Dr Jayant Mahadevan is among the first Indians to complete a Doctorate of Medicine in the super-specialisation of addiction psychiatry. Today, he is an assistant professor at the Centre for Addiction Medicine at the National Institute of Mental Health and Neuro Sciences, Bengaluru. Dr Mahadevan believes in offering quality service within this niche vertical of psychiatry. In this interview, he offers expert insights into the neurology of addictions, with special emphasis on online gambling. Excerpts:
Are certain kinds of people more prone—genetically or through conditioned experiences—to exhibiting addictive tendencies? Can you please elaborate?
Addiction occurs due to many reasons. However, at its core, it is the interaction between a host of factors that increase vulnerability. These include genetic factors and environmental factors such as early childhood adversity, parenting, poverty, undernutrition, and environmental pollution to name a few. These are known to affect key structures in the brain that underlie functions such as decision-making, impulse control and emotional regulation. This can culminate in behavioural patterns or temperaments that predispose the individual to experiment with and, later, get hooked on to substances/risky behaviours.
These behavioural patterns can manifest as externalising disorders such as Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder or Conduct Disorder as well as internalising disorders such as depression and anxiety. All these may be considered pathways to addiction.
However, repetitive indulgence in certain substances or behaviours in themselves also change, to differing degrees, the functioning of key structures in the brain, and these changes often stay entrenched even after the individual stops indulging. This explains why some people experience addiction as a chronic condition.
Are activity addictions such as gambling different from substance addictions in terms of neural mechanisms or challenges involved?
Activity addictions such as gambling do exhibit similarities to substance addictions, but also some differences. The vulnerabilities that put a person at risk of developing gambling addictions also increase the risk of chemical addictions. There is also research to suggest that gambling addictions can affect the same parts of the brain as chemical addictions, although this is not as robustly established.
How is online gambling different from “brick-and-mortar” gambling? Has technology changed the landscape in terms of behaviour, rituals, pace at which the addiction escalates and other such factors?
There seem to be some differences between online gambling and traditional brick-and-mortar gambling although the research pertaining to this remains scant in the Indian context. The easy access to online gambling makes the person indulge more. Resultantly, online gamblers can more rapidly progress from occasional to habitual and reach significant financial consequences sooner than traditional gamblers. Also, even those who have lower temperamental/personality vulnerabilities such as impulsivity can succumb to online gambling.
In what manner do addicts experience an addiction differently in the beginning of the addiction cycle as opposed to the end of the cycle? Does this manifest in any unique manner for online gamblers?
Individuals in the early stages of addiction cycle often (but not always) report experiences of pleasure and a high from using the substance. In later stages of the addiction cycle, this typically changes to a need to escape a negative state induced by the absence of the substance or behaviour. In other words, they may need to indulge in the substance or behaviour to “feel normal”.
This kind of progression may also be experienced by online gamblers where the early stages may feature thrill and excitement while later stages may be focussed on chasing losses from gambling.
- Dr Jayant Mahadevan, assistant professor at the Centre for Addiction Medicine at the National Institute of Mental Health and Neuro Sciences, offers insights into the neurology of addictions, with special emphasis on online gambling in an interview.
- Genetic factors and environmental factors are known to affect key structures in the brain that underlie functions such as decision-making, impulse control and emotional regulation.
- From the side of the government, there is a role for regulation of online gambling which at present is largely unregulated.
- There is at present limited expertise amongst mental health professionals in India for addressing online gambling addiction.
Has the advent of online gambling changed the landscape of addictions in India?
Clinics are witnessing an increasing number of cases pertaining to online gambling and this is likely only the tip of the iceberg. There are currently no estimates of the prevalence of online gambling or problematic online gambling in India. I feel we are likely to see a worsening of this problem in the years to come.
What should family members of online gamblers understand about their addicted loved ones? In what way can they support them? And in what way can they make them accountable?
The most important thing for family members of individuals with online gambling addiction is to understand that their loved one is suffering from a condition that leads them to lose control over their gambling behaviour and persist with it despite adverse consequences related to the same, much like in other addictions.
It is imperative to recognise online gambling addiction as a medical condition and seek professional help, particularly when individuals have faced adverse outcomes. Individuals with online gambling addictions often experience significant guilt and shame related to their behaviour and may often become defensive when confronted or made to confess.
For the most fruitful results, the treatment can rely on a broad focus that includes improving other aspects of the individual’s life. As this happens, it is helpful for the family to remember that there is more to the individual than just his/her addiction.
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What will a holistic intervention for online gambling addiction look like? What components (such as rehab, counselling, medication etc.) should be included?
It would include:
1. Psychotherapy to enhance motivation to change the problematic behaviour, identifying factors associated with a resumption of the problematic behaviour and addressing the same. It helps to identify high-risk situations, manage cues, handle difficult emotions, and understand cognitive misinterpretations that lead to usage.
2. There is also a role for medications to address both the addiction and underlying psychiatric conditions, which are extremely common in this population.
3. Wherever possible, the intervention should include the family, which may need help to understand the individual’s problem and rebuild the trust which may be broken due to the lies and deceptions used to conceal the extent of gambling.
4. The intervention may also need to help establish a financial management plan to settle outstanding debts stemming from gambling losses; not doing so can often lead to a relapse.
5. Finally, regular follow-up with a mental/addiction health professional is seen to greatly improve outcomes and is a necessary part of the intervention.
What can the government, mental health professionals and civil society at large do to prevent this addiction from spreading unchecked to the next generation?
From the side of the government, there is a role for regulation of online gambling which at present is largely unregulated. This can enable more accountability being placed on online gambling websites and portals who, at present, engage in a number of methods to lure individuals and get them hooked to their product.
Among mental health professionals, identification and improvement of skills required to manage these conditions would be vital.
Civil society can acquire a greater recognition of the problem, including the fact that a subset of individuals may develop uncontrolled or problematic use and therefore require intervention that involves a specialist.
Are psychiatrists, psychologists and counsellors in India trained sufficiently to help those addicted to online gambling? If not, what is lacking?
There is at present limited expertise amongst mental health professionals in India for addressing online gambling addiction. This is partly due to the fact that there are not too many centres which get to see such cases. There is also a paucity of locally relevant interventions. However, the scenario is changing rapidly, particularly with an increase in the influx of such cases at clinics.
You spoke about insufficient research happening in India with regard to online gambling. Can you please elaborate?
Limited research has been done, mainly surveys of the prevalence of gambling in different populations. Very few studies have investigated the profiles of online gamblers, the course taken by online gambling addiction or the effects of treatments for gambling. Thus, there is plenty of scope for original and relevant research in this field.
Eshwar Sundaresan is an author, freelance journalist, counsellor, life skills trainer, and bestselling ghostwriter.