Suicide

Introduction

People with problem gambling have higher rates of suicidality, including suicidal thinking, attempts and completed suicide (Karlsson & Håkansson, 2018; Maccallum & Blaszczynski, 2003). Furthermore, people who experience problem gambling are at higher risk of having past and current suicidal thoughts, history of suicide attempts and suicide mortality compared to the general population (Karlsson & Håkansson, 2018; Maccallum & Blaszczynski, 2003). Ongoing suicide assessment is critical to identify and support clients who are at high risk for these potential harms.

One Canadian study of people who recently attempted to quit gambling showed that almost 40 per cent of participants had thought about suicide and 33 per cent had made an attempt (Hodgins et al., 2006). Another Canadian study found that people with problem gambling were three times more likely to attempt suicide than people without problem gambling (Newman & Thompson, 2003). A more recent Swedish study showed that people with problem gambling had a rate of suicide mortality that was 15 times higher than the rest of the population (Karlsson & Håkansson, 2018).

This webpage provides an overview of the evidence on the prevalence of suicide in people with gambling problems, common risk factors and practice guidelines to reduce this risk. Intended for mental health and addiction services, this information is based on a review of the literature and was reviewed by an expert in the field.

About suicide

Suicide is defined as “the act of intentionally causing one's own death” (Kessler et al., 2008) and is a complex outcome of interconnected biological, social, psychological and cultural factors (Nock et al., 2008). Having suicidal thoughts or participating in suicidal behaviour not only increases a person’s risk of suicide, but is both distressing and debilitating. In addition, completed suicide affects not only those who die, but also their family and social networks (Cerel et al., 2008).

We know that people with problem gambling are at higher risk of suicidal thinking, attempts and completed suicide (Karlsson & Håkansson, 2018; Maccallum & Blaszczynski, 2003). For this reason, it is important to identify problem gambling clients who have additional risk factors for suicide, especially those with a history of suicidal behaviour and other mental health problems such as ongoing substance use (Bischof et al. 2016).

By assessing suicide risk and monitoring it over time, clinicians can help ensure their clients are receiving the appropriate level of care, and work with them and their other care providers to promote safety and target risk factors that can be changed (Jacobs et al., 2010).

What does the evidence say?

Evidence on the link between problem gambling and suicide lends support to the need for early identification of clients at high risk (National Collaborating Centre for Mental Health, 2012).

About 20 to 40 per cent of adults with problem gambling in treatment settings have a history of suicide attempts (Séguin et al., 2010). In addition, estimated rates of suicidal ideation among clients in mental health and problem gambling support settings have ranged between 17 and 80 per cent (Maccallum & Blaszczynski, 2003). Adolescents with problem gambling are four times more likely to have suicidal thoughts and 18 times more likely to attempt suicide than those without problem gambling (Cook et al., 2014).

Research suggests that certain factors can increase a person’s risk of suicide, such as having more severe problem gambling and having certain mental health disorders (e.g., mood disorders, personality disorders, and impulsivity/attention deficit hyperactivity disorders) (Bolton et al., 2015; Carter et al., 2017; Fowler, 2012; Frank et al., 1991; Kausch, 2003; Large et al., 2016; National Collaborating Centre for Mental Health, 2012; Newman & Thompson, 2003; Quinlivan et al., 2017; World Health Organization, 2014).

While there is less research on the role of protective factors (Kleiman & Liu, 2013), several studies have shown that certain factors are linked to a lower risk of suicide, such as having strong social support, attending religious services regularly and having effective coping and problem-solving skills (Jacobs et al., 2010; Kleiman & Liu, 2013; Kleiman & Liu, 2014; World Health Organization, 2014).

Suicide risk assessment can systematically collect and evaluate information to help estimate a client’s risk of suicidal behaviour (Jacobs et al., 2010; Zaheer et al., 2017). These assessments involve gathering information from the client, family members and close contacts, other healthcare professionals involved in their care, and available clinical records.

