Depression and Disordered Gaming: Does Culture Matter?

Game genres and motivation have been found to be key risk factors for DG. Demetrovics and colleagues suggested that socialization, escapism, competition, coping with difficulties, developing skills, fantasy, and recreation constitute the main motivations for gaming (Demetrovics et al., 2011). Similarly, and aiming to identify higher and more inclusive gaming motivation domains, Yee, Ducheneaut and Nelson (2012) psychometrically supported that various game motivations comprise three higher-level categories (i.e., achievement, socialization and immersion). Alternatively, adopting the perspective of self-determination theory, Lafrenière, Verner-Filion and Vallerand (2012) asserted that gaming motivation is explained by intrinsic motivation, integrated, identified, introjected and external regulation, as well as amotivation-related needs and drives.

However, different game genres constitute broad categories of games that promote unique experiences and result in different motives for individual gamers (Ghuman & Griffiths, 2012). Although there is no clear consensus on a universal genre typology, these can indicatively include shooters (e.g., Call of Duty), multiplayer online battle arena (MOBA) (e.g., League of Legends) and strategy games (e.g., Tetris), among others. Genres incorporate different structural characteristics and in-game mechanisms (such as reward stimulation and hierarchical ranks) that moderate emotional and cognitive processes by targeting gamer’s motivations (Caplan, Williams, and Yee, 2009; Liu & Peng, 2009; Elliott et al., 2012; Müller et al., 2015). Primary excessive gaming drives have been identified, including (i) achievement and/or competition; (ii) socializing and/or belonging, and (iii) game immersion and/or identification with one’s virtual character (Hoeft et al., 2008; Müller et al., 2015). These motivations may elicit cognitive and emotional compensatory processes whereby the user may aim to substitute real-life deficits (i.g., achievement; Morcos et al., 2019). Research has found that of various gaming genres, the massively multiplayer online role-playing game (MMORPG) genre employs mechanisms appealing to these motives most profoundly (i.e., achievement, socialization and identity motives; Müller et al., 2015; Laconi et al., 2017; Burleigh et al., 2018). In considering the moderating impact on emotion and cognition, the MMORPG genre is assumed to pose greater DG risk to users predisposed to mood disorder symptoms, and especially depression (Stavropoulos et al., 2018b; Morcos et al., 2019). Therefore, the present study focuses on the MMORPG genre, while investigating the association between depression and DG symptoms.

In addition to game genre and motivation, significant comorbidities have been supported between DG and other psychopathologies (Woelfling et al., 2008; Mihara & Higuchi, 2017; Pearcy et al., 2017; Kim et al., 2017; Adams et al., 2018; Liu et al., 2018), while addictions (such as DG) have been assumed to accommodate mood-regulation difficulties (Müller et al., 2015). In this context, depressive symptoms, including feelings of worthlessness, helplessness and hopelessness, difficulty concentrating, physical agitation (e.g., fidgeting), social isolation, and lethargic withdrawal from regular activities, have been strongly associated with addiction in general, and DG in particular (APA, 2013; Burleigh et al., 2018; Liu et al., 2018). Interestingly, associations between depressive and DG symptoms have been envisaged as complex, implying that symptoms of depression can initiate DG behaviors (as relief behaviors), which could later accommodate higher depression tendencies (Ho et al., 2014; Lee et al., 2017; Liu et al., 2018; Stavropoulos et al., 2019a). An individual experiencing feelings of worthlessness and low affect, for instance, may turn to internet gaming to gain a sense of self-worth and fulfillment, while finding their needs easily compensated for by features of the game itself (Stavropoulos et al., 2016; Liu et al., 2018). These align with the compensatory internet use hypothesis (Kardefelt-Winther, 2014), which proposes that gamers may counterbalance real-life experiences of distress and depression with positive experiences produced by game mechanisms. Consequently, behavioral addictions such as DG may on one side provide immediate relief and gratification from depressive symptoms, whilst promoting them in the longer term (Petry & O’Brien, 2013; Kaptsis et al., 2016; Kim et al., 2017).

Despite the established depression-DG association, there is a dearth of evidence assessing its potential cultural variations. This is imperative in the light of research consistently supporting that symptoms of depression and DG can be moderated by culture (and culturally dictated drives such as those for competitiveness and hierarchy; Arsenault, 2009; González & Adelantado, 2016). Research by Stavropoulos and colleagues (2019) has underscored the importance of such findings in developing culturally responsive interventions for multicultural countries (i.e., Australia and the USA). Consequently, the present study aims to address how the association between depression and DG may be moderated by cultural differences.

