Gaming disorder and psychological distress among Iranian adolescents: the mediating role of sleep hygiene

Evidence on psychological outcomes of gaming disorder (GD) is still scarce. This study aimed to investigate the mediating role of sleep hygiene in the relationship between GD and psychological distress (depression and anxiety) among Iranian adolescents.

This was a cross-sectional study among school students in Qazvin city, Iran. We administered GD, anxiety, and depression questionnaires in a paper-and-pencil format. GD was measured using the GD S4-SF scale, and anxiety and depression were evaluated using the DASS-21. We assessed sleep health as a mediator using the Sleep Hygiene Behaviors scale. Covariance-Based Structural Equation Modeling (CB-SEM) was employed for data analysis, accounting for sex and physical activity as the main confounders. Statistical significance was determined using various fit indices and confidence intervals.

The sample consisted of 600 adolescents (41% female). CB-SEM revealed a positive but not statistically significant association between GD and depression, along with a negative statistically significant association with anxiety. Notably, sleep hygiene was identified as a partial mediator in the relationship between GD and depression, indicating that poor sleep practices may exacerbate depressive symptoms among adolescents with GD. However, no mediating effect was observed for anxiety.

Our data supported a mediating role for sleep hygiene in the association between GD and depression among participants. Our results highlight the critical need for targeted policy interventions to improve sleep hygiene among adolescents with GD.

In recent years, most people have spent significant time on smartphones, social media, and online games on various electronic devices [1]. The World Health Organization (WHO) has recently included gaming disorder (GD) in the International Classification of Diseases (ICD-11) [2]. According to the definition, GD is a pattern of behavior in digital or video gaming that includes losing control of gaming activities and putting gaming ahead of other activities to the point where it gets in the way of daily tasks and interests. GD also encompasses the continuation or escalation of gaming despite the occurrence of negative consequences [3].

GD can affect physical activity, sleep quality, quality of life, education, and social relations [4, 5]. Moreover, GD is associated with self-esteem issues [6], anxiety, and depression [7, 8]. Internet gaming disorder (IGD) is linked to increased family conflicts and poor relationships [9]. GD may affect the well-being of children as well as their parents [10]. The symptoms of GD are linked to various motivational factors, including the desire to avoid negative emotions, engage in escapism, relieve stress, and participate in in-game social interactions [11, 12].

In a recent meta-analysis, the prevalence of IGD among adolescents ranged from 0.6% to 19.9% [13]. Some research has shown that the tests for GD and IGD are stable across different groups of people and situations, which is called factorial invariance [14]. In contrast, other research highlights inconsistent and lower levels of agreement between the two measures [15]. Additionally, findings reveal a 73% overlap in the diagnostic criteria for IGD and GD [16]. However, this partial overlap does not warrant the interchangeable use of these terms, as each set of criteria addresses distinct facets of GD [17].

Assessing sleep hygiene as a determinant of mental health, well-being, and individual functional performance is essential [18]. GD is strongly correlated with insomnia among adolescents [19]. Most of the existing research has focused on IGD. However, studying GD as a whole lets researchers get a more complete picture of the problem, fill in any gaps in our knowledge, and come up with more effective ways to prevent and treat it. To our knowledge, evidence of the mediating role of sleep hygiene in the association between GD and psychological distress (depression and anxiety) among adolescents is still scarce. Therefore, this study aimed to determine the mediating role of sleep hygiene between psychological distress (depression and anxiety) and GD among Iranian adolescents in the city of Qazvin.

Qazvin is located in the northwest part of Iran. Ten high schools were selected from the comprehensive list of all high schools in Qazvin, ensuring representation from various areas of the city. All adolescents and their parents were required to sign an informed consent prior to their participation in the study. Following their consent, participants were requested to complete a form that outlined the study objectives and included the questionnaires. Two research associates conducted interviews and filled out the questionnaires using a paper-and-pencil format. The study was approved by the Ethics Committee of Qazvin University of Medical Sciences (no. IR.QUMS.REC.1403.200) and the Organization for Education in Qazvin.

We measured GD as our main exposure using the GD S4-SF, a brief self-report scale consisting of four items based on DSM-5 criteria. Participants responded using a five-point Likert scale, ranging from 1 (never) to 5 (very often). A higher total score reflects a greater severity of GD [20].