A risk assessment allows the clinician not only to determine if a client needs immediate help (e.g., to see a psychiatrist or go to a hospital emergency department), but also to identify any treatment they may need, help them use their strengths and support network, and develop a safety plan (see the Developing a safety plan section) (Jacobs et al., 2010; Perlman et al., 2011; Zaheer et al., 2017).

By using multiple suicide risk assessments, the clinician and client can identify changes in their suicide risk and whether they need treatment for underlying mental health, substance use and/or psychosocial problems (Jacobs et al., 2010; Perlman et al., 2011; Zaheer et al., 2017).

When conducting a suicide risk assessment, keep in mind that there is a difference between risk factors and warning signs. Risk factors increase the likelihood that a person might contemplate suicide at some point in their life, while warning signs show that a person might consider suicide in the near future (Perlman et al., 2011).

Warning signs of suicide

• Threatening to harm or end one’s life.
• Seeking or access to means: seeking pills, weapons or other means.
• Showing evidence of or expressing a suicide plan.
• Expressing (writing or talking) ideation about suicide, wish to die or death.
• Expressing feelings of hopelessness.
• Expressing feelings of rage or anger, or seeking revenge.
• Acting recklessly, engaging impulsively in risky behaviour.
• Expressing feelings of being trapped with no way out.
• Showing increased or excessive substance use.
• Withdrawing from family, friends and/or society.
• Showing evidence of anxiety, agitation and/or abnormal sleep (too much or too little).
• Showing dramatic changes in mood.
• Expressing no reason for living, no sense of purpose in life.

For clients who are found to be at high risk of suicide, a variety of clinical approaches can reduce the likelihood of suicide attempts, including psychotherapy, group and family-based therapy and various medications.

How do I put the evidence into practice?

The suicide risk assessment

Conducting a suicide risk assessment with a client who has problem gambling should cover the following areas (Bolton et al., 2015; Bryan & Rudd, 2006; Perlman et al., 2011):

• predisposition to suicidal behavior (based on risk factors)
• stressors (e.g., significant financial loss)
• presentation of symptoms (e.g., symptoms of co-occurring mood disorder or personality disorder)
• presence of hopelessness and other warning signs
• access to lethal means, such as firearms
• previous suicidal behaviour (i.e., frequency and context, perceived lethality and outcome, opportunity for rescue and help seeking, preparatory behaviours)
• presence of protective factors (e.g., internal factors such as effective problem-solving and coping skills, and external factors such as strong family or community supports).

The discussion with your client will help you not only identify risk factors and warning signs, but also their strengths and level of resiliency, which will help encourage hope and reduce their risk of suicide (Perlman et al., 2011). However, keep in mind that the presence of protective factors does not reduce suicide risk in clients with severe warning signs (Perlman et al., 2011).

One method that can help reduce your client’s anxiety about the risk assessment and help build your therapeutic relationship is to increase the intensity of the discussion using a gradual approach (Bryan & Rudd, 2006). Begin by identifying what brought on the suicidal thoughts, move on to questions about symptoms, then uncover the nature of their suicidal thinking (Bryan & Rudd, 2006).

For examples of this line of questioning, listen to the two simulations below, which describe a client with acute suicidality (Simulation 1) and a client with suicidal ideation with no active plan (Simulation 2).

Simulation 1

Kyle was referred to outpatient services after receiving a diagnosis of major depressive disorder, with one prior suicide attempt. The therapist and Kyle have been working together for eight months and have built a trusting therapeutic relationship. It was discovered early in counselling that Kyle was experiencing problems with gambling. The therapist worked on this with Kyle,, which helped him to abstain from gambling for most of the eight months. Recently, Kyle had a relapse due to stressors in his life and suffered a major financial loss. As a result, Kyle again became suicidal. Listen to the audio simulation or read the transcript.