Research has assumed that different cultural aspects may accommodate different forms of psychopathology including DG (Triandis, 1996; Charlton & Danforth, 2007; Stavropoulos et al., 2016; Stavropoulos et al., 2020). Moreover, the cross-cultural assessment of excessive internet use behaviors, including online gaming, has been the focus of scholarly examination because different response patterns may apply (Kiraly et al., 2019; Laconi et al., 2018; Lopez-Fernandez et al., 2019). Similarly, it has been supported that experiences of psychosocial, addictive, and psychopathological disorders differ across cultures, implicating specific cultural syndromes (Triandis, 1996; Wan & Chiou, 2006; Anderson et al., 2017).

Triandis (1996) implied that cultural syndromes (i.e., shared cultural perspectives) may have significant associations with disordered behaviors and addictions using a continuum ranging from “collectivism” to “individualism”. More specifically, collectivism describes one’s self-perception and behavior in line with a collective (e.g., the family or societal norms), while individualism describes one’s perception of self as independent and autonomous from the group where personal interests are prioritized.

These constructs occur in horizontal or vertical variations (Singelis et al., 1995; Triandis & Gelfand, 1998). Verticality describes cultural endorsement of social hierarchy, where individual worth is measured by competitive success, while horizontality describes cultural endorsement of equality, where all individuals are considered equal (Triandis, 2018). Research has suggested that verticality may have significant associations with DG, where verticality-related competitive goals and motivations interact with corresponding game modalities (such as achievement), increasing DG vulnerability (Stavropoulos et al., 2016). Similarly, individualistic features, related to independence and social disconnection aspects, may predispose addictive disorders such as DG. Furthermore, a combined vertical-individualistic cultural orientation could predict higher DG risk (Györkös et al., 2013; Stavropoulos et al., 2016).

Despite the rationale supporting these hypotheses, there is scarcity of empirical research validating them. This is of particular importance to multicultural populations (e.g., Australia, USA, UK), where cultural diversity implicates differences in psychopathological risk and responsiveness to treatment (Györkös et al., 2013; Stavropoulos et al., 2016). More specifically, multicultural countries (such as the USA and Australia) have been assumed to present with a dominant cultural orientation of a westernized vertically individualistic quality (e.g., competitiveness and hierarchy tend to be more prominent and common), while at the same time, variations on these vertically individualistic tendencies exist due to the concurrent influence of other cultures (Vargas & Kemmelmeier, 2013). Therefore, one could assume that game motivations related to achievement and hierarchy, in the context of vertically individualistic tendencies, may differ across gamers from multicultural societies. Further, the extent that the effect of other DG-related factors, such as depressive mood, could be moderated (exacerbated) by a more vertically individualistic cultural orientation remains questionable (Stavropoulos et al., 2016; Stavropoulos et al., 2019b). Competitive and independence game-related motivations, potentially appealing among vertically individualistic gamers, could exacerbate DG vulnerability in the MMORPG context (Györkös et al., 2013; Stavropoulos et al., 2016). Given the aforementioned gap in the literature, the present study examines if—and to what extent—the association between depressive mood and DG behaviors can be exacerbated by higher vertically individualistic tendencies among a sample of gamers coming from multicultural societies.

Aside from broader cultural dimensions, research has identified individual factors, such as gender, as concurrently implicated in DG and depression vulnerability (Burleigh et al., 2018; Adams et al., 2018). Understanding the distinct influences of gender variations has been repetitively emphasized in developing effective interventions. More specifically, gender differences are reflected in motives underpinning gaming engagement (Müller et al., 2015). Males are typically driven by competition and achievement while females by social relationships (Taymur et al., 2016; Laconi et al., 2017). Similarly, it can be assumed that gender experiences can vary across different cultural orientations, with more individualistic cultures pertaining less distinct gender roles and drives than more collectivist cultures. Specifically, in more collectivistic cultures, drives of achievement and hierarchy are mostly enhanced among males compared to females, who are usually more driven by social and relationship needs (Anderson et al., 2017; Laconi et al., 2017).

