Main findings
To our knowledge, this study was one of the first studies from India to add to the existing literature’s findings on internet gaming. First, a significant positive relationship was detected between the degree of IGD symptoms and scores of perceived stress and suicidal behaviour in a sizeable sample of Indian medical students. Second, the mediating analysis demonstrated an inverse relationship with large effects between sleep quality and IGD scores and small effects between sleep quality and perceived stress or suicidal behaviour. Finally, the hypothesised mediating effect of sleep quality (indirect effect) was significant. This finding is a prompt for policymakers to consider the essentiality of sleep quality when constructing intervention strategies to mitigate the risk of mental health issues in medical students with IGD symptoms.
Research on Asian and Western university students32 33 showed a strong and positive significant association between IGD severity and perceived stress, supporting the present survey results. Also, an Indian survey conducted on 922 medical students revealed that addiction to gaming behaviour correlated with perceived stress among undergraduate medical students.11 Andreetta et al
7 observed that students with IGD symptoms could perceive greater stress regardless of age, grade, ethnicity, race or socioeconomic status. The plausible reason for this could be that online gamers with IGD symptoms spent much time in gaming activities, provoking more emotional difficulties that directly affected their academics and family relationships.33 34 Furthermore, medical students experiencing problem gaming might have been exposed to more negative facets of gaming, for example, violence and cyber victimisation, sequentially increasing the tendency for impulsive suicidal behaviour.35 In agreement with previous research among adolescents36 this demonstrated that internet gaming addiction behaviour was significantly associated with suicidal ideation/attempts, the present survey also showed that IGD symptoms directly affected suicidal behaviour. A systematic review37 revealed significant positive and crude associations between IGD and suicidal behaviour after adjusting possible confounding variables. In contrast, research by Severo et al
38 revealed an inverse non-significant association between IGD symptoms and suicidal behaviour. The Diagnostic and Statistical Manual of Mental Disorders-5 diagnostic criteria for gaming disorder incorporates tolerance and withdrawal aspects that describe how often a gamer is consistently unable to control gaming and feels irritated, restless, frustrated and angry about stopping gaming.39 Previously, it was suggested that these symptoms were responsible for increased sleep latency and poor sleep quality among gamers by activating circadian rhythm changes and causing delayed phases in the circadian rhythm.25 33 40 The current research offers empirical evidence to support this hypothesis by unveiling similar results, demonstrating that an increase in IGD scores was significantly correlated with higher PSQI scores or poor sleep quality. Compared with other Western studies,25 33 the current survey also suggested a strong relationship between IGD and poor sleep quality.
The present study unveiled the significant mediating effect of sleep quality in the IGD-perceived stress link among medical students. Moreover, the mediating analysis suggests an indirect effect of IGD on perceived stress via sleep quality, and sleep quality is recognised as a meaningful partial mediator. The key observation was that sleep quality explained 30.62% of the total effect of IGD on perceived stress. Such an interpretation agrees with a study among Chinese college students where sleep quality explained 18% of the total effect of IGD on perceived stress.25 This finding may be better comprehended by contemplating the following mechanisms. Earlier, existing research indicates that the IGD–sleep quality association is well documented.25 33 40 As aforementioned, IGD prompted poor sleep quality. Consequently, pathological gamers with poor sleep quality have manifested relatively more cognitive diversion from real-world problems and more expressive suppression due to low cognitive reappraisal; this, in turn, might worsen the gamers’ unresolved emotional difficulties and causes significant stress in this population.41 42
Similarly, the association between IGD, sleep quality and suicidal behaviour in the correlational analysis was explained by the mediational analysis; that is, IGD significantly influenced students’ sleep quality (negatively), which then influenced their suicidal behaviour (inversely), as revealed in other surveys.20 43 Another pivotal observation of the present survey was that sleep quality explained 27.93% of the total effect of IGD on suicidal behaviour; the Chinese population survey demonstrated that the mediating role of sleep quality explained 35% of its total effects on the IGD–suicidal behaviour link.43 However, Sami et al
44 found that sleep quality failed to mediate the pathway to suicidal behaviour among pathological gamers significantly. Our finding may be better comprehended by contemplating the following mechanisms. As mentioned earlier, students who reported higher IGD symptoms were presumed to be more susceptible to having concurrently poor sleep quality. A recent study on Chinese medical students established that students with poor sleep quality have a higher proportion of interpersonal difficulties, poor face-to-face communication with peers and family members, decreased social support and increased loneliness, which, in turn, may have increased the risk of suicidal behaviour.45 Investigations on the sleep framework have postulated that enhanced suicidal behaviour is attributed to the brain’s electrophysiological activity during sleep; explicitly, central nervous system hyperarousal during sleep could be the underlying neurobiological correlate of suicidal behaviour.46 Thus, it is entirely plausible that higher degrees of IGD symptoms are linked to suicidal behaviours through poor sleep quality.
In a research study on Brazilian undergraduate students,38 the prevalence of IGD was reported as 18.2% of 555 gamers, nearly corroborating the current study’s observations (15.7%); however, that study used a different tool (Nine-item Internet Gaming Disorder Scale - Short form, IGD9-SF) to measure gaming disorder. Other research conducted globally also yielded comparable results.20 47 48 In addition, other international and national studies49 50 of medical students found a substantially higher prevalence (>30%) of IGD than the present survey. More worrisome, an Indian scoping review revealed that the IGD prevalence ranged from 3.20% to 91.00% in clinical populations.51 In dissonance with the present survey, research among medical students of different ethnicities revealed lower rates of IGD: 3.6%–6.98% in Indian gamers9 10 and 4% in Chinese gamers.52 Such variations in these results could be attributable to differences in methodology, population size, questionnaires used to estimate IGD and disparities in the targeted populations’ sociocultural systems and attitudes. The present research also revealed the prevalence of suicidal behaviour, perceived stress and poor sleep quality among medical students who engaged in gaming behaviour to be 22.7%, 84.0% and 62.0%, respectively, which were significantly higher than those who did not engage in gaming behaviour (15.6%, 67.6% and 47.3%, respectively). Similarly, other studies20 25 33 53 conducted on medical students or other younger populations also found that playing online games had increased the risk of suicidal behaviour, perceived stress and poor sleep quality.
