Uncovering the Hidden Link Between Gambling Addiction and Suicide in Veterans

In this interview, Dr Shane Kraus, associate professor of psychology at the University of Nevada, Las Vegas, and Karen Valle Frias, clinical psychology student, discuss their research which revealed strong links between gambling disorder and suicide risk among veterans, emphasizing the urgent need for routine screening, gender-sensitive prevention, and accessible, evidence-based treatment within the VA system.

Please introduce yourself by stating your name, title, and any relevant experience you’d like to share.

Shane Kraus, PhD: My name is Dr Shane Kraus. I'm an associate professor of psychology at the University of Nevada, Las Vegas. I run the Behavioral Addictions Lab, and we focus a lot on what we call behavioral addictions, such as gambling disorders.

We look at problematic sexual behavior, convulsive sexual behavior, and pornography-related issues. We also do a lot of work on substance use. In the last 3 years we've been doing a lot of work on problem gambling in military and veterans, but I've been publishing on gambling in veterans for probably the last 7 or 8 years. It's something I'm known for in an area. I have a lot of research expertise, and again, I'm a clinical psychologist, so I'm a clinician first as well.

Karen Valle Frias, BS: My name is Karen Valle Frias. I am a second year clinical psychology student in Dr Kraus' lab. My focus is a lot on gambling, broadly looking at underrepresented communities such as veterans and other minority groups.

Your study found that over 40% of veterans with gambling disorder reported a suicide attempt. What practical steps do you think VA clinicians and treatment programs can take right now to identify and support veterans at greatest risk?

Dr Kraus: This is a great question and something we've been trying to figure out for a while. This finding, although it seems really shocking, is actually not that surprising. It's something that's been found before. A number of years ago, we just studied in primary care. We said, "Hey, let's just screen every veteran who comes into primary care." This was at Bedford Hospital, part of the VA. What we found is that when you just screen people for gambling, like you screen for everything else, you find out that some people actually have an issue and will tell you about it.

We need to standardize screening in primary care. I would screen for gambling like we screen for tobacco and suicide. We also want to screen for gambling and suicide among people with mental health disorders.

What you'll see is that there are high rates of attempted suicide and suicidality among those with gambling disorders. However, people with gambling disorders don't just have gambling problems. They have lots of other issues, such as post-traumatic stress disorder (PTSD) and substance use disorders. If you're screening for gambling, you're also going to be screening for suicide, and vice versa.

I'd be screening anyone coming in reporting suicidality for gambling. Suicide attempts happen among veterans or active-duty members with gambling addiction because of the negative consequences of gambling for years and years. We saw in our primary care study that it's possible to screen for this.

We identified 3 veterans at that time who were actively suicidal but never told a single person. Again, we just started screening for gambling, and we found suicide. This is something to think about. It's should be a broader conversation in the hospital, VA, and across health workers. We should be screening and making space for problem gambling to be treated as a real issue, because many of the people with problem gambling unfortunately also have suicidal ideation or suicidal history attempts.

Women veterans in your sample were especially likely to report a suicide attempt. What factors might explain this elevated risk among women, and how should future prevention efforts account for these gender differences?

Valle Frias: In our study, we found that nonstrategic gamblers are overall more likely to report a history with suicide attempt. We find that the women in our sample were most likely to be nonstrategic gamblers, which again supports this finding. Past research has found that women are more likely to engage in nonstrategic gambling games; however, it also found that with that gambling preference comes an overall lower quality of life, unemployment, being single, lower emotional regulation, and high impulsivity. These factors could lead to that elevated risk among women veteran, and suicidality, as high impulsivity is related to that as well.

In addition, having a comorbid diagnosis on top of a gambling disorder, as well as how the disorders are portrayed and presented in women could potentially make them more vulnerable to suicidality.

In terms of prevention efforts, we can screen and look at the whole picture—not just for women, but also for men and other individuals—by making sure they have resources and asking about their gambling preferences. It's important to make sure we're assessing and considering an individual's whole system and integrating that into their treatment.

Dr Kraus: On top of that, screening for gambling and these issues in women's health clinics is essential. Karen is part of another study that we have where we've been interviewing active-duty members and veterans on problem gambling. What we know is that women veterans have, like most veterans, experienced a lot of shame and stigma, but they also carry a heavy load to disclose gambling because of how people around them may treat them. It's important to make space for women.

Again, this finding seems to stand out, but I would say prior work suggests that women veterans are at risk here for problem gambling too.

Your results suggest that impulsivity and gambling preferences—strategic versus nonstrategic—play different roles in suicidality among veterans. Can you elaborate on how these patterns might inform personalized treatment approaches?

Dr Kraus: What we know about gambling treatment is that treatment works. For some people, going to a group such as Gamblers Anonymous or social support groups is important. Sometimes faith-based community resources and psychotherapy is very helpful. Treatment works, but we also want to adapt treatment to be for that veteran.

Veterans have specific needs. Sometimes they have mental health issues, so we want to think about co-occurring trauma, substance use, and things like that. We've been doing a lot more work in mindfulness-based relapse prevention. We're looking for treatments that are broader and are addressing impulsivity, struggling to stop or start, acting out under strong emotional states, and things like that. Incorporating mindfulness and acceptance commitment therapy might be really helpful for veterans who are struggling with impulsivity. Incorporating those things into treatment and psychotherapy would be really helpful.

We want things that are transdiagnostic. It means that they are broad enough strategies and skills that they help people with multiple issues. Gambling is like bananas, the problems come in bunches. How do we get something that helps people to deal with their emotional intensity, their thoughts, their feelings, and their challenges around gambling?

There are differences in the types of strategies, but ultimately mindfulness-based treatments and acceptance commitment therapy are probably broader ways that I would recommend for treatment for folks with a gambling disorder.

Valle Frias: Additionally, with these preferences comes different sets of cognition, risk, and impulsivity. Taking time to assess individual's beliefs about their gambling, their cognition, and how they view their behavior will be really important when tailoring more personalized treatment with gambling preferences.

Based on your findings, what are the most urgent questions that future research should address to better understand and prevent suicide among veterans with gambling disorder?

Valle Frias: There are a lot of questions, but one of them could be should we continue investigating these risk factors and potential treatment pathways for veterans to help reduce the suicide risk?

Looking at larger samples of women or minority groups is really important. Longitudinal studies would be important to examine how these factors are changed and maintained, how they look over time, and how they contribute to suicide risk.

Dr Kraus: We have a paper that's publicly available called “Barriers to Care for Active Duty and Veterans for Gambling.” It talks a lot about these issues. There are a lot of barriers for veterans seeking help. We want to figure out what those barriers to care are. When someone's in VA, they might have struggled with gambling for 10 years. It's pretty bad. We have to do a two-pronged approach.

One is that we need to provide better education and prevention and let people know early about some of the warning signs. We need more work on screening and outreach. Education goes a long way.

The other one is engaging people into treatment. When we did this study, we interviewed 28 people. It was a great study; we're still publishing other papers on it. I really thought we'd get a lot of veterans and some service members from the VA, and we didn't get a single one from the VA.

I work a lot with the VA; I publish a lot with VA data. This told me that we have a disconnect. How do we engage people in the VA? How do we engage people who need to get mental health and gambling treatments? The reality is, we know that gambling is incredibly treatable. I've worked with people who thought their life could never improve and it did. There is hope, we just have to figure out how to engage them. Right now, I don't know that we are to the degree that I wish we were.