We used the Depression, Anxiety, and Stress Scale-21 (DASS-21) to evaluate the study outcomes: depression and anxiety. Respondents rated all 21 items using a four-point Likert scale that ranges from 0 (not applicable to me at all, never) to 3 (applied to me very much, or most of the time, almost always). The total score for each subscale, which is the sum of the items, ranges from 0 to 21; a higher score indicates a greater level of distress in that area. The Persian version of the DASS-21 has demonstrated very good to excellent internal consistency, with Cronbach’s alpha ranging from 0.84 to 0.91 [21].

We examined the mediating role of sleep health in the relationship between GD, depression, and anxiety. The Sleep Hygiene Behaviors assessment, validated for psychometric reliability in Persian [22], consists of three items and uses a five-point Likert scale ranging from 1 (never) to 5 (always). A higher score reflects better sleep hygiene practices. The three items focus on (1) establishing a calming atmosphere in the bedroom, (2) steering clear of hunger or thirst before sleep, and (3) refraining from engaging in stress-inducing activities prior to bedtime [23].

The individual and social/relational factors play a significant role as barriers and facilitators of physical activity. Therefore, we considered psychological distress as a potential antecedent influencing the level of physical activity. We also did extra tests to see how physical activity might affect the relationship between the mediator and the outcome. It is generally accepted that at least 180 min per week should be dedicated to exercise in the form of three 60-min sessions of moderate intensity [24].

We have established evidence for sex differences in psychological distress (outcome) and sleep hygiene (mediator)[25]. We standardized the mediator and outcome variables, stratifying them based on sex as described above. Some evidence suggests a moderating effect of sex in the exposure-mediator and exposure-outcome paths [26]. Consequently, we included an interaction term between sex and GD in all analyses.

This study utilized Covariance-Based Structural Equation Modeling (CB-SEM) to estimate parameters and to test hypotheses regarding the relationships illustrated in Fig. 1. We first examined the paths between GD and psychological distress. Subsequently, we included sleep hygiene as a mediator in the models. We incorporated the covariance into the model and analyzed the residual matrix to assess the correlation of the residual covariance between variables. We considered sex and physical activity as confounding variables, retaining them in the final model if they were statistically significant. All factor loadings, measurement errors, covariances, and path coefficients were estimated using the Maximum Likelihood (ML) estimator. We evaluated model fit using the Standardized Root Mean Square Residual (SRMR) and Root Mean Square Error of Approximation (RMSEA), both of which should be less than 0.08. And also using the Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), and Goodness-of-Fit Index (GFI), all expected to exceed 0.9 [27]. Finally, we reported non-standardized and standardized beta coefficients (Stand. Beta), standard deviations (SD), and P-values for each direct, indirect, and total effect within the examined paths. Effects were deemed significant if the confidence interval did not encompass zero. We used STATA version 17 and R Studio version 4.2.2 (Lavaan Package 0.6–12) to clean and manage the data and conduct the statistical analysis. We used the open-source SEM diagram for path visualization [28].

The study sample included 600 participants, of whom 246 (41.0%) were female (Table 1). Over half (54.7%) of the participants engaged in less than 180 min of physical activity per week. The mean age was 16.3 years (95% CI [16.1, 17.2]). Nearly half of participants’ fathers the (47.1%) and mothers (45.1%) had high school diplomas as their highest completed education. Females had lower sleep hygiene scores (8.8, 95% CI [8.4, 9.1]) compared to males (9.4, 95% CI [9.1, 9.7]). However, males had a higher anxiety level (17.9, 95% CI [17.5, 18.3]) than females (15.8, 95% CI [15.3, 16.3]). The depression scores were similar between males (16.4, 95% CI [16.1, 16.7]) and females (16.4, 95% CI [16.1, 16.8]).

Participants with less than 180 min of physical activity per week had a lower sleep hygiene score (8.7, 95% CI [8.4, 9.0]) compared to those with ≥ 180 min of activity (9.6, 95% CI [9.3, 9.9]). Anxiety was also higher among those with higher physical activity (17.4, 95% CI [16.9, 17.9]) than participants with a lower level of physical activity (16.8, 95% CI [16.3, 17.2]). However, depression scores were similar between participants with a high (16.5, 95% CI [16.2, 16.9]) and those with a low physical activity (16.3, 95% CI [16, 16.7]) score.

Table 2 and Fig. 2 report the final SEM analysis results. Assessing the confounding effects of sex and physical activity on each hypothesized path indicated a confounding role of sex in the model. The goodness of fit of the SEM based on the ML estimator indicated excellent fit based on all tests (CFI: 0.956, TLI: 0.945, GFI: 0.948: RMSEA: 0.037, and SRMR: 0.041).