Simulation 2

Adrian has been seeing a counsellor for problem gambling and was struggling to get her gambling under control with some degree of success. Her partner thinks that Adrian was abstaining from gambling while seeing the counsellor, but eventually she discovered that Adrian was still gambling when she opened up a credit card statement. Listen to the audio simulation or read the transcript.

Notice that the therapist uses information-seeking questions used in this risk assessment. Through direct questions about the presence of suicidality, we learn that Adrian has suicidal thoughts but does not have any planned methods or active intent. This is a more passive style of ideation where the client endorses vague expression of thoughts of death. The therapist explores these thoughts with Adrian, asking questions related to methods, timing, frequency, suicide planning and past suicidal behaviours to help determine if: a) the client should go to the hospital for acute care, b) a safety plan is necessary, or c) no risk is present. In this case, the therapist and Adrian decide to co-create a safety plan. Listen to the simulation or read the transcript to find out how the therapist and Adrian co-developed the safety plan.

Use a clear and direct approach to questioning your client (Dazzi et al., 2014). As they provide answers, reflect on their answers to identify factors that might influence their risk level (Bischof et al. 2016; Brandt & Fischer, 2017; Frank et al., 1991; Kausch, 2003; Ledgerwood & Petry, 2004; Manning et al., 2015; Moghaddam et al., 2015).

Sample questions to identify factors that might influence a client’s risk level include the following (Bischof et al. 2016; Brandt & Fischer, 2017; Frank et al., 1991; Kausch, 2003; Ledgerwood & Petry, 2004; Manning et al., 2015; Moghaddam et al., 2015):

• Does this client have a mental health diagnosis, specifically mood disorders and personality disorders?
• Does this client have a substance use problem?
• Is this client receiving gambling treatment?
• Does this client have an impulsivity problem or ADHD?
• Is there a family or relationship conflict?
• Did this client start gambling at an early age?
• Does this client steal to support their gambling?
• Is this client dealing with significant debt?
• Is the patient hopeless?
• Does the client have the capacity to act?

It is important to recognize that the risk assessment only reflects your client’s suicide risk at a specific point in time (Jacobs et al., 2010). For this reason, it is a good idea to repeat the risk assessment at important life stages, such as following a change in clinical status or during a period of acute or extreme stress (e.g., after a significant loss) (Bartlett & Siegfried, 2012; Jacobs et al., 2010; Monk & Samra, 2007; Stanley & Brown, 2012).

During the risk assessments, consider your client’s risk relative to a similar population, such as all clients who are receiving care for problem gambling (i.e., their risk status) and their risk compared to their own personal baseline or to other times in their life (i.e., their risk state) (Pisani, et al., 2016; Zaheer et al., 2017).

Intervention for high-risk clients

If the risk assessment leads you to determine that your client is at high risk of suicide, make sure that someone is with the client in a safe, secure room while you contact a psychiatrist with admitting privileges at a nearby hospital and/or arrange for an ambulance to bring the client to the hospital (Hirschfeld & Russell, 1997).

If a client who is acutely suicidal refuses help, ask them about their access to lethal means, such as weapons or medications. Do what you can to make them inaccessible to the client. Call the police to help protect their safety (Hirschfeld & Russell, 1997).

If the risk of suicide is high but not imminent, obtain your client’s permission to contact a family member or another person who is close to them. Inform this person of the problem and suggest they remain alert and available to help your client deal with the problem (Hirschfeld & Russell, 1997).

Suggest to your client that they connect more frequently with you and let them know you are there to help them stay safe.

Discuss the various options available to reduce their suicide risk. Some of these options (such as pharmacological therapy) may require you to refer them to specialized services (Hirschfeld & Russell, 1997). Keep in mind that some clients are at higher risk of suicide in the days after they start psychiatric medications, so monitor them closely to identify potential problems as early as possible.

