Access to health care for gaming disorder: A patient-centred approach to address the continuum of need

doi:10.21203/rs.3.rs-30827/v1

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Research article

Access to health care for gaming disorder: A patient-centred approach to address the continuum of need

https://doi.org/10.21203/rs.3.rs-30827/v1

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Background

Problematic gaming, including its most serious form known as gaming disorder (GD) in the ICD-11, affects approximately 1–3% of the population and can have significant negative impacts on health and wellbeing. Research to determine the optimal health system responses to GD remains limited. This study aimed to identify and describe the key components of a patient-centred approach to prevention, early intervention, and treatment of GD.

Methods

Online interviews were conducted with 20 adults (90% male; M_age=23y) currently seeking help for GD-related issues. The interview protocol was guided by a health care access framework which investigated participants’ experiences and needs related to accessing professional support. Transcripts were analysed in Nvivo using qualitative content analysis to systematically classify participant data into the themes informed by this framework.

Results

Although the characteristics and resultant harms of GD were broadly recognised, participants indicated that these issues may not always be viewed by healthcare providers as a serious problem that requires intervention or that could be addressed through treatment. This highlights a significant barrier to access at the beginning of the patient journey when patients may perceive that they have a legitimate need for care and seek a relevant, tailored, and safe service to meet this need. Participants described the essential components of an effective health service for GD as including: valid and reliable screening tools for GD; practitioners with specialist knowledge of GD that includes, or is strongly informed by, lived experience of peers; and access to a multimodal system of intervention, including web-based and face-to-face options that allow gamers to transition between types and intensity of support.

Conclusion

A comprehensive health care approach for gaming disorder is currently in its infancy and there are numerous service access and delivery issues still to be resolved. This study highlights the importance of involving individuals with GD in developing solutions that are fit for purpose and address the spectrum of intervention needs. These findings recommend a stepped GD healthcare system that adheres to evidence-based practice tailored to each individual and the implementation of standard assessment and routine outcome monitoring.

Health Economics & Outcomes Research

Health Policy

gaming disorder

treatment

internet gaming

screening

intervention

Gaming disorder is recognised as a mental health issue that impacts approximately 1–3% of people internationally (1–3). The condition is associated with physical (e.g., sleep disruption), psychological (e.g., anxiety and depression), social (e.g., impaired quality of relationships) and legacy harms such as reduced employment or educational attainment (4–6). Gaming disorder is highly comorbid with anxiety, depression, ADHD, social phobia, and anxiety, and appears to be more prevalent in male gamers (7, 8). Following a provisional status for ‘internet gaming disorder’ in the DSM-5 (American Psychiatric Association, 2013), gaming disorder was officially adopted at the World Health Assembly in May 2019 as a diagnosis in the eleventh edition of the International Classification of Diseases (ICD-11) (9). Gaming disorder within these health classification systems is characterized by persistent gaming behaviour, impaired control over gaming, and functional impairment due to gaming for a period of at least 12 months in most instances.

Recent systematic reviews and meta-analyses have examined the evidence quality and effectiveness of GD prevention (10–13) and treatment (14–17). To date, research on prevention has tended to focus on school-based prevention programs. Much of the work in this area has been conducted in Asian settings (18, 19), including South Korea and China, where there have been parallel developments in trialling targeted technology-restriction measures including content filters and gaming time limits aimed particularly at younger users (20–23). In terms of treatment, the most common approach has been cognitive-behavioural therapy (CBT), usually delivered in brief individual and group-based formats, and other non-CBT psychotherapeutic interventions (14–16, 24, 25). CBT for GD may be an effective short-term intervention for reducing GD and depressive symptoms, but more studies with follow-up are needed to assess longer-term gains (24, 26). Pharmacological interventions have predominantly employed antidepressants (i.e., bupropion and escitalopram), but their effectiveness is currently unclear due to lack of controlled trials (14). Some treatment centres provide brief voluntary retreats, which typically involve abstinence (so-called ‘detox’) from digital technologies, group therapy and social activities, but these options may be financially burdensome and have limited evidence for their long-term efficacy.

The growing body of literature examining early intervention and treatment for GD highlights several important gaps (14, 15, 19, 25). Zajac et al.’s (15) review of 15 studies reported that the majority had targeted school age samples with just six studies involving adults. The majority of participants were male and almost all were conducted in university settings, however there was some heterogeneity in terms of problem severity (mild, moderate and severe problems) and time spent gaming (ranging daily to weekly sessions, and very low to high levels of gaming time). Treatment was often brief intensive, being conducted over 4 to 8 weeks, and almost all were delivered via face-to-face consultation. Other reviews (14, 25) have reported most studies have been conducted in East Asian settings, indicating a need for cross-cultural perspectives. There are well-documented problems of validity across a wide range of GD tools, including those employed in intervention studies (27, 28). A related problem is that many intervention studies, particularly those in Asia, have relied on problematic internet use measures to evaluate gaming. Together, these reviews suggest that GD interventions may be enhanced by a range of improvements and wider consideration of alternative treatment approaches and delivery methods.

Although many individuals and their families experience gaming-related harm, very few will seek professional help (13, 29). A longitudinal study involving over 4000 adults in Canada reported just 3 percent of the 201 with gaming problems had sought professional help over a 5-year period (30). The type of help surveyed included a family physician, psychologist, psychiatrist, counseling service or telephone helpline. Rates of professional treatment-seeking for other addictive behaviours is approximately 10% (31), much higher than is reported for GD. The reason for the low rate of treatment seeking may be due to structural issues such as the homogeneity of available treatments (intensive and face-to-face). In addition, individual factors related to GD may delay or inhibit treatment seeking, such as low insight, procrastination, impulsivity, and shyness or introversion (32–35). Another possibility is that some individuals with gaming-related problems may initially seek out information, social support and assistance from less formal, convenient sources, such as online support groups (36).

