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Background and aims: Gambling disorder (GD) appears to be an independent risk factor for suicide, and all-cause mortality has been sparsely studied in patients with GD. This study aims to explore mortality and suicide rates in individuals with GD compared to the general population as well as explore risk factors associated with all-cause mortality and suicide mortality. Methods: This is a nationwide register study on 2,099 individuals with a GD diagnosis in the Swedish inpatient and/or outpatient specialist health care system between the years of 2005-2016. Comorbid diagnoses from treatment episodes included in national registers were categorized into diagnostic groups according to the 10th revision of International Classification of Diseases, and prevalence rates (any occurrence during 2005-2016) were calculated for each diagnostic group. Multivariate Cox regression analyses on risk factors for death and suicide were performed, controlling for age, gender, and major categories of comorbidity. Standardized mortality ratios (SMRs) were calculated for men and women with regard to overall mortality and suicide compared to the general Swedish population. Results: The population consisted of 1,625 men and 474 women ranging from 18 to 83 years of age at first GD diagnosis (mean: 36.5 years). Sixty-seven individuals passed away, among whom 21 deaths were due to suicide. SMR calculations showed a 1.8-fold increase in mortality for individuals 20-74 years old with GD compared to the general population, and a 15-fold increase in suicide mortality. All-cause mortality was predicted by higher age and any treatment episode for cardiovascular disease, whereas suicide death was predicted by depression. Discussion and conclusions: Mortality and suicide rates are significantly elevated among individuals with GD. Although common mental health comorbidities did not predict overall mortality, depression predicted suicide death. Findings call for attention to long-term risk of death in GD patients and interventions against comorbid health problems.
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Gambling disorder, increased mortality, suicidality, and associated
comorbidity: A longitudinal nationwide register study
Faculty of Medicine, Department of Clinical Sciences Lund, Psychiatry, Lund University, Lund, Sweden
Clinical Research Unit, Malmö Addiction Center, Region Skåne, Sweden
(Received: May 28, 2018; revised manuscript received: September 8, 2018; accepted: October 14, 2018)
Background and aims: Gambling disorder (GD) appears to be an independent risk factor for suicide, and all-cause
mortality has been sparsely studied in patients with GD. This study aims to explore mortality and suicide rates in
individuals with GD compared to the general population as well as explore risk factors associated with all-cause
mortality and suicide mortality. Methods: This is a nationwide register study on 2,099 individuals with a GD diagnosis
in the Swedish inpatient and/or outpatient specialist health care system between the years of 20052016. Comorbid
diagnoses from treatment episodes included in national registers were categorized into diagnostic groups according to
the 10th revision of International Classication of Diseases, and prevalence rates (any occurrence during 20052016)
were calculated for each diagnostic group. Multivariate Cox regression analyses on risk factors for death and suicide
were performed, controlling for age,gender, and major categories of comorbidity. Standardized mortality ratios (SMRs)
were calculated for men and women with regard to overall mortality and suicide compared to the general Swedish
population. Results: The population consisted of 1,625 men and 474 women ranging from 18 to 83 years of age at rst
GD diagnosis (mean: 36.5 years). Sixty-seven individuals passed away, among whom 21 deaths were due to suicide.
SMR calculations showed a 1.8-fold increase in mortality for individuals 2074 years old with GD compared to the
general population, and a 15-fold increase in suicide mortality. All-cause mortality was predicted by higher age and any
treatment episode for cardiovascular disease, whereas suicide death was predicted by depression. Discussion and
conclusions: Mortality and suicide rates are signicantly elevated among individuals with GD. Although common
mental health comorbidities did not predict overall mortality, depression predicted suicide death. Findings call for
attention to long-term risk of death in GD patients and interventions against comorbid health problems.
Keywords: gambling disorder, suicide, mortality, comorbidity, standardized mortality ratios, nationwide
The prevalence of problem gambling [including both prob-
lem gambling and gambling disorder (GD)] has been esti-
mated to somewhere between 0.12% and 5.8% (Calado &
Grifths, 2016), and lifetime prevalence rates for GD have
been estimated to around 0.5% (Kessler et al., 2008;Petry,
Stinson, & Grant, 2005).
An association has been found between problem gam-
bling and completed suicide (Blaszczynski & Farrell, 1998),
which means that problematic gambling has been described
to be relatively common prior to suicide (Wong, Cheung,
Conner, Conwell, & Yip, 2010), and authors have called for
increased knowledge about the connection between gam-
bling and suicide (Tse, Tang, & Wong, 2014). However,
several studies on gambling and suicidal behavior have been
focused on non-fatal suicide attempts, or suicidal ideation,
consistently showing high rates of suicidal ideation or
suicide attempts in problem gamblers, in comparison to the
general population (Hansen & Rossow, 2008;Kausch,
2003;Komoto, 2014;Ledgerwood, Steinberg, Wu, &
Potenza, 2005;Moghaddam, Yoon, Dickerson, Kim, &
Westermeyer, 2015;Ronzitti et al., 2017). Newman and
Thompson (2007) demonstrated that GD was associated
with elevated risks of attempting suicide, with an odds ratio
of 3.43 (95% CI: 1.378.60; Newman & Thompson, 2007).
Given these alarming numbers, more knowledge is need-
ed to identify individuals at risk. Currently, however, fewer
than 10% are estimated to seek help for their GD (Braun,
Ludwig, Sleczka, Buhringer, & Kraus, 2014;Suurvali,
Hodgins, Toneatto, & Cunningham, 2008), making research
on and prevention of suicide challenging.
For non-fatal suicidal behavior, several risk factors have
been identied among individuals with GD, such as depres-
sion (Newman & Thompson, 2007), cluster B personality
disorders (Bischof et al., 2015), alcohol dependence (Newman
& Thompson, 2007), or a co-occurring attention-decit and
hyperactivity disorder (Retz, Ringling, Retz-Junginger,
Vogelgesang, & Rosler, 2016). In addition, studies have
* Corresponding author: Anders Håkansson; Clinical Research
Unit, Malmö Addiction Center, Södra Förstadsgatan 35, plan 4,
Malmö S-205 02, Region Skåne, Sweden; Phone: +46 70 313 56
77; Fax: +46 46 149 853; E-mail:
This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License,
which permits unrestricted use, distribution, and reproduction in any medium for non-commercial purposes, provided the original author and
source are credited, a link to the CC License is provided, and changes if any are indicated.
© 2018 The Author(s)
FULL-LENGTH REPORT Journal of Behavioral Addictions
DOI: 10.1556/2006.7.2018.112
concluded that while male gamblers are in majority, female
gamblers may be at increased risk of attempting suicide
(Bischof et al., 2015;Husky, Michel, Richard, Guignard, &
Beck, 2015;Komoto, 2014). While Newman and Thompson
(2007) observed that the increased risk of attempting suicide
for women was explained by their higher prevalence of
depression (Newman & Thompson, 2007), another study
demonstrated that female gender was indeed a weak but
independent risk factor for attempting suicide when control-
ling for depression (Bischof et al., 2015).
