Suicidal attempt in a patient with gambling disorder: A rare case report

Background: Gambling disorder is characterized by a compulsive, repetitive and maladaptive pattern of gambling that results in significant distress. It is now classified into the “Substance-Related and Addictive Disorders'' group in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some participants do present with psychiatric complications ranging from mood, substance use, abnormal personality traits and even suicidality. This comorbidities complicates both presentation and treatment. Methods: In this report, we presented a case of a 32 year old civil servant who presented with repeated engagement in online sport gambling with ensuing accrued debts, strained interpersonal relationships, depressive symptoms and subsequent suicidal attempt by hanging himself in a closed room at night. This was a rare case of pathological gambling that was complicated by a severe depressive episode and suicidal attempt with a fatal means (hanging) in a patient with family history of gambling and psychotic illness. Conclusion: Pathological gambling is an addictive behavior with far reaching consequences such as mood disorders, suicidal behaviors and subsequent affectation of functioning of the individuals involved. Early detection and prompt intervention is essential to prevent further complications.


Introduction
There is growing evidence that youth in Sub-Saharan Africa are becoming more and more interested in gambling-related activities.If this trend is not addressed, it may have negative effects on their lives, 1 including financial difficulties, criminal activity, and mental health issues.Gambling disorder was recently reclassified into the "Substance-Related and Addictive Disorders'' group of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).It is characterized by a compulsive, 2 repetitive and maladaptive pattern of gambling that results in significant distress.Many gamblers are able to regulate their activity without causing any distress or coming to clinical attention.However, some do present with psychiatric complications ranging from mood, substance use as well as suicidality.In the United States of America and other western nations, a 12 months prevalence ranged from 0.5 to 3.0%, with three to four times as many people reporting subclinical difficulties and harm.Participation in electronic gaming machines, horse race, sports betting and casino table games, is considerably more 3 strongly connected to problem gambling than participation in other types of lottery games.Few prevalence studies exist in Africa, a study in South Africa found that the majority (68 %) of respondents had gambled at some time in their lives, but only 20 % had ever visited a casino and only 2 % had done so in the previous month.By gambling type, regular lottery (34 %), cards (12 %), scratch cards (11 %) and local games such as 'coin spinning' 4 and 'caps' (5 %) had the highest prevalence.Sports (soccer) bets are the most popular type of gambling among Nigerian young adults.Conservative estimates place the number of Nigerians who wager on football at more than 60 million.Every fourth Nigerian bets on sports, with the southwest reported to have the most sports betting stalls of any section of the country.A recent study by Taiwo et al, found the prevalence of pathological gambling at 38% 5 which is higher than that reported elsewhere.Pathological gambling have been linked psychiatric comorbidities especially mood disorders and suicidal behaviors.Those gamblers with suicidal behaviors have also been found to been found to have problems related to drug and alcohol abuse, psychiatric comorbidities, finance and relationship than other problem gamblers without suicidal 6 behaviors.Recent reviews found two patterns of suicide behaviors in pathological gamblers; first are those with severe gambling addiction whom have accumulated so much debts and are in huge financial/legal crises to the extent that suicide becomes the only 'escape' plan.The second pattern involves gamblers whose suicide behaviors are mainly precipitated by comorbid psychiatric morbidities, impulsivity and interpersonal, work

Case Report
This is a case of a 32-year-old civil servant who presented with repetitive online sport gambling with an associated progressive increase in daily amount invested in betting from the initial N5,000-to about N50,000 just prior to presentation.He spends an average of 4-6 hours daily on the betting site and has persistent thoughts of reliving past gambling experiences or thinking of means of sourcing more money to further invest in gambling.He had several unsuccessful attempts to regulate his gambling activity but always became restless, irritable and had poor sleep whenever he attempted to stop or reduce this behavior.He admitted to lying to his parents and spouse in order to conceal the extent to which he is involved in gambling whenever they raise an alarm about it.He had incurred a huge debt and had sold many of his useful personal belongings in order to finance his gambling.This has led to a strained relationship with his wife, parents, friends and co-workers as some have already reported him to the police.Had no history of any psychiatric disorder.There is family history of gambling in one of his siblings and of a psychotic illness in his mother.Two months before presentation, patient began to develop persistent sad feelings with loss of enjoyment and body weakness associated with poor sleep, guilt feelings and hopelessness attempt to end his life a day prior to presentation by hanging in an empty room at night but was saved by relations when he was overheard struggling for breath.On mental state examination he was depressed, agitated and insightful.Had normal physical examination findings.Baseline biological investigations were unremarkable and urine multidrug tests was negative for all the substances tested.He was admitted under close nursing supervision and was commenced on oral Fluoxetine 20mg daily, Naltrexone 50mg daily.Both personal and family psychoeducation were offered.Patient was discharged after four weeks on admission and was seen for follow up on three occasions with significant improvement in depressive symptoms and non-involvement in gambling.Six months after discharge, patient was able to settle all his debt, no longer have depressive symptoms and have completely abstain from gambling activities with only occasional urge to get involved.

Discussion
We presented a case of a 32-year-old civil servant with severe gambling addiction who later developed a depressive episode after incurring huge amount of debt that culminated in a serious suicidal attempt.This case in unique in two ways, first is the rarity of both published gambling and suicide studies especially in north-western Nigeria.Secondly, considering the religious background of the patient, 8,9 both gambling and suicide are prohibited.The patient also fits into the two profiles of pathological gamblers with suicide attempt identified in the 7 literature .This patient has incurred debt of a huge amount of money and also had problems with work and family and later developed a severe depressive episode before his suicide attempt.From the way the events unfold in this case, it is possible that the two profiles are actually interrelated with one contributing to development of the other and viceversa.The family history of gambling in his sibling and of a psychotic illness in his mother could point towards a shared genetic loading that predisposes to both gambling and psychosis.Indeed a genetic study conducted in the United Kingdom found that polygenic risk for schizophrenia was associated with pathological gambling in young adults.This cross-disorder association suggests that common genetic factors have pleiotropic effects on pathological gambling and schizophrenia, though more robust genetic studies will be needed to 10 ascertain the strength of this relationship.With the visible proliferation of online sport betting shops, it is possible that this case is just a tip of an i c e b e rg w h e n c o n s i d e r i n g t h e h a r m f u l consequences of gambling.Regular screening of individuals involved is recommended for early detection and prompt management.Further epidemiological studies need to be conducted to ascertain the magnitude of this problem so that relevant stakeholders can be involved in prevention and management.

Conclusion
Pathological gambling is an addictive behavior with far reaching consequences such as mood disorders, suicidal behaviors and disruption in overall functioning of the individuals involved.Early detection of this problems is essential to prevent further complications.

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other social problems.