : 21-28J

Blaszczynski, A. and Farrell, E. (1998) A Case Series of 44 Completed Gambling Related Suicides. Journal of Gambling Studies Vol 14 (2) Summer

Ciarrocchi, J. (1987) Severity of Impairment in Dually Addicted Gamblers. Journal of Gambling Behaviour. 3 (1) : 2 16-26

Crockford, D. and el – Guebaly, N. (1998). Psychiatric Comorbidity in Pathological Gambling : A Critical View. Canadian Journal of Psychiatry. 43 : 43-50

New Zealand Health Information Services (2002). Suicide Attempt www.nzhis.govt.nz/stats/suicidefacts3.html 16 May

New Zealand Health Information Services (2001). Suicide Trends in New Zealand 1978-98 www.nzhis.govt.nz/publications/Suicide.html 30 May

Paton-Simpson, G., Gruys, M. and Hannifin, J. (2002). Problem Gambling Counselling in New Zealand: 2001 National Statistics. The problem Gambling Committee, April

Productivity Commission (1999). Australia’s Gambling Industries. Draft Report, Canberra. July

Sullivan, S. (1994) Why Compulsive Gamblers Are a High Suicide Risk. Community Mental Health in New Zealand Vol 7, No 2. May

Sullivan, S. (1999). The GP “Eight” Gambling Screen. Doctor of Philosophy Thesis. University of Auckland

Welte, J., Abel, E. and Wieczorek, W. (1988). The Role of Alcohol in Suicides in Erie County, NY, 1972-1984. Public Health Reports. 103(6) : 648-652