In addition, and compared to the extensive literature of
mortality on substance-related addictive disorders, where
mortality rates have been shown to be highly elevated
(Laramée et al., 2015;Singleton, Degenhardt, Hall, &
Zabransky, 2009;Sordo et al., 2017;Whiteford et al.,
2013), very little has been published about the overall
mortality in patients diagnosed with a GD. While GD has
been demonstrated to be associated with poor physical
health (Black, Shaw, McCormick, & Allen, 2013;Morasco
et al., 2006;Pilver & Potenza, 2013) and health conditions
such as obesity (Black et al., 2013), arteriosclerosis, and
heart conditions (Pilver & Potenza, 2013), limited research
has attempted to study the course of patients with GD in
regard to overall mortality, including both physical and
mental disorders. Furthermore, physical illness may also
contribute to mental health-related causes of death; physical
illness has been associated with elevated risks of committing
suicide even after controlling for mental health-related and
socioeconomic risk factors (Crump, Sundquist, Sundquist,
& Winkleby, 2014), and for those with both physical and
mental illness, this risk might be even greater (Qin, Hawton,
Mortensen, & Webb, 2014). On the whole, to be best of our
knowledge, all-cause mortality to date has not been de-
scribed in patients with GD, and furthermore, the limited
number of studies on GD and completed suicide calls for
further research of its extent and risk factors, including its
association with other health-related co-factors in the GD
In this study, for the aforementioned reasons, it was hy-
pothesized that not only suicide rates but also general
mortality would be increased for individuals with GD. Since
there is no previous knowledge on mortality or the frequen-
cy of completed suicide in this population, we aimed to
investigate standardized mortality ratios (SMRs) for patients
with GD as well as to compare mortality and suicide rates to
the general population. Furthermore, we aimed to investi-
gate the effects of specic risk factors previously associated
with suicidality and/or suicide attempts on completed sui-
cide among individuals with GD as well as to investigate
risk factors in general for mortality.
This is a nationwide cohort study using national registers
containing information on diagnoses and mortality. The
study is based on information from the Swedish National
Patient Register (NPR) and the Swedish Cause of Death
Register (CDR). The NPR is assessed to have a positive
predictive value of 85%95% and covers 99% of all somatic
and mental health hospital discharges and around 80% of all
hospital-based outpatient care (Ludvigsson et al., 2011),
the latter percentage probably being lower due to missing
data from private caregivers and some mental health outpa-
tient treatment (Forsberg, Rydh, Jacobsson, Nyqvist, &
Heurgren, 2009). Diagnoses were not reported for as many
as 56% of visits in 2005 and 23% in 2006 for outpatient
psychiatry, but missing data have now reached a level of 4%
in outpatient specialist treatment as a whole (The Swedish
National Board of Health and Welfare, 2018).
The NPR covers among other information data on pri-
mary and secondary diagnoses according to the 10th revi-
sion of International Classication of Diseases (ICD-10) in
patients discharged from inpatient care as well as hospital-
based outpatient physician visits. Primary care is not yet
included in the register (The Swedish National Board of
Health and Welfare, 2018).
Participants and outcome variables
Between the years of 20052016, 2,172 individuals in the
NPR had received a diagnosis of GD (pathological gam-
bling, F63.0 according to the ICD-10). In this study, the GD
terminology is used, as this is the nomenclature chosen in
the upcoming ICD 11 and also is the term in use in the fth
edition of Diagnostic and Statistical Manual of Mental
Disorders (American Psychiatric Association, 2013;World
Health Organization, 2018). For these individuals, 1,024
hospital admissions and 5,236 medical appointments in the
outpatient care were noted, where GD had been either the
primary or secondary diagnosis. Mental health and physical
comorbidities (Table 1) were described as any occurrence
for each ICD-10 diagnostic category at any time during the
study period (20052006), that is, both prior to and after an
individualsrst GD diagnosis, in order to describe an
extensive picture of disease potentially associated with a
risk of death.
Seven hospital admissions were registered where infor-
mation on personal identication number (PIN) was missing
(six men between 27 and 56 years of age and one with a
male of unknown age). This was also the case for seven
appointments in the specialized outpatient care (men of
unknown age). Since PINs were missing, it was impossible
to state whether these were 13 different individuals or just a
few who had attended the medical system several times.
Neither was it possible to follow these individuals in the
registers and they were hence excluded. It is likely that these
individuals are asylum seekers or non-Swedish residents
(The National Board of Health and Welfare). Furthermore,
73 individuals (67 men and 6 women) were excluded, since
they were younger than 18 years when included in the study
(none of these individuals passed away).
The remaining study population consisting of 2,099
individuals was matched in the CDR and information on
causes of death with the subsequent ICD diagnoses were
handed to us. The CDR contains information according to
the International Form of Medical Certicate of Cause of
Journal of Behavioral Addictions
Karlsson and Håkansson
Death. Swedish physicians are obliged to report these data to
the National Board of Health and Welfare within 3 weeks
from the time of death (Brooke et al., 2017).
All deaths due to homicide are to be reported by the
physician performing the forensic autopsy, which is man-
datory in these cases, and in 95% of the deaths due to suicide
as well, deaths among known or suspected individuals with
alcohol or drug use disorders are also routinely investigated
through forensic autopsy (Brooke et al., 2017). In 90% of
forensic autopsies in Sweden, a comprehensive analysis of
alcohols, pharmaceuticals, and illicit drugs is to be per-
formed (Brooke et al., 2017). The quality of the Swedish
CDR has been estimated through comparison to case reports
looking at individuals who passed away in hospital, and
77% agreement on underlying cause of death was found
with higher accuracy among younger patients and 98% for
those between 0 and 44 years of age and 91% for those
between 45 and 64 years of age (Johansson, Björkenstam, &
Westerling, 2009).
We chose not to include diagnoses classied as unde-
termined event(i.e., ICD-10 codes X40X49 and/or Y10
Y34) in the suicide or self-harm categories but rather to keep
these apart. This approach has previously been suggested by
Björkenstam et al. (2014) who concluded that several
background factors separated these cases from clear suicide
Statistical analyses
Descriptive statistics on overall mental health comorbidity
were performed for the whole study population as well as for
men and women separately.
SMRs were calculated for overall mortality as well as for
suicidal events looking at age categories: 2074, 2049, and
5074 years of age for all individuals as well as for men and
women separately. The SMRs were calculated through
comparison to the Swedish population. Data on mortality
and suicide for the general Swedish population were re-
trieved from an open access service on Statistics Swedens
ofcial website (Statistics Sweden, 2018). The data provid-
ed by Statistics Sweden is readily displayed as number of
deaths per 100,000, stratied for sex and age (Statistics
Sweden, 2018).
Multivariate Cox regression analyses were performed
using SPSS version 24.0 (Armonk, NY, USA) to investigate
risk factors for all-cause mortality (all fatalities vs. all other
cases) and for suicide mortality (suicide cases vs. all other
deceased or surviving cases). The time variables included in
the study were the time from inclusion in the cohort (rst
diagnosis of GD) until censoring (study end) or time of
death. In addition to gender and age, comorbidities included
as potential predictors of death were dened as any occur-
rence of the diagnostic categories included, at any time
during the full study period (20062016). Given the rela-
tively low absolute number of deaths, the number of poten-
tial predictors was kept low; in addition to gender and age
(age at the start of the observation period), the three
markedly most common diagnostic categories of mental
health disorders were included; depression (F32F33), anx-
iety disorders (F4), and substance-use disorders (F1). For
physical disease, a number of diagnostic categories were
roughly equally common, and here, the categories corre-
sponding to the most common physical causes of death in
the data set were chosen for inclusion as possible predictors
of mortality, that is, any treatment episode for these dis-
orders (malignant disease including diseases of the blood
and the immune system, ICD-codes C and D, and cardio-
vascular disease, code I). In the analysis of prediction of
suicide, as the absolute number of cases with this outcome
were lower, physical disorders were analyzed together and
mental health disorders together and thereafter signicant
predictors from each analysis were entered together, con-
trolling for gender and age in each analysis.
