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Gambling addiction in India: A survey of Indian psychiatrists.

INTRODUCTIONV

Gambling, betting something of value (usually money) on an event whose outcome is determined by chance, as a social pastime is prevalent in most cultures across the world. For the large majority who gamble, they do so without it impacting negatively on their lives. However for a significant minority (estimates range from 1% to 3%) (1), it becomes a problem and can develop into an addiction. DSM V (2) for the first time in psychiatric classification has included gambling disorder in the category of addictions. Gambling is the only behavioural (or non-substance) addiction to sit alongside more traditional substance addictions as only this had the evidence base to support this transition (3) .

Gambling has a deep origin in ancient Indian texts and scriptures (4) and it has been a popular pastime in ancient, medieval, colonial and modern India (5) . It is difficult to estimate the size of the gambling industry (legal and illegal) in India. Rough estimates are that it is worth about $ 60 billion per year, half of which is illegal. Anecdotally, illegal betting, primarily on sports such as cricket, is very popular. Currently, the legal forms of gambling in India are state-run lotteries, horse racing, card games and casinos (in two states). With the exception of the lottery, the Public Gaming Act of 1867 regulates most forms of gambling.

Despite the above, surprisingly very little systematic research has been published from India in the area of gambling addiction. Neither does gambling addiction seem to have any place within mainstream Indian psychiatry when it comes to research, policy or practice. However anecdotally, psychiatrists working in India come across gambling addicts and their affected families, in their clinical practice.

It is in this context that we carried out a survey of 121 psychiatrists in India. We wanted to specifically explore their 'exposure' to gambling addicts, their ability to manage these patients, their understanding of gambling addiction, their perceived role and feasibility in managing these patients, etc. To our knowledge, this is the first survey of its kind from India.

METHODOLOGY

We handed out self-completion questionnaires to 121 Indian psychiatrists who had come to attend a psychiatric conference in the state of Kerala, India. Psychiatrists working in various parts of India attended this conference, as this was a national conference.

A brief questionnaire was devised by the authors. The questionnaire consisted of some demographic questions (age, gender, years as psychiatrist, etc); some questions which could be given Yes/No answers; some statements with the option of choosing the following responses: strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree, and two open-ended questions. A copy of the questionnaire is available from the corresponding author upon request.

All the data was entered into a Microsoft Excel spreadsheet and analyzed using appropriate statistical methods

RESULT

Age and gender distribution of psychiatrists

102 of the 121 psychiatrists (84.3%) were men and 19 (15.7%) were women. The age distribution of the sample was as follows: less than 30 years (24; 19.8%) 31 to 40 years (54; 44.6%); 41 to 50 years (16; 13.2%); 51 to 60 (14; 11.6%); and aged 60 and above (13; 10.7%).

Psychiatrists' 'exposure' to patients with gambling addiction

Of the 121 psychiatrists, 98 (80.9%) said they had seen patients addicted to gambling in their clinical practice. Of the 93 who answered the question about how many of these patients they had seen in the past 12 months, 72% had seen between 1 and 5 patients, 16.1% had seen between 6 and 10 patients, 5.4% had seen between 11 and 15 patients, and 3.2% each had seen between 16 and 20 patients and more than 20 patients. Participants were also asked if they had seen 'patients indirectly affected by the gambling of a third party (e.g. partner, other family member, etc)': 76.8% said they had while 23.2% said they had not.

Teaching/training in the management of gambling addiction

When asked 'have you ever received any teaching/training in the management of gambling addiction?' 89/110 (80.9%) said they had not, and the rest had (21/110; 19.1%). Psychiatrists were also asked 'would you like to be involved in the management of gambling addiction?' 90/108 (83.3%) answered affirmatively and 18 (16.7%) said no.

Psychiatrists' understanding of gambling addiction

Table 1 shows psychiatrists' understanding of gambling addiction.

Indo-Chinese comparison

Table 2 shows a comparison of responses of Indian and Chinese (marked in bold) psychiatrists to the same questions.

Psychiatrists' perception of their roles in management of gambling addicts and their views on its feasibility

38.7% strongly agreed and another 59.5% agreed with the statement, 'Psychiatrists have a role in managing gambling addicts.' (1.8% had 'no opinion', and no one disagreed or strongly disagreed). To assess their views on the feasibility of getting involved, they were presented with the statement 'it is feasible for psychiatrists to be involved in the management of gambling addiction.' 31.9% strongly agreed with this statement, 59.3% agreed, 7.1% expressed no opinion and 1.8% disagreed. They were also asked if they would like to receive training in the treatment of gambling disorders and the responses were as follows: strongly agreed (30.7%), agreed (50%), no opinion (14%), disagreed (4.4%) and strongly disagreed (0.9%).

DISCUSSION

This is the only study from the Indian sub-continent to have explored psychiatrists' awareness of gambling addiction and their attitudes to getting involved in treating these patients. Despite the inherent limitations of a questionnaire survey, we still believe there are some important findings that warrant further thought and action.

The very large majority (80.9%) of psychiatrists had seen patients with gambling addiction in their clinical practice. However, only 19.1% reported ever having received any teaching or training in the management of gambling addicts. This points to a major gap and unmet need that exists currently within psychiatric teaching/training. More positively and much more encouragingly, 90.2% of psychiatrists said it was feasible for them to be involved in the management of gambling addiction, and 80.7% of those who responded specifically said they would like to receive training in the treatment of gambling disorders. Equally encouraging was the proportion that agreed that gambling was a public health problem (89.1%), and those who saw it as an addictive disorder (93.6%).