Effective approaches to suicide risk reduction:

• cognitive behaviour therapy (CBT; Jacobs et al., 2010; Bolton et al., 2015; Zalsman et al., 2016; Meerwijk et al., 2016)
• manual-assisted cognitive therapy (Zalsman et al., 2016)
• dialectical behaviour therapy (clients with a diagnosis of borderline personality disorder) (Jacobs et al., 2010; Meerwijk et al., 2016; Zalsman et al., 2016)
• group therapy (with elements of CBT, DBT and problem-solving therapy) (Bolton et al., 2015; Zalsman et al., 2016)
• family-based approaches (Zalsman et al., 2016)
• active outreach (e.g., postcards, phone calls, and home visits) (Meerwijk et al., 2016)
• medications (e.g., antidepressants, anti-anxiety medications, lithium) (Jacobs et al., 2010; Zalsman et al., 2016)
• electroconvulsive therapy (clients with treatment-resistant depression or intractable suicidal thoughts) (Bolton et al., 2015; Jacobs et al., 2010)
• means restriction (Jacobs et al., 2010; Zalsman et al., 2016).

Once you have addressed your client’s immediate risk, focus on protective factors. For example, work with them to build their social support network and their coping and problem-solving skills (Jacobs et al., 2010; Kleiman & Liu, 2013; Kleiman & Liu, 2014; World Health Organization, 2014).

Developing the safety plan

After conducting the risk assessment, work with your client to develop a safety plan (Mann, 2012; Monk & Samra, 2007). This will help you gather information and identify resources your client can use in a crisis situation. Consider the following areas (Stanley & Brown, 2012):

• warning signs of an imminent crisis
• coping skills that help reduce distress in a crisis
• contact information for people who can help during a crisis
• contact information for mental health professionals or emergency resources (e.g., hotlines)
• potential lethal means the client should avoid
• ways to address practical concerns, such as people who can pay rent or feed pets if the client is in the hospital
• a list of crisis centres available 24 hours a day in Canada to keep within reach in case of emergency.

Once you have developed the safety plan, ask your client to consider whether the components are useful and realistic to them (Stanley & Brown, 2012).

Give the client multiple copies of the safety plan to keep in locations they can access easily in a crisis (e.g., wallet, nightstand and smartphone) and send to everyone who is listed in the plan. Revisit the safety plan with them at each visit to ensure it remains relevant and up to date (Stanley & Brown, 2012).

Dealing with a client emergency

Having a client who makes a suicide attempt or dies as a result of suicide can result in feelings of guilt, shame, disbelief, incompetence, anger, depression and fear for the clinician (Kleespies & Dettmer, 2000). In some cases, the clinician can exhibit symptoms that are similar to those of clients with post-traumatic stress.

Proper training of clinicians who work with high-risk clients should include a comprehensive orientation on the topic as well as a mentorship model of training and supervision that includes role modelling of healthy responses to a client’s suicide attempt or death (Kleespies & Dettmer, 2000).

Agencies with clients who may be at risk of suicide also should provide frequent opportunities for clinicians to discuss clients they consider to be at risk, so that team members can express their emotional responses to the work, learn from each other and offer support. Effective approaches to coping with a client’s suicide include talking with a colleague or colleagues who knew the client or who experienced a similar situation, performing a post-event case review, and seeking the support of a family member or other loved one (Kleespies & Dettmer, 2000).

Clinical simulation video

Download transcript

This video clip shows a fictitious therapist and client session for teaching purposes.

In this scenario, the clinician and client (Joseph) have worked together for many months and have developed a trusting therapeutic relationship. Since he presented as passively suicidal in the past, they have created a list of emergency contacts. In the video clip, the client presents with a flat affect and with thoughts of suicide. The clinician asks the client directly about the frequency of his suicidal thoughts and asks whether he has any plans for acting on them. The clinician then reviews options for further support and helps Joseph identify various coping strategies.

After providing the necessary referrals and supports, the clinician will continue to check in with the client regularly, closely monitor his mental status, document the plan thoroughly and provide an update to the inter-professional team (including the psychiatrist) about the client’s current risk level and plan.

