Mediating role of depression and gender in the relationship between daily video games exposure and internet gaming disorder (IGD) among college students – BMC Psychology

Internet Gaming Disorder (IGD) is an addictive condition characterized by excessive Video Games exposure and negative consequences, similar to other addictive behaviours. IGD is a serious condition that affects both children and adolescents [1] According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed., 2013), IGD is recognised as a clinical phenomenon that warrants further study [2]. In 2019, the World Health Organization (WHO) classified gaming disorder as a mental disease and under the category of the disorders caused by addictive behaviours [3].

The prevalence of IGD fluctuates between 4.9% and 14.3% across different regions, due to variations in assessment tools and demographic dynamics [4, 5]. There are mediating factors that affect the formation of IGD, and not everyone who plays Video Games for a long time develops IGD. The development of IGD is influenced by psychological, biological, and social factors [6]. The role of Depression in the development of IGD has been gaining more attention. Studies have shown that gamers often exhibit higher levels of depressive symptoms than non-gamers [7]. Neurobiological studies have observed structural alterations in the prefrontal cortex linked to IGD and Depression, which illustrates the complex interplay between the two mental disorders and the risk factors they may share [8]. Other studies have revealed that Depression can act as a proximal factor that leads to the development of IGD, and may mediate its relationship with mental resilience, perceived stress. This suggests that individuals with lower mental resilience and higher stress levels are more likely to develop IGD when they experience depressive symptoms [9]. The cycle of addiction is experienced by IGD patients during withdrawal, when they assuage their symptoms of Depression and negative emotions, by playing games, which maintains and reinforces the condition [10].

Gender-related differences play a significant role in IGD susceptibility, encompassing both biological gender differences and psychosocial gender influences. Neuroimaging studies show males exhibit stronger reward system activation (vmPFC, ACC, putamen) and weaker impulse control during risk-taking – patterns that are specifically altered in males with IGD but not affected females [11]. These neural differences interact with gender-specific behavioral patterns: males show greater impulsivity and reward-seeking, while females demonstrate more emotional dysregulation throughout IGD development and maintenance [12]. These findings suggest that Depression and gender play key roles in the development of IGD.

In this study, we specifically targeted freshman and sophomore university students (typically aged 18–20) for the following scientifically grounded reasons: China’s 2024 “Minor Internet Protection Regulations” implement strict real-name registration and playtime controls for minors (< 18 years). However, university students immediately upon entering college (≥ 18 years) become a high-risk population in this regulatory blind spot, suddenly transitioning from supervised adolescence to unmonitored internet access. Moreover, as emerging adults (typically 18–25 years), this population exhibits incomplete prefrontal cortex maturation [13], resulting in weaker impulse control that predisposes them to IGD. A meta-analysis of 407,620 participants across 33 countries (155 studies) reveals higher IGD prevalence among university students than adolescents [5]. Depression rates in this demographic show a global upward trend, now exceeding general population levels [14]. Male university students demonstrate significantly higher IGD rates than female counterparts [15, 16]. These factors collectively establish the critical need to investigate Depression and gender effects on IGD development in this vulnerable transitional population.

Based on the above research conclusions, the hypothesis of this study is that Depression plays a significant role in the development of IGD, and may mediate its relationship with gaming time. Additionally, gender plays a modulating role in this context. To verify this hypothesis, this study adopted the Internet Gaming Disorder Test-20 (IGD-20) [17] and Patient Health Questionnaire − 9 (PHQ-9) [18] to determine the prevalence and influencing factors of IGD among college students, further explore the relationship among IGD, daily Video Games exposure, gender and Depression. This will provide a theoretical foundation for the intervention and prevention of IGD in college students. The conceptual framework of the study was shown in Fig. 1.

The hypothesized moderated mediation model

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Participants

A cross sectional study was conducted between September 18 to October 30, 2023. We conducted a cross-sectional survey using cluster random sampling (whole-class method) to recruit participants from four universities in Bengbu City, Anhui Province, China. Participants were randomly selected from more than two freshman and sophomore classes were in each college. The students were provided with links to an online questionnaire through a QQ or WeChat group. To ensure only valid response were given, participants were only allowed to fill one questionnaire and with each being linked to their Internet Protocol addresses. The survey was administered in person by class advisors/instructors. A written informed consent form was attached to the front page of the questionnaire, clearly stating participants’ right to refuse participation. From the initial collection of 1,559 questionnaires, we excluded 32 responses that were completed too rapidly (< 1 min), resulting in 1,527 valid questionnaires and an effective response rate of 97.90%.