The study procedures were carried out in accordance with
the Declaration of Helsinki, although due to the study design
consent was not obtained. The study was approved by the
regional ethics committee of Lund, Sweden (le number:
A total of 2,099 individuals were included, 1883 years old
at rst GD diagnosis (mean: 36.5 years old, SD: 11.9) and a
majority were men (77%), individuals were followed for an
average 4.7 years. In the inpatient care setting, 29% of the
individuals had GD as a main diagnosis at some point,
whereas 66% in the outpatient setting had GD as a main
diagnosis in the outpatient setting. On the whole, 55% had
GD as main diagnosis at some point in either inpatient or
outpatient care.
The most common categories of mental health comor-
bidity during the whole study period were depression (51%),
anxiety disorders (60%), and substance-use disorders
(41%). Nineteen percent of subjects received a suicide
attempt diagnosis at some time during the full study period
(for full results on mental health comorbidity, see Table 1).
During this period, 67 individuals passed away (52 men
and 15 women), among whom 21 deaths (18 men, three
women) were due to suicides. Median age at death was 51
years (interquartile range: 3962 years), and the median age
at suicide death was 32.5 years (interquartile range: 4149.5
years). The leading causes of death were suicide (31%)
followed by neoplasms (16%) and diseases of the circula-
tory system (12%). The entire list can be found in Table 2.
The SMR results for overall mortality indicated a
1.8-fold increase in mortality for individuals 2074 years
old with GD compared to the general population, for men
1.5 times and for women 2.1 times. In the younger age
categories, 2049 years of age, mortality was 6.2 times
greater than that of the general population, 4.6 times for men
and 10.5 times for women. There was no signicant increase
in the age category 5074 years of age (Table 3).
SMR for suicide indicated a 15.1 times increase for men
and women 2074 years of age and in the younger and older
age categories 19.3 and 9.6 times, respectively. For men alone,
the overall increase was 12.1 times (14.3 times for those
2049 years of age and 9.5 for those 5074 years of age). For
women, no signicant results were obtained (Table 4).
Journal of Behavioral Addictions
Suicide and mortality in pathological gambling
Table 1. Comorbidity in the study population (N=2,099) occurring at any time during the study period (20052016) in inpatient or outpatient
specialist care
ICD-10 code Disease n%
AB Certain infectious and parasitic diseases 447 21
CD Neoplasms, diseases of the blood, and diseases involving the immune mechanism 385 18
E Endocrine, nutritional, and metabolic diseases 376 18
G Diseases of the nervous system 414 20
H Diseases of the eye and the ear 493 23
I Diseases of the circulatory system 397 19
J Diseases of the respiratory system 516 25
K Diseases of the digestive system 656 31
L Diseases of the skin 500 24
M Diseases of the musculoskeletal system 848 40
N Diseases of the genitourinary system 604 29
O Pregnancy, childbirth, and the puerperium 122 6
Q Congenital malformations 56 3
R Symptoms, signs, and ndings, not elsewhere classied 1,225 58
ST Injury, poisoning, and other consequences of external causes 1,365 65
V0X59 Accidents (excluding accidental poisoning) 1,085 52
X40X49 Accidental poisoning 68 3
X60X84 Intentional self-harm 406 19
X85Y09, Y35Y36 Assault, legal intervention, or operation of war 226 11
Y10Y34 Events of undetermined intent 96 5
Y40Y98 Other external causes 319 15
F00F09 Organic, including symptomatic and mental disorders 48 2
F10F19 Mental and behavioral disorders due to psychoactive substance use (substance-use disorders) 859 41
F10 Mental and behavioral disorders due to use of alcohol 618 29
F11F19 Mental and behavioral disorders due to use of drugs 534 25
F20F29 Schizophrenia, schizotypal, and delusional disorders 196 9
F32F33 Depressive disorders 1,073 51
F30F31 Bipolar disorders 250 12
F34F39 Other mood disorders 123 6
F40F48 Neurotic, stress-related, and somatoform disorders (anxiety disorders) 1,252 60
F50 Eating disorders 57 3
F52 Sexual disorders 28 1
F60F62 Personality disorders 408 19
F63 Impulse control disorders (excluding F63.0) 99 5
F64F69 Other disorders of personality 41 2
F70F79 Mental retardation 37 2
F80F89 Pervasive and specic developmental disorders 129 6
F90F98 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence 360 17
F99 Unspecied disorder 72 3
Note. Diagnostic categories derived from the International Classication of Disease 10th revision (ICD-10).
Table 2. Underlying cause of death (N=67) categorized according to the International Classication of Disease 10th revision (ICD-10)
ICD code Diagnostic category n%
A00B99 Certain infectious and parasitic diseases 2 3
C00D48 Neoplasms 11 16
F00F99 Mental and behavioral disorders 2 3
G00G99 Diseases of the nervous system 2 3
I00I99 Diseases of the circulatory system 8 12
J00J99 Diseases of the respiratory system 4 6
N00N99 Diseases of the genitourinary system 1 1
R90R99 Unknown cause of death 4 6
W00W99 Falls 1 1
X4049 Accidental poisoning by and exposure to noxious substances 4 6
X60X84 Intentional self-harm 21 31
X85Y09 Assault 1 1
Y10Y34 Event of undetermined intent 6 9
AY All deaths 67 100
Journal of Behavioral Addictions
Karlsson and Håkansson
In the multivariate Cox regression analysis, all-cause
mortality was predicted by older age and by having a
cardiovascular diagnosis at any time during the study period
(Table 5). For suicide mortality, none of the physical disease
variables (malignant disease and cardiovascular disease)
were signicant predictors (Table 6). Among mental health
variables, while controlling for gender and age, suicide
deaths were signicantly predicted by a depression diagno-
sis anytime during the study period (Table 7).
To our knowledge, this is the rst longitudinal, nationwide
study on suicide and mortality rates among individuals with
GD, and it is one of the few studies focusing on completed
suicide in GD. Suicide was indeed the leading cause of death
in this population (n=21, 31%) and the present ndings
indicate elevated risks of both suicide and premature death
in individuals with GD. The increase in mortality was
especially pronounced among younger individuals, that is,
below 49 years of age. This is notable since GD is more
common in the young (mean age: 36.5 years). The second
and third leading causes of mortality were neoplasmsand
diseases of the circulatory system.
Table 3. SMRs stratied for different sex and age categories presented with a 95% CI
2074 years old 2049 years old 5074 years old
SMR 95% CI SMR 95% CI SMR 95% CI
Men and women 1.8* [1.42.2] 6.2* [4.18.4] 1.3 [0.91.8]
Men 1.5* [1.11.9] 4.6* [2.76.5] 1.2 [0.81.7]
Women 2.1* [1.03.3] 10.5* [2.718.2] 1.3 [0.32.3]
Note. Swedish individuals with gambling disorder compared to the Swedish general population in 2016. CI: condence interval; SMR:
standardized mortality ratio.
*Signicant result.
Table 4. SMRs for suicide stratied for different sex and age categories presented with a 95% CI
2074 years old 2049 years old 5074 years old
SMR 95% CI SMR 95% CI SMR 95% CI
Men and women 15.1* [8.7 to 21.6] 19.3* [9.8 to 28.7] 9.6* [1.218.0]
Men 12.1* [6.5 to 17.7] 14.3* [6.5 to 22.0] 9.5* [1.217.8]
Women 16.1 [2.1 to 34.3] 30.1 [4.0 to 64.2] **
Note. Swedish individuals with gambling disorder compared to the Swedish general population in 2016. CI: condence interval;
SMR: standardized mortality ratio.
*Signicant result. **No documented suicides in this category.
