Laura Ladekarl, Class of 2025

THE IMPACT OF COVID-19 ON MENTAL HEALTH AND GAMING
As we got locked out of the world and got stuck inside, our computers became our escape. The impact of the coronavirus disease (COVID-19) was more than just shutdowns and quarantines, it impacted our behaviors and mental health. Specifically, there was an increase in depression, anxiety, and loneliness, along with an upswing in gaming. Gaming is a term used to refer to when people play online or electronic games. Sometimes people get addicted to gaming and develop a gaming disorder, otherwise known as a video game addiction, characterized by a drastic reduction in control over gaming activity (1).
Despite the global experience of COVID-19, countries and individuals had varying responses and methods of coping. The restrictive measures, including mask mandates, social distancing, and quarantines, varied in severity and frequency, leading to differing degrees of isolation and mental strain. Loneliness often makes people feel stuck, especially those in urban areas with more confined private outdoor spaces (2). The sudden jump caused a lot of chaos and discomfort in people’s routines and interactions. For example, being forced to stay at home also caused a lot of family disputes (3), as many were not used to spending 24/7 with their families or roommates. The sudden lifestyle shift and lack of social outlets were some of the increased risk factors for many maladaptive and addictive behaviors during the pandemic, including starting or increasing substance use to deal with stress or other emotions (4).
One of the maladaptive behaviors includes excessive gaming. In moderation, gaming can be beneficial, as it can promote socializing and allow for an overall improvement in well-being (5). During the pandemic, government regulations forced people to limit their social interaction, leading a lot of people to increase the amount of time they spend on online platforms and gaming services as a coping mechanism (5). The numerous hardships, such as the loss of steady income or the death of a family member, caused people to need more mental and social stability at a time when even necessary resources were scarce. Even when these resources were available, they were online, limiting the connection and understanding that both the patient and resource provider could receive. The inability to provide social support in the necessary capacity caused maladaptive coping mechanisms to become more common or severe (4).
Internet Gaming Disorder (IGD) carries many negative consequences, including a worse performance at school or work due to excessive time gaming as the user prioritizes the game over other obligations. This can cause an exacerbated feeling of low self-esteem, through feelings of failure or insufficiency (6,7). An increase in gaming can also cause the user to drop activities they previously enjoyed, mainly spending time with friends, which can cause a decrease in perceived social support (6,7). The lack of or perceived lack of meaningful connections can create a sense of detachment from the rest of the world and their social communities. It also can cause negative behaviors like lying about the time being played or reducing hygiene patterns to play more (6). IGD has destructive consequences for a person’s relationships, mental health, and overall well-being. COVID-19 transformed not only the lives of people but also their behaviors. This transformation led to maladaptive outcomes like gaming addictions, which had many negative consequences for the person’s health.

COPING DURING THE PANDEMIC
Due to the stressful nature of the pandemic, many people leaned on adverse coping mechanisms. Specifically, avoidant-coping strategies allowed people to avoid their stressors instead of dealing with them (8). Avoidant-coping strategies can be useful for short-term stressors in which a person has no way of avoiding the stress, like waiting for a test result. However, when the stressor is long-term, the strategy can lead to prolonged distress and often is combated with negative health outcomes, such as excessive gaming.
The current Diagnostic and Statistical Manual of Mental Disorders (DSM-V) classifies “Gaming Disorder” as a disorder that is under a category for conditions that need further study (9). The disorder has thus far been characterized by instances when internet gaming causes the user notable impairment or distress in several aspects of the patient’s life. During times of stress, video games can become maladaptive coping strategies, as people use them to temporarily escape reality and their problems and relieve themselves from negative moods (6). Research also found a link between difficulties regulating emotions and problematic gaming, suggesting that an increase in video game use could have been lessened by proper mental health resources, allowing people to understand and better cope with their emotions during the pandemic (10).
Internet Gaming Disorder is associated with anxiety, depression, and sleep disorders (11). For anxiety, IGD is specifically linked with “Generalized Anxiety Disorder” (GAD). The DSM-V classifies GAD as excessive and difficult-to-control worrying that occurs on most days over six months (12). Problematic and excessive gaming can increase anxiety by reducing life satisfaction, perceived social support, and self-esteem (7). These actions allow for anxious and negative thoughts specifically about yourself and your relationship with others. This relationship can go both ways, however, as anxiety can also be a cause of IGD, specifically a fear of missing out (FoMO) (13). FoMO may lead to more time gaming due to not wanting to miss out on time with friends, as those with FoMO had an increased time spent gaming compared to those who do not have FOMO (13). Understanding the pathways between how gaming influences anxiety can help create better interventions to address anxiety and IGD.
Gaming not only can affect anxiety but other psychological issues as well, including depression. Depression is also linked to video games due to the loneliness and lack of in-person social interactions, especially when playing a single-player game (14). Though people can play video games with friends and communicate with them, there is a lack of physical interactions. Social withdrawal has been related to the time spent gaming, as it may cut into and affect the time an individual would usually spend either talking to friends or family in person. In addition to depression, sleep disorders like insomnia can also be caused by prolonged gaming (15). The lack of sleep is partially due to blue light radiated from electronic devices which can cause a feeling of being awake and impact the circadian rhythm, making your body believe it is the middle of the day. The addictive nature of some games can make it hard for the person to stop even though they know they should be sleeping (16). They also provide mental stimulation and can cause stress, making it harder for the player to fall asleep after playing them. The lack of face-to-face interactions can cause intensified feelings of depression, especially through loneliness and isolation. Gaming habits can cause short-term relief from stressors, however, if the playtime becomes excessive, they can cause mental health challenges to the user. When used as a coping strategy gaming can easily become addictive, as it allows for an escape from reality. Excessive gaming is correlated with mental health disturbances including anxiety, depression, and sleep disturbances, affecting a person’s relationship with themselves and others. This can be specifically detrimental when the whole world is going through a pandemic, like COVID-19.