The total effect of GD on depression was not statistically significant (β: 0.2, 95% CI [−0.1, 0.3]). However, GD had a statistically negative total effect on anxiety (β: −0.3, 95% CI [−0.5, −0.2]).

For direct effects, the relationship between GD and depression was not statistically significant (β: 0.1, 95% CI [−0.1, 0.2]). However, the direct effect of GD on anxiety was statistically significant (β: −0.3, 95% CI [−0.5, −0.1]). Sleep hygiene had a significant negative direct effect on depression (β: −0.9, 95% CI [−1.2, −0.6]), while its effect on anxiety was not statistically significant (β: 0.2, 95% CI [−0.3, 0.8]).

Different sleep hygiene habits had different indirect effects on depression and anxiety. The effect on depression was statistically significant (β: 0.1, 95% CI [0.0, 0.2]), which suggests some mediation. The effect on anxiety was not significant (β: 0.0, 95% CI [−0.1, 0.1]).

This study included a sample of female and male high school students in the city of Qazvin, Iran, to investigate the potential mediating effects of sleep hygiene in the relationship between GD and depression and anxiety. GD had a direct negative effect on anxiety. Sleep hygiene was negatively associated with depression. GD had an indirect effect on depression, which may indicate that sleep hygiene mediates the relationship between GD and depression.

Sleep hygiene is crucial for improving sleep quality. Previous studies have shown that poor sleep hygiene practices are associated with declined sleep quality among adolescents [29] and are a major risk factor for insomnia [30]. Behavioral treatments for insomnia often include sleep hygiene recommendations [31]. We don’t see the usual pattern of full mediation, where a significant total effect becomes non-significant after controlling for the mediator. This is because the total effect of GD on depression wasn’t significant before sleep hygiene was added. Instead, our results support an indirect-only mediation, which means that GD’s effect on depression shows up through good sleep hygiene instead of a direct path.

In mediation analysis, “partial mediation” in mediation analysis happens when the direct effect stays the same but becomes less important when the mediator is added. “Indirect-only” mediation happens when the direct effect is not important, but the indirect path through the mediator is important. This is exactly what we see when we look at how GD affects depression. Hence, our data suggest that GD influences depression largely by affecting sleep hygiene rather than by a direct mechanism. These findings highlight the indirect link between GD and depression, with sleep hygiene playing a key mediating role [32]. Combined with evidence showing the relationship between sleep hygiene and depression, these results suggest that GD may affect adolescents through multiple pathways. Therefore, family members and guardians should monitor the time and frequency of their children engaging in gaming, both online and offline [33, 34].

Our findings suggest that we can understand the mechanism of GD’s effects on depression through the lens of sleep hygiene. One legitimate explanation could be the reward system. Many popular games have re-login bonuses, called contingent bonuses, that reward players with free virtual goods every time/day they log in [35], which are based on principles of behavioral economics [36]. Operant conditioning of a given behavior with positive reinforcement, in this case, frequent logins by associating them with a reward (e.g., a gift of in-game goods). During reward claims, users associate positive feedback with logging behavior and tend to associate this positive feeling with gaming. As a result, users play more frequently and longer [37,38,39]. The orbitofrontal cortex, like the amygdala and the hippocampus, plays an important role in such arousal-inducing behaviors [40]. Over time, more and more of the substance (or any other thing that can lead to dependence and addiction) is needed to get the desired effect. This leads to a decrease in the effectiveness of the brain’s natural reward system, which in turn activates an anti-reward system, making it more challenging for the addict to find biological reinforcers that provide positive feelings [41]. Griffiths’ Components Model of Addiction outlines six key elements of gaming addiction: salience, mood modification, tolerance, withdrawal, conflict, and relapse [42]. Salience makes gaming the central focus of life, often at the expense of sleep. Mood modification temporarily alleviates negative emotions but disrupts sleep patterns. Tolerance leads to longer gaming sessions, further impairing sleep. Withdrawal symptoms, such as irritability and anxiety, worsen sleep disturbances. Conflict arises from struggles to balance gaming with responsibilities, which increases stress. Relapse occurs when excessive gaming resumes during stressful periods, perpetuating poor sleep and depressive symptoms. These components underscore the complex relationship between gaming and sleep, highlighting broader impacts.