Research tools

Demographic questionnaire

The Demographic questionnaire was used to record variables, such as gender, age, daily Video Games exposure(hours) over the past 12 months, and Video Games duration (years).

Internet gaming disorder Test-20 (IGD-20)

Developed by Pontes et al. [19], the IGD-20 Test was used to provide a valid and reliable measure for IGD according to the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The Chinese version of the IGD-20 has undergone standardized translation and validation procedures, demonstrating good applicability among Chinese populations [20]. The Test consists of 20 items which examine the six factors, including: salience, the extent to which gaming becomes the most important activity in an individual’s life; mood modification, the idea that individuals play games to cope with negative feelings or to induce positive ones; tolerance, the need for increased amounts of gaming to achieve the desired effect; withdrawal, the negative emotional and physical reactions experienced when an individual is unable to game; conflict, the struggles that arise between gaming and other areas of life, such as work, education, relationships, and hobbies; and finally, relapse which is the inability to control gaming behaviour despite attempts to cut back. The Chinese version of the IGD-20 combines ‘salience’ and ‘tolerance’ into a single ‘salience-tolerance’ factor, whereas this study retains the original six-factor structure. Participants rated each item on a 5-point Likert scale ranging from “strongly disagree” (1) to “strongly agree” (5). A score above the cut-off point of 71 suggested a higher likelihood of IGD, indicating that further assessment or intervention may be required [19]. The internal consistency, was measured by Cronbach’s α at 0.885.

Patient health questionnaire − 9 scale (PHQ-9)

The PHQ-9, which is divided into five levels, 0–4, 5–9, 10–14, 15–19, and 20–27, corresponds to no Depression, mild Depression, moderate Depression, moderate to severe Depression, and major Depression, respectively, was used to diagnose depressive symptoms [21,22,23]. The Cronbach’s α coefficient for the PHQ-9 was 0.932.

Statistical analysis

The statistical analyses were conducted using SPSS software (Version 25.0). Measured data were expressed as the mean ± standard deviation. An independent sample t-test was used to compare the data of the two groups, while one-way analysis of variance (ANOVA) was used for multiple comparisons. The spearman correlation analyses were used to identify the relationships between variables, with α of p < 0.05. The multiple linear regression was conducted with IGD-20 total scores as the dependent variable. The mediation analysis was used to explore whether Depression plays a mediating role between gaming time and IGD. The deviation correction method, with 5,000 bootstraps, was used to obtain a 95% confidence interval to test the significance of the effects. If the confidence interval did not contain 0, then the statistical result was considered to be significant. A simple slope analysis was examined if the interaction of moderation effect was significant. All P values were derived from two-tailed tests and results were regarded as statistically significant at P < 0.05.

General data of the subjects

A total of 1527 students with a mean age of 18.61 ± 1.01, completed the survey. 645 (42.2%) were males and 882 (57.8%) females. The mean of the IGD-20 total scores was 35.99 ± 2.57. The number of students who had a score of 71 and above was 7, which accounted for 0.5%. Among the participants, 1,340 individuals (87.8%, the majority) reported playing video games for less than 2 h per day. The mean of the PHQ-9 scores was 5.10 ± 4.28, indicating an average level of mild Depression. The rest of the data are shown in Table 1.

Distribution of depressive symptoms according to the PHQ-9 scores

Distribution of depressive symptoms according to the PHQ-9 survey is shown in Table 2. Among the participants, 167 (10.93%) university students scored at the moderate Depression level or above.

Correlation analysis

The Spearman correlation analysis was used to analyse the correlations between Age, gender, IGD-20 total scores, PHQ-9 scores, daily Video Games exposure(hours), and Video Games duration (years). The results revealed that all the variables were positively correlated with each other (P < 0.01), except for IGD-20 total scores and age which had a negative correlation (P >0.05) Table 3.

Gender differences in IGD-20 scores, PHQ-9 scores, daily video games exposure (hours), video games duration (years)

The total scores and factor scores of IGD-20, daily Video Games exposure(hours) and Video Games duration (years) of males were significantly higher than those of females (P < 0.01), which pointed to IGD being more severe in males than in females. There was no significant difference in PHQ-9 scores between genders (P >0.05) Table 4.

Comparison of the age, IGD-20 scores, PHQ-9 scores, video games duration(years)among subjects with different daily video games exposure

Dose-response analysis of gaming time demonstrated that increased daily Video Games exposure was associated with progressively higher IGD-20 scores, PHQ-9 scores, and Video Games duration (years). These results indicate significant dose-response relationships between gaming time and all measured variables, establishing a foundation for subsequent mediation analysis (P < 0.001) Table 5.