The results of the current survey revealed that sociodemographic and personal domains such as gender (being male), living with a single parent and using the internet for 1–3 hours or more than 3 hours a day for something other than academic purposes were significant risk factors for IGD, whereas other covariates included in the survey were insignificant for the dependent variables. On the contrary, several studies have found a link between sociodemographic or personal covariates and IGD.47 54 The present survey found that male participants had a 3.2 times greater odds risk of IGD than their female counterparts. Pre-existing literature observed that being male was significantly related to an elevated odds risk of IGD, providing consistent and robust support for the present study findings.38 54 When confronted with gaming cues, women may exhibit greater executive control than men, perhaps offering better resiliency against developing IGD.55 Also, it might be reasonable that poor self-control among men would result in a more pronounced unwillingness to quit playing without accomplishing gaming activities. These stronger cognition distortions among men may illustrate why they have a higher risk of IGD than women.56 Contrary to the present survey findings, another similar Indian survey was unable to demonstrate significant differences in vulnerability to development of IGD among both genders.9 Other clinical research on medical students noted that students who lived with both parents had only one-third the risk of developing IGD.54 In the present study, students living in single-parent families had a 4.1 times higher odds risk of addiction to internet gaming, similar to a recent survey in Thailand, where these students also had a 1.7 times higher odds risk of IGD.15 Other researchers argued that an increased risk of developing IGD in respondents living in single-parent families could be due to lower parental behavioural control and poorer family functioning.57 Like the present study, substantial evidence has linked the timing of using the internet for something other than academic purposes or social networking and IGD.58 59 Participants using the internet for something other than academic purposes for 1–3 hours or more than 3 hours in a day have a three to five times higher odds of risk of IGD in comparison with those who use it for less than 1 hour. Researchers have shown that time spent on social networking was a weaker predictor for IGD,58 59 but our study found it to be the second-highest predictor for IGD. Surprisingly, many social networking sites that incorporate social media games are witnessing a growth in demand. The latest Facebook figures indicate that around 375 million inhabitants play Facebook-connected games each month, and smartphone applications forward an average of 735 million recommendations of games nearly daily.60 However, on the contrary, the multivariable logistic regression could not substantiate the evidence of this relationship among medical students in the research conducted in India9 61 and Saudi Arabia.62 In line with our results, increased gaming time per day (in hours) was established as the strongest predictor for IGD (13.5 times the odd risk).38 Significantly, respondents who reported gaming more than 3 hours a day had a 10.8 times odds risk of developing IGD compared with those who reported gaming time less than 1 hour/day. Furthermore, many existing Indian studies also have established a significant link between IGD severity and time spent on gaming.9 11 61 A survey from Liao et al
47 determined that as the time spent playing increases, players obtain more motivations for increasing play time, such as gaining status among players and obtaining rewards. Thus, intervention strategies designed to curtail the amount of time spent on gaming and excessive internet use may be a more beneficial approach to preventing and managing IGD among medical students. Notably, Billieux et al
63 discovered that individuals’ motivations and inherent characteristics of the game genre anticipate overall in-gaming behavioural patterns and gaming commitment. However, violent gaming raises the gamer’s immersion (a type of motive) during play, attributed to more competitive behaviour and intellectual thinking among these types of gamers compared with non-violent play gamers.64 Existing research supports that gaming motivations like immersion were strongly linked with IGD.63 64 It was also thought that playing violent internet games was potentially highly addictive among students.9 65 Interestingly, our study’s results provided supporting evidence regarding violent gaming being a substantial risk factor; those who played violent games had a 2.8 times odds risk of developing IGD symptoms compared with other gamers. As a result, assessing gaming trends among gamers may help determine troublesome implications and suggest appropriate behavioural modifications.66
The main strength of the present survey was that the relationship between IGD and health outcomes was assessed robustly by mediation analysis instead of multiple regression analysis, providing an appropriate inference mechanism in this interplay. It also analysed the dual roles of the mediator and the indirect and direct effects of IGD on health outcomes. Thus, the findings are noteworthy, with important clinical implications for preventing perceived stress and suicidal behaviour among online gamers. Additional survey strengths were the considerably larger data set, incorporation of multiple covariates and use of standardised diagnostic criteria.
Limitations
This cross-sectional research has several limitations, some of which propose possibilities for future research. First, outcomes cannot be representative and generalised to other populations because the respondents were recruited from rural medical institutions, and this survey was conceptualised at a female-only centre, resulting in a predominance of women in the study population. Second, this cross-sectional type of study design precluded the exploration of the causal link between IGD and perceived stress and suicidal behaviour, despite using mediation analysis, and thus warrants the need for longitudinal surveys to establish this causal relationship. Third, the cascade from IGD to suicidal behaviour may involve other elements besides the mediator studied here. For example, impulsivity is closely linked to addictive illnesses (eg, IGD) and other dangerous behaviours (eg, suicidal ideation). Fourth, information, selection, recollection and response bias cannot be ruled out in the current study due to using a self-administered questionnaire. Fifth, the magnitude and covariates for IGD were not examined individually for each academic year. Furthermore, including only rural medical students might have resulted in overestimating the association due to the resource-restrained settings. Future research should look at other psychological traits that may be linked to suicidal behaviour because students are prone to internal psychological transitions and external interpersonal adjustments.