Another important consideration for interventions is the complex nature of GD cases. Given high rates of co-morbidity and GD (e.g., depression, anxiety, substance use and gambling disorder) it may be that people with GD attend other services for more acute issues and therefore do not report seeking help for GD (35). Lau et al. (37) for example, examined the records of 5820 clinically referred youth in the Canadian mental health system and reported that moderate to severe problematic gaming was reported by 13% of the sample; however, most of the sample had been referred for issues including threat or danger to self or others, or other psychiatric symptoms. GD treatment is also challenged by the ubiquity of gaming opportunities and the common perception among patients that maintaining their commitment to the gaming world is preferable to living in reality (38). This suggests a need to examine how health care can be provided so that appropriate services are readily available to anyone concerned about their gaming and is designed appropriately to reflect a range of client insights, preferences, and goals.

Taken together, the evidence suggests a need to broaden the scope of research into GD interventions to address the complexities and varied needs of individuals. To address complex issues related to GD health care, the current study undertook interviews with people experiencing problems with gaming to gather their views of the components of an effective integrated health care approach. Although GD prevalence in New Zealand (NZ) is currently unclear, there is evidence of problematic gamers in this region (39) and surveys of psychiatrists and mental health professionals that suggest NZ gamers and their support networks may seek help via addiction and related services (40, 41). The aims of this study were to: (i) describe the experiences and needs of people with gaming-related problems; and (ii) identify the optimal components of a health care system to support prevention, early intervention and treatment of GD.

Participants

Twenty adults volunteered to participate in a semi-structured online interview examining the need, experiences, and preferences for treatment-seeking in New Zealand. Recruitment occurred over a one-month period between April and May 2019 through social media advertising, posters in the Auckland community (university, schools, supermarkets) and word of mouth. Recruitment was part of a larger study investigating the feasibility of a self-directed internet delivered intervention. Inclusion criteria were: (a) 18 years of age or older (b) not currently receiving treatment for gaming disorder, and (c) intention to limit or reduce gaming in the next 30 days. No specific exclusion criteria were applied. All participants received a NZ$50 shopping voucher as compensation for their time. The research was approved by the University of Auckalnd Human Participants Ethics Committee (022614).

Table 1 presents a summary of participant information. The majority of participants were male (n = 18, 90%). The average age of participants was 23 years (range: 20 to 35 years). The sample primarily identified as New Zealand European (n = 10, 50%) and as Asian (n = 7, 35%). Using the Gaming Addiction Scale-21 (42) to screen for problematic gaming, 16 participants were classified as problematic gamers which included 5 who endorsed all items. Four participants indicated concerns about their gaming but did not meet the GAS cut-off score. The average hours spent online per week was 29 (SD = 23) with an average frequency of 9 sessions per week (SD = 4.7).

Table 1

Participant characteristics at baseline
ID	Age & Gender	Gender	Employment	GAS criteria	Frequency gaming p/w	Hours gaming p/w	Psychological Distress (K6)
1	20	Female	Student (not employed)	Unmet	17	6	24
2	20	Male	Unemployed, not looking for work	Problem gaming	11	21	12
3	25	Male	Employed part time	Problem gaming	18	70	21
4	24	Male	Student (not employed)	Problem gaming	9	74	22
5	21	Male	Student (not employed)	GD	11	40	15
6	36	Male	Other (not stated)	GD	7	74	7
7	21	Male	Student (not employed)	Problem gaming	5	10	19
8	21	Male	Employed part time	GD	7	47	19
9	20	Male	Unemployed, looking for part time work	Problem gaming	10	34	18
10	23	Male	Employed part time	GD	10	18	18
11	22	Male	Employed full time	Problem gaming	18	28	21
12	21	Male	Student (not employed)	Problem gaming	4	4	17
13	22	Male	Unemployed, not looking for work	Problem gaming	9	17	14
14	21	Female	Employed part time	Unmet	3	5	10
15	22	Male	Employed part time	Unmet	7	14	13
16	26	Male	Student (not employed)	Problem gaming	7	13	21
17	20	Male	Unemployed, looking for part time work	GD	16	58	14
18	21	Male	Employed full time	Problem gaming	11	25	17
19	20	Male	Employed part time	Unmet	2	10	11
20	32	Male	Employed full time	Problem gaming	7	10	23
GAS: Game Addiction Scale; K6: Kessler-6.

Procedure

All participants completed a participant information sheet and informed consent form in Qualtrics survey software. This included completion of demographic (age, gender, employment, ethnicity) and gaming-related measures. The survey included the 21-item Game Addiction Scale (42) which measures seven dimensions of problem gaming (i.e., salience, tolerance, mood modification, relapse, withdrawal, conflict and problems). Participants also completed the Time Line Follow Back (43, 44) to determine the duration and frequency of gaming, and the Kessler 6 measure of non-specific psychological distress (45)

A semi-structured interview schedule was developed based on the components of the patient-centred model for accessing health care by Levesque (2013) and colleagues (46). As indicated in Fig. 1, this access framework highlights the important relationship between the design of health services and the capabilities of those who seek help to access appropriate health care and improved health.

The purpose of the interviews was to identify treatment-seeking needs and preferences specific to gaming disorder. The first part of the interview schedule focused on the capabilities of gamers, or the individual barriers and facilitators to help seeking. This included the questions “I understand that you are interested in doing something about your gaming. What made you make this decision?” and “What might stop you from getting help? What could help address these barriers?” Additional prompts were included in the semi-structured interview schedule to continue the conversation if it became stalled (i.e., the participant needed more context on the nature of the questions). These included: reasons for wanting to change gaming and reasons for seeking help; barriers and facilitators to help seeking and knowledge of services. The second part of the interview schedule focused on service needs. Specifically, participants were asked: “Consider what services that could be developed for people wanting help for gaming. Let’s say you decide you want to seek help in the future. What would be important to you in a service?” Prompts included accessibility (cost, waiting times, travel, location, type of support), quality (treatment types, qualifications, relationships, desired resources) and equity (considerations for culture, age, gender and social disadvantage).