Comparison of the age, IGD-20 scores, daily video games exposure(hours)and video games duration(years)among subjects with different levels of depression

Dose-response analysis of PHQ-9 scores confirmed that higher Depression levels were associated with progressively elevated IGD-20 scores, longer daily Video Games exposure(hours), and greater cumulative Video Games history (years). These findings demonstrate significant dose-response relationships between depressive symptoms and all measured variables, providing a basis for subsequent mediation analysis (P < 0.001) Table 6.

Common-method bias test

The results from Harman’s single-factor test on data from PHQ-9 scores and IGD-20 total scores, revealed that the initial eigenvalues of five factors were greater than 1 without rotation, while the variance explanation rate of the largest factor was 35.62% which was lower than the critical standard of 40%. This showed that the data collected in this study conformed with the standard of the common-method bias test, and that there was no multi-collinearity was expected.

Multivariate linear regression analysis

Using IGD-20 total scores as the dependent variable and gender, PHQ-9 scores, and daily Video Games exposure(hours) – which showed significant correlations in univariate analysis – as independent variables, we performed multiple linear regression analysis. The results demonstrated that gender, PHQ-9 scores, and daily Video Games exposure(hours) were independently associated with IGD-20 total scores (Table 7).

Mediation analysis

Moderated mediation effect test

Using age as a control variable, a moderated mediation effect test was conducted using the Model 59 in PROCESS 4.1. The results indicated that daily Video Games exposure significantly positively predicted PHQ-9 scores (B = 0.163, t = 5.645, P < 0.001). The predictive effect of daily Video Games exposure on IGD-20 total scores was also significant (B = 0.28, t = 11.052, P < 0.001). The positive predictive effect of PHQ-9 scores on IGD-20 total scores was significant (B = 0.31, t = 13.902, P < 0.001), suggesting that the mediation effect of Depression is established. The predictive effect of PHQ-9 scores × Gender on IGD-20 total scores was significant (B = -0.09, t = -4.254, P < 0.001), indicating that gender has a moderating effect on the mediation model, specifically moderating the PHQ-9 scores → IGD-20 total scores path.

However, the predictive effects of daily Video Games exposure× Gender on both IGD-20 total scores (B = -0.007, t = -0.287, P = 0.774) and PHQ-9 scores (B = -0.013, t = -0.464, P = 0.643) were not significant, suggesting that the moderating effect of gender on the daily Video Games exposure→ IGD-20 total scores and daily Video Games exposure→ PHQ-9 scores paths is not established. (Table 8; Fig. 2)

Standardized path coefficients for the moderated mediation model. PHQ-9: Patient Health Questionnaire-9;IGD-20:Internet Gaming Disorder Test-20;***P<0.001

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Simple slope analysis

To further explain the moderating effect of gender, a simple slope analysis was conducted on the above model. The results indicated that as PHQ-9 scores increased, there was a trend of increasing IGD-20 total scores for both males (β = 0.420, t = 12.690, P < 0.001) and females (β = 0.230, t = 7.640, P < 0.001). Moreover, males with high levels of PHQ-9 scores had higher IGD-20 total scores compared to females, suggesting that males with high levels of Depression are more susceptible to IGD. (Fig. 3)

Gender moderates the effect between PHQ-9 scores(Depression) and IGD-20. IGD: Internet Gaming Disorder

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Online Video Games have become a major form of entertainment for young people. Excessive Video Games behaviour has a negative impact on academic performance and mental health [24]. This study found that the incidence of IGD (IGD-20 total scores 71 and above) in college students was low at 0.5%, against previous reports of ∼ 4.7% [25], The low incidence of IGD in this study may be related to the fact that the participants were college students who are well educated and thus have better self-management abilities which results in lower cases of addiction. This is also consistent with the results of our previous studies [26].

IGD and gender differences

This study showed that the severity of IGD in males college students was significantly higher than that in females. Previous Multiple studies have similarly shown that males exhibit higher IGD prevalence and severity than females [27,28,29]. A study reviewed the published studies on prevalence of IGD among adolescents prior to March 2017,and found that male adolescents generally reported higher prevalence rate (6.8%, 95% CI = 4.3%-9.7%) than female adolescents (1.3%, 95% CI = 0.6%-2.2%) [30]. Another study selectively reviewed research publications that evaluated IGD separately for males and females collected in approximately one hundred publications over the past 20 years. The available data in this narrative review indicate that IGD is strongly dimorphic by gender for both its psychological features and the involvement of different brain areas [31].