Accompanying these, depression and DG are both known to manifest differently across genders (Chumbley & Griffiths, 2006; Stavropoulos et al., 2016; Anderson et al., 2017). Females are twice as likely as males to experience depression (APA, 2013), in contrast with DG, where males present more vulnerability (Liu et al., 2018). Based on previous research, it can be assumed that gender may additionally influence the moderation effect of a more vertically individualistic cultural orientation on the association between depressive and DG behaviors. For instance, males experiencing lack of purpose and achievement (in the context of a more depressive mood) may utilize internet games to compensate for it at different levels, depending on the extent of their vertically individualistic cultural orientation (Griffiths et al., 2004; Hoeft et al., 2008). Contrastingly, females experiencing isolation (in the context of depressive mood) may also compensate with excessive engagement in social aspects of the game at different levels, depending on their level of vertically individualistic cultural orientation (that encourages independence; Müller et al., 2015).

However, the specific effect that broader cultural dimensions, and especially vertical individualism, may have on such gender-related game motivations is yet to be understood empirically. This is important as literature has suggested that in more vertically individualistic cultures, combined motivations of achievement and competition may be exacerbated in male gamers (Beard & Wickham, 2016; Stavropoulos et al., 2019c). In this context, differences in gender motivations may culturally vary the established association between depression and DG symptoms (Laconi et al., 2017; Stavropoulos et al., 2019d). Thus, to shed light on these complex relationships, the present study considers the impact of gender on the potential moderating effect of higher vertically individualistic tendencies in the association between depressive mood and DG behaviors.

To conceptualize and explain its findings, the present study adopts an integrative framework. Contemporary research and extant empirical findings have emphasized that DG symptoms can be explained by the dynamic interplay between various elements related to the gamer, their surrounding and the game itself (Valkenburg & Peter, 2013; Masten, 2014; Petry & O’Brien, 2013). Indicatively, Stavropoulos et al., (2016) advocates an integrated model encompassing individual, contextual, and game-related factors to conceptualize DG behaviors on a severity continuum ranging from minimum to maximum risk. This model posits that individual (e.g., sociodemographic, psychopathologies, and developmental factors) and real contextual factors (e.g., family climate and community culture) may accommodate (“push towards”) DG, while game factors (such as features of the game itself) may “pull” (invite) the individual (Stavropoulos et al., 2016). While the interactions between these push and pull mechanisms are reflected in previous theoretical models, researchers have highlighted that concurrent presentations of cultural and gender differences have yet to be investigated (Pearcy et al., 2017; Laconi et al., 2017).

Based on the review of the literature conducted, the present study investigated the contribution of gender in the established association between depression and DG from a specific cultural perspective examining a population of gamers recruited from multicultural societies. Accordingly, it considers a more vertically individualistic cultural orientation as a factor that may moderate the relationship between depression and DG. Finally, in order to ascertain distinctions between gender experiences in the depression-DG association across variable levels of vertical individualism, the present study considers gender as an additional moderator of DG risk. Therefore, in order to achieve the aforementioned aims, the following hypotheses were developed to be tested (see Fig. 1):

Eligible participants for the present study involved adults over the age of years 17, with residency in Australia, the USA, the UK, Canada, and New Zealand and familiarity with gaming applications (N = 1032 M_age = 24, SD_age = 7, males = 503 [48.7%], females = 529 [51.3%]). The estimated maximum sampling error (at the 95% confidence interval) for 1032 participants is 3.11%, which satisfies Hill’s (1998) recommended acceptance level of ± 4%, respectively. Further sociodemographic and internet gaming information are found in Table 1.

Demographic (such as age and gender) and internet use questions (such as time spent gaming) were presented to participants prior to the primary self-report scales (of depressive and DG symptoms and cultural orientation).

This project was approved by the institution’s Human Research Ethics Committee prior to commencing in December 2018. Criteria for eligible participants included a minimum age of 18 years; residency in Australia, the USA, the UK, Canada, and New Zealand, and internet gaming experience. Sampling methods entailed sharing the online survey across media platforms (e.g., Facebook), through advertisement flyers, and virtual chat rooms (e.g., Discord). Given this study’s interest in gamer populations, independent distribution of the research survey was encouraged in online gaming communities. Responses were collected through SurveyGizmo, where participants first engaged with the Plain Language Information Statement (PLIS). This notified them of the voluntary nature of the study, the anonymous and secure storage of data, and required the digital provision of informed consent prior to continuation with the survey. Withdrawal was permitted prior to submitting a completed survey without penalties.