Additional Resources

Risk assessment tools

The following tools are available for clinicians to use during a suicide risk assessment:

• Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) for Mental Health Professionals. This two-page resource lists risk and protective factors, topics to cover during a suicide risk assessment, interventions that can be used at different risk levels and various resources for clinicians. A SAFE-T pocket card and a mobile app are also available. The SAFE-T tool was developed by the Suicide Prevention Resource Center and Screening for Mental Health Inc. Learn more about SAFE-T tool.
• Depressive Symptom Index: Suicidality Subscale (DSI-SS). This index can help identify and prevent suicidal ideation. It consists of four items that assess the presence and severity of suicidal thoughts, plans and urges. Each item consists of a group of statements with scores that reflect the severity of suicidality. The tool was developed by the Laboratory for the Study and Prevention of Suicide-related Conditions and Behaviors in Florida. Learn more about the DSI-SS.
• Suicidal Ideation Attributes Scale (SIDAS). This scale identifies the presence and severity of suicidal thoughts. The scale includes five items that target different attributes of suicidal thoughts, such as frequency, controllability, closeness to attempt, level of distress associated with the thoughts and impact on daily functioning. Responses are measured on a 10-point scale, with higher total scores reflecting more severe suicidal thoughts. This tool was developed by the Australian National University. Learn more about the SIDAS scale. Reference: Van Spijker, B.A.J., Batterham, P.J., Calear, A.L., Farrer, L., Christensen, H., Reynolds, J. & Kerkhof, A.J.F.M. (2014). The Suicidal Ideation Attributes Scale (SIDAS): Community-based validation study of a new scale for the measurement of suicidal ideation. Suicide and Life-Threatening Behavior, 44 (4), 408-419.

Safety planning tools

You can use the following tools when developing a safety plan:

• Holistic Crisis Planning toolkit is a comprehensive set of resources and templates for holistic crisis planning with youth and their families. It provides an overview of the guiding principles of person- and family-centred holistic crisis planning and the stages of change, as well as various templates for safety planning, communicating with clients and family members, gathering demographic information and more. The tools and approach were originally developed by Kappy Madenwald of Madenwald Consulting, LLC for the Massachusetts Executive Office of Health and Human Services and have since been updated and adapted for use by human and social services agencies in the Region of Peel in Ontario. Learn more about the holistic crisis planning toolkit.
• The Safety Planning Intervention (www.suicidesafetyplan.com) consists of a list of coping strategies and sources of support that your clients can use to cope during a crisis.  This tool lists the warning signs of a suicidal crisis, coping strategies, as well as people and settings that can help distract from suicidal thoughts or help cope during a crisis. The tool was evaluated in a variety of settings and was adapted for use with a variety of client populations. The intervention was developed by researchers at Columbia University College of Physicians & Surgeons and University of Pennsylvania’s Perleman School of Medicine and was identified as a best practice by the Suicide Prevention Resource Center/American Foundation for Suicide Prevention Best Practices Registry for Suicide Prevention. http://www.suicidesafetyplan.com/.

The following templates are also available for use by clinicians and their clients:

• My Support Numbers helps clients identify and list the individuals they can contact during a crisis. This template is part of the Wellness and Comfort Activities Toolkit created by the Centre for Addiction and Mental Health’s Portico Network, with resources also available in French.
• Be Safe is an Ontario-based mobile application designed for young people by the London Service Collaborative and mindyourmind in partnership with a group of youth and professionals. Available as a free download for both IOS and Android platforms, it helps young clients create a safety plan and access information about local mental health and addiction resources. It includes a decision-making aid that can be used during a crisis and helps clients create a personalized “get help script.”
• Alternative Comfort Activities Check List provides a list of wellness-promoting activities that can bring comfort to clients during difficult times and includes a planning calendar. This template is part of the Wellness and Comfort Activities Toolkit created by CAMH's Portico Network, with resources also available in French.