Depression is a mediator between daily gaming time and IGD

One study that reviewed the prevalence of IGD between 1998 and 2016, found no significant increase during this period despite significant increases in the accessibility of Internet games [25]. Studies report that more than two-thirds of gamers do not present with any symptoms, and only a small percentage meet the diagnostic criteria for IGD (0.3%-1.0%) [32]. The above study suggests that there are some mediating factors between the time used in playing Video Games and the development of IGD. This study found a positive correlation among PHQ-9 scores, IGD-20 total scores, and daily Video Games exposure. It suggests that as the severity of Depression increases, the duration of daily Video Game exposure and the degree of IGD also rise accordingly. Similarly, PHQ-9 scores and IGD-20 total scores increased with increased daily Video Games exposure. Further mediating analysis found that PHQ-9 scores partly mediated the relationship between daily gaming time and IGD-20 total scores, meaning that the amount of daily gaming time did not entirely determine whether IGD would occur, and Depression also played a part of the mediator role.

The reason for this may be related to the withdrawal symptoms and tolerance of IGD. While moderate gaming can benefit emotional well-being, excessive gaming – even at subclinical addiction levels – may adversely affect mood [26]. When excessive gaming is stopped or the need for a gradual increase in pleasure is not met, IGD patients tend to experience abstinence-related symptoms of low mood and gaming cravings leads to Depression, which subside temporarily once gaming is resumed or increased, resulting in a vicious cycle [10]. Previous studies found that individuals with IGD often have more severe depressive symptoms compared to the general population, irrespective of whether they have received a clinical diagnosis of Depression or not [9, 33]. Approximately one out of three individuals with IGD also suffer from Depression [33,34,35]. Playing games can lead to addiction by temporarily alleviating Depression and bringing happiness, similar to the effect addictive drugs have on the brain’s reward system [36]. The presence of depressive symptoms can increase the likelihood of developing IGD [37].

Another reason may be related to emotion focused coping strategies. Research indicates that emotion-focused coping strategies, which involve attempts to manage emotional distress rather than addressing the source of the problem, are prevalent among individuals with Depression [38]. This aligns with findings that suggest behavioral addictions often serve as avoidant strategies to cope with emotional distress, particularly in males who may resort to such behaviors to escape negative feelings [39]. Research has established a clear link between negative emotional states and the development of internet gaming addiction, with individuals often using gaming as a maladaptive coping strategy to mitigate feelings of Depression and anxiety [40]. The cycle of addiction often perpetuates itself, as individuals may find temporary relief from their emotional pain through addictive behaviors, which in turn exacerbates their underlying psychological issues [41].

The regulatory role of gender

In verifying the moderating effect of gender on the mediating model, we found that gender only regulates the PHQ-9 scores -IGD-20 total scores pathway. A further simple slope plot analysis showed that male with high levels of Depression were more likely to develop IGD than female. It means that males are more likely than females to cope with Depression through excessive use of Video Games. There may be several reasons: (1)In males, game cues activated some brain regions associated with reward processing and motivation. However, no such activation pattern was observed in females [42]. Activation of these brain regions makes it easier for the male players to experience higher levels of satisfaction in the face of game rewards, which makes them crave for more [43]. This suggests that males and females differ in neural responses to play cues, which may help to explain the gender difference in IGD in Depression. (2) In addition, male adolescents also showed a significantly higher level of maladaptive cognition, such as: males pay too much attention to the rewards brought by games; or the sense of accomplishment when winning games; and the happiness of grade improvement, which is a cognitive factor which leads to the gender differences in IGD prevalence [44]. (3) There are also differences in how males and females cope, with studies finding that males often resort to avoidant behaviors, such as substance use or internet gaming, when faced with emotional challenges, like Depression [45]. Males tend to use the internet for power and control, which can lead to addictive behaviors as a form of emotional escape [46]. This contrasts with females, who are more likely to seek social support and express their feelings, suggesting that males may be more inclined to use addiction as a coping mechanism for their emotional difficulties [47].

In conclusion, males are indeed more likely to cope with negative feelings through addictive behaviors when they are depressed. Understanding these dynamics is crucial for developing effective interventions aimed at addressing both Depression and addiction in males.

