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International Health

December 4, 2020

Associations Between Gaming Disorder and Depression or Anxiety Are Unclear, New Study Finds

Also: A Q&A with Michelle Colder Carras, the lead author of the study, about the role of public health research in gaming and online communities, as well as their potential for delivering public health information and services.

Video game controller

Michelle Colder Carras, a faculty associate in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health, recently led a review of published systematic review studies that look at the associations between gaming disorder and depression or anxiety. The study, published in PLOS One, found that the link is not clear. Moreover, the authors found selective outcome reporting and a general lack of rigor in the systematic reviews they evaluated. Despite these problems with the evidence base, many organizations, such as the WHO and the American Psychiatric Association, are targeting gaming as a public health concern. 

Some key study findings:

  • There are plenty of studies, but the evidence about links between disordered gaming and depression/anxiety has not been systematically reviewed in a rigorous way.
  • The study authors found selective outcome reporting in all reviews, indicating bias in the literature. That is, the reviews left out outcomes that found no association between gaming disorder and depression or anxiety.
  • Every review about gaming disorder included studies measuring Internet addiction or some other form of technology use problem in general, meaning that, from the perspective of researchers and reviewers, there is likely still conceptual overlap between these various disorders.
  • What’s really needed are well-conducted systematic reviews on gaming disorder that follow current standards for reviews and separate gaming from other behaviors—these would better inform policy and prevention measures.

Colder Carras answers some questions about her study and what she sees the role of public health research is in gaming and online communities, as well as their potential for delivering public health information and services. She also discusses some of her ongoing research she is conducting with Alain Labrique, PhD '07, MHS '99, MS, a professor of International Health at the Bloomberg School and Director of the Johns Hopkins Global mHealth Initiative. 

What is gaming disorder, and how big of a problem is it?

Gaming disorder as defined by WHO is an addictive behavior caused by video gaming that lasts for at least a year and leads to significant life impairment. In these cases the gaming behavior has serious negative consequences such as impairment in work or family functioning, but the person continues the harmful patterns of gaming despite these consequences. The prevalence of gaming disorder worldwide is difficult to measure because of a lack of agreement on measurement scales. The prevalence seems to be higher for adolescents than for adults, and greater for males than females. Global estimates range from less than 1% (representative samples in Europe) to 27.5% (gamers recruited from online gaming websites).

What’s the difference between playing a lot of video games and gaming disorder? How do you know if you should be worried for your kids or yourself?

Many people play video games a lot. They can be a way to take a break from the stress of everyday life, which has been vital during the pandemic when other activities aren’t accessible. They can be a great way to connect, too, whether you’re playing with someone you’re with or someone halfway across the world. But when play really interferes with life and the person doesn’t cut back on playing in response to negative consequences, that may indicate a problem. This may be caused by other problems, like depression, anxiety, or a pandemic. If you’re playing so much that you’re not spending time with your significant other, or if your play makes it hard to do your job, that’s a problem. If your child skips sleep or meals to play, that’s also a problem. 

Your study showed that the evidence linking gaming disorder with mental health problems was flawed. Do we need to worry about gaming and mental health?

Our study showed that systematic reviews that talked about these links had sometimes serious flaws, but that doesn’t mean the links aren’t there. The evidence for gaming disorder is just not very systematically collected. There are still many, many different ways to measure it, and many different disciplines where these studies are done. In public health, it’s important to conduct and report studies about health problems in a standardized way—we know that’s how we have to work towards a body of evidence that helps us make decisions about population health. We’re not seeing that yet in this literature, but that doesn’t mean there’s not a problem. 

There are specialized games made for health purposes, but can commercial games be good for you too?

Clinicians and researchers have realized for decades how useful games could be to help people learn about health conditions, and the FDA just issued its first approval of a video game as a medical device. With games for health, the problem is that they often aren’t fun enough to keep people playing. Clinicians are now realizing the potential therapeutic uses of commercial video games, which are created for entertainment, for things like physical rehabilitation. That’s why I like to study how commercial video games themselves, and the communities that spring up around them, might be useful if they're incorporated into health interventions. A person who is suffering from social isolation or social anxiety, for example, may benefit from playing games that involve interacting with other players. 

Is game socializing as good as in-person socializing?

Socializing while playing a game is different and has unique advantages and disadvantages. What's obvious now from the pandemic is that people can and do use commercial video games to connect—to create and maintain social bonds. Through these bonds we give and receive the kind of social support that helps buffer against stress, including the stress of the pandemic. The anonymity of online settings can help people be more authentic by opening up more. But online settings have downsides related to this as well. Sometimes people behave in a negative way online, whether in games, social media, or through other communication platforms. Trolling, toxicity, and cyberbullying are problems that reflect ways people engage sometimes. These are unfortunate extensions of real-life behaviors that are made easier by online anonymity. Communities that make clear rules of behavior, then monitor and enforce them, are doing the right thing to protect their community members. 

How do you study how games might be useful for health? What kind of data do you collect?

I’ve conducted a few different kinds of studies that examine relationships between gaming and health. A review we did in 2018 showed that there’s a small but growing body of evidence to support that gaming can have beneficial health effects. For example, people who played Tetris within a few hours of a traumatic event had fewer intrusive thoughts in the following weeks, and people with depression who played Bejeweled had clinically significant improvement in their depressive symptoms. I recently conducted a qualitative study where I spoke to military veterans who were in treatment for mental health problems about how they felt games helped their mental health. Our team found that veterans used games to connect with others, to distract them from overwhelming mental and behavioral health symptoms, such as suicidal thoughts and substance cravings, and even to bring meaning to their lives through reframing difficult experiences of providing job opportunities in professional gaming. Right now we're working with a nonprofit veteran and military gaming organization to learn about how their Discord server promotes connectedness and supports the mental health of its members. For this study, we're collecting chat data and combining that with a survey and interviews to get a more complete picture of the ways in which different aspects of online connection support mental health, especially during the pandemic.

How can people balance the potential problems of gaming with the benefits you've mentioned?

Gaming and the communities that spring up around gaming can provide a lot of potential benefits. This is the same for all health interventions, from medicines to health promotion campaigns. They can be really helpful, but in some cases and for some people, they can have negative effects. As with any other life area, there has to be balance. More public health research needs to be done on how commercial video games can help people. These are games that you would buy for fun, not games that are made for health purposes. We need this research to be especially rigorous, because we already know that some people might be vulnerable to problems caused by out-of-control play. It's important that this research directly examines links between games and actual health outcomes, and that it addresses the types of bias inherent in different designs to make sure that any claims about the health outcomes of playing commercial games clearly reflect the nuanced factors that contribute to any advantages and disadvantages.