The same questionnaire survey was carried out among a sample of Chinese psychiatrists, and the results are published elsewhere (6) . Apart from the higher proportion of Indian psychiatrists (19.1% vs. less than 1% of Chinese psychiatrists) who had received training/teaching in this area, results were broadly similar. Although direct comparisons are not particularly relevant as the gambling landscapes of the two countries are dissimilar, it is still worth noting (as shown in table 2) that psychiatrists in both countries come across gamblers in their clinical work, they acknowledge it as an addiction and a public health problem, large majority do not receive any formal training/teaching, and the large proportion expressed a willingness to get more involved in helping this patient group.

CONCLUSION

From this survey, two key actions could follow. First, more needs to be done to plug the gap that exists in teaching and training psychiatrists in India as regards identification, assessment and treatment of gambling addicts. As a minimum, psychiatrists should be trained in screening and brief interventions, and where expertise and feasibility permit, in the more specialist treatment of gambling addicts (7) . Second, at a more strategic level, gambling addiction needs to be given a more prominent place within clinical, policy and academic discourse within the landscape of Indian psychiatry. And this calls for collaborative strategic planning and joint action by various stakeholders including policy makers, clinicians and academics. This is where India could look to the West to tap into existing expertise, knowledge and skills base.

ACKNOWLEDGEMENT

We thank Mr Ajayakumar G who helped in data collection and all those who participated in this survey

REFERENCES

(1.) Shaffer HJ, Hall MN, Vander Bilt J. Estimating the prevalence of disordered gambling behavior in the United States and Canada: a research synthesis. Am J Public Health. 1999;89(9):1369-76.

(2.) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th edn) (DSM-V). Washington, DC: APA. 2013.

(3.) Petry N. Pathological gambling and the DSM IV. Int Gambl Stud. 2011;10:113-5.

(4.) MacDonell AA. A vedic reader for students containing thirty hymns of the Rig Veda in the original Samhita and Pada texts, with transliteration, translation, explanatory notes, introduction vocabulary. Motilal Banarsidass Publishers private limited, New Delhi. 1992;187-94.

(5.) Benegal V. Gambling experiences, problems and policy in India: a historical analysis. Addiction. 2013;108(12):2062-7..

(6.) Xiquin H, Shijun D, George S. Gambling addiction in China: a survey of Chinese psychiatrists. International Psychiatry. 2014;11(4):98-9.

(7.) George S, Bowden-Jones H, Orford J, Petry, N. Problem gambling: what can psychiatrists do? The Psychiatrist. 2013; 37(1):1-3.

Sanju George ([PSI]) (1), Jaisoorya T S (2)

(1) Rajagiri hospital, Chunagamvely, Aluva, Kerala, India

(2) Department of Psychiatry, Government Medical College (formerly Cochin Medical College), Ernakulam, Kerala, India

(Received 20 October 2015 and accepted 05 January 2016)

([PSI]) Correspondence at: Senior consultant psychiatrist, Rajagiri hospital, Chunagamvely, Aluva - 683112, Kerala, India; Email: sanjugeorge531@gmail.com

DOI: http://dx.doi.org/10.4314/ijmu.v11i2.3
Table 1: Psychiatrists' understanding of gambling addiction

                                   Strongly    Agree
                                   agree

Gambling is an important public    45 (40.5%)  54 (48.6%)
health problem
Gambling is an addictive disorder  58 (51.7%)  47 (41.9%)
Gambling addicts have              51 (45.1%)  52 (46%)
significant psychiatric
comorbidity
Undetected comorbid gambling       37 (33%)    69 (61.6%)
problems can adversely affect the
mental health of an individual
Gambling addiction can             66 (59.4%)  43 (38.7%)
negatively impact on family
members

                                   Neither agree  Disagree  Strongly
                                   nor disagree             disagree

Gambling is an important public    3 (2.7%)       9 (8.1%)  0
health problem
Gambling is an addictive disorder  6 (5.3%)       1 (0.9%)  0
Gambling addicts have              9 (7.9%)       1 (0.8%)  0
significant psychiatric
comorbidity
Undetected comorbid gambling       6 (5.4%)       0         0
problems can adversely affect the
mental health of an individual
Gambling addiction can             1 (0.9%)       1 (0.9%)  0
negatively impact on family
members

Table 2: Indo-Chinese comparison

                                   Strongly   Agree      Neither agree
                                   agree                 nor disagree

Gambling is an important public    40.5% vs.  48.6% vs.  2.7% vs.
health problem                     51.8%      37.3%      8.2%
Gambling is an addictive disorder  51.7% vs.  41.9% vs.  5.3% vs.
                                   35.4%      47.3%      9.1%
Gambling addicts have              45.1% vs.  46% vs.    7.9% vs.
significant psychiatric            20%        48.2%      24.5%
comorbidity
Undetected comorbid gambling       33% vs.    61.6% vs.  5.4% vs.
problems can adversely affect the  19.1%      70.9%      8.2%
mental health of an individual
Gambling addiction can             59.4% vs.  38.7% vs.  0.9% vs.
negatively impact on family        56.4%      41.8%      0.9%
members

                                   Disagree  Strongly
                                             disagree

Gambling is an important public    8.1% vs.  0 vs.
health problem                     2.7%      0
Gambling is an addictive disorder  0.9% vs.  0 vs.
                                   6.4%      0.9%
Gambling addicts have              0.8% vs.  0 vs.
significant psychiatric            6.4%      0
comorbidity
Undetected comorbid gambling       0 vs.     0 vs.
problems can adversely affect the  0.9%      0
mental health of an individual
Gambling addiction can             0.9% vs.  0 vs.
negatively impact on family        0         0.9%
members
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Title Annotation:Original Work
Author:George, Sanju; T.S., Jaisoorya
Publication:Internet Journal of Medical Update
Geographic Code:9INDI
Date:Jul 1, 2016
Words:1931
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