A Very Public Deception – Part IV

Is it ever ethical to invent mortality statistics?

Photo by Annie Spratt on Unsplash

This is the fourth article in our series on attempts by state bodies to claim large-scale suicide mortality associated with ‘problem gambling’. In the first three articles we demonstrated why estimates prepared by Public Health England (‘PHE’) and the Office for Health Improvement and Disparities (‘OHID’) are unsound; we examined the conduct of PHE and OHID, including attempts to mislead and misdirect; and we considered the role played by the Gambling Commission, the Advisory Board for Safer Gambling and others in propagating the PHE-OHID claims while suppressing concerns about their reliability. We conclude by addressing the wisdom of attempts to boil down a matter as complex as suicide to any single factor.

It has long been accepted that people with gambling disorder are at elevated risk of death by suicide. The DSM-5 (the American Psychiatric Association’s ‘bible’) observes that people in treatment for gambling disorder are at elevated risk of self-harm (something that is true of a range of other mental health conditions). This warrants concern. It is also widely accepted that suicide is a complex matter. In their 2016 meta-analysis of 50 years of suicide research, Franklin et al. made the following observation:

“…any individual with nearly any type of mental illness (i.e. internalizing, externalizing, psychotic, or personality disorder symptoms), serious or chronic physical illness, life stress (e.g. social, occupational, or legal problem), special population status (e.g. migrant, prisoner, non-heterosexual), or access to lethal means (e.g. firearms, drugs, high places) may be at risk for [suicidal behaviours and thoughts]. A large proportion of the population possess at least one of these risk factors at any given time, with many people possessing multiple factors.”  

Gambling disorder is a risk factor for suicide – but one that demands context. Understanding this can be helpful when it comes to devising self-harm prevention strategies. For example, Hakansson & Karlsson (the Swedish researchers whose analysis was misused by PHE-OHID) conclude their 2020 study with the following recommendation:

“The findings call for improved screening and treatment interventions for patients with gambling disorder and other mental health comorbidity.”

It is questionable however whether discrete associations between any single activity or human characteristic and death by suicide should – by itself - be used to justify state controls on that activity.  By way of illustration, a 2021 study on the prevalence of suicidal behaviour in a group of patients with behavioural addictions (Valenciano-Mendoza et al., 2021) found:

“the highest prevalence of suicide attempts was registered for sex addiction (9.1%), followed by buying–shopping disorder (7.6%), gambling disorder (6.7%), and gaming disorder (3.0%).”

Such findings are useful for addressing risk of self-harm within population groups suffering from these conditions. They do not – by themselves - justify state controls on sex, shopping or playing video games. A 2017 study of young adults in England (aged 20-24 years, n=106) by Appleby et al., found that four deaths by suicide were linked to ‘gambling problems’; and this has been used by activists to claim that 250 deaths by suicide each year are ‘gambling-related’ (i.e. 4% of all such deaths). The same study however,  also found that 44 of those who had died “had a reported history of excessive alcohol use. Illicit drug use was reported in 54 (51%)”; seven “were reported as experiencing problems related to being a student” (including five experiencing “academic pressures”). Those who have used this study to allege there are 250 ‘gambling-related suicides’ every year, must therefore believe that 3,200 suicides are related to illicit drug use; 2,625 to excessive alcohol use; and 440 to academia. The findings in Appleby et al. should prompt concern; but it is questionable whether they should be used to demand bans on advertisements for betting, beer or university degree courses.

Some activists have called for coroners to assess, as a matter of routine, the possible involvement of gambling in suicide cases. The Bishop of St Albans has doggedly pursued a Private Members Bill to mandate this. While understanding the causes of suicide is an important endeavour, this requirement would impose impossible expectations on coroners; and create distortion if other factors were not investigated with the same degree of rigour. The presence of Adverse Childhood Experiences (‘ACEs’), for example, is a well-documented antecedent of suicide. One study (Dube et al., 2001) found that as many as 80% of suicide cases analysed had a history of ACEs. There are also well-documented associations between relationship breakdown and self-harm. Franklin et al. (2016) found that “accurate STB {Suicidal Thoughts and Behaviour] prediction will likely require a complex combination of a large number of factors (i.e., > 50), many of which are time varying”. The practicality and wisdom of asking coroners to probe into every corner of the deceased’s life should be carefully considered.

