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James Donaldson on Mental Health – Suicide and attempted suicide in gambling disorder – results from a nationwide case-control study
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Adonay Kidane a
, Anna Karlsson b
, Anders Håkansson
Highlights
•Few studies have analyzed suicidal behavior in gambling disorder compared to control subjects.
•Suicidal behavior was 11 times more common in gambling disorder patients than in controls.
•Among patients with gambling disorder, comorbidities increased the risk of suicidal behavior.
Abstract
Background: Gambling disorder severely impacts the affected individual’s daily life and is considered to be a major public health issue. Gambling disorder may be a risk factor for suicidal behavior, but matched case-control studies are few. This study aims to explore suicidal behavior, and risk factors for it, among patients with GD in comparison with age- and gender-matched controls. Methods: This is a nationwide age- and gender-matched case-control study, based on all cases of gambling disorder diagnosed in Swedish specialist health care between 2005–2019. Suicidal behavior was defined as either fatal suicides or suicide attempts. Comparative statistics and multiple logistic regressions on risk factors for suicidal behavior were performed. Results: The population consisted of 10,782 individuals (78 % were men), including 3594 with gambling disorder, with an average follow-up of 4.6 years. In the gambling disorder group, 17.7 % displayed suicidal behavior, in comparison to 1.6 % of controls. Multiple logistic regression indicated a risk increase for suicidal behavior if diagnosed with gambling disorder, substance use disorders, depressive disorders, anxiety disorders, and female gender. Psychiatric comorbidity in the gambling disorder group consisted of anxiety disorders (44 %), depressive disorders (38 %) and substance use disorders (33 %). Conclusions: Suicidal behavior is elevated among individuals with gambling disorder, compared to matched controls. Findings call for further research in order to explore mechanisms and prevent suicidal behavior among patients with gambling disorder.
Introduction
Gambling Disorder (GD) is the first behavioral, non-substance-related addiction to be recognized as a psychiatric diagnosis (American Psychiatric Association, 2013) GD is characterized by a persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress (Potenza et al., 2019). GD has far-reaching negative consequences for the individual patient, but also for families and society at large. In a previous Swedish study, a cohort of GD patients displayed a 1.8-fold increase in overall mortality (Karlsson and Håkansson, 2018), and GD is clearly associated with other psychiatric comorbidities (Lorains, Cowlishaw, and Thomas, 2011). A meta-analysis from 2015 suggested that the most common comorbid disorders were mood disorders (23.1 %), alcohol use disorders (21.2 %), anxiety disorders (17.6 %) and drug use disorder (7 %) (Dowling et al., 2015). In an out-patient treatment program, 42 % of the study population had a comorbid personality disorder and 33 % were alcohol-dependent, respectively (Ibáñez et al., 2001). Results from the National Epidemiologic Survey on Alcohol and Related Conditions in the US displayed that almost three quarters of the gamblers were alcohol-dependent and 61 percent had any type of personality disorder (Petry, Stinson, and Grant, 2005).
The prevalence of problematic gambling varies among different studies but has been estimated worldwide at 0.1 to 5.8 % (Calado and Griffiths, 2016). International research concludes significant differences between men and women in prevalence and severity, with a historical ratio of approximately 2:1 (Blanco et al., 2006). Men gamble more often and to a larger extent, with higher risks and greater loss (Wong et al., 2013). Women seem to have an onset later in life and gambling problems, whereas they develop gambling problems over a faster course than men (Díez et al., 2014). Problematic gambling occurs less often in groups with high incomes and higher education (Dowling et al., 2017), and people living in disadvantaged neighborhoods with low socioeconomic status are more prone to develop problematic gambling habits (Welte et al., 2017). Moreover, impulsiveness, antisocial behavior and emotional instability are known risk factors (Welte et al., 2017). In terms of age at onset of disease, several studies suggest means between mid 20 s to late 30 s (Black et al., 2015; Blanco et al., 2006, Kessler et al., 2008).
Suicide is a complex human behavior involving biological, mental and social factors, with over 700,000 deaths per year worldwide (Organization, 2021). Risk identification, prevention and follow-up of suicide risk is complex, and involves a large number of psychiatric factors, as well as considerations related to overall health, interactions with society as a whole, and in addition, the large complexity in defining suicide and non-fatal suicidal behavior including suicide attempts (Gorecki and Brent, 2016; Favril et al., 2023).
There is previous evidence that problematic gambling may represent one of the factors in society and individual health that play a role in suicidal behavior. In 1984, McCormick et al. observed suicidal tendencies among individuals with pathological gambling (McCormick et al. 1984). In the 90 s, comprehensive epidemiological studies identified psychiatric comorbidity and suicidal behavior among gamblers in the general population to a larger extent (Bland et al., 1993;Cunningham-Williams et al., 1998). In 1998, Blaszczynski and Farrell demonstrated, using case records in an Australian sample, a clear link between pathological gambling and complete suicide (Blaszczynski and Farrell, 1998). A large, more recent, American study displayed that both suicidal ideation and suicide attempts were associated with pathological gambling (Moghaddam et al., 2015). Also, a Canadian survey study on suicide attempts, with a nationally representative sample of Canadians including almost 37,000 subjects, demonstrated a link between attempted suicide and pathological gambling (Newman and Thompson, 2007).
Reasons leading to suicide in people with GD include unemployment, financial difficulties, comorbid depression, and relational problems (Blaszczynski and Farrell, 1998). Level of gambling-related debt and significant monetary loss appear to play an important contributing role in the process underlying suicidal behavior in GD, as well as feelings of shame and guilt (Marionneau and Nikkinen, 2022). Likewise, depression, substance use disorder, cluster B personality, and ADHD are cited as risk factors of non-fatal suicide attempts in GD. Although males constitute the majority of the gambling population, female gamblers appear to have an increased risk of attempting suicide, seeming to compose an independent risk factor even when controlling for confounders (Bischof et al., 2015).
