Online gambling and suicide: Gambling with lives

Gambling is defined as an activity that involves betting or staking something of value, with the consciousness of risk, in the hope of gaining something of greater value. Popular gambling activities include lottery, sports betting, bingo, casino games like roulette, and card games like poker, rummy, and teen patti. While almost all forms of gambling are illegal in India, some card games such as online rummy have been defined as “games of skill”, thereby bypassing most anti-gambling laws. Backed by robust evidence, the nosological status of gambling disorder (GD) is clearly established and should not be confused with internet addiction or internet gaming disorder.[1] GD is a valid diagnosable mental disorder under both the International Classification of Disorders, 11^th revision (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In the past (DSM-4), pathological gambling was considered as an “impulse control disorder” along with conditions such as trichotillomania and kleptomania.[2] However, recent literature clearly shows a significant overlap in its underlying neurobiological and genetic factors with substance-related disorders. This led to GD being moved to the substance-related disorder section in the DSM-5. The ICD-11 further categorizes GD into (i) predominantly offline and (ii) predominantly online.

The negative impact of the COVID-19 pandemic on individuals, industries, health systems, and the economy is well documented. The abrupt disruption to lifestyles, social isolation, financial losses, and grief are a few of the factors that led to anxiety, depression, and negative emotional states during this period. Addictive behaviors such as substance abuse and online gaming and gambling grew markedly during this period, possibly as a means to alleviate those negative emotional states.[3] Online platforms that host rummy and similar games reported a huge spike in the number of people playing this game during the lockdown in March 2020. It is estimated that there are around 20,000 to 30,000 people playing rummy in India at any given time. When compared to offline gambling, factors such as availability, accessibility, affordability, anonymity, and convenience make online gambling far more attractive. The average age of online gamblers was significantly lesser (by 10 years) than offline gamblers. Factors such as poor impulse control and poor decision-making—inherent to the youth—coupled with external factors such as online peer pressure and aggressive online marketing really highlight the potential harm that online gambling can cause to young vulnerable individuals.[4] Data from a 2020 report on online gaming in India included games such as teen patti, rummy, and poker as they were, again, considered “games of skill”. The report revealed that the online gaming industry grew 40% in 2019 to reach INR 65 billion and is expected to reach INR 187 billion by 2022. Specifically, games like rummy, poker, and teen patti grew by 30% compared to the previous year. They found this growth to be driven by (i) incentives to win money instantly in transaction-based games, (ii) a more pervasive mobile payment ecosystem and (iii) active marketing and branding campaigns led by celebrities.[5]

Gambling-related harm could be diverse, with homelessness, domestic violence, debt, family breakdown, depression, and suicide occurring commonly.[6] Gambling disorders have been strongly associated with comorbid substance use disorders, anxiety, and depression. In fact, more than 90% of the population with GD have a diagnosable mental disorder and more than 60% have three or more co-occurring psychiatric disorders.[7] These associations are particularly strong among young people who gamble on the internet.[8] Those with high-risk gambling behaviors also have an increased risk of suicidality. Eight studies from USA reported that those with GD had the highest suicide rate of any addiction disorder with one in five GD patients having attempted suicide. Similar findings were reported from the UK where those with GD were six times more likely to have suicidal thoughts and 15 times more likely to make a suicidal attempt. Even after adjusting for confounding factors (such as depression, substance abuse, and financial problems), researchers found that GD patients were still three times more likely to consider or attempt suicide. Nineteen percent of those with GD had considered suicide in the past year compared to 4.1% of the general population, while 4.7% attempted suicide compared to 0.6% of the wider population.[9] A recent qualitative study found that indebtedness and shame were factors that strongly linked suicidality and GD. Heavy indebtedness continued to strongly link GD and suicide, even after adjusting for factors such as comorbid depression.[8] Adding to the problem is the fact that only 8% of the gamblers ask for help and this usually happens only in the face of severe psychological distress and depression. This goes to show that there is a huge population of gamblers, facing varying degrees of gambling-related problems, who are neither seeking nor receiving the help they need.[10] Though national data on gambling-related suicide is scarce, online rummy–related suicides in Tamil Nadu has been gaining attention recently, with more than 30 reported cases. This led the state government to form an expert committee that had unanimously recommended a total ban of online rummy.

Treatment for those with GD in the form cognitive behavioral therapy, gambling anonymous, and motivational interviewing has shown effectiveness. Pharmacotherapy may also be important in the context of co-occurring depression, suicidal behaviors, and substance use disorders. However, policy level control over gambling should be prioritized over individual therapies, as only this would prevent excessive gambling and related suicidality. The UK with a population of 65 million spends less than half of what New Zealand (population 4.7 million) does on gambling treatment, education, and research. The gambling-related policies are controlled by the Department of Internal Affairs in New Zealand, but in the UK, it comes under the purview of the Department for Digital, Culture, Media and Sport.[11] This comparison was only made to highlight the importance of legislative and public health policies that deal with gambling-related harm. One should also be wary of industry-driven research on GD and the use of terms such as “problem gamblers and responsible gamblers” that attempts to normalize gambling and projects the problem as occurring due to individual irresponsibility.

Gambling addiction is fast becoming a worldwide public health problem with the development of electronic forms of gambling and growing liberalization of the gambling market. Approaches need to move the focus from “personal responsibility” to social, economic, and environmental interventions at the population level. Legislators, health care professionals, and researchers need to come together and adopt a multi-faceted public health approach to reduce gambling-related harm.