Screening, assessment and management of gaming disorder: recent evidence and future directions

Video gaming is a thriving billion-dollar industry and among the most popular leisure and entertainment activities in the world. The mass appeal of digital games as a consumer product can be attributed to their low cost and convenience, few restrictions or barriers to entry, and seamless integration with most digital devices and platforms in the modern technological landscape. Psychologically, games are desirable because they provide excitement, relaxation, amusement, a sense of achievement, and an escape from reality. Games also provide opportunities for socializing and cultural participation (e.g., esports), which can further support and normalize gaming as a dominant routine and lifestyle choice. Although gaming can have personal and social benefits, there is increasing public health awareness of the negative consequences of excessive gaming, including harmful effects on mental and physical health, academic and work performance, and interpersonal relationships. There is also growing research on game design properties1 supporting the notion that games are not always fun and transient entertainment; they can be highly sophisticated products designed to encourage persistent engagement and preoccupation. Certain games employ financial elements (e.g., microtransactions and “loot boxes”) to strengthen players’ commitment to the game and its ecosystem, which can pose risks related to overspending and gambling-like behaviors. The study of problematic gaming as an issue of clinical and public health relevance has made significant advances in recent years2. An important step forward has been the World Health Organization (WHO)'s formal inclusion of “hazardous gaming” and “gaming disorder” categories in the ICD-11. Notably, gaming disorder was not included in the DSM-5-TR, but the disorder is under consideration for the next edition of that diagnostic system. Gaming disorder is defined by impaired control over gaming behavior, increasing priority given to this behavior so that it takes precedence over other life interests and daily activities, continuation of the behavior despite negative consequences, and consequent significant distress or impairment in important areas of functioning. A Delphi study of international experts has confirmed that these criteria have high diagnostic and clinical validity and prognostic value3. The clinical descriptions of gaming disorder in the ICD and DSM systems have been influential in guiding research and clinical programs in the rapidly growing field of behavioral addictions, and have bolstered the field's credibility alongside other addictions and health science in general. The formalization of gaming disorder has also paved the way for research into other digital technologies that can be harmful and addictive, including social media and smartphone use in general. An important objective in research on gaming disorder has been determining the nature and scale of gaming-related problems in vulnerable populations (e.g., adolescents) as well as the general population. Epidemiological research has reported trends of increasing gaming and related screen time, particularly noting a sharp rise during the COVID-19 pandemic4. Reviews and meta-analyses have estimated that the prevalence of gaming disorder is about 1 to 3%, and the condition is more common among young males5, with higher rates reported in East Asian nations. Identifying and monitoring gaming disorder is challenging for several reasons, including the covert and highly time-consuming nature of gaming. Individuals with gaming disorder can be difficult to reach because they spend most of their time playing games privately and have become disengaged from school, work, or community institutions. The constant mental and physical demands of habitual gaming preclude normal engagement in, or “multi-tasking” with, other activities. Gaming is often more hidden than activities such as drinking or smoking. Conducting research into this area is difficult, particularly when one tries to target highly committed gamers. For example, in studies with an interest to target people at higher risk, researchers have often relied on the goodwill of online gaming communities to opt in to surveys, which has potentially biased the findings. At the tertiary or treatment-seeking level, researchers often find that affected individuals rarely engage with health systems to address gaming-related issues. Help-seeking usually occurs under pressure from a partner or family, which makes it difficult to effectively track the progression and recovery rates of the disorder. A further issue is that of comorbidity. Gaming disorder may receive less attention when it co-occurs with other conditions, particularly in the case of autism spectrum disorder and attention-deficit/hyperactivity disorder (ADHD), where habitual gaming may be seen as intractable or a necessary coping strategy. Another challenge has been that the literature on gaming disorder has a history of inconsistent screening and assessment. Early approaches to measurement commonly involved adaptations of problem gambling or substance use symptom checklists, prior to the field developing its own more specific measures. There has been a “silo effect” in psychometric validation studies, where research teams have developed and evaluated their own tool rather than gather and pool data on select tools. More than 50 tools or composite measures for gaming disorder have been created in the past two decades6. These tools have been developed in treatment centers where they have been used primarily for management of the center's caseload and trials and rarely adopted elsewhere. The WHO is developing a screening and diagnostic tool for gaming disorder to provide a “gold standard” which may unify assessment practices7. On a more positive note, the evidence on treatment of gaming disorder is steadily developing in the context of increasing global demand for interventions. Psychotherapeutic approaches, particularly cognitive-behavioral therapy (CBT), have the most empirical evidence, but there are few high-quality studies8. A randomized controlled trial evaluated manualized CBT for gaming disorder, and reported that most patients (69%) showed remission, compared with 24% of the waitlist control9. Treatment studies have also examined motivational interviewing and counseling, family therapy, and psychosocial rehabilitation. Medication trials have evaluated drugs for depression (bupropion, escitalopram) or ADHD (methylphenidate, atomoxetine) and have shown less effectiveness than CBT. The treatment literature has been generally limited by small samples, lack of randomization and follow-up measures, and lack of control for psychiatric comorbidities. There are several priority areas for future research. The field would benefit from greater consistency in measuring gaming-related problems across the continuum. There is a need for high-quality population and platform user studies using innovative sampling strategies to understand the onset and progression of gaming disorder, as well as the risk factors and vulnerabilities that influence its severity. The field could consider more sensitive technological measures embedded in game software that detect the escalation of gaming behavior. Studies should evaluate game design features that drive excessive play and spending. Interventions for gaming disorder are hindered by poor engagement by the predominantly young male gamer population. Psychological treatment providers should consider co-designing interventions with gamers and other stakeholders to optimize their content and delivery. Given the broad continuum of problem gaming, there is a need for stepped care approaches that can flexibly match the intensity of treatment to the needs and profile of the individual gamer. Just as digital games become more sophisticated, it is imperative that the field of gaming disorder innovates its research and clinical practices to address this globally prevalent condition.