Table 5. Multivariate Cox regression analysis of predictors of
all-cause mortality (N=2,099)
Factor HR 95% CI p
Female gender 0.82 [0.461.48] .51
Age at rst gambling disorder
diagnosis (years)
1.04 [1.021.07] <.001*
Substance-use disorder 1.18 [0.721.94] .51
Depression 1.01 [0.611.70] .96
Anxiety 0.84 [0.501.40] .50
Malignant disease 1.62 [0.962.73] .07
Cardiovascular disease 2.32 [1.334.02] <.01*
Note. This table shows hazard ratios (HR) with a 95% condence
interval (95% CI) and level of signicance (p).
*Signicant result.
Table 6. Multivariate Cox regression analysis of potential physical
diseases as predictors of suicide death, controlled for gender and
age (N=2,099)
Factor HR 95% CI p
Female gender 0.63 [0.182.17] .47
Age at rst gambling disorder
diagnosis (years)
1.02 [0.991.06] .21
Malignant disease 0.38 [0.091.69] .20
Cardiovascular disease 1.02 [0.343.03] .98
Note. This table shows hazard ratios (HR) with a 95% condence
interval (95% CI) and level of signicance (p).
Table 7. Multivariate Cox regression analysis of potential
psychiatric predictors of suicide death, controlled for gender and
age (N=2,099)
Factor HR 95% CI p
Female gender 0.49 [0.141.67] .25
Age at rst GD diagnosis (years) 1.02 [0.981.05] .37
Substance-use disorder 1.10 [0.462.63] .83
Depression 5.45 [1.5718.93] <.01*
Anxiety 0.87 [0.342.22] .77
Note. This table shows hazard ratios (HR) with a 95% condence
interval (95% CI) and level of signicance (p).
*Signicant result.
Journal of Behavioral Addictions
Suicide and mortality in pathological gambling
SMRs on overall mortality and suicide were elevated in
this study as expected. To our knowledge, there have not
been any previous attempts to estimate SMRs for indivi-
duals with GD and thus we will attempt to compare these to
literature on other mental and addictive disorders. Con-
cerning general SMRs, these were at similar to lower levels
when comparing to literature on different populations with
mental disorders. A meta-analysis on bipolar disorder
indicated SMR levels similar to this study (Hayes, Miles,
Walters, King, & Osborn, 2015). In a population of
individuals with amphetamine use in the criminal justice
system in the setting studied here, the SMR for the younger
age category (2049 years of age) was also similar
(Ericsson, Brådvik, & Håkansson, 2014); although when
looking at the entire age span (2074 years of age), the
SMR in this study was slightly lower (Ericsson et al.,
2014). Similarly, the present SMR gures were lower than
in a cohort of injecting amphetamine users (Åhman,
Jerkeman, Blomé, Björkman, & Håkansson, 2018), and
in patients with heroin dependence (Pan et al., 2014).
When comparing to a study on individuals with general
mental disorders, SMR levels in this study were also
slightly lower (Charrel et al., 2015), and markedly lower
when compared to a population of individuals hospitalized
for substance-use disorders (Fugelstad, Annell, & Ågren,
2014). However, the much higher mortality rate in the
latter study might be explained by the fact that many of the
participants in this study were instead included from
outpatient care.
Regarding SMRs for suicide, the results were similar to
those described for other populations of individuals with
mental disorders. The aforementioned studies on bipolar
disorder, other mental disorders, and individuals hospital-
ized for substance-use disorders, as well as a large study on
recent-onset mental illness in the Scandinavian countries
indicated SMRs for suicide at comparable levels (Charrel
et al., 2015;Fugelstad et al., 2014;Hayes et al., 2015;
Nordentoft et al., 2013). On the whole, mortality and
completed suicide are elevated when compared to the
general population, and this is markedly more pronounced
for suicide mortality than for all-cause mortality, and the
risk increase is roughly in line with the increased mortality
and suicide rates observed in other populations with mental
Older age and diseases of the circulatory system pre-
dicted general mortality. This nding, together with the
knowledge that GD is associated with increased prevalence
of arteriosclerosis and heart conditions (Pilver & Potenza,
2013), calls for further research on the association between
GD and diseases of the circulatory system. Screening for
cardiovascular disease might be of future interest among
individuals with GD. None of the mental disorders investi-
gated increased the general mortality. However, having a
diagnosis of depression increased the risk of completed
suicide. Suffering from depression was indeed the only risk
factor for committing suicide in this study. The link between
depression and suicide deaths, although assessed in this
cohort of subjects with GD, is far from surprising; depres-
sion is a well-known predictor of suicide (Ferrari et al.,
2013). Given the low absolute number of suicides in this
study, more research is needed in larger data materials, in
order to describe the potential role of additional mental
health disorders.
An increase in mental health comorbidity among
women was observed in a descriptive study on the present
register data (Håkansson, Karlsson, & Widinghoff, 2018),
and women were more likely than men to have affective
disorders (ICD-10 code F3), neurotic, stress-related
and somatoform disorders, behavioral syndromes associ-
ated with physiological disturbances and physical
factors, and disorders of adult personality and behavior
(ICD-10 codes F4, F5, and F6, respectively) (Håkansson
et al., 2018). In addition, in the literature, several reports
have concluded that female sex may be a risk factor of
suicidality and/or suicide attempts in patients with GD
(Bischof et al., 2015;Husky et al., 2015;Komoto, 2014).
In some contrast to the overall risk increase for suicide in
men in the general population (Hawton & van Heeringen,
2009), importantly, in this study, male gender was not a
risk factor as expected from the general population. This
further draws the attention to female gender as a relative
risk factor for suicide in GD patients, compared to other
mental health disorders. Future studies on women with
GD and completed suicide are required; also, as the
proportion of women diagnosed with GD in this material
was rather small, this may require further investigation in
larger data materials. It has been predicted that the
proportion of women with problem gambling will in-
crease slightly in the present setting (Abbott, Romild,
& Volberg, 2018), further enhancing the need to focus on
gender-specic risk factors for suicide.
Regarding the diagnostics of suicide, we chose to
include only those with a diagnosis of intentional self-
harm.As previously mentioned, this decision was taken
due to differences on risk factors for death due to inten-
tional self-harmand events of undetermined intent
(Björkenstam et al., 2014). In addition, in drug use
disorder research, different risk factors have been associ-
ated with the two diagnostic groups (Olsson, Brådvik,
Öjehagen, & Håkansson, 2016). However, it has been
reported that some deaths classied as events of unde-
termined intentmay in fact represent actual suicides, and
in an effort to investigate diagnoses in Scandinavian death
certicates, it was estimated that as many as 21% of
deaths due to event of undetermined intentshould be
considered intentional self-harm(Tøllefsen et al.,
2015). Rates of suicide have although been estimated to
remain roughly the same in the Scandinavian countries
when investigating these two diagnostic categories with
some deaths being incorrectly classied as deaths due to
intentional self-harmand similarly some deaths classi-
ed as events of undetermined eventsshould have been
classied as intentional self-harm(Tøllefsen et al.,
2015). In this study, six individuals passed away due to
event of undetermined intent,such that some of these
individuals potentially may indeed have represented in-
tentional self-harm.