Interviews were conducted by a postgraduate population health student under supervision. The interviewer was trained in motivational interviewing and the administration of a semi-structured interview schedule. Interviews were by appointment and delivered via the participants’ preferred instant messaging platform (Facebook Messenger, Skype, WhatsApp). Instant messaging was used instead of recording video call to provide greater participant anonymity, increase personal disclosure, and provide more coherent verbal expression for qualitative analysis. Transcripts were created by copying and pasting the online conversation into a word document. The average time per interview was 90 minutes (range 40 to 180 minutes) and the average word count was 839 (range 377 to 1988).

Data analysis and application of framework

We applied the conceptual framework of patient-centred access to health care (46). This framework describes the client and provider perspectives on treatment-seeking (see Fig. 1). From the client perspective, the framework outlines five processes that influence access to treatment. These include ability to perceive a need for treatment (including health literacy, health beliefs and knowledge of services); ability to seek, reach and pay for treatment as well as an ability to engage (facilitating minimal attrition and maximum adherence). From the treatment provider perspective, client access to health care is influenced by the degree of approachability (service information, screening tools), acceptability (values and culture of the organisation and support for client autonomy), availability (physical location, mode of delivery, qualifications of provider and flexible opening hours), affordability (time and resource costs) and appropriateness (delivery of evidence-based treatment tailored to client need). A qualitative content analysis (47) was used to group our data into this framework. This method was selected because we wanted to systematically classify participant data into themes guided by an established framework (47).

NVivo software was used to assist the qualitative content analysis. Transcripts were read twice for familiarity with the data and initial codes developed. Two complete transcripts were coded by two researchers (JP and SR) and the codes discussed and any disagreements resolved. Common codes were grouped by the first author into themes that were adjusted to accommodate additional data. As outlined by Hsieh and Shannon (47), this data was then grouped into broad categories which reflected the selected framework. Data that could not be coded into one of the broad categories were re-examined to describe different manifestations of treatment needs and these were merged into the framework and noted accordingly. The findings was structured according to: (1) participant ability with supporting illustrative quotes, and (2) the proposed components of a health care system response specific to GD. The number and percentage of participant statements aligned to each of the five components of the framework is presented. Where quotes were used, these were de-identified to ensure participant anonymity. Quotes were also cleaned to improve readability (i.e., spelling and punctuation) as well as clarity (i.e., grammar corrected).

1. Treatment needs and preferences

Table 2 presents a summary of the five components of the framework from the client perspective. The most frequently discussed participant experiences related to ability to seek help with relatively less discussion on ability to pay for services. The ability to perceive a need for support was focused on health beliefs, health literacy and knowledge of services (n = 97, 17% of statements). Health beliefs involved a cycle of minimising potential risk associated with uncontrolled gaming as well as the perceived seriousness of gaming-related harm. While participants stated that excessive gaming caused a range of harms and there were many different reasons for change, this was coupled with the belief that the problem was not as serious as other addictions despite very large amounts of time being spent on gaming. For some participants, there were co-occurring issues such as alcohol or cannabis or mental health issues that were perceived as more acute and/or deserving of attention. This low perceived seriousness was due to the general perspective that GD was not real, trivial, or a “soft” addiction. Participants indicated they had a reasonable understanding of the characteristics of GD including its nature, prevalence, and resultant harms. However, participants indicated limited knowledge of treatment options and their benefits.