However, little or no research has been conducted regarding GD and suicidal behavior in relation to comparable large-scale control groups. For example, in the present setting, elevated rates of suicidal behavior, mainly non-fatal attempted suicide, have been demonstrated from earlier register research in the present setting, in nationwide Swedish data up to 2016, (Håkansson and Karlsson, 2020). Likewise, recently, the high prevalence of prior suicide attempts in GD patients has been clearly demonstrated (Armoon et al., 2023; Wardle et al., 2023; Chamberlain and Grant, 2024), but matched case-control research is sparse. Thus, there is need to study suicidal behavior beyond the narrower group of people dying from a complete suicide, including in larger datasets, and there is need to assess patients with GD in comparison to directly comparable control groups. Therefore, the present paper aims to explore suicidal behavior among patients with GD in comparison with age-and gender-matched controls, and whether GD itself can be considered as an isolated risk factor for suicidal behavior. A hypothesis in the design of the study is that GD predicts suicidal behavior, and the study aims to answer the following research questions: 1) How does the rate of suicidal behavior for individuals with GD in Sweden between 2005–2019 relate in comparison with age- and gender-matched controls? 2) What risk factors (age, gender and psychiatric comorbidity) mediate suicidal behavior among all individuals with GD in Sweden between 2005–2019, compared to age- and gender-matched controls?
#James Donaldson notes: Welcome to the “next chapter” of my life… being a voice and an advocate for #mentalhealthawarenessandsuicideprevention, especially pertaining to our younger generation of students and student-athletes. Getting men to speak up and reach out for help and assistance is one of my passions. Us men need to not suffer in silence or drown our sorrows in alcohol, hang out at bars and strip joints, or get involved with drug use. Having gone through a recent bout of #depression and #suicidalthoughts myself, I realize now, that I can make a huge difference in the lives of so many by sharing my story, and by sharing various resources I come across as I work in this space.#http://bit.ly/JamesMentalHealthArticle Find out more about the work I do on my 501c3 non-profit foundation website www.yourgiftoflife.org Order your copy of James Donaldson’s latest book, #CelebratingYourGiftofLife: From The Verge of Suicide to a Life of Purpose and Joy
This study is a nation-wide cohort study based on the Swedish National Patient Register (NPR) and the Swedish Cause of Death Register (CDR). Currently, more than 99 % of all specialized health care contacts (hospitalizations and out-patient specialist care) for psychiatric and physical diseases in Sweden are included in the NPR, with a positive predictive value of 85–95 % for inpatient care, and around 80 % for outpatient care (Ludvigsson et al., 2011). Missing cases can partly be led to
Results
Demographic characteristics of study subjects are displayed in Table 1. Age at the time for inclusion of the GD cohort (n = 3594) ranged from 18 to 93 years old with a median of 34 years, and a mean of 36 years. A total of 2788 of the GD cases (78 %) were male, whereas 806 (22 %) were female. As the controls were age-and gender-matched, they demonstrated similar age ranges and gender distribution. Time in study for the GD study population ranged from 0 to 14 years, with an average follow up of
Discussion
The results of this paper confirm the hypothesis that suicidal behavior in fact is clearly overrepresented in a population with GD in relation to comparable controls (17.7 % vs 1.6 %). Elevated frequency of suicidal behavior in a gambling study population is in line with existing research in the area, although levels have varied in different studies. In a previous Swedish register study, 19 % of help-seeking gamblers had a suicide attempt (Håkansson and Karlsson, 2020), and in a German sample
Conclusions
Suicidal behavior is greatly elevated among individuals with a GD diagnosis compared to age- and gender-matched controls. GD itself can be considered as an isolated risk factor for suicidal behavior, even after controlling for age, gender and common psychiatric comorbidity. Female gamblers may be at increased risk of suicidal behavior, in this population as in the general population. Findings call for earlier detection and treatment, as well as market-related policy making in the area of
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James Donaldson is a Washington State University graduate (’79). After an outstanding basketball career with WSU, he went on to play professional basketball in the NBA with the Seattle Supersonics, San Diego/L.A. Clippers, Dallas Mavericks, New York Knicks, and Utah Jazz. He also played for several teams in the European Leagues in Spain, Italy, and Greece, and he toured with The Harlem Globetrotters to wrap up his career. James was an NBA All-Star in 1988 while playing center for the Dallas Mavericks. In 2006, James was inducted into the Pac-10 Sports Hall of Fame and also the Washington State University Athletic Hall of Fame. In 2010, James was elected as a board member for the NBA Retired Players Association.
James frequently conducts speaking engagements (motivational, inspirational, educational) for organizations, schools, and youth groups.
In 2010, James was the recipient of the NBA Legends of Basketball ABC Award, awarded for outstanding contributions in Athletics–Business–Community.
He believes in being a role model for success and professionalism to the scores of young people to whom he devotes so much of his time. He currently serves on several boards and committees and is a member of many organizations.
James believes in developing relationships that create a “Win-Win” environment for everyone involved, and in being the best he can be!
For more information about James Donaldson or to request he speak at your event, contact him at:
James Donaldson is the author of “Standing Above The Crowd” and “Celebrating Your Gift of Life” and founder of the Your Gift of Life Foundation which focuses on mental health awareness and suicide prevention, especially pertaining to our school aged children and men.
If you’re interested in having James come and speak to your group of young adults, business entrepreneurs, aspiring political and community leaders, and athletic teams, please contact him at [email protected] and or leave a personal message for him at 1-800-745-3161. Keep up with him and read about how he is reaching out and making a difference in the lives of so many around the world at www.yourgiftoflife.org
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