Future research on suicide among individuals with GD
would preferably combine mental health comorbidity,
socioeconomic factors such as bankruptcy rates as well
as family history of GD and other addictions. As for
socioeconomic factors, a study from Hong Kong on
Journal of Behavioral Addictions
Karlsson and Håkansson
completed suicide indicated a 19% incidence of prior
gambling activities among which 42% had been put into
dept due to gambling (Wong et al., 2010). Financial
problems have also been associated with attempted
suicide (Komoto, 2014;Wong et al., 2010), as have
bankruptcy (Komoto, 2014), nancial debts (Ronzitti
et al., 2017), unemployment (Komoto, 2014), addiction
among family members (Komoto, 2014), being a teenager
(Newman & Thompson, 2007), and having lower educa-
tion level (Newman & Thompson, 2007). In addition,
research on the genetic aspects of suicide among indivi-
duals with GD might be motivated in the future. It has
been suggested that 43% of the propensity to engage in
gambling is attributable to genetics (Slutske et al., 2009),
and that the genetic impact is even greater for women
(Slutske, Ellingson, Richmond-Rakerd, Zhu, & Martin,
2013). Thus, several factors need to be taken into account,
apart from only diagnostic variables and basic demo-
graphic data. However, this study provides diagnostic
data in a relatively large data set of patients. Future
longitudinal follow-up in GD may merit from a more
in-depth combination of diagnostic and sociodemo-
graphic, including nancial data.
Treatment uptake for GD is increasing in the Swedish
health care system, but there is still a gap between the
number of gambling patients in the health care system and
the number of individuals with a likely GD in the population
(Håkansson et al., 2018). Furthermore, since primary care is
not included in the national registers, there are some indi-
viduals with GD who could not be investigated in this study.
It is therefore likely that results may be skewed toward a
population of individuals with more severe forms of GD. It
is likely that this once again implies that this study sample
might contain patients with higher mental health comorbid-
ity, as well as individuals with more severe forms of GD,
since these individuals are more likely to receive specialized
psychiatry care.
Furthermore, since this study investigates completed
suicide rather than attempts or suicidal ideation, the
number of analyses possible to run were limited due to
the relatively low number of events. That being said,
research investigating completed suicide plays a very
important part of understanding the relationship between
GD and suicide, and larger studies are needed in the area.
Also, another limitation is the lack of a control group;
thus, mortality and risk factors are assessed within the
group of patients with GD, rather than in comparison to
non-GD patients.
Furthermore, this study did not assess those younger
than 18 years of age due to the risk of confusion in
terminology; the Swedish word for gambling is the same
as that for gaming, which, however, is not represented by a
diagnostic entity in the ICD-10 system used here. We
feared that it would be problematic to assume that the
greater majority of those below 18 years of age did have a
GD. As awareness and knowledge of GD is likely to
increase over time, future research might provide better
means of researching this younger population in a similar
manner, providing important knowledge on younger indi-
viduals with GD.
This is a nationwide study in which a large number of
individuals diagnosed with GD have been included. The
extensive information in the national registers on causes
of death as well as mental disease and other diseases
allows for unique opportunities to investigate actual
suicide and mortality rates among individuals with GD
compared to the general population as well as investi-
gating risk factors for premature death and suicide. This
study investigates completed suicide and also utilizes a
longitudinal design, which to our knowledge has not
previously been done with regard to suicide and GD.
Nor have previous calculations on SMRs, to our knowl-
edge, been undertaken.
Mortality and particularly suicide rates are greatly elevated
among individuals with a diagnosis of GD. Regarding
overall mortality, standardized mortality rates were highest
for those younger than 49 years of age. Efforts to assess
and prevent the risk of suicide for individuals with GD as
main or secondary diagnosis are important. Neither of the
most common mental health disorders or substance-use
disorder diagnoses predicted overall mortality (which
was predicted by cardiovascular disease and older age),
but this calls for further study and prevention of health
problems, including physical disease, in GD patients.
Depression was a signicant predictor of suicide death,
and this calls for enhanced focus on the mental health
comorbidity in GD.
Funding sources: No nancial support was received spe-
cically for this study. AH holds at position as professor at
Lund University nanced in collaboration between Lund
University and the Swedish gambling operator monopoly,
Svenska spel AB, as a part of the latter parts responsibility
for gambling and research policy, but this funding is not
aimed for any projects specically, and the funding body
has no inuence on the research ideas, research designs or
interpretations, and publications of ndings.
Authorscontribution: AK: contributed in performing the
statistical analysis and interpretation of data as well as
literature review and the main writing of the paper. AH:
overall responsible of the research idea and the project lead;
responsible for ethics permission, study design, and appli-
cation for register data access; had full access to the data;
and interpreted the results, study supervision, and co-writing
of the paper.
Conict of interest: The authors declare no conict of
interest with relevance to this study.
Journal of Behavioral Addictions
Suicide and mortality in pathological gambling
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Journal of Behavioral Addictions
Suicide and mortality in pathological gambling
... In Italy, the incidence rate ratio for suicide among those diagnosed with gambling disorder was 93.72 compared to the general population (18). In Sweden, individuals with diagnosed gambling disorder have been shown to have a 1.8fold increase in mortality and a 15-fold increase in suicide mortality compared to the general population (25). Based on another Swedish population-based study, suicidal attempts were twice as common among those who gamble problematically (6.6 percent) compared to controls (3.3 percent). ...
... Personality characteristics, such as impulsivity or poor coping skills (17,37) or life situations such as trauma (17), loss of family relationships or home (38), family conflict (39), or a family history of addiction (40) have each been connected to the co-occurrence of gambling and suicidality. Furthermore, mood disorders, anxiety, and substance use disorders have been associated with suicidal ideation among diagnosed pathological gamblers (10,17,25,38,(41)(42)(43)(44). ...
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The relationship between gambling and suicides or suicidality has received much research attention in recent years. Review studies have already mapped the quantitative occurrence of suicide attempts, suicides, and self-harm among gamblers, and found a positive association. Related comorbidities and conditions have also been charted in previous reviews. However, there is still a gap in knowledge regarding the actual processes that connect gambling and suicidal behavior. To understand these processes, the current paper conducts a systematic review of qualitative evidence on gambling-related suicides and suicidality. The aim was to identify the role of gambling as well as of confounding factors in suicidality, and what kind of support suicidal individuals have received or would need. We searched for relevant literature in seven scientific databases. We included all studies that presented empirical qualitative evidence on gambling-related suicide, suicidality and/or self-harm (N = 20). The results show two main processes that connect gambling and suicidal behavior: indebtedness and shame. At the same time, suicide is a multifactorial phenomenon, and related to other confounding factors. These include psychiatric conditions, personality traits, and life conditions. In many cases, these appear to emerge as a consequence of gambling. Treatment for suicidality has been effective in some cases, but indebtedness and shame may also function as barriers to help-seeking. We conclude that effective prevention is needed by adapting a more comprehensive public health approach and population-level interventions.
... Problem gambling has been found to be associated with several adverse outcomes, including financial problems (e.g. unmanageable debts), legal problems, job loss, relationship problems, decreased mental and physical health, and even suicide (Adolphe et al., 2019;Black et al., 2012;Karlsson & Håkansson, 2018;Lorains et al., 2011). Such harms extend beyond the individual gambler as it often also affects their close others, extended family, employers, as well as society as a whole given the costs of e.g. ...