To assess the predictive association between depression (DASS scores) and DG behavior (H₁), a two-step hierarchical linear regression analysis was conducted using the IBM Statistical Package for the Social Sciences (SPSS, 25th edition). Age and gender (dummy coded 0 = females, 1 = males) were inserted as independent variables to control for potential confounding effects (Step₁), with depression inserted as an independent variable (Step₂). To enhance the quality of the results, bootstrapping at the optimum level of 5000 resamples was applied (Hayes, 2017).

Based on Model 1 of the Process macro (by Hayes, 2017), a moderation analysis was then conducted to assess the potentially exacerbating effect of the gamer’s levels of vertical individualism on the depression-DG association (H₂). Age and gender functioned as covariates to account for their potentially confounding effects. Depression was used as the independent (predictor) variable, with DG scores as the dependent (outcome) variable, and measured levels of the cultural dimension of vertical individualism as the moderating variable.

To assess H₃, a moderated moderation analysis was conducted. Model 3 of the Process macro (Hayes, 2017) was applied to investigate whether the interactive effect between symptoms of depression, vertical individualism, and DG behavior varied according to the gender of the gamer. Age was simultaneously controlled for any potentially confounding effect. For this model, depression was the predictor variable, with DG as the outcome variable, vertical individualism as the moderator variable, and gender as the moderating moderator variable. Lastly, the Johnson-Neyman (J-N) technique was applied to indicate specific levels of significance (i.e., points of transition) of the moderating effects in both Model 1 and Model 3 on DG behavior (Hayes, 2017).

The present study provided findings indicating that gamers experiencing elevated symptoms of depression would report increased DG behaviors (H₁). This supports a substantial body of literature emphasizing the risk posited by symptoms of depression in developing addictive behaviors, particularly those of DG (Müller et al., 2015; Taymur et al., 2016; Burleigh et al., 2018; Adams et al., 2018; Liu et al., 2018; Stavropoulos et al., 2019b). More Specifically, gamers presenting with symptoms of depression may be at significantly higher risk of developing symptoms of DG than other gamers. This is in line with the suggestion that individual factors may contribute to DG behaviors advocated by the integrative theoretical framework adopted (Stavropoulos et al., 2016).

Specifically, this finding could be interpreted by past literature suggesting that the depression and DG association is based on cognitive and emotional processes perpetuated by excessive internet gaming (Yen et al., 2019). Interestingly, the compensatory internet use hypothesis (Kardefelt-Winther, 2014) explains how gamers may counterbalance real-life experiences of distress and depression with positive experiences promoted by gaming mechanisms (such as reward stimulation and social connection). Gamers experiencing low affect and helplessness, for instance, may utilize internet games for their motivational appeal to immersion and achievement, thus providing them with relief of their offline depression. When utilized excessively, however, this compensatory process may result into a maladaptive emotional regulation strategy, leading to DG (Kardefelt-Winther, 2014; Stavropoulos et al., 2016; Taymur et al., 2016; Morcos et al., 2019; Stavropoulos et al., 2019c).

Conversely, research has suggested that excessive internet gaming behavior places gamers at higher risk for real-life dysfunction (e.g., the loss of one’s job) that would in turn precipitate and/or perpetuate symptoms of depression (Griffiths, Kuss & Pontes, 2016; Adams et al., 2018; Stavropoulos et al., 2018c). These interactions advocate bi-directional and cyclical associations, whereby symptoms of depression and DG can not only initiate and maintain one another but may also occur concurrently to exacerbate one another’s severity (Stavropoulos, Kuss, Griffiths & Motti-Stefanidi, 2016; Liu et al., 2018). In this context, the findings of the present study encourage the development of clinical intervention strategies that target internet gaming behavior functioning as a maladaptive emotion regulation strategy to alleviate symptoms of depression.

