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People with problem gambling have higher rates of suicidality, including suicidal thinking, attempts and completed suicide.1,2 Ongoing suicide assessment is critical to identify and support clients who are at high risk for these potential harms.

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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.1,2  

One Canadian study of people who recently attempted to quit gambling showed that almost 40 per cent had thought about suicide and 33 per cent had made an attempt.3 Another Canadian study found people with problem gambling were three times more likely to attempt suicide than people without problem gambling.4 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.1

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. 


Suicide is defined as "the act of intentionally causing one's own death"5 and is a complex outcome of interconnected biological, social, psychological and cultural factors.6 Having suicidal thoughts or participating in suicidal behaviour not only increases a person's risk of suicide, but is distressing and debilitating on its own. In addition, completed suicide affects not only those who die but also their family and social networks.7  

We know that people with problem gambling are at higher risk of suicidal thinking, attempts and completed suicide.1,2 For this reason, it is important to identify problem gambling clients who have additional risk factors for suicide, especially those with a past history of suicidal behaviour and other mental health problems such as ongoing substance use.8

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 are able to be changed.9


Evidence on the link between problem gambling and suicide lends support to the need for early identification of clients at high risk.12,13

About 20 to 40 per cent of adults with problem gambling in treatment settings have a past history of suicide attempts.10 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.2 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.11

Research suggests that certain factors can increase a person's risk of suicide, for example, having a more severe problem gambling12–14 and having certain mental health disorders (e.g., mood disorders, personality disorders, and impulsivity/attention deficit hyperactivity disorders; Table 1).4,12,15–20

While there is less research on the role of protective factors,21 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 (Table 1).9,13,21,22

Table 1. Risk and protective factors for suicidal attempts in adults with problem gambling
Type of factor
​Risk factor
​Protective factor
  • ​Being female
​Level of problem gambling severity
  • ​Having a greater gambling severity12–14
  • ​Having a psychiatric diagnosis, specifically mood disorders, personality disorders, and attention deficit hyperactivity disorders4,12,15–20
  • Having a substance use problem and/or a family history of substance use3,14,16,18,19
  • ​Effective clinical care for mental, physical and substance use disorders
  • Support through ongoing medical and mental health care therapeutic relationships
  • Easy access to a variety of clinical interventions and support for seeking help
​Behaviour and personality
  • ​Being impulsive12,18,19
  • ​Skills in problem solving, coping, and conflict resolution
  • Sense of belonging, sense of identity, and good self-esteem
  • Identification of future goals
  • Constructive use of leisure time (enjoyable activities)
  • ​Starting to gamble at an earlier age12,14,19
​Relationships and community involvement
  • ​Being married12,39
  • ​Strong connections to family and community support
  • Strong cultural connections and values
​Financial status
  • ​Having serious gambling debts12,16,39
​Religion or spirituality
  • ​Strong spiritual and religious connections and beliefs
  • ​Access to highly lethal means of suicide
  • ​Restricted access to highly lethal means of suicide

Suicide risk assessment can systematically collect and evaluate information that helps estimate a client's risk of suicidal behaviour.9,23 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).9,23,24

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.9,23,24

When conducting a suicide risk assessment, keep in mind that there is a difference between risk factors (see Table 1) 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.24

Warning signs of suicide

  • Threatening to harm or end one's life
  • Seeking or access to means: seeking pills, weapons, or other means
  • Evidence or expression of a suicide plan
  • Expressing (writing or talking) ideation about suicide, wish to die or death
  • Hopelessness
  • Rage, anger, seeking revenge
  • Acting reckless, engaging impulsively in risky behaviour
  • Expressing feelings of being trapped with no way out
  • Increasing or excessive substance use
  • Withdrawing from family, friends, society
  • Anxiety, agitation, abnormal sleep (too much or too little)
  • Dramatic changes in mood
  • Expresses no reason for living, no sense of purpose in life.