In addition, sleep deprivation exacerbates maladaptive emotional regulation, leading to elevated neural and behavioral responses to negative and aversive experiences [43]. Individuals may engage in self-regulation strategies that involve problematic gaming behaviors, which can ultimately compromise their mental well-being and contribute to poor sleep hygiene. After adding sleep hygiene to the model, the relationship between GD and anxiety was no longer statistically significant. In addition, the results of direct effects indicated a (weak to medium) negative relationship between GD, anxiety, and sleep hygiene.

In addressing the complex interplay between GD and sleep hygiene among adolescents [44], it is imperative to explore community-based interventions to effectively mitigate existing challenges. Schools represent a critical environment for implementing targeted educational programs that raise awareness about the detrimental effects of GD on sleep hygiene and psychological distress. Such programs can empower students and parents alike to establish healthy boundaries around gaming, promote balanced lifestyles, and foster open dialogues about mental well-being. Additionally, the incorporation of peer support groups within school settings can enhance social cohesion and provide adolescents with a platform to share experiences and strategies for healthier gaming habits. By emphasizing grassroots initiatives, we can create a supportive framework that not only addresses the immediate concerns of GD but also promotes long-term improvements in sleep hygiene and reduces psychological distress among young individuals.

The main limitation of this study was its relatively small and non-representative sample. Our results may have low generalizability to high-resource settings. Given that Iran is a resource-limited country, with very expensive and low-speed internet, such socioeconomic factors in addition to other cultural conditions may significantly influence the engagement of adolescents in GD and especially IGD, which in turn may affect their outcomes. It is essential to replicate our study in countries with more active gaming communities and in high-resource settings. Additionally, as our study is cross-sectional, we cannot infer definitive causality. The observed ‘indirect-only’ mediation model should be interpreted as an association rather than a proven cause-and-effect pathway. Cohort studies are needed to ascertain temporality, to monitor the outcomes of adolescents with GD over time, and to document their mental health outcomes.

This study was a survey on GD and its psychological impacts among high school students in the city of Qazvin, Iran. Our findings indicated a correlation between GD and depression, highlighting the negative effects of GD on psychological distress among adolescents. However, the indirect effect of GD on sleep hygiene suggested that improving sleep health might help keep teens with GD from experiencing mental distress.

The data that support the findings of this study are available from the corresponding author upon formal request.

Comparative Fit Index

CB-SEM:

Covariance-Based Structural Equation Modeling

GD:

Gaming Disorder

GFI:

Goodness-of-Fit Index

DASS-21:

Depression, Anxiety, and Stress Scale-21

ML:

Maximum Likelihood

RMSEA:

Root Mean Square Error of Approximation

SD:

Standard deviations

Stand. Beta:

Standardized beta coefficients

SRMR:

Standardized Root Mean Square Residual

TLI:

Tucker–Lewis Index

Authors would like to acknowledge the school officials, study participants and their parents/guardians for their kind cooperation.

The Vice Chancellor of Research at Qazvin University of Medical Sciences provided financial assistance for the project (28/20/27371).

Department of Biostatistics and Epidemiology, School of Health, Guilan University of Medical Sciences, Rasht, Iran

Leila Molaeipour

Non-Communicable Diseases Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran

Reza Jabarbeigi & Elahe Jafari

Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran

Tina Lari & Elahe Jafari

Division of Clinical Epidemiology and Pharmacoepidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden

Mehdi Osooli

Center for Primary Health Care Research, Lund University, Malmö, Sweden

Mehdi Osooli

E.J. and L.M. contributed to the conception. E.J., L.M. and M.O. contributed to the design of the study. R.J. and T.L. contributed in data collection under supervision of E.J., L.M. contributed to data analysis and the interpretation of findings. E.J. and L.M. drafted the manuscript. M.O. contributed in interpretation of the findings and revised the drafted manuscript. All authors reviewed manuscript draft, helped in revision, and approved the final version of the manuscript before submission, and committed to full responsibility for maintaining the accuracy and integrity of the study. The title page lists all of the writers as co-authors, indicating that they all fulfilled the requirements for authorship.

The study was conducted according to the guidelines of the Declaration of Helsinki. The Qazvin University of Medical Sciences institutional review board and ethics committee examined and approved the study protocol (protocol code: IR.QUMS.REC.1403.200). We obtained an informed consent from each participant and at least one of their parents/guardians. Participants were informed about the study’s goals, and that participation was entirely optional, and that all collected information would be kept private and anonymously.

Not applicable.

The authors declare no competing interests.

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