The findings of this study also indicated that gamers report increased symptoms of DG when presenting concurrently with higher symptoms of depression and higher levels of vertical individualism (H₂). In this context, gamers experiencing symptoms of depression, who might be more vertically individualistically orientated may find themselves at a significantly greater risk of developing symptoms of DG. This finding supports a significant body of literature advocating the influence of cultural orientation on the associations between psychopathologies and addictive behaviors in general, and in particular DG (Singelis et al., 1995; Györkös et al., 2013; Winkler et al., 2013; Taymur et al., 2016; Stavropoulos, Anderson et al., 2017; Stavropoulos et al., 2018c). More specifically, employing the integrative internet abuse framework, suggested by Stavropoulos et al. (2016), a more vertically individualistic orientation may foster and host achievement, competition, and ranking drives that when matched by mechanisms of the game could render the gamer more vulnerable to DG (Singelis et al., 1995; Györkös et al., 2013; Stavropoulos et al., 2018b). Indeed, vertically individualistic cultural orientation endorses behaviors related to self-driven achievement, an innate cultural value that is strongly reflected in the motivational appeal of the MMORPG genre. Interestingly, research has assumed that such overlaps may result in DG behaviors (Taymur et al., 2016; Laconi et al., 2017; Pearcy et al., 2017; Stavropoulos et al., 2018b). Such associations could become strengthened alongside concurrent gamer-related psychopathological features that may ‘push’ to a digital escape (i.e., symptoms of depression). In this context, depressed gamers, who are concurrently more vertically individualistically directed, may be at higher risk of developing DG than gamers presenting with equal levels of depression and lower vertically individualistic inclinations (i.e., achievement, competitiveness, and ranking). In developing prevention and intervention strategies, these findings encourage practitioners to consider in their case formulations and treatment plans cognitions and behaviors that may reflect more vertically individualistic tendencies, which could exacerbate DG risk effects, such as symptoms of depression (Griffiths, Kuss & Pontes, 2016).

With regard to the findings related to H₃, the present study found no significant gender differences in the interaction between vertical individualism and symptoms of depression on DG behaviors. This finding contradicts existing literature describing the influence of gender on DG behaviors (Singelis et al., 1995; Chumbley & Griffiths, 2006; Yen et al., 2019; Anderson et al., 2017; Beard et al., 2017). Regarding the broad associations between gender differences and internet gaming motivations (aside of cultural orientation differences), research has in general emphasized that males are typically driven by achievement and immersion, while females are typically driven by social relationships (Györkös et al., 2013; Burleigh et al., 2018; Adams et al., 2018; Stavropoulos et al., 2018b; Stavropoulos et al., 2018c). However, gender-based motivations have been found to vary across cultures, as indicated by cross-cultural research (Beard & Wickham, 2016; Stavropoulos et al., 2018b). Nevertheless, gamers from westernized multicultural societies were examined here. In such societies, vertically individualistic tendencies related to the dominant culture could neutralize such gender differences, because both males and females tend to adopt motivations of achievement and ranking, which could therefore explain the results obtained (Beard & Wickham, 2016; Stavropoulos et al., 2018c; Stavropoulos et al., 2019c).

Despite its strengths, there are significant potential limitations to the present study. Firstly, participants held residence primarily in Australia and the USA, which may not be completely representative of the range of vertically individualistic variations. Secondly, the cross-sectional nature of the study compromises the clear causal direction between the associations examined. Thirdly, the exclusive use of self-report measures may have limited the capacity of the study to reflect clinical features of DG behavior, with the reliability of responses being vulnerable to uncontrolled factors (such as participant mood, intelligence, and situational effects).

To address these potential limitations, future research should examine a broader range of countries to capture a more diverse range of vertically individualistic variations. Additionally, qualitative approaches and longitudinal research designs are also recommended to aid estimating the reliability and accuracy of the associations revealed and to better reflect clinical features of DG across distinct segments of the global population of gamers. Finally, research should emphasize and identify protective factors associated with DG to assist the development of effective prevention and intervention strategies.

Considering the prevention of DG, the findings of the study suggest that gamers (particularly females) presenting with concurrent symptoms of depression and stronger vertical-individualistic orientation (with strong overlapping achievement, immersion, and social drives) should be prioritized within multicultural societies. Furthermore, the findings encountered suggest that clinical treatment of DG may benefit by targeting maladaptive cognitive and emotional-regulation tendencies associated with the gamer’s culture and gender, particularly those of vertical individualism.

In conclusion, the present study examined how symptoms of depression may precipitate DG behaviors differently, when considering the moderating effects of vertically individualistic cultural inclinations and gender within multicultural societies. Findings demonstrated that while symptoms of depression increase DG risk, a more vertically individualistic cultural orientation could exacerbate this effect, slightly more so among females than males. These emphasize the importance of understanding differences in the relationship between depression and DG risk in relation to cultural orientation, particularly in rapidly evolving multicultural societies.