Table 2

Mapping participant experiences against the five constructs
Construct	Participant experiences	Indicative quotes
Ability to perceive a need for support	Health beliefs • Perceived seriousness of harm including wasted time, energy, ability to focus on more meaningful achievement, entrenched lifestyle, ignoring personal hygiene or disrupted sleep. • Decisional balance between benefits of gaming (positive hobby, social connection, skill building, enjoyable, relaxing) versus negatives (health, work, social). Cons of gaming of gaming start to outweigh the benefits. • Understand the reasons for excessive gaming including loneliness, isolation, boredom, lack of excitement, safe, respect (player), sense of achievement, relaxation, distraction, alter mood such as to feel good, fill a void, stress management. • Other mental health (depression or anxiety) or substance use disorders (alcohol, cannabis) are perceived as more acute and associated with immediate harm. Health literacy • Understand the potential seriousness of addiction in terms of the risk for harm. This includes understanding the nature of addiction and how it relates to gaming. • Understand the prevalence, biological and psychological characteristics, harm and risk factors associated with problematic gaming. Knowledge of services • Limited knowledge of where to seek help. Limited knowledge of how treatment works.	• Gaming addictions certainly appear to be seen as “soft” addictions, especially in comparison to chemical addictions, and as such are not taken seriously until it’s too late. (#2) • Gaming has become a way of life for me recently to the point of gaming from when I wake up till when I sleep (#FRFA) • I think there is more just a problem in that the addiction just isn't seen as being as serious despite the hours and money spent on it (MAMC) • I think it works like any other addiction. Whether physical or mental we build a reliant on things. Mine is gaming for dopamine I guess (TRKA) • I don’t know where to seek help for a potential gaming addiction - I don’t know of any available local services for specifically this. (#2) • I think if it was made known that these other programs could also assist with things such as a gaming habit it would help people like me take the issue more seriously because until recently it never seemed a serious enough issue next to the other problems these programs deal with. (#7) • I find it difficult to navigate the healthcare system. I just don’t know where to go (WYBR)
Ability to seek support	Appropriateness of help seeking • A perception that services already have too much need and that gaming is not as important or harmful as other issues. Associated view that services are unable or unwilling to make time for gaming issues. • Locating gaming treatment with perceived more serious issues discourages help-seeking. • Services do not convey a knowledge of gaming culture or specific approaches to treatment. • Encouragement from friends, partners, and family to game less, but limited encouragement, support or motivation to seek help or engage in behaviour change. Stigma and shame • A feeling of shame or embarrassment that help is needed and that the issue is beyond self-management. • Help seeking is not typical amongst gamers and the gaming culture does not support leaving gaming networks. Age and gender appropriate • Perception that treatment may not be age or gender appropriate. This includes the way information is currently provided (needs to be brief and targeted) as well as the type of information conveyed (e.g., relevant to young adults). • Recognise that females have gaming problems too and likely experience stigma. This should not be repeated in treatment settings. Desire for autonomy • Desire to choose personal gaming reduction goals (stay the same, reduce, abstain) and to determine the speed of change. Not wanting to be placed into a specific type of treatment that does not respect individual choice. • Preference to self-manage and take a do it yourself approach. • Preference to be treated as an adult and able to make own decisions.	• People I know have told me that I should “solve my problem” and that “I need to stop gaming” but they technically have never actually encouraged me to say seek a service to assist in the matter. (#5) • I would be reluctant to engage in counselling because of the strain on local services and cost of private services. (ANBR) • Other programs dedicated to helping people overcome personal issues tend to be focused on more serious problems such as mental health, living conditions, or family issues, and therefore these programs don't advertise the fact that they could help with something like this. (JABR) • Yeah of course there’s stigma around it. It’s quite embarrassing, especially today’s university students since my friends play the same amount as I do it isn’t embarrassing within our circle however outside of that people will always question and shame it (JAPR) • I feel like people would perceive me in a strange/snowflake way if I were to get help for 'playing too much games' (EDHE) • Anyone my age or close probably wouldn't want the information to be incredibly detailed and long but more key phrased and engaging (TRKA) • Not being treated like a child when I'm not is a big thing though. If they don't respect me what's the point? The service did not understand addictive behaviour, only physical addiction, and didn't have an understanding of the factors that relate to addiction enough to actually help and I ended up giving up seeking help (DAST)
Ability to reach for support	Transport, travel and wait times • Few service options means travelling distances to receive help. Ideally it is available within own town or region. • Willing to travel around 30 minutes to receive treatment. Must have access with public transport • Willing to wait for an appointment because it is not generally acute or life threatening. Acceptable wait times ranged from a few days to a few months Location • Co-location with addiction services or problem gambling. Could be co-located with a university counselling service • Access to advice and screening from primary care providers. Facilitate opportunistic interventions. • Available weekends and in the evenings. • If online there was a preference that the person had some local context. Modality • Multiple modalities including face-to-face and online. Need for flexible, convenient and discrete access as required. Online or face to face individual or group treatment. • Smart phone access for tracking behaviour and getting help as need and a website for screening and information. Qualifications of provider • The provider should understand gaming culture and technology and be an expert in treatment of gaming • Some preferred lived experience or peer support	• It’s much easier and faster to converse over a digital interface, especially because I live out of town and traveling can be frustrating. A 30 minute drive is standard for me to get into town to receive service). (#2) • It should be accessible. Have multi-platform ideally, with in-person and online communication pathways (ANBR) • Time and communication are the biggest barriers. Much easier and faster to converse over a digital interface, especially because I live out of town and traveling can be frustrating. (#2) • I like online services more than text/phone because I’m more used to typing online, it allows me to think through my words as I’m speaking for clear communication and reading replies is easier than listening to them. Online communication is great when you can’t make it into town easily. (#2) • If it was closer to exam time I'd be a bit more desperate and therefore want help as quickly as possible, but other times through more relaxed parts of the year I'd be willing to wait a week or two. (#7) • Definitely someone who understands game culture. I feel like having to explain concepts and things like that all the time would make me feel like I couldn't relate to the person on this topic. (#7)
Ability to pay for support	Direct fees • Expectation that there would be a cost to attend a treatment. The recommend tiered approach based on income. For students the reasonable amount per session was around $20 and for those who were employed around $100. • Expectation that there could be private and public options and that health insurance would cover the fees. Factors impacting ability to pay • Expected value for money. Willing to pay more for better and more effective treatment. Likely only want to pay if there were serious harm or impact • Difficulty getting time to attend appointments due to inflexible work or study. • Transition away from family home to university or community living put pressure on finances. Money was spent on gaming which decreased the ability to spend money on treatment.	• I am a student and currently not working, so I cannot afford the service if it’s over $20. The cheaper the better. • hmmm given that general counselling sessions normally range to about $100 i could probably accept say 150–200 given expertise, specialisation and success rates (CHRA) • Depending on how the long the sessions would be I would say $20 an hour, because if I can take the advice from the counsellor and use it would be worth and it’s a reasonable price (RAXI) • People most advantaged would be people with high incomes that could be more flexible with taking time off as well as affording the service itself. (MAMC)
Ability to engage with support	Service delivery characteristics • Confidential, private and capacity for anonymity. Culturally appropriate • Pre-treatment screening so as to not waste time • Multiple modalities (face to face, group, online) and blended treatment (different types of service options such as peer and one-to-one). Single session or ongoing treatment. • Peer support forums moderated by a professional • Able to be tailored to need (varying intensity from screening and drop in to residential care) • Resources include online and written materials. Treatment needs • Skills development for relationships and social situations, emotional intelligence, time and stress management and sleep hygiene. • Treat underlying comorbidities such as impulsivity, substance use (alcohol, cannabis), depression and anxiety. • Enhance self-efficacy and belief in capacity to change. Support increased accountability, commitment, goal setting, urge management and self-monitoring. Relationship with provider • Professional but not formal with demonstrated unconditional positive regard. Facilitate empathic and approachable partnerships. Adequacy of service • Participants should be satisfied with the quality of service and experience the treatment as effective.	• Some pre-involvement lead-up (such as questions like the ones we talked about earlier) so that the professional I was seeing could jump straight into tackling the problem from the first time I met them. (CHRA) • For me I feel like confidentiality is the most important which getting help with mental disorder. I want to keep it as secret as possible and sometime you don't even want the professional to know you cause sometime you feel insecure about yourself. (Sika) • Definitely confidentiality, nobody likes the idea of others thinking they have a problem. But by this I don't just mean private counseling but actually setting up appointments and things like that. For instance I'd much rather email or text someone to set up a meeting or begin a programs than have to call or come in to somewhere to do this (JABR) • I think building the skills and confidence myself, with the help of your tools, will help me go further with gaming reduction. (#10) • Accountability and some form of consultation would be good. Booklets or handouts containing tips would be good, maybe something regarding logging time online, or time spent doing other stuff, and some form of online based community with others. (#2) • I've been trying to tackle other elements around addiction such as alcohol and marijuana but the truth is I have an addictive personality that extends to many areas of my life (DAST)