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

Putting evidence Into Practice

The suicide risk assessment

Conducting a suicide risk assessment with a client who has problem gambling should cover the following areas:15,24,25

  • 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 to encourage hope and reduce their risk of suicide.24 Keep in mind, however, that the presence of protective factors does not reduce suicide risk in clients with severe warning signs.24

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.25 Begin by identifying what brought on the suicidal thoughts, move on to questions about symptoms, then uncover the nature of their suicidal thinking.25

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 they have built a trusting therapeutic relationship. Early on in counselling, it was discovered that Kyle was experiencing problems with gambling. The therapist worked with Kyle on this, 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 the style of questions used in this risk assessment, focused on information-seeking questions. Through direct questions about the presence of suicidality, we learn 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 have decided 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.26 As they provide answers, reflect on their answers to identify factors that might influence their risk level.8,14,18,27–31

Sample questions to identify factors that might influence a client's risk level:8,14,18,27–31

  • 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?

At the same time, the risk assessment only reflects your client's suicide risk at a specific point in time.9 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, such as after a significant loss.9,32–34

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).23,35

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.36

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.36 Call the police to help protect their safety.36

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.36

Suggest to your client that they connect more frequently with you and let them know you're there to help them stay safe.36

Discuss the various options available to reduce their suicide risk (see Table 5). Some of these options (such as pharmacological therapy) may require you to refer them to specialized services.36 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.36

Effective approaches to suicide risk reduction:

  • Cognitive behaviour therapy (CBT)9,15,40,41
  • Manual-assisted cognitive therapy40
  • Dialectical behaviour therapy (clients with a diagnosis of borderline personality disorder)9,40,41
  • Group therapy (with elements of CBT, DBT, and problem-solving therapy)15,40
  • Family-based approaches40
  • Active outreach (e.g., postcards, phone calls, and home visits)41
  • Medications (e.g., antidepressants, anti-anxiety medications, lithium)9,40
  • Electroconvulsive therapy (clients with treatment-resistant depression or intractable suicidal thoughts.)9,15
  • Means restriction15,40

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.9,13,21,22

Developing the safety plan

After conducting the risk assessment, work with your client to develop a safety plan.32,37 This will help you gather information and identify resources your client can use in a crisis situation.34

  • Some areas to consider are listed below:34
  • 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.34

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.34 Revisit the safety plan with them at each visit to ensure it remains relevant and up to date.34

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.38 In some cases, the clinician can exhibit symptoms that are similar to those of clients with post-traumatic stress.38

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 modeling of healthy responses to a client's suicide attempt or death.38

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.38

Approaches to coping with a client's suicide that have been shown to be effective 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.38

Clinical simula​tion vid​eo​

Download video 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.


Risk assessment tools. 

Several tools are available for clinicians to use during a suicide risk assessment. Available tools are listed below:

  • Crisis Assessment Template. This six-page questionnaire helps determine whether a client might pose danger to themselves or others. It includes questions about suicidal or violent thoughts, hallucinations, planning, access to suicide methods, and suicide planning. This resource was developed by clinicians in Alcohol, Drug and Gambling Services at the Social and Public Health Services Division of the City of Hamilton and Regional Municipality of Hamilton-Wentworth. Learn more about the crisis assessment template.
  • 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.

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 ( consists of a list of coping strategies and sources of support that your clients can use to cope during a crisis.25 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.

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.
  • Patient Safety Plan helps clinicians and their clients develop a list of warning signs, coping strategies, people, and settings that can help distract clients during a crisis, and people and agencies they can contact during a crisis.
  • Helping you create an effective plan: Tips for individuals/families helps clients and family members make a list of people who can help during a crisis, activities that the client and others can do during a crisis, phone numbers they can call, and people that should have a copy of the plan . This template is part of the Holistic Crisis Planning Resources hosted by CAMH's Portico Network, with resources also available in French, Punjabi, Urdu and Polish .
  • 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 professionalsAvailable 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.


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L​ast updated: July 23rd, 2020