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Several studies have investigated attitudes toward gambling using the Attitudes Towards Gambling Scale (ATGS), however, their findings have not previously been synthesized or systematically reported. Thus, we conducted a systematic literature review on studies employing the ATGS to summarize the current evidence. Database searches were conducted in January 2022 in Cinahl, Embase, PsycInfo, Pubmed, Web of Science, GreyNet, and Google Scholar. Papers were included if they presented data based on the ATGS and were published in a European language. Twenty-six papers presenting the results from 23 unique studies met the inclusion criteria. Two reviewers independently extracted the data and assessed the risk of bias. Most of the studies were cross-sectional and used the short (8-item) version of ATGS. The synthesis indicates an overall incline towards negative attitudes. More positive attitudes were associated with being male, younger age, and higher gambling frequency. Studies were divergent in findings concerning problem gambling and gambling attitudes, which could be due to variance in problem gambling severity in the samples. The current evidence base is encumbered by limitations in study quality and designs. Future research should emphasize longitudinal designs, include non-western samples, and investigate the directionality and causality of variables associated with attitudes towards gambling. ARTICLE HISTORY
... The contribution of gambling itself is difficult to isolate and measure, and causal pathways may likely work in both directions, with problem gambling leading to mental health conditions such as anxiety and depression, while pre-existing conditions such as impulse control disorders may exacerbate gambling behaviours [3]. In addition, there is a significant correlation between gambling problems and suicidal ideation, 2 of 13 as well as death by suicide [4]. Gambling-related harms such as interpersonal losses and conflicts, including relationship breakdowns, increase the likelihood of a suicide attempt [5]. ...
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The evidence base for internet therapies is building but little is known yet about the acceptability and effectiveness of providing telehealth online in a group format for the treatment of gambling disorders. Therefore, this uncontrolled, real-world study aimed to evaluate the feasibility and effectiveness of providing evidence-based treatment in a group format using an online platform. This innovative approach to treatment of people experiencing gambling harm was developed during the COVID pandemic so that gamblers could access evidence-based treatment from their homes. A closed group treatment program was developed using telehealth, enabling gamblers to come together weekly to engage in a treatment program based on behavioral therapy using cue exposure. Four online gamblers who met the criteria for Gambling Disorder were recruited from a gambling help service. A case report evaluation methodology was used to gain an in-depth understanding of the effectiveness of this approach to treatment. Treatment was conducted weekly over 12 months. All participants engaged with the program and after completing treatment participants no longer met the criteria for a Gambling Disorder, were abstinent for 12 months post treatment and achieved improved life functioning. This program provides preliminary evidence that providing treatment online in a group setting can be an acceptable and effective model in the delivery of treatment for clients unable to attend face-to-face clinics or preferring telemedicine as an option for treatment delivery. These findings warrant further exploration through a larger randomized controlled study.
... The lifetime prevalence of the disorder is estimated to be around 0.4-1.0% of the population (American Psychiatric Association, 2013) although wide variations in past-year problem gambling rates across different countries in the world have been described ranging from 0.12 to 5.8% (Calado & Griffiths, 2016). GD is associated with severe consequences including suicidal behavior (Karlsson & Håkansson, 2018). Manning et al. (2015) reported that 11.2% of patients with GD who sought treatment had attempted suicide in their lifetime. ...
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Background and aims Mental disorders with high levels of impulsivity such as bulimic spectrum eating disorders (BSED) and gambling disorder (GD) are associated with high risk of suicidal behavior. The aim of the present study was to identify the common and differential vulnerability factors behind suicide attempts in a sample of patients with BSED compared to patients with GD. Methods A total of 6,077 adults who sought treatment and met criteria either for BSED ( n = 2,391) or GD ( n = 3,686) were assessed at a specialized hospital unit. Personality traits, psychopathological symptomatology, lifetime history of suicide attempts and socio-demographic variables were evaluated. Results The prevalence of suicide attempts was higher for BSED patients (26.2%) compared to GD patients (7.1%) being anorexia nervosa (Binge/Purge type) and bulimia nervosa the most affected subtypes. In the predictive model, the transdiagnostic vulnerability factors with the highest contribution to the risk of suicidal behavior both in BSED and GD were unemployment, early age of onset of the disorder, worse psychopathological state, and self-transcendence personality trait. However, specific risk factors for suicidal acts were identified in each disorder: longer duration of the disorder, lower education levels and reward dependence were exclusively associated with BSED while female gender, older age, and higher harm avoidance were associated with GD. Discussion Patients with GD and BSED share certain vulnerability factors although certain factors are exclusive to each disorder. Conclusions Interventions need to pay special attention to both common and specific vulnerability factors to mitigate the risk of suicidal acts in these disorders.
... However, for interventions at the individual and aggregate level, secondary outcomes included mental health symptoms and wellbeing. While problematic gambling can be accompanied by significant financial strain (often concealed from, or at the detriment to, close relationships) and is associated with both depressive symptoms and suicidality [e.g., (13)(14)(15)], this was considered outside the scope and purpose of the current review. Therefore, any study with a primary focus on the relationship between gambling and suicidal behaviors or ideation and/or interventions addressing problematic gambling to prevent suicidal behaviors or ideation were excluded. ...
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Understanding the social determinants and risk factors for suicidal behaviors underlies the development of effective suicide prevention interventions. This review focused on recently published literature (2010 onwards), with the aim to determine the role of economic factors (at the individual and population level) on suicidal behaviors and ideation as well as the effectiveness of interventions addressing these factors in reducing suicidal behaviors and ideation. Where available, literature examining the economic impact of COVID-19 was highlighted. Economic recession and unemployment are associated with increased risk of suicidal behavior at the population and individual level. Additionally, personal financial problems such as debt and financial strain are associated with increased risk of suicidal behavior and ideation at the individual level. Regarding interventions, unemployment benefits, employment protection legislation, higher minimum wage and active labor market programs may reduce suicide at the population level. However, it is not clear what impact they have at the individual level, nor in relation to suicide attempts, self-harm, or suicidal ideation. There was a lack of evidence as to the effectiveness of financially focused suicide prevention interventions at either level. Current findings were contextualized within, and advance, prominent social theoretical models. Recommendations focused on future areas of research, including the unfolding economic impact of COVID-19, as well as the co-design and evaluation of tailored interventions and/or gatekeeper training for those in the financial and welfare sector, and enhanced early education aimed at increasing financial literacy in young people before onset or exacerbation of financial hardship.
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Gambling disorder is a problem that is affecting increasingly more people. It is associated with difficulties in emotion regulation, gambling motives, blame, and shame. This study aims to study the relationship between gambling severity, blame, and shame, independently and together with emotion regulation and gambling motives; to analyse the mediating role of emotion regulation in the relationship between gambling severity and shame; and to compare mean differences in the study variables according to the sample group. For this purpose, a clinical and non-clinical sample of 158 individuals (119 males and 39 females) ranging in age from 12 to 30 years ( M = 19.70, SD = 5.35) was divided into three groups. The questionnaires were administered online and on paper. The results showed that blame and shame are related to the severity of gambling. In the case of shame, this relationship was found to be partially mediated by the emotion regulation strategy of self-blame. Gambling severity, blame and shame were also found to be related to various gambling motives and different emotion regulation strategies. All this information can be of great use in the prevention and treatment of gambling problems.
Purpose To explore the personal gambling behavior and problem symptoms of social workers and other mental health providers to gauge their level of self-awareness, an important prerequisite to identifying and assisting clients who gamble. Method A survey was conducted with a convenience sample of 2,317 social workers and other mental health providers. Results Bivariate and regression analyses found that than 76% of participants reported gambling in the past year, and nearly 30% gambled at moderate or high frequency. About 5% reported one or more problem gambling symptom. Nearly 78% of participants, endorsing between two and ten gambling activities, denied they gambled, and 23% gambled at moderate to high frequency. Overall, 55% of all participants with at least one problem gambling symptom denied gambling. Discussion/Conclusion It is critical for providers to receive training and education to understand their own gambling behaviors and problem symptoms, which could adversely impact the therapeutic relationship.