The interplay of gaming duration, depression and gender in IGD pathogenesis

Gaming duration is not a diagnostic criterion for addiction, as evidenced by highly engaged players (e.g., esports professionals) who can engage in prolonged gaming without developing addiction. This suggests that the relationship between gaming time and addiction is mediated by other factors. However, prior studies have reported positive correlations between gaming duration and addiction [48, 49], while others found only weak associations [50], consistent with our results: correlation coefficients ranged from 0.098 to 0.253 in Table 3, beta values varied between 0.016 and 0.265 in Table 7 (multivariate regression), and mediation analysis in Table 8 showed beta values of 0.090–0.280. These data indicate that gaming time and related variables exhibit weak associations with IGD-20 total scores, underscoring the multidimensional nature of internet addiction pathogenesis. In this complex mechanism, gaming duration, Depression, and gender represent just one component of interacting biological, psychological, and social determinants. Other contributing factors include genetic predisposition, inadequate social support and interpersonal relationships, and poor impulse control. Despite modest effect sizes, the identified mediation (via Depression) and moderation (by gender) effects retain clinical significance: (1)Regarding mechanistic exploration, the findings suggest a stronger association between Depression and IGD among male individuals;(2) This enables identification of high-risk subgroups – particularly males exhibiting both prolonged gaming behavior and depressive symptoms who demonstrate increased vulnerability to addiction, warranting targeted clinical attention;(3) Shifting intervention focus from simplistic time-based warnings to personalized approaches addressing underlying psychological vulnerabilities – especially by implementing Depression-management strategies for university students (with particular emphasis on male cohorts) – may represent a critical pathway for IGD prevention and intervention.

Additionally, in light of the critiques raised by Billieux et al. [51], our findings warrant further discussion regarding the variables examined in this study. Billieux and colleagues caution against the overpathologization of everyday behaviors by emphasizing the need for a process-based approach, rather than relying solely on symptom-based criteria [52]. The subcomponents of the IGD-20 scale, such as loss of control, cognitive salience, and mood regulation, may reflect heterogeneous psychological processes rather than a uniform addiction construct. For instance, the observed mediation effect of Depression suggests that excessive gaming could serve as a maladaptive coping mechanism for underlying emotional distress. Our results, which demonstrate a significant association between daily gaming exposure, Depression, and IGD, align with their call for a more nuanced understanding of behavioral addictions. In summary, while our findings support the association between gaming, Depression, and IGD, they also underscore the need to contextualize these relationships within broader psychological processes. This perspective mitigates the risk of overpathologizing normative behaviors.

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Author notes

1. Li-Jin Wang, Lin-Lin Mu and Xiang-Yu Li contributed equally to this work.

Authors and Affiliations

1. School of Mental Health, Bengbu Medical university, Bengbu, Anhui, China

   Li-Jin Wang, Lin-Lin Mu, Xiang-Yu Li, Pei-Pei Song, Zheng-Ze Pan, Yu-Xin Gao, Fan Duan, Hao-Nan Li, Wen-Bo Du, Xun Song, Jin-Xuan Chen, Yue Wang & Dong-Liang Jiao

2. Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China

   Na Zhong

3. CAS Key Laboratory of Brain Function and Disease, School of Life Sciences, University of Science and Technology of China, Hefei, Anhui, China

   Xiao-Chu Zhang

4. Anhui Engineering Research Center for Neural Regeneration Technology and Medical New Materials, Bengbu Medical University, Bengbu, 233000, China

   Dong-Liang Jiao

Contributions

Conceptualization, P.-P.S., J.-X.C. and Y.W.; methodology, L.-J.W., L.-L.M., X.-Y.L., P.-P.S., Z.-Z.P., F.D., W.-B.D., X.S. and D.-L.J.; software, L.-J.W.; validation, L.-J.W., L.-L.M., Z.-Z.P. and H.-N.L.; formal analysis, L.-J.W., F.D., H.-N.L. and N.Z.; investigation, H.-N.L., W.-B.D., J.-X.C. and Y.W.; resources, X.-C.Z.; data curation, L.-J.W., L.-L.M. and Z.-Z.P.; writing—original draft preparation, L.-J.W., L.-L.M. and X.-Y.L.; writing—review and editing, X.-C.Z. and D.-L.J.; visualization, L.-J.W., X.-Y.L. and P.-P.S.; supervision, L.-L.M., X.-Y.L., Y.-X.G., X.S. and D.-L.J.; project administration, Y.-X.G. and X.-C.Z.; funding acquisition, D.-L.J. All authors have read and agreed to the published version of the manuscript.

Corresponding author

Correspondence to Dong-Liang Jiao.

Ethics approval and consent to participate

The study approved by the Institutional Review Board of the Biomedical Ethics Committee of Bengbu medical University (Ethical number:2023-347) and the procedures were carried out in accordance with the Declaration of Helsinki. All participants were informed about the study and gave their informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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