The ability to seek support was focused predominantly on beliefs that treatment-seeking for GD was inappropriate and that services would not be willing or able to respond (n = 146, 26%). Participants perceived that the individual should be able to solve the problem themselves and that the issue was not as serious as other conditions. Informing this view was social group responsivity that either minimised the problem or suggested the solution was simple (‘just stop’). Participants reported feeling embarrassed at having to seek help and to have to tell their friends that they needed to cut back on gaming for a while. There was also a perception that health resources would be made available according to the burden of disease where gaming was less of a priority concern (due to it not being associated with serious harm). Participants stated services were already over-burdened and over-subscribed and there was a view not to contribute towards this situation. Some participants who had previous experience with addiction or health care services reported concerns on the appropriateness of service models that were either adolescent-centric (thereby being more family-centred in their approach) or focused on a disease model of addiction (abstinence over harm minimisation).

The ability to reach services referred to the ease of access and location where they are most needed (n = 150, 26%). The absence of a service system for GD was highlighted in this theme whereby participants who had sought treatment from addiction or private providers either had to travel long distances to seek help or instead sought help online from international sources. They expressed that help should be in a convenient physical location such as co-located with university or other health care services, including those that address comorbidities such as alcohol and cannabis use. There was a preference for a range of different modalities for treatment spanning online and face-to-face as well as individual and group options. Online treatment was especially attractive for its convenience, less time to access or engage with, allowed participants to type instead or talk (which was preferable initially for introverted help-seekers). There was also a view that some service options should be local, immediate, and available 24/7, which would help to address urgent issues before they became desperate, such as the need to decrease gaming time during exams. Some participants referred to the need for treatment providers to understand the wider context of gaming culture.

The ability to pay related to the direct costs of treatment as well as factors impacting on the ability to pay (n = 55, 10%). There was a preference for direct costs to be assessed according to employment status and income. For those with low income there was an expectation of paying around $20p/h for the service and upwards of $100p/h for those that were employed. Factors impacting on ability to pay included recent transitions from home to independent living arrangements. Other factors included over-spending on gaming such as the frequent purchase of loot boxes, new games and other products such as cards and tokens.

The ability to engage with a service related to the quality of fit between client need and the content and delivery modality of treatment (n = 120, 21%). There was a view that services should be tailored according to the amount of treatment needed and the presenting problem. The range of treatment needs was extensive and included gaming focused needs such as enhancing self-efficacy, competency and skill development in limiting or reducing gaming. Treatment need also included co-morbidities such as addiction (cannabis and alcohol) as well as depression and anxiety. Other areas requiring assistance included sleep and stress management, social skills, and time management. The perceived quality of the relationship with the provider was perceived as important and this focused on the development of rapport through unconditional positive regard with a general empathic and non-judgemental approach.

2. Service system components

Figure 2 depicts the five components of an accessible health care system response. The approachability of services related to the importance of information on GD, screening tools and the provision of service information. There was a need for evidence-based information on the nature and risk of GD. This information would be ideally supported by valid and reliable screening tools that can be self-administered or integrated into treatment phases. Participants expressed confusion and uncertainty as to whether they really had a problem, indicating a need for clear feedback on problem severity and prognosis. While there are currently few community-based treatment options, participants indicated a need for clear service information that could guide decisions about service options based on level of severity as well as modality of delivery.

Acceptability of services involved themes of responsivity and specificity, and values of partnership and mutual respect. Participants expressed a need for high quality specialist gaming services that have in-depth knowledge of gaming and its prevention and treatment. Responsive services would value treatment-seeking for gaming and promote this as a normal and reasonable response to these issues. Gaming services should be established for adolescent and adult gamers and avoid a ‘one-size-fits-most/all’ approach. Clinical staff should be experienced in working with young people and have relevant gaming knowledge.

The availability of services related to flexible access, location and the qualifications of the provider. Participants expressed a need for a multi-modal system that supported online, smartphone, and face-to-face treatment accessible in individual and group-based formats. Participants expressed that services should be available after-hours including evenings and weekends as well as located in or near health care centres or universities. Treatment should be able to be accessed via public transport and ideally located in each major centre. The workforce should have an in-depth knowledge of gaming and addictions including gaming culture and its comorbidities. There is also a need to consider the role and involvement of lived experience and how those that have recovered can support others.