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Aim: Prevalence studies on gambling have largely relied on survey samples. Little is known about the diagnosed prevalence of gambling disorder (GD) based on register data. This study examines the annual prevalence rate of GD between 2011 and 2020 among Finns by gender and age. Methods: Aggregated data on the diagnosis of GD (corresponding to pathological gambling, code F63.0 in the ICD-10) were retrieved from the following national registers: Register of Primary Health Care Visits, and Care Register for Health Care, including specialised outpatient and inpatient health care, and inpatient Care Register for Social Welfare. Primary and secondary diagnoses of adults were included. Average population during a calendar year (4,282,714–4,460,177 individuals) was utilised to calculate annual prevalence. Results: The annual prevalence of diagnosed GD in the population increased from 0.005% ( n = 196) to 0.018% ( n = 804) within nine years. In 2011, the annual prevalence rate was 0.006% for men and 0.003% for women, compared to rates in 2020 of 0.025% and 0.011%. Gender discrepancy was relatively stable across years: 27.2–33.8% of the diagnoses were for women. The prevalence of GD varied between age groups within genders. GD was most prevalent among 18–44-year-olds. The prevalence rates increased the most among 30–44-year-old women. Conclusion: The extremely low prevalence rate of GD implies that the problem remains under-diagnosed, yet, it has increased among all age groups across genders, except for women aged 60 years or older. Active efforts are needed to increase awareness of GD among both primary and specialised healthcare professionals and the public for better recognition and early detection.
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Gambling problems are often associated with homelessness and linked to elevated psychiatric morbidity and homelessness chronicity. We performed a systematic review and meta-analysis on prevalence rates of problem gambling (PG) and gambling disorder (GD) in homeless people. Following PRISMA guidelines, we searched databases Medline, Embase and PsycINFO from inception of databases to 4th may 2021. We included studies reporting prevalence estimates on clinical gambling problems in representative samples of homeless people based on standardized diagnostics. Risk of bias was assessed. A random effects meta-analysis was performed, and subgroup analyses based on methodological characteristics of primary studies were conducted. We identified eight studies from five countries, reporting information on 1938 participants. Prevalence rates of clinically significant PG and GD ranged from 11.3 to 31.3%. There was evidence for substantial heterogeneity with I2 = 86% (95% CI 63–97%). A subgroup of four low risk of bias studies displayed a significantly lower results ranging from 11.3 to 23.6%. Additionally, high rates of subclinical problem gambling were reported (11.6–56.4%). At least one in ten homeless persons experiences clinically significant PG or GD. Social support and health care services for the homeless should address this problem by implementing models for early detection and treatment.
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Background Gambling appears to be an independent risk factor for suicide among the young population worldwide. Blind boxes are collectable toys packed randomly in the box, which share certain similarities with gambling and are popular among the young population. This is the first study that examined the association between blind box engagement and suicide risk in the young population, the leading consumption group of blind boxes. Methods This study is part of a large-scale, cross-sectional study using convenience sampling conducted Oct 26 to Nov 18, 2021, which covered all the university and college students in the Jilin province, China. A total of 73,206 participants completed the survey with valid data for the current study (male: N = 28,762; female: N = 44,444; Mean age = 19·59). Participants’ blind box engagement, suicide risk, depression, anxiety, alcohol use, smoking habit, and sociodemographic characteristics were assessed. First, we used univariate and multivariable binary logistic regression models to examine the relationship between blind box engagement and suicide risk in all participants. Second, we tested whether depression and anxiety would mediate the association between blind box engagement and suicide risk. Third, we analysed the association between “Frequency (i.e., frequency of blind box engagement),” “Bet (i.e., expenditure on the blind box that exceeds affordability),” “Tolerance (i.e., level of addiction),” “Borrowed (i.e., the amount of money borrowed for blind box engagement),” and suicide risk in the group with blind box engagement history. Findings 4,195 participants (5·73%) have engaged in blind boxes, with 3,255 females (77·59%) and 940 males (22·41%). In the univariate models, binary logistic regression showed that blind box engagement was associated with suicide risk in both male and female participants (male: OR = 2·21, 95% CI = 1·86-2·63; female: OR = 1·64, 95% CI = 1·50-1·78). In the multivariable models, after controlling age, subjective socioeconomic status, per capita disposable income, alcohol use, and smoking habit, blind box engagement still was associated with suicide risk across genders (male: OR = 2·25, 95% CI = 1·89-2·68; female: OR = 1·58, 95% CI = 1·45-1·73). Depression (male: indirect effect = 0·31, SE = 0·04, p < 0·001; female: indirect effect = 0·20, SE = 0·02, p < 0·001) and anxiety (male: indirect effect = 0·26, SE = 0·03, p < 0·001; female: indirect effect = 0·13, SE = 0·02, p < 0·001) mediate the association between blind box engagement and suicide risk. Within the blind box engagement group, forward binary logistic regression revealed that “Tolerance” was associated with participants’ suicide risk in both males (p = 0·001) and females (p < 0·001); “Borrowed” (p = 0·019) alone was associated with the male participants’ suicide risk. Interpretation Our findings showed that blind box over-engagement is positively associated with suicide risk in both young males and females, and this association persisted after adjusting for influencing factors. In spite of the limitations in this study (e.g., cross-sectional, convenience sampling), current findings can assist policymakers in developing regulations for such a prosperous youth-dominant consumption industry while protecting youth's mental health worldwide. Funding None.
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Background: Psychiatric comorbidity is common in gambling disorder, a condition with low rates of treatment seeking. There is a paucity of documented nationwide data on gambling disorder and its co-occurring psychiatric comorbidities in the health care system. Methods: This is a nationwide register-based study of all patients aged above 18 years who were diagnosed with gambling disorder (corresponding to pathological gambling, code F63.0, in the ICD-10) in Swedish specialized out-patient health care or in-patient care, from 2005 through 2016. All psychiatric disorders co-occurring with the diagnoses were recorded, along with age, gender and the type of medical specialty. Results: A total of 2,099 patients were included (1,784 in out-patient care and 629 patients in in-patient care), among whom 77 percent were men. Treatment uptake during the study period increased significantly in out-patient care, with an increasing uptake of younger individuals, whereas in-patient treatment uptake remained stable. A co-occurring psychiatric diagnosis was registered in 73 percent of patients, more commonly in females (77 vs. 71 percent, p < 0.01). Several diagnostic subgroups were more common in women, with anxiety and affective disorders being the most common subgroups. Prevalence of substance use disorders did not differ with respect to gender. Conclusions: Despite a large gap between probable population prevalence of gambling disorder and the number of treated patients, the number of patients treated in out-patient health care with a gambling disorder diagnosis increased over time, with an increasing treatment uptake in younger individuals. Psychiatric comorbidity is common in gambling disorder patients in the health care system, with a higher prevalence in women.
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Background: Abuse of amphetamines is a worldwide problem with around 34 million users, and amphetamine is commonly used by people who inject drugs (PWID). Despite this, there is relatively little research on mortality and cause of death among people who use amphetamines primarily. The present study aimed to examine mortality and causes of death among people who inject amphetamine, and compare these results to the general population. Methods: This retrospective cohort study was based on data from The Malmö Needle Exchange Program in Sweden (MNEP) and on data from The Swedish National Cause of Death Register. Participants in the MNEP, between 1987 and 2011, with registered national identity number and amphetamine as their primary drug of injection use, were included in the study. Standardized mortality ratios (SMR) was calculated for overall mortality and categories of causes of death. Results: 2019 individuals were included (mean follow-up-time 13.7 years [range 0.02-24.2 years], a total of 27,698 person-years). Of the 448 deceased, 428 had a registered cause of death. The most common causes of death were external causes (n = 162, 38%), followed by diseases of the circulatory system (n = 67, 16%). SMR were significantly elevated (8.3, 95% CI [7.5-9.1]) for the entire study population, and for every category of causes of death respectively. Conclusions: People injecting amphetamine as a primary drug were found to have significantly elevated mortality compared with the general population, with high rates of both external and somatic causes of death.