SWEDEN AND GAMING HABITS
In a study led by Mohamed S. Mohamed, researchers studied how the COVID-19 epidemic in Sweden influenced both gambling and gaming and the associated psychological consequences (17). The study broke the COVID-19 pandemic into periods they called waves. The study evaluated the differences between the waves of COVID-19, specifically Wave 3 and 4. Wave 3 (w3) started in 2018 and is considered “pre-COVID” and Wave 4 (w4) started in 2021 and is considered “post-COVID” data, or post-COVID restrictions data.
The researchers performed a cross-sectional analysis of participants who completed both a questionnaire during the w4 and the w3 period The research group utilized the Gaming Addiction Identification Test (GAIT), a test used as a screening tool for measuring’ gaming activity. The GAIT is a questionnaire of 15 questions ranging from a response of 1-4 (1 meaning the statement was not relevant and 4 meaning the statement was highly relevant). The severity of the participants’ gaming habits was evaluated based on the total number of their responses. The scores allowed the researchers to see the extent of gaming issues in the participants and also see the link between gaming and anxiety, depression, and loneliness. The scale was completed by 676 of the w4 participants and 857 of the w3 participants and subsequently evaluated by the researchers. They also used the Adult Anxiety Scale (AAS-15), a self-rating scale for the measurement of the severity of anxiety symptoms. These results were then used to establish a connection between anxiety and gaming habits. The results of both surveys showed that 12.3% of participants increased their gaming during the pandemic.
The overall trend of the findings was that those who increased their gaming also had increased negative emotional consequences like loneliness, depression, and anxiety. Out of the participants who increased their gaming, 54.2% had increased feelings of loneliness, while those who did not increase their gaming only had a 32.5% increase in loneliness. This finding was statistically relevant because it shows those who felt more isolated were likely to turn to gaming as a coping mechanism. The participants who felt more isolated, especially due to being forced inside because of COVID-19 regulations, may use gaming as a coping mechanism. There was an increased feeling of depression for 50.5% of the participants who showed an increase in their gaming. In contrast, only 27% of those who showed a decrease in their gaming had an increase in depressed symptoms, and 21.1% even showed a decrease in depressive symptoms. Lastly, feelings of anxiety were increased for 35.2% for those who had an increased amount of gaming and increased for 18.5% for those who did not have an increase in their gaming.
The study also found that both social and generalized anxiety were associated with problem gaming. However, if they adjusted for insomnia they found that only social anxiety was associated with problem gaming, which has not truly been studied in the context of gaming. Social Anxiety is a fear of being judged by others (18). The study suggested that social anxiety’s association with gaming may be because of its association with escape motives. This finding is important as IGD is exclusively tied to GAD right now as other types of anxiety have not been researched enough in context to IGD. The study highlights how people got accustomed to gaming as a primary social outlet, a shift that is important for mental health professionals to understand how to approach treating gaming disorders. Of those who increased gaming, the young adults of the population were more likely to report all of the psychological impacts observed. The study shows the psychological impact that COVID-19 had on young adults and the behavioral coping mechanisms they had adopted as a response, emphasizing the need for mental health interventions to address not only the video gaming behavior but also the underlying causes and effects of this behavior.

Figure 1. This graph depicts the differences in the percent increase in feelings of loneliness, depression, and anxiety in the participants of the study who increased and those who did not increase their gaming.