References

Bartlett, M.L. & Siegfried, N. (2012). Best practice clinical interventions for working with suicidal adults. Alabama Counseling Association Journal, 38 (2), 65–79. Available: https://files.eric.ed.gov/fulltext/EJ1016283.pdf. Accessed March 18, 2020.

Bergen, H., Hawton, K., Waters, K., Cooper, J. & Kapur, N. (2010). Psychosocial assessment and repetition of self-harm: The significance of single and multiple repeat episode analyses. Journal of Affective Disorders, 127 (1–3), 257–265. Available: https://doi.org/10.1016/j.jad.2010.05.001. Accessed March 18, 2020.

Bischof, A., Meyer, C., Bischof, G., John, U., Wurst, F. M., Thon, N. et al. (2016). Type of gambling as an independent risk factor for suicidal events in pathological gamblers. Psychology of Addictive Behaviors, 30 (2), 263–269. Available: https://doi.org/10.1037/adb0000152. Accessed March 18, 2020.

Bolton, J.M., Gunnell, D. & Turecki, G. (2015). Suicide risk assessment and intervention in people with mental illness. BMJ (Online), 351. Available: https://doi.org/10.1136/bmj.h4978. Accessed March 18, 2020.

Brandt, L. & Fischer, G. (2017). Adult ADHD is associated with gambling severity and psychiatric comorbidity among treatment-seeking problem gamblers. Journal of Attention Disorders. Available: https://doi.org/10.1177/1087054717690232. Accessed March 18, 2020.

Bryan, C.J. & Rudd, M.D. (2006). Advances in the assessment of suicide risk. Journal of Clinical Psychology, 62 (2), 185–200. Available: https://doi.org/10.1002/jclp. Accessed March 18, 2020.

Carter, G., Milner, A., McGill, K., Pirkis, J., Kapur, N. & Spittal, M.J. (2017). Predicting suicidal behaviours using clinical instruments: Systematic review and meta-analysis of positive predictive values for risk scales. British Journal of Psychiatry, 210 (6), 387–395. Available: https://doi.org/10.1192/bjp.bp.116.182717. Accessed March 18, 2020.

Cerel, J., Jordan, J.R. & Duberstein, P.R. (2008). The impact of suicide on the family. Crisis, 29 (1), 38–44. https://doi.org/10.1027/0227-5910.29.1.38.

Cook, S., Turner, N.E., Paglia-Boak, A., Murray, R., Adlaf, E.M., Mann et al. (2014). Problem gambling among Ontario students: Associations with substance abuse, mental health problems, suicide attempts, and delinquent behaviours. Journal of Gambling Studies, 31 (4), 1121–1134. Available: https://doi.org/10.1007/s10899-014-9483-0. Accessed March 18, 2020.

Dazzi, T., Gribble, R., Wessely, S. & Fear, N.T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 3361–3363. Available: https://doi.org/10.1017/S0033291714001299. Accessed March 18, 2020.

Fowler, J.C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49 (1), 81–90. Available: https://doi.org/10.1037/a0026148. Accessed March 18, 2020.

Frank, M.L., Lester, D., & Wexler, A. (1991). Suicidal behavior among members of Gamblers Anonymous. Journal of Gambling Studies, 7 (3), 249–254.

Hirschfeld, R.M.A. & Russell, J.M. (1997). Assessment and treatment of suicidal patients. New England Journal of Medicine, 337 (13), 910–915. Available: https://doi.org/10.1249/jsr.0000000000000000. Accessed March 18, 2020.

Hodgins, D.C., Mansley, C. & Thygesen, K. (2006). Risk factors for suicide ideation and attempts among pathological gamblers. American Journal on Addictions, 15 (4), 303–310. Available: https://doi.org/10.1080/10550490600754366. Accessed March 18, 2020.

