Background

Psychotic disorders (PD), are major mental disorders that affect 3% of the population [1]. They occur during a critical period of life, specifically in late adolescence and early adulthood [2]. Their consequences include an increased rate of suicide and acts of violence[3-5], low employment rates [6], reduced life expectancy by 15 years [7, 8], as well as homelessness and experiences of stigmatization [9, 10]. In Canada, the economic burden of these conditions was estimated to be $7 billion in 2004 while the global estimates indicate a range between 0.02% and 1.65% of the gross domestic product in 2016 [11, 12]. While antipsychotic medications are effective in alleviating certain symptoms, such as delusions and hallucinations, they are not sufficient for achieving full recovery [13]. In fact, PD are frequently associated with psychiatric comorbidities, including substance use disorders, personality disorders, and attention-deficit/hyperactivity disorder (ADHD), which can further exacerbate the consequences associated with PD [14]. Therefore, treating comorbidities is crucial for achieving recovery, particularly in patients with first episode psychosis (FEP), where early intervention has demonstrated the greatest impact on patients’ long-term outcomes [15]. Amongst other comorbidities, excessive video gaming has become a cause for concerns for clinicians due to its impact on patients’ lives, in particular among young adults, but a literature review conducted by our team [16] has highlighted a significant paucity of data on video gaming comorbid with FEP, despite recent interest and developments on this topic.
In recent decades, there has been a growing interest about the consequences of excessive video gaming on mental health. This attention has been prompted by the inclusion of Internet Gaming Disorder (IGD) as a “Condition for Further Study” in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DMS-5), in 2013 [17]. The recognition of this disorder as an official diagnosis in the 11th edition of the International Classification of Diseases (ICD-11) under the term Gaming Disorder (GD) has reinforced the importance and urgency to better understand the clinical impacts of this condition [18]. GD is defined as a persistent and recurrent pattern of gaming behavior, involving digital or video gaming, characterized by an impaired control over gaming as well as an increased priority placed on gaming over other activities to the extent that it takes precedence over other interests and daily activities. Individuals with GD continue or escalate their gaming behavior despite experiencing negative consequences such as reduced occupational or academic functioning [18].
The reported prevalence of GD in the general population varies from 0.2% to 20% across studies [18]. This variability can be explained by several factors, including the age of the participants studied, the country where the study was conducted, or the definition of GD used in the study. There are three main categories of risk factors associated with GD: 1) those related to gaming and its practice (e.g. duration and frequency of gaming, online and multiplayer games), 2) individual factors (e.g. isolation, low self-esteem, impulsivity, difficulties in emotion regulation, feelings of stigmatization, sex, gender, young age, low education level), and 3) environmental factors (e.g. family dysfunction, harassment and childhood neglect) [19, 20]. GD has also been associated with other symptoms, mental disorders, and impairments in functioning, such as depression, social anxiety, ADHD, impaired academic performance, and deterioration in interpersonal relationships, but a causal relationship has not been clearly established [21-30]. In terms of treatment, promising results have been achieved with various approaches, including cognitive-behavioral therapy. However, there is currently insufficient data to draw solid conclusions regarding the effectiveness of existing approaches [31].
Regarding the comorbidity between GD and PD, the available literature is limited to a few case reports describing the occurrence of brief psychotic episodes following excessive video game use or abrupt cessation [16]. Research on this comorbidity is therefore scarce and lacks prospective data, which hinders the improvement of prevention, detection, and treatment strategies. However, individuals with PD present several common risk factors with GD: the male gender, social isolation, low self-esteem, difficulties in emotion regulation, impulsivity or behavioral inhibition, and onset of disorders during adolescence or early adulthood [19, 20, 32-34]. Additionally, little is known about the patterns of video game use among individuals with PD (e.g. gaming time, game content, interface [console, mobile, computer, online or offline]). For the affected youth, the consequences of GD added to those of PD may further hinder recovery. Studying GD among young adults with PD is then particularly relevant, as the risk factors common to GD and PD are even more prevalent in this population compared to the overall population with PD alone (e.g., substance use disorders, male predominance, younger age) [35, 36]. Furthermore, it is well established that clinical interventions in FEP significantly influence clinical outcomes of affected individuals [15].
In line with prevalent societal beliefs, video games have often been associated with a negative perception that links them to aggressive and criminal behavior [37]. However, an increasing body of evidence suggests that video games can have beneficial effects and even serve as a therapeutic tool. The term ’serious games’ refers to software that incorporates playful elements for educational, training, and therapeutic purposes. Such games have been employed in the treatment of individuals with PD, demonstrating a significant reduction in psychotic symptoms [38, 39]. Additionally, they have shown improvements in cognitive functions, social cognitions, and occupational status [40-43]. Although the understanding of the impact of commercial video games on PD is limited, a recent literature review highlights several advantages of these types of games, with seven studies reporting positive outcomes [44]. Among them, four studies revealed enhanced processing speed, memory, and executive functions through the use of commercial video games, while three studies demonstrated improvements in aerobic fitness and walking speed in patients who engaged in active video games utilizing the Kinect for Xbox game system [45-48]. These potential benefits in individuals with PD underscore the unique nature of gaming addiction, where the objective is to promote healthy gaming habits rather than complete avoidance, as seen in other forms of addiction. In order to help patients to reach these healthy habits, it is imperative to enhance our comprehension of the influence of gaming on the clinical trajectory of individuals diagnosed with PD.
Using an innovative screening and assessment procedure for GD tailored to young adults with FEP, the aim of this study is to better understand the impact of gaming in people with FEP by: 1) determining the prevalence of GD among FEP patients; 2) determining the consequences of GD on the clinical trajectory of FEP patients; and 3) assessing individual factors that differentiate patients who developed GD among the overall study population