Dan Waugh-Regulus Partners May 2024
This is the fourth and final article in our series on attempts by state bodies to claim widespread suicide mortality associated with problem gambling. In the first three articles we demonstrated why estimates prepared by Public Health England and the Office for Health Improvement and Disparities were irretrievably flawed; we examined the conduct of PHE and OHID, including evidence of bias and inappropriate behaviour; and we considered the role played by the Gambling Commission, the Advisory Board for Safer Gambling and others in either propagating the PHE-OHID claims or withholding concerns about their reliability. We conclude by addressing the wisdom of attempts to boil down a matter as complex as suicide to any single factor.
It has long been understood that people with gambling disorder are at elevated risk of death by suicide. The DSM-5 (the American Psychiatric Association’s ‘bible’) comments on elevated rates of suicide ideation and attempts among people in treatment for gambling disorder (and makes similar observations in relation to a large number of other mental health conditions, including alcohol use disorder). Concerns in relation to gambling disorder and self-harm – and what might be done to prevent suicide by people with the disorder – are entirely valid.
It is also widely accepted that suicidality is a complex matter. In their 2016 meta-analysis of 50 years of suicide research, Franklin et al. made the following observation:
“…any individual with nearly any type of mental illness (i.e. internalizing, externalizing, psychotic, or personality disorder symptoms), serious or chronic physical illness, life stress (e.g. social, occupational, or legal problem), special population status (e.g. migrant, prisoner, nonheterosexual), or access to lethal means (e.g. firearms, drugs, high places) may be at risk for [suicidal behaviours and thoughts]. A large proportion of the population possess at least one of these risk factors at any given time, with many people possessing multiple factors.”
Understanding that people with a gambling disorder are at elevated risk of suicide is helpful when it comes to devising self-harm prevention strategies. For example, Hakansson & Karlsson (the Swedish researchers relied upon by PHE-OHID) conclude their 2020 study with the following recommendation:
“The findings call for improved screening and treatment interventions for patients with gambling disorder and other mental health comorbidity.”
It is questionable however whether studies of discrete associations between any single activity or human characteristic and death by suicide should – by themselves – be used to justify state controls on that activity. By way of illustration, a 2021 study on the prevalence of suicidal behaviour in a group of patients with behavioural addictions (Valenciano-Mendoza et al.) found:
“the highest prevalence of suicide attempts was registered for sex addiction (9.1%), followed by buying–shopping disorder (7.6%), gambling disorder (6.7%), and gaming disorder (3.0%).”
These findings may be useful for addressing risk of self-harm within population groups suffering from these mental health conditions. They do not – by themselves – justify bans on sex, shopping or playing video games. A 2017 study of young adults in England (aged 20-24 years, n=106) by Appleby et al., found that four deaths by suicide were linked to ‘gambling problems’; and this has been used to suggest that 250 deaths by suicide each year are ‘gambling-related’. The study also found that 44 of those who had died “had a reported history of excessive alcohol use. Illicit drug use was reported in 54 (51%)”; seven “were reported as experiencing problems related to being a student” (including five experiencing “academic pressures”. One might therefore estimate (using the same methodology as for gambling problems) that around 3,200 suicides are related to illicit drug use; 2,625 to excessive alcohol use; and 440 to academia. Such findings should prompt concern and policy responses; but it is questionable whether these should extend – for example – to complete bans on advertisements for beer or universities.
Some activists have called for coroners to assess, as a matter of routine, the possible involvement of gambling in deaths under investigation – the Bishop of St Albans has doggedly pursued a Private Members Bill to mandate this. At first blush it seems to be a reasonable suggestion. The problem is that it places an additional requirement on already over-burdened coroners; and risks distortion if other known factors are not also investigated with the same degree of rigour. The presence of Adverse Childhood Experiences (‘ACEs’) is a well-documented antecedent of suicide with one study (Dube et al., 2001) finding that as many as 80% of suicide cases analysed had a history of ACEs. There are also well-documented associations between relationship breakdown and self-harm. The practicality and wisdom of asking coroners to probe into every corner of the deceased’s life should be carefully considered.
Those determined to produce figures on the prevalence of gambling-related suicide should first set out a clear operationalised definition of what this term means. How is the relationship to be characterised (e.g. does the individual need to have gambled in the prior 12 months? Does he or she need to have a diagnosis of gambling disorder?) and to what extent is there evidence of causal contribution to death (e.g. was gambling disorder a significant factor or a minor factor?). Finally, they should be required to contextualise their findings by reference to other risk factors.
Running through some of the institutional responses to PHE-OHID is the idea that unreliable estimates of mortality serve a valid purpose pending the production of more robust statistics – something along the lines of ‘fake it until you can make it’. The chair of the Gambling Commission’s Advisory Board for Safer Gambling (‘ABSG’), Dr Anna van der Gaag, for example has written that:
“Good research, especially if it is on an under-researched area like this one, tends to begin and end in a different place, prompting challenge, replication, debate, and the research in this important area is no different.”
It is a view that overlooks four important points. First, the PHE-OHID work on the cost of gambling harms is riven with errors (including mathematical mistakes) and should not be considered “good research”. Second, the ABSG specifically called for “action” as a result of the PHE estimates – with no suggestion of the need for caution or refinement. Third, rather than welcoming challenge, the ABSG has engaged in ad hominem disparagement of those attempting to apply scrutiny to the PHE-OHID claims (likening this, without substantiation, to the activities of Big Oil). Fourth, it is questionable how far we should trust ‘better research’ if those responsible for it have propagated or tolerated misinformation in the past. As we saw during the Covid pandemic, the production of misleading statistics may in fact set back the cause of harm prevention by undermining trust in authority.
Suicide risk among people with a gambling disorder is a legitimate issue and warrants an intelligent response; but this is unlikely to be achieved through the publication of spurious estimates of prevalence. As the US economist, Professor Douglas Walker has observed;
“If researchers continue to offer social cost estimates, they should estimate costs that are measurable. But for other costs such as psychic costs that cannot be measured…let us identify them without providing spurious empirical estimates. Offering methodologically flawed cost estimates does not improve our understanding nor does it promote sound policy…In areas where research is still quite primitive, perhaps no data would be better than flawed data.”
Coda
We are aware that some individuals and organisations will resent this series of articles on PHE-OHID (not least the OHID researchers themselves). Our intention in writing them has not been to hurt or insult – but to shine a light on the way that some statistics are created and the distortive effect that ‘bad statistics’ can have on government policies. The application of scrutiny to research is an important part of the scientific process; and where state bodies are concerned, an important part of the democratic process too. It is entirely consistent to be concerned about a particular issue (e.g. risk of self-harm in a gambling context) and at the same time to believe that research into that issue should be conducted with honesty, openness and in accordance with scientific principles. In this way, we may hope to reduce the stigma associated with self-harm (such that gambling firms and other businesses gain the confidence to openly confront it); and that, over time, we may apply greater intelligence to the prevention of suicide in a gambling context and more generally.
Geoff Banks Online Reports 