Jacobs, D.G., Baldessarini, R.J., Horton, L., Ph, D., & Pfeffer, C.R. (2010). Practice guideline for the assessment and treatment of patients with suicidal behaviors. American Psychiatric Association. Available: https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed March 18, 2020.

Karlsson, A. & Håkansson, A. (2018). Gambling disorder, increased mortality, suicidality, and associated comorbidity: A longitudinal nationwide register study. Journal of Behavioral Addictions, 7 (4), 1091–1099. Available: https://doi.org/10.1556/2006.7.2018.112. Accessed March 18, 2020.

Kausch, O. (2003). Suicide attempts among veterans seeking treatment for pathological gambling. Journal of Clinical Psychiatry, 64 (9), 1031–1038. Available: https://doi.org/10.4088/JCP.v64n0908. Accessed March 18, 2020.

Kessler, R.C., Hwang, I., Labrie, R., Petukhova, M., Sampson, N.A., Winters, K.C. et al. (2008). DSM-IV pathological gambling in the National Comorbidity Survey Replication. Psychological Medicine, 38 (9), 1351–1360. Available: https://doi.org/10.1017/S0033291708002900. Accessed March 18, 2020.

Kleespies, P.M. & Dettmer, E.L. (2000). The stress of patient emergencies for the clinician: Incidence, impact, and means of coping. Journal of Clinical Psychology, 56 (10), 1354–1369. Available: https://doi.org/10.1002/1097-4679(200010)56:10%3C1353::AID-JCLP7%3E3.0.CO;2-3. Accessed March 18, 2020.

Kleiman, E.M. & Liu, R.T. (2013). Social support as a protective factor in suicide: Findings from two nationally representative samples. Journal of Affective Disorders, 150 (2), 540–545. Available: https://doi.org/doi:10.1016/j.jad.2013.01.033. Accessed March 18, 2020.

Kleiman, E.M. & Liu, R.T. (2014). Prospective prediction of suicide in a nationally representative sample: Religious service attendance as a protective factor. British Journal of Psychiatry, 204 (4), 262–266. Available: https://doi.org/10.1192/bjp.bp.113.128900. Accessed March 18, 2020.

Large, M., Kaneson, M., Myles, N., Myles, H., Gunaratne, P. & Ryan, C. (2016). Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: Heterogeneity in results and lack of improvement over time. PLoS ONE, 11 (6), 1–17. Available: https://doi.org/10.1371/journal.pone.0156322. Accessed March 18, 2020.

Ledgerwood, D.M. & Petry, N.M. (2004). Gambling and suicidality in treatment-seeking pathological gamblers. The Journal of Nervous and Mental Disease, 192 (10), 711–714. Available: https://doi.org/10.1097/01.nmd.0000142021.71880.ce. Accessed March 18, 2020.

Maccallum, F. & Blaszczynski, A. (2003). Pathological gambling and suicidality: An analysis of severity and lethality. Suicide & Life-Threatening Behavior, 33 (1), 88–98.

Mann, J.J. (2012). Neurobiology of suicidal behaviour. Psychiatria Danubina, 24 (Suppl. 3), 336–341. Available: https://doi.org/10.1038/nrn1220. Accessed March 18, 2020.

Manning, V., Koh, P.K., Manning, V., Koh, P.K., Yang, Y., Ng, A. et al. (2015). Suicidal ideation and lifetime attempts in substance and gambling disorders. Psychiatry Research, 225 (3), 706–709. Available: https://doi.org/10.1016/j.psychres.2014.11.011. Accessed March 18, 2020.

Meerwijk, E.L., Parekh, A., Oquendo, M.A., Allen, I.E., Franck, L.S. & Lee, K.A. (2016). Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: A systematic review and meta-analysis. The Lancet Psychiatry, 3 (6), 544–554. Available: https://doi.org/10.1016/S2215-0366(16)00064-X. Accessed March 18, 2020.