The affordability of services was proposed to be income-based and should represent value for money. Service costs were proposed as ranging from $20 upwards depending on private or public funding. Services should meet the needs of a potentially heterogeneous group of gamers and their family. To do this, services should implement valid and reliable screening tools that can inform treatment plans and the selection of modality and intensity of treatment. This means supporting a transition between service types and intensity whereby individuals are able to alter care plans and arrangements as required. Co-locating treatment within mental health services would ensure that co-morbidities were addressed however the treatment primarily should be focused on gaming specific issues. Identified treatment strategies included such as behaviour change therapies, urge management and psychosocial rehabilitation via replacement activities. Services should be routinely assessed for quality and compliance with standards with these evaluations available to all clients.

The aim of this study was to understand the health care needs of individuals with GD. We applied a patient-centred framework for conceptualising the components of a system for the early intervention and treatment of GD. Gamers’ perceptions and experiences reflected the components of the framework in terms of facilitators and barriers to the ability to perceive, seek, reach, pay and engage with treatment. This approach identified critical issues in GD healthcare that also arise across the spectrum of addictive disorders (e.g., barriers to help seeking shame, stigma and health beliefs around the seriousness and susceptibility of having a problem) as well as use of health care more broadly (being able to navigate, locate and reach service options). The second aim was to identify the components of a healthcare system informed by the framework and accounting for participant expectations and need. Critical discussion of this system included the need for greater access to treatment in conjunction with services to address issues that often intersect with GD including mood disorders, substance use, relationship difficulties, and lack of social skills and adaptive functioning.

Gaps in health care identified in this study included the adequate screening and assessment, access to evidence-based treatment and routine outcome monitoring. Screening and assessment has been identified as a major problem in GD research that has a direct impact on service ability to provide valid and reliable feedback to gamers (13, 48). At the same time, some participants expressed that there was uncertainty about the legitimacy of GD as a condition, which is likely to compound limitations of current assessment approaches when these measures may not be taken seriously on face value. Inconsistencies in definitions and screening are a barrier to offering services that rely on brief information-gathering to identify client needs, and to developing consumer trust in the service offered.

The evidence base for treatment of GD is still developing, with promising work being conducted in the area of structured cognitive-behavioural therapy programs (Kim et al., 2012; Wölfling et al., 2019). However, there are currently few RCTs for GD suggesting that the development of an evidence-based treatment model is some way in the future (26, 49). The lag between clinical practice and the development of evidence is not unusual in addictions research. More research with a broader focus on therapies matched to meet the needs of gamers is required to develop a sound evidence base. This includes a wider range of treatment content beyond CBT and low and high intensity service options. A recent study indicated that gamers may engage with a broad range of self-managed cognitive and behavioural strategies to limit their gaming (50) and adhere to personal change goals (51). There are currently few options for self-directed treatment or additional support for what people attempted to recover without intervention. To increase the reach and accessibility of treatment, there is a need for resources for self-management and brief interventions made available across online and face-to-face settings.

A limitation of the field is the absence of quality information on people with severe GD, including case reports and clinical data. Routine outcome monitoring has the potential to address this problem as well as provide insight into the scope of the problem, patterns of use, and responsivity to different treatments (52). Ideally, routine outcome monitoring is informed through international consensus on a minimum dataset with a set of recommendations for clinical outcome and process measures. In particular, there is a need to better understand how problematic gaming may intersect with issues of comorbidity, such as mood disorders, and how such considerations may influence case formulation and treatment planning. Less is known about the efficacy of structured treatments for GD, including psychological and pharmacological treatment, in the context of other mental disorders, because such issues are often excluded from trials and other intervention studies.

This is the first study to consider the optimal components of a service system for GD from a holistic perspective but this work had several limitations. First, the study sampled adults which limits the generalisability of these results to adolescents. To date, most of the clinical research on GD has focused on adolescent or school age samples (15). However, the sample was consistent with the typical profile of predominantly young males in their early 20 s engaged in tertiary study (15, 16, 24). The sample was recruited from New Zealand which is a relatively affluent country accustomed to low-cost universal health care. Whereas our participants were concerned about burdens on services, this concern may be greater in regions with weaker health systems. Another limitation was the lack of coverage of pharmacological approaches which may reflect cultural preferences in New Zealand. Finally, participants reported an intention to change their gaming behaviour. This would suggest that there was some self-awareness and openness to change, meaning that this group may have been more inclined to discuss options for gaming reduction and/or self-help, rather than consider the needs of individuals at different stages of problem recognition or awareness.

A comprehensive health care approach for gaming disorder is currently in its infancy and there are numerous service access and delivery issues still to be resolved. A challenge that has received relatively less attention has been the issue of treating GD and its comorbid disorders. This study’s findings are consistent with lessons from the gambling field that suggest that treating the presenting problem of GD is as important as addressing comorbid issues. The pathways model of problem gambling, for example, explains that access to gambling opportunities as well as changes to the reward system as a result of repeated gambling is equally important as individual psychopathology (53).

Currently, health care systems lack a stepped care approach whereby a gamer can transition between levels of treatment as needed (13). This system may be especially beneficial with younger populations (54), where there is often greater family support and potential for change, and opportunistic interactions with other allied services. This study raises the possibility of blended treatment approaches, such as gaming-specific CBT treatment delivered online with adjunctive professional support, or access to a psychologist who provides CBT in conjunction with a psychiatrist who provides pharmacological treatments for comorbid depression, anxiety or substance use. Finally, this study highlights the importance of involving individuals with GD in developing solutions that are fit for purpose and address the spectrum of intervention needs. With growing scientific interest in a range of excessive behaviors and how they may become addictive, greater efforts are needed to improve our knowledge of the needs of those with GD and develop best practice guidelines for interventions for this small but important population.

Gaming Disorder

DSM-5

Diagnositic and Statistical Manual Version 5

ICD-11

International Classification of Diseases

CBT

Cognitive and Behavioural Therapy

GAS

Gaming Addiction Scale

Ethics approval and consent to participate: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The research was approved by the University of Auckland Human Participants Ethics Committee (022614).