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Aims: To estimate the prevalence, incidence, and gender and age-specific incidence of problem gambling in the Swedish adult population. Design: Longitudinal cohort study with linkage to register data. Setting: Sweden. Participants: Stratified random sample aged 16-84 at baseline (n = 8,165) re-assessed a year later (n = 6,021). Measurements: Problem gambling (lifetime and past 12 months) was measured by the South Oaks Gambling Screen-Revised (SOGS-R). Past 12 months (current) problem gambling was also measured by the Problem Gambling Severity Index (PGSI). Findings: The SOGS-R combined current pathological and problem gambling prevalence rate (PR) was 2.1 (CI 1.8-2.4) at baseline and 1.7 (1.4-2.0) at follow-up, approximately double the corresponding lifetime estimates. PGSI combined current problem and moderate-risk gambling PRs were 2.2 (1.9-2.5) at baseline and 1.9 (1.6-2.2) at follow-up. Combined incidence rates (IRs) were 1.0 (0.8-1.3) (SOGS-R) and 1.4 (1.1-1.7) (PGSI) with over three-quarters being new cases. While first time IRs did not vary by gender, males had a higher relapse IR and proportionately more females were new cases. The young adult IR was more than double the older adult IR. Similar proportions were new cases. Conclusions: The actual incidence of problem gambling relapse in Sweden is likely to be higher than estimated. The profile of problem gambling in Sweden is likely to change over time, with increased proportions of women and older adults.
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Sweden has a long tradition of recording cause of death data. The Swedish cause of death register is a high quality virtually complete register of all deaths in Sweden since 1952. Although originally created for official statistics, it is a highly important data source for medical research since it can be linked to many other national registers, which contain data on social and health factors in the Swedish population. For the appropriate use of this register, it is fundamental to understand its origins and composition. In this paper we describe the origins and composition of the Swedish cause of death register, set out the key strengths and weaknesses of the register, and present the main causes of death across age groups and over time in Sweden. This paper provides a guide and reference to individuals and organisations interested in data from the Swedish cause of death register. Electronic supplementary material The online version of this article (doi:10.1007/s10654-017-0316-1) contains supplementary material, which is available to authorized users.
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Objective To compare the risk for all cause and overdose mortality in people with opioid dependence during and after substitution treatment with methadone or buprenorphine and to characterise trends in risk of mortality after initiation and cessation of treatment. Design Systematic review and meta-analysis. Data sources Medline, Embase, PsycINFO, and LILACS to September 2016. Study selection Prospective or retrospective cohort studies in people with opioid dependence that reported deaths from all causes or overdose during follow-up periods in and out of opioid substitution treatment with methadone or buprenorphine. Data extraction and synthesis Two independent reviewers performed data extraction and assessed study quality. Mortality rates in and out of treatment were jointly combined across methadone or buprenorphine cohorts by using multivariate random effects meta-analysis. Results There were 19 eligible cohorts, following 122 885 people treated with methadone over 1.3-13.9 years and 15 831 people treated with buprenorphine over 1.1-4.5 years. Pooled all cause mortality rates were 11.3 and 36.1 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 3.20, 95% confidence interval 2.65 to 3.86) and reduced to 4.3 and 9.5 in and out of buprenorphine treatment (2.20, 1.34 to 3.61). In pooled trend analysis, all cause mortality dropped sharply over the first four weeks of methadone treatment and decreased gradually two weeks after leaving treatment. All cause mortality remained stable during induction and remaining time on buprenorphine treatment. Overdose mortality evolved similarly, with pooled overdose mortality rates of 2.6 and 12.7 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 4.80, 2.90 to 7.96) and 1.4 and 4.6 in and out of buprenorphine treatment. Conclusions Retention in methadone and buprenorphine treatment is associated with substantial reductions in the risk for all cause and overdose mortality in people dependent on opioids. The induction phase onto methadone treatment and the time immediately after leaving treatment with both drugs are periods of particularly increased mortality risk, which should be dealt with by both public health and clinical strategies to mitigate such risk. These findings are potentially important, but further research must be conducted to properly account for potential confounding and selection bias in comparisons of mortality risk between opioid substitution treatments, as well as throughout periods in and out of each treatment.
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Background and aims Problem gambling has been identified as an emergent public health issue, and there is a need to identify gambling trends and to regularly update worldwide gambling prevalence rates. This paper aims to review recent research on adult gambling and problem gambling (since 2000) and then, in the context of a growing liberalization of the gambling market in the European Union, intends to provide a more detailed analysis of adult gambling behavior across European countries. Methods A systematic literature search was carried out using academic databases, Internet, and governmental websites. Results Following this search and utilizing exclusion criteria, 69 studies on adult gambling prevalence were identified. These studies demonstrated that there are wide variations in past-year problem gambling rates across different countries in the world (0.12–5.8%) and in Europe (0.12–3.4%). However, it is difficult to directly compare studies due to different methodological procedures, instruments, cut-offs, and time frames. Despite the variability among instruments, some consistent results with regard to demographics were found. Discussion and conclusion The findings highlight the need for continuous monitoring of problem gambling prevalence rates in order to examine the influence of cultural context on gambling patterns, assess the effectiveness of policies on gambling-related harms, and establish priorities for future research.
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Attention-deficit/hyperactivity disorder (ADHD) is a frequent mental disorder with childhood onset and high persistence into adulthood. There is much evidence that ADHD increases the risk for the development of other psychiatric disorders and functional problems in several domains of everyday life. In this study, the association of ADHD with gambling disorder (GD) was investigated. 163 adult subjects suffering from GD were examined for childhood and current ADHD according to DSM-5 as well as co-morbid psychiatric disorders. Moreover, characteristics of gambling behavior have been evaluated. The prevalence of lifetime ADHD was 28.8 %, with 25.2 % of the study population presenting ADHD as a full syndrome according to DSM-5. The prevalence of co-morbid substance use disorders and adjustment disorders and cluster B personality disorders was higher in GD patients with current ADHD than in the group without. Also, an increased rate of suicide attempts was detected in gamblers with ADHD. In contrast with gamblers without ADHD, those with ADHD were reported to spend more time with gambling, a sedative effect of gambling and a faster development of GD. The high prevalence of ADHD in patients with GD indicates that childhood ADHD is a risk factor for the development of GD in later life. Moreover, treatment of patients with GD and ADHD is complicated by a high rate of co-morbid disorders. Regarding therapeutic approaches, it should be considered that functional aspects of gambling differ in GD patients with and without ADHD.
Background: Studies show higher lifetime prevalence of suicidality in individuals with pathological gambling. However, less is known about the relationship between pathological gambling and current suicidal ideation. Objectives: We investigated socio-demographic, clinical and gambling-related variables associated with suicidality in treatment-seeking individuals. Methods: Bivariate analyses and logistic regression models were generated on data from 903 individuals to identify measures associated with aspects of suicidality. Results: Forty-six percent of patients reported current suicidal ideation. People with current suicidal thoughts were more likely to report greater problem-gambling severity (p<0.001), depression (p<0.001) and anxiety (p<0.001) compared to those without suicidality. Logistic regression models suggested that past suicidal ideation (p<0.001) and higher anxiety (p<0.05) may be predictive factors of current suicidality. Conclusions: Our findings suggest that the severity of anxiety disorder, along with a lifetime history of suicidal ideation, may help to identify treatment-seeking individuals with pathological gambling with a higher risk of suicidality, highlighting the importance of assessing suicidal ideation in clinical settings.