Those determined to produce figures on the prevalence of gambling-related suicide should first set out a clear operationalised definition of what this term means. How is the relationship to be characterised? Does the individual need to have gambled in the prior 12 months? Does he or she need to have a diagnosis of gambling disorder? To what extent is evidence of causality necessary? Finally, they should be required to contextualise their findings by reference to other risk factors.

Running through some of the institutional responses to PHE-OHID is the idea that unreliable estimates of mortality serve a valid purpose pending the production of more robust statistics – a matter of ‘fake it until you can make it’. The chair of the Gambling Commission’s Advisory Board for Safer Gambling (‘ABSG’), Dr Anna van der Gaag, defended PHE-OHID’s manipulations by writing:

“Good research, especially if it is on an under-researched area like this one, tends to begin and end in a different place, prompting challenge, replication, debate, and the research in this important area is no different.”

It is a view that overlooks four important points. First, the PHE-OHID work on the cost of gambling harms – riven with basic errors, deceptions and indications of bias - cannot be considered “good research”. Second, Dr van der Gaag and the ABSG have shown little interest in “replication and debate”, demanding instead that demonstrably bad research should prompt “action”. Third, rather than welcoming challenge, the ABSG and the OHID have reacted to scrutiny with evasion, hostility and ad hominem disparagement. Dr van der Gaag herself has likened critics of PHE-OHID – without any substantiation - to ‘Big Oil’. Fourth, it is questionable how far we should trust ‘better research’ if those responsible for it have propagated or tolerated misinformation in the past.

The fabrication of statistics about gambling and suicide is not simply an academic matter. PHE-OHID’s claims provided the justification for the inclusion of gambling in the Department of Health’s Suicide Prevention Strategy for England; and are also cited in National Institute for Health and Care Excellence draft guidelines for treating harmful gambling. They formed the backdrop for the introduction of a regulatory requirement that all licensed operators (with the exception of the National Lottery) should be required to report any customer death by suicide to the Gambling Commission, regardless of how recently, frequently or intensely the individual had gambled. These may prove to be positive developments – but policy should not be based on misinformation; and the consequences of doing so can be harmful.

Suicide risk among people with a gambling disorder is a legitimate issue and warrants an intelligent response; but this is unlikely to be achieved through the publication of spurious prevalence estimates. As the US economist, Professor Douglas Walker has observed;

“If researchers continue to offer social cost estimates, they should estimate costs that are measurable. But for other costs such as psychic costs that cannot be measured…let us identify them without providing spurious empirical estimates. Offering methodologically flawed cost estimates does not improve our understanding nor does it promote sound policy…In areas where research is still quite primitive, perhaps no data would be better than flawed data.”

Coda

We are aware that some people may resent this series of articles on PHE-OHID (not least the OHID officials who have displayed such aversion to scrutiny). Our intention in writing them has not been to hurt, insult or distract – but to shine a light on the way that statistics are created and the distortive effect that junk science can have on regulatory policies. The application of scrutiny to research is an important part of the scientific process; and where state bodies are concerned, an important part of the democratic process too. It is entirely consistent to be concerned about a particular issue (e.g. risk of self-harm in a gambling context) and at the same time to believe that policy should not be based on misinformation.

The involvement of PHE, OHID and the Gambling Commission in the manipulation of statistics appears to fit a wider pattern of behaviour by public bodies in Great Britain; involving the abuse of authority and cover-up. It is time for these organisations to set aside their agendas, acknowledge and take responsibility for past mis-steps and start to engage with a wide range of stakeholders (including licensees) on addressing an important and complex issue with intelligence and sensitivity.