Are 409 suicides a year caused by problem gambling?

Public Health England's final factoid

It is becoming common for any article about gambling in Britain to include a claim about suicide:

A Public Health England study published in September estimated that there are more than 409 suicides a year in England associated with problem gambling. (The Guardian)

The statistics are stark and brutal – between 400 and 500 people die by suicide related to gambling issues in the UK every year (The Telegraph)

The Gambling Commission has looked into just nine deaths since 2016 – a tiny proportion of the total number. Yet there are thought to be 409 gambling suicides a year in England alone (Daily Mail)

The same statistic has been quoted by Chris Philp who, until a few days ago, was the gambling minister at DCMS.

We now have evidence, including a Public Health England report, which identified 409 gambling suicides a year. It is imperative that we respond to that. Change is certainly needed.

There is no doubt that some problem gamblers commit suicide and that gambling and gambling-related debt can be an underlying cause of suicide.

But 409 suicides is a curiously specific figure for something that is not recorded on death certificates and for which the UK collects practically no data.

A variation of this estimate was used in the closing stages of the campaign against fixed odds betting terminals (FOBTs). In October 2018, the government announced that it would be cutting the stake limit on FOBTs to £2 from October 2019. Sports minister Tracey Crouch claimed that this was an unacceptable delay and that the government had previously promised to enforce the new law from April 2019. The government had never said any such thing, but she nevertheless resigned over the matter and ultimately pressured the government into bringing it forward to April 2019.

In her resignation letter, Crouch claimed that two people committed suicide every day ‘due to gambling related problems’, thereby implying that there were 700 gambling-related suicides a year.

When the government capitulated and brought the stake reduction forward, she said:

‘There was never any excuse for delay. Bringing forward by six months the day maximum stakes are capped will save an estimated 120 lives.’

This implied that 240 suicides took place every year as a result of FOBT gambling alone. I have no idea where she got this figure from. I suspect it was rectally sourced.

At around the same time, Nicky Morgan MP said of the Chancellor’s explanation for the 12 month ‘delay’:

‘it doesn’t really help the expected 300 people who may end up taking their lives, suffering mental health problems from gambling addiction’.

Insofar as these claims were based on evidence, they seem to have come from an unpublished estimate by the pressure group Gambling With Lives. Based on extrapolations from three studies from the UK, Hong Kong and Sweden, they estimated that there were between 250 and 650 gambling-related suicides per annum. They later described their workings in a submission to a House of Lords Select Committee, but it has a back-of-an-envelope feel and is far from being an official estimate.

The official estimate of 409 suicides per annum comes from a 2019 Public Health England report. This was one of the last things it published before it was dissolved and the methodology is frankly terrible.

The figure is entirely based on one study from Sweden published in 2018. The study looked at 2,099 people who had been diagnosed with gambling disorder by a doctor while receiving inpatient or outpatient care (but not primary care) in the Swedish health system between 2005 and 2016. Of these 2,099 individuals, 67 subsequently died, including 21 who committed suicide. This suicide rate implied that these people were 15 times more likely to kill themselves than members of the general population.

Public Health England arrived at their estimate by working out how many problem gamblers were in England in 2019 (based on a prevalence rate of 0.4%). Adjusting for age and gender, they then extrapolated from the suicide data in the Swedish study and applied it to England’s problem gambling population to work out how many gambling-related suicides took place in that year. They did not show their workings and described their methodology in a single paragraph:

The ONS age-standardised suicide rates for 2019 (42) are multiplied by the prevalence of problem gambling in the general adult population (0.4%, sourced from the HSE (3)) to first estimate the number of gamblers who died by suicide in England for all persons (25; 95% CI 14 and 44). Multiplying this figure by the age-standardised SMRs (sourced from Karlsson, and others (36)), produces an estimate of the expected number of suicides (434; 95% CI 257 and 746). Calculating the difference between these figures results in the estimated number of deaths by suicide associated with problem gambling only (409; 95% CI 242 and 702).

You can’t do this! You can’t take a prevalence estimate from one group of people and apply it to a totally different group of people. I don’t mean that Swedes and Brits are totally different - although there may be important differences - I mean that a group of 2,099 people who are seeking medical help are very different from the several hundred thousand people who are estimated to be problem gamblers in England.

These are the questions in the survey used to estimate problem gambling in the UK:

Thinking about the last 12 months…

1. Have you bet more than you could really afford to lose?

2. Have you needed to gamble with larger amounts of money to get the same feeling of excitement?

3. When you gambled, did you go back another day to try to win back the money you lost?

4. Have you borrowed money or sold anything to get money to gamble?

5. Have you felt that you might have a problem with gambling?

6. Has gambling caused you any health problems, including stress or anxiety?

7. Have people criticized your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true?

8. Has your gambling caused any financial problems for you or your household?

9. Have you felt guilty about the way you gamble or what happens when you gamble?

You can say never (zero points), sometimes (1 point), most of the time (two points) or almost always (three points). If you get 8 points or more, you are a problem gambler.

The test is fine as a diagnostic tool. It is used internationally. But someone who scores 27 points is clearly in a worse state than someone who scores 8.

The point is that problem gambling is on a spectrum. Most problem gamblers do not suffer serious consequences as a result of their gambling. Most problem gamblers stop being problem gamblers at some point (a large proportion are young men who essentially grow out of it). But others get into serious trouble. A small number get into horrendous debt and some end up needing professional help.

The Swedish study is slanted towards the latter. Obviously, not everybody who gets treated by the Swedish health system is asked to complete a problem gambling questionnaire. 2,099 people is an incredibly small proportion of all the people who had medical treatment in Sweden between 2005 and 2016. These individuals took the test because there was something manifestly wrong with their physical or mental health. For example, they may have been admitted because of a suicide attempt which may or may not have been related to gambling. (The authors of the study don’t say, but it seems likely that the problem gambling questionnaire was one of several mental health questionnaires they were asked to fill out.)

Whatever they were being treated for, it is clear that the Swedish patients were at higher risk of all sorts of things that the average problem gambler. The authors say this explicitly:

It is therefore likely that results may be skewed toward a population of individuals with more severe forms of GD [gambling disorder]. It is likely that this once again implies that this study sample might contain patients with higher mental health comorbidity, as well as individuals with more severe forms of GD, since these individuals are more likely to receive specialized psychiatry care.

51% of the Swedish patients were suffering from depression. 60% had an anxiety disorder. 41% had a substance-use disorder. 29% had an alcohol-use disorder. 12% were bipolar. 19% had a personality disorder. This was not a normal group of people, even by the standards of problem gamblers. Some of their problems may have been exacerbated by gambling, but it takes some heroic assumptions to suggest that they would have all been fine had they never gambled or that gambling was at the root of all their problems.

Applying the suicide rate from this group of people to all the people in England who score 8 or more in the problem gambling questionnaire is like taking the liver cirrhosis rate among people who have been to Alcoholics Anonymous and applying it to everyone who drinks more than 14 units a week. It is - quite obviously - an apples and oranges comparison.

There were 5,316 suicides in England in 2019. Undoubtedly, some of them were related to gambling, but there is no reason to think that there were 409 suicides caused, directly or indirectly, by problem gambling. The true figure could be higher but it is probably lower. We really have no idea.