Moghaddam, J.F., Yoon, G., Dickerson, D.L., Kim, S.W. & Westermeyer, J. (2015). Suicidal ideation and suicide attempts in five groups with different severities of gambling: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions. American Journal on Addictions, 24 (4), 292–298. Available: https://doi.org/10.1111/ajad.12197. Accessed March 18, 2020.

Monk, L. & Samra, J. (2007). Working With the Client Who is Suicidal: A Tool for Adult Mental Health and Addiction Services. Centre for Applied Research in Mental Health and Addictions. Vancouver, BC: Centre for Applied Research in Mental Health and Addiction. Available: https://www.health.gov.bc.ca/library/publications/year/2007/MHA_WorkingWithSuicidalClient.pdf. Accessed March 18, 2020.

National Collaborating Centre for Mental Health. (2012). Self-Harm: The Longer-term Management of Self-harm. Available: http://www.nice.org.uk/guidance/cg133. Accessed March 18, 2020.

Newman, S.C. & Thompson, A.H. (2003). A population-based study of the association between pathological gambling and attempted suicide. Suicide and Life-Threatening Behavior, 33 (1), 80–87. Available: https://doi.org/10.1521/suli.33.1.80.22785. Accessed March 18, 2020.

Nock, M.K., Borges, G., Bromet, E.J., Cha, C.B., Kessler, R.C. & Ling, S. (2008). Suicide and suicidal behaviour. Epidemiology Reviews, 30, 133–154. Available: https://doi.org/10.1093/epirev/mxn002. Accessed March 18, 2020.

Perlman, C., Neufeld, E., Martin, L., Goy, M. & Hirdes, J.P. (2011). Suicide Risk Assessment Guide. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute. Available: https://www.patientsafetyinstitute.ca/en/toolsResources/SuicideRisk/Documents/Suicide Risk Assessment Guide.pdf. Accessed March 18, 2020.

Pisani, A.R., Murrie, D.C. & Silverman, M.M. (2016). Reformulating suicide risk formulation: From prediction to prevention. Academic Psychiatry, 40 (4), 623–629. Available: https://doi.org/10.1007/s40596-015-0434-6. Accessed March 18, 2020.

Quinlivan, L., Cooper, J., Meehan, D., Longson, D., Potokar, J., Hulme, T. et al. (2017). Predictive accuracy of risk scales following self-harm: Multicentre, prospective cohort study. British Journal of Psychiatry, 210 (6), 429–436. Available: https://doi.org/10.1192/bjp.bp.116.189993. Accessed March 18, 2020.

Séguin, M., Boyer, R., Lesage, A., McGirr, A., Suissa, A., Tousignant, M. et al. (2010). Suicide and gambling: Psychopathology and treatment-seeking. Psychology of Addictive Behaviors, 24 (3), 541–547. Available: https://doi.org/10.1037/a0019041. Accessed March 18, 2020.

Stanley, B. & Brown, G.K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19 (2), 256–264. Available: https://doi.org/10.1016/j.cbpra.2011.01.001. Accessed March 18, 2020.

World Health Organization. (2014). Preventing Suicide: A Global Imperative. Geneva, Switzerland: World Health Organization. Available: https://apps.who.int/iris/bitstream/handle/10665/131056/9789241564779-ger.pdf. Accessed March 18, 2020.

Zaheer, J., Eynan, R., Links, P.S. & Kurdyak, P. (2017). Canadian Armed Forces Clinician Handbook on Suicide Prevention. Ottawa, ON: Canadian Psychiatric Association. Available: https://www.cpa-apc.org/wp-content/uploads/CAF-Clinician-Handbook-18-FIN-EN.pdf. Accessed March 18, 2020.

Zalsman, G., Hawton, K., Wasserman, D., van Heeringen, K., Arensman, E., Sarchiapone, M. et al. (2016). Suicide prevention strategies revisited: 10-year systematic review. The Lancet Psychiatry, 3 (7), 646–659. Available: https://doi.org/10.1016/s2215-0366(16)30030-x. Accessed March 18, 2020.