Consent for publication: Not applicable

Competing interests: The authors have no competing interests to declare in relation to this article.

Availability of data and materials: The datasets and materials used and analysed during the current study are available from the corresponding author on reasonable request.

Funding: This research was undertaken as part of a Health Research Council early career grant awarded to the senior author (17/548). Additional funding for participant recruitment and remuneration was provided by Internet NZ. The funders had no role in the design or conduct of the study or decision to publish the findings.

Authors' contributions: Author SR designed the study and sought the funding. Author JP conducted literature searches and prepared the first draft of the manuscript. Author JP and SR conducted the analysis. All authors contributed to and have approved the final manuscript.

Acknowledgements: We would like to thank the Change Strategies Project team for their assistance with the recruitment of participants.

Ferguson CJ, Coulson M, Barnett J. A meta-analysis of pathological gaming prevalence and comorbidity with mental health, academic and social problems. J Psychiatr Res. 2011;45(12):1573–8.
Przybylski AK, Weinstein N, Murayama K. Internet gaming disorder: Investigating the clinical relevance of a new phenomenon. Am J Psychiatry. 2017;174(3):230–6.
Mihara S, Higuchi S. Cross-sectional and longitudinal epidemiological studies of I nternet gaming disorder: A systematic review of the literature. J Neuropsychiatry Clin Neurosci. 2017;71(7):425–44.
Saunders JB, Hao W, Long J, King DL, Mann K, Fauth-Bühler M, et al. Gaming disorder: Its delineation as an important condition for diagnosis, management, and prevention. Journal of behavioral addictions. 2017;6(3):271–9.
Petry NM, Rehbein F, Gentile DA, Lemmens JS, Rumpf HJ, Mößle T, et al. An international consensus for assessing internet gaming disorder using the new DSM-5 approach. Addiction. 2014;109(9):1399–406.
Long J, Liu T, Liu Y, Hao W, Maurage P, Billieux J. Prevalence and correlates of problematic online gaming: a systematic review of the evidence published in Chinese. Current Addiction Reports. 2018;5(3):359–71.
Andreassen CS, Billieux J, Griffiths MD, Kuss DJ, Demetrovics Z, Mazzoni E, et al. The relationship between addictive use of social media and video games and symptoms of psychiatric disorders: A large-scale cross-sectional study. Psychol Addict Behav. 2016;30(2):252.
Wang HR, Cho H, Kim D-J. Prevalence and correlates of comorbid depression in a nonclinical online sample with DSM-5 internet gaming disorder. J Affect Disord. 2018;226:1–5.
World Health Organisation (WHO). 6C51 Gaming Disorder. Retrieved online: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1448597234.2019.
King DL, Delfabbro PH. Prevention and policy related to Internet gaming disorder. Current Addiction Reports. 2017;4(3):284–92.
Vondráčková P, Gabrhelik R. Prevention of Internet addiction: A systematic review. Journal of behavioral addictions. 2016;5(4):568–79.
Xiang Y-T, Jin Y, Zhang L, Li L, Ungvari GS, Ng CH, et al. An Overview of the Expert Consensus on the Prevention and Treatment of Gaming Disorder in China (2019 Edition). Neuroscience Bulletin. 2020:1–4.
Rumpf H-J, Bischof A, Bischof G, Besser B, Brand D, Rehbein F. Early Intervention in Gaming Disorder: What Can We Learn from Findings in the Substance Abuse Field? Current Addiction Reports. 2018;5(4):511–6.
King DL, Delfabbro PH, Wu AM, Doh YY, Kuss DJ, Pallesen S, et al. Treatment of Internet gaming disorder: An international systematic review and CONSORT evaluation. Clin Psychol Rev. 2017;54:123–33.
Zajac K, Ginley MK, Chang R. Treatments of internet gaming disorder: a systematic review of the evidence. Expert Rev Neurother. 2020;20(1):85–93.
Zajac K, Ginley MK, Chang R, Petry NM. Treatments for Internet gaming disorder and Internet addiction: A systematic review. Psychol Addict Behav. 2017;31(8):979–94.
Kuss DJ, Lopez-Fernandez O. Internet addiction and problematic Internet use: A systematic review of clinical research. World journal of psychiatry. 2016;6(1):143.
Shek DT, Yu L. Longitudinal impact of the project PATHS on adolescent risk behavior: what happened after five years? The Scientific World Journal. 2012;2012.
Yeun YR, Han SJ. Effects of psychosocial interventions for school-aged children's internet addiction, self-control and self-esteem: meta-analysis. Healthcare Informatics Research. 2016;22(3):217–30.
Wang Q, Ren H, Long J, Liu Y, Liu T. Research progress and debates on gaming disorder. General psychiatry. 2019;32(3).
King DL, Delfabbro PH, Doh YY, Wu AM, Kuss DJ, Pallesen S, et al. Policy and prevention approaches for disordered and hazardous gaming and Internet use: An international perspective. Prev Sci. 2018;19(2):233–49.
Davies B, Blake E. Evaluating existing strategies to limit video game playing time. IEEE Comput Graph Appl. 2016;36(2):47–57.
Király O, Griffiths MD, King DL, Lee H-K, Lee S-Y, Banyai F, et al. Policy responses to problematic video game use: A systematic review of current measures and future possibilities. Journal of Behavioral Addictions. 2018;7(3):503–17.
Stevens MW, King DL, Dorstyn D, Delfabbro PH. Cognitive–behavioral therapy for Internet gaming disorder: A systematic review and meta-analysis. Clin Psychol Psychother. 2019;26(2):191–203.
Costa S, Kuss D. Clinical Practices for Gaming Disorders: A Systematic Review. Frontiers in psychology. 2019;10:578.
Wölfling K, Müller KW, Dreier M, Ruckes C, Deuster O, Batra A, et al. Efficacy of short-term treatment of internet and computer game addiction: a randomized clinical trial. JAMA psychiatry. 2019;76(10):1018–25.