JAPAN AND GAMING DISORDERS
A study published in 2021 by Taika Okat et al. evaluated Internet (video) gaming disorders in Japan (19). This study focused exclusively on adults in Japan since worsening internet gaming disorder rates during COVID-19 have already been proven in children and adolescents (20). To test the increased rates of IGD in adults, nearly one hundred thousand participants were given pre-pandemic surveys in December 2019 where they reported their psychiatric states. A follow-up survey was then given in July 2020, with additional questions about how they might have been impacted by the coronavirus. Some participants were excluded due to reporting issues and others dropped out of the study. In the end, the study used almost four thousand participants’ surveys to analyze and collect data.
The study had questions corresponding to each of the nine possible symptoms of IGD defined by the DSM-V, of which you need five symptoms to have a diagnosis. Based on the responses to the surveys, the prevalence of IGD increased more than 1.6 (2.2%) times during the pandemic. However, in young adults (those under 30 years old), the prevalence increased by 1.8 (8.6%) times, the highest of which was among young males. In the entire study population, all symptoms of IGD also increased, with younger people having a 2.1 times greater risk of having IGD than older adults. Those who had been infected with COVID-19 at least once had a 5.67 times greater risk of being diagnosed with IGD. The study suggests that loneliness and boredom may have been a driver for these behaviors in those affected by COVID-19. This is because these feelings allow for an escape from real-world loneliness, providing a way to cope by using multiplayer games to interact with people.
Games can be a disruption of the everyday routine, specifically when activities with others are not as readily available. These feelings may have arisen because they used the games as a coping mechanism to distract from the stress and responsibility felt. Those highest at risk of IGD were students, who had an increase from only 8.0% having IGD at the beginning of the pandemic to 23.5% at the end. College students’ levels may have been due to adverse coping to college life, including more responsibilities and the shutdown of schools. This study is important because it explains the mental health impact of COVID-19 in Japan, how it leads to an increase in IGD, and how the disorder has an impact on people’s participants. It also helps identify the most vulnerable people: young people and those who got infected by COVID-19.

DISCUSSION
There are several reasons for the differences in prevalence and changes in the two different countries. The first is the cultural practices. Japanese people tend to spend more time indoors than outdoors, while Swedish people tend to spend most of their time outdoors (21). Additionally, Japanese people also work longer hours, more days a week than Swedish people, which may lead to higher stress levels. On top of this, Japanese people are not given as many days off as the Swedish government allows, Japanese labor laws require at least 10 days of paid leave per year for employees (22). Swedish workers are entitled to a minimum of 25 days of paid vacation per year, as mandated by the Annual Leave Act (23), allowing for a more stress-free environment.
Another possible reason for the differences between these two studies is the COVID-19 regulation differences between Sweden and Japan. Sweden avoided a general lockdown during COVID-19, as their constitution states that Swedish citizens have “freedom of movement and the right to leave the country” (24). The measures put in place by the government were voluntary, the only time physical distance was enforced was in bars, restaurants, events, or visiting elderly care homes. Their response was less invasive than many other countries (25). Japan’s approach to implementation of COVID regulations was very different from Sweden’s. First, they declared a one-month state of emergency without much preparation which caused the immediate closure of schools, leaving a lot of people stressed about what was happening (26). They also encouraged most people to stay at home. Even though the complete closure of schools was stopped after the mandatory month, most schools continued to be closed for a certain period after that (26). During the mandatory stay-at-home period, there was a sharp increase in the number of Google searches for divorce (27) as well as increases in adverse coping mechanisms as a response to the regulations including an increase in suicides and domestic violence against children (26).
Cultural factors and COVID regulations are not the only influences on how people responded to COVID through various extremities of gaming use. However, what can be said is that there was an increase in gaming in both countries when COVID regulations were in place. The increase in gaming and gaming disorders correlates to an increase in negative mental health consequences, specifically loneliness, anxiety, and depression.

CONCLUSION
The COVID-19 pandemic had a significant role in a change in gaming behavior, which allowed for maladaptive coping mechanisms and mental health challenges to become more prominent. Multiple studies have shown that the incidences of IGD have had a steep increase during the COVID-19 pandemic (28). The studies from Sweden and Japan highlighted previously to show how an increase in gaming behavior is correlated with escalated levels of loneliness, anxiety, and depression, especially among young adults. Unfortunately, there is not enough data on IGD and how to prevent it that is currently available. More research needs to be conducted on what exact preventative measures are needed to decrease the overall rates of gaming, however, the differences between the two studies show that it is possible and beneficial to do so. Further research needs to be done on the long-term effects of gaming as a coping mechanism for the pandemic, as it may have lasting mental health or behavioral impacts (29). It is important to allow video gaming to be used as a source of friendships and entertainment instead of addiction and isolation.

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