King DL, Billieux J, Carragher N, Delfabbro PH. Face validity evaluation of screening tools for gaming disorder: Scope, language, and overpathologizing issues. Journal of behavioral addictions. 2020;9(1):1–13.
King DL, Chamberlain SR, Carragher N, Billieux J, Stein D, Mueller K, et al. Screening and assessment tools for gaming disorder: A comprehensive systematic review. Clin Psychol Rev. 2020;77:101831.
Feng W, Ramo D, Chan S, Bourgeois J. Internet gaming disorder: trends in prevalence 1998–2016. Addictive behaviors. 2017;75:17.
Thege BK, Woodin EM, Hodgins DC, Williams RJ. Natural course of behavioral addictions: A 5-year longitudinal study. BMC Psychiatry. 2015;15(1):4.
Grant BF, Goldstein RB, Saha TD, Chou SP, Jung J, Zhang H, et al. Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA psychiatry. 2015;72(8):757–66.
Yeh Y-C, Wang P-W, Huang M-F, Lin P-C, Chen C-S, Ko C-H. The procrastination of Internet gaming disorder in young adults: The clinical severity. Psychiatry research. 2017;254:258–62.
Müller KW, Beutel M, Egloff B, Wölfling K. Investigating risk factors for Internet gaming disorder: a comparison of patients with addictive gaming, pathological gamblers and healthy controls regarding the big five personality traits. Eur Addict Res. 2014;20(3):129–36.
Lee YS, Son JH, Park JH, Kim SM, Kee BS, Han DH. The comparison of temperament and character between patients with internet gaming disorder and those with alcohol dependence. Journal of Mental Health. 2017;26(3):242–7.
Burleigh TL, Griffiths MD, Sumich A, Stavropoulos V, Kuss DJ. A systematic review of the co-occurrence of Gaming Disorder and other potentially addictive behaviors. Current Addiction Reports. 2019;6(4):383–401.
King DL, Adair C, Saunders JB, Delfabbro PH. Clinical predictors of gaming abstinence in help-seeking adult problematic gamers. Psychiatry research. 2018;261:581–8.
Lau C, Stewart SL, Sarmiento C, Saklofske DH, Tremblay PF. Who is at risk for problematic video gaming? Risk factors in problematic video gaming in clinically referred Canadian children and adolescents. Multimodal Technologies Interaction. 2018;2(2):19.
Humphreys G. Sharpening the focus on gaming disorder. World Health Organization Bulletin of the World Health Organization. 2019;97(6):382–3.
Drummond A, Sauer JD, Ferguson CJ, Hall LC. The relationship between problem gambling, excessive gaming, psychological distress and spending on loot boxes in Aotearoa New Zealand, Australia, and the United States—A cross-national survey. Plos one. 2020;15(3):e0230378.
Keough B. Video game addicts seek help from gambling foundation as most health board don’t provide treatment. 2018 [Available from: https://www.stuff.co.nz/national/health/109179959/video-game-addicts-seek-help-from-gambling-foundation-as-most-health-boards-dont-provide-treatment.
Dullur P, Hay P. Problem Internet use and Internet gaming disorder: A survey of health literacy among psychiatrists from Australia and New Zealand. Australasian Psychiatry. 2017;25(2):140–5.
Lemmens JS, Valkenburg PM, Peter J. Development and validation of a game addiction scale for adolescents. Media psychology. 2009;12(1):77–95.
Weinstock J, Whelan JP, Meyers AW. Behavioral assessment of gambling: an application of the timeline followback method. Psychol Assess. 2004;16(1):72–80.
Sobell LC, Sobell MB. Timeline Follow-Back. In: Litten R, Allen J, editors. Measuring Alcohol Consumption: Humana Press; 1992. pp. 41–72.
Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand S-L, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological medicine. 2002;32(6):959–76.
Levesque J-F, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12(1):18.
Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.
King DL, Haagsma MC, Delfabbro PH, Gradisar M, Griffiths MD. Toward a consensus definition of pathological video-gaming: A systematic review of psychometric assessment tools. Clin Psychol Rev. 2013;33(3):331–42.
Kim SM, Han DH, Lee YS, Renshaw PF. Combined cognitive behavioral therapy and bupropion for the treatment of problematic on-line game play in adolescents with major depressive disorder. Computers in human behavior. 2012;28(5):1954–9.
Rodda SN, Booth N, Vacaru M, Knaebe B, Hodgins DC. Behaviour change strategies for internet, pornography and gaming addiction: A taxonomy and content analysis of professional and consumer websites. Comput Hum Behav. 2018;84:467–76.
King DL, Kaptsis D, Delfabbro PH, Gradisar M. Craving for Internet games? Withdrawal symptoms from an 84-h abstinence from massively multiplayer online gaming. Comput Hum Behav. 2016;62:488–94.
King DL, Delfabbro PH. Internet gaming disorder treatment: a review of definitions of diagnosis and treatment outcome. Journal of clinical psychology. 2014;70(10):942–55.
Blaszczynski A, Nower L. A pathways model of problem and pathological gambling. Addiction. 2002;97(5):487–99.
Tanner-Smith EE, Lipsey MW. Brief alcohol interventions for adolescents and young adults: A systematic review and meta-analysis. Journal of substance abuse treatment. 2015;51:1–18.

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Access to health care for gaming disorder: A patient-centred approach to address the continuum of need

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Background

Methods

Participants

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Data analysis and application of framework

Results

1. Treatment needs and preferences

2. Service system components

Discussion

Conclusions

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