1. Introduction
Depression and anxiety are significant health burdens, and the rate of death is higher among depressed and anxious patients [
1]. Economically, the severity of depression is linked to increased unemployment and reduced work performance [
2]. At the global level, mental disorders such as anxiety and depression are common in undergraduate students, particularly first-year students [
3,
4,
5]. We previously reported that undergraduate health science students exhibited a higher risk of developing anxiety and depression in the first wave of the pandemic [
5]. We have also reported that the prevalence of depression is about 50% in cross-sectional settings during the second wave of COVID-19 [
6]. Comparable findings were reported in a study of first-year Irish undergraduate students. Further, their results showed that about 30% of participants with a risk of depression experience suicidal ideation [
7], indicating the immense burden of depression, especially in the young population.
The first year at university is considered a massive transition from late adolescence to adulthood, as students are expected to take on greater responsibilities [
8,
9]. According to the American Psychological Association (APA), around 35% of first-year university students are diagnosed with mental health disorders worldwide [
9]. In comparison to other study years, first- and last-year students reported a higher prevalence of depression and anxiety [
10]. These mental disorders have many negative consequences on students’ lives. Studies showed that depression and anxiety are associated with quality of life impairments [
11,
12,
13], lower academic performance and GPA among undergraduate students [
14,
15], sleeping disorders [
16], burnout, suicidal ideation [
17], and higher dropout rates [
18,
19]. In addition, undergraduate students have a high prevalence rate of insomnia, which also affects their physical and mental health, academic achievement, and quality of life [
16,
20,
21].
Over the last decade, many people of different ages consumed their leisure time in online gaming and are motivated to play these games for many reasons, including their feelings of challenge, socialization, and relaxation [
22]. Gaming disorder (GD) is characterized by a predominant occupation with gaming behaviors over at least one year. GD was included in the 11th edition of the International Classification of Diseases (ICD-11) as a clinical condition, mainly when individuals’ social, educational, or occupational life aspects are impaired [
23]. The global prevalence of GD was approximately 3% in meta-analysis studies [
24,
25] and reached up to 17% in a recent study conducted among Chinese adolescent game players [
26]. In Saudi Arabia, a couple of studies have been conducted to examine the prevalence rate of GD, which was estimated at 5% among Saudi adolescents [
27] and 8.8% among medical students at King Saud University [
28].
Younger age was positively associated with a higher frequency of GD [
29,
30]. Online gaming and GD were also reported among college students [
31,
32,
33]. It was estimated that almost half of college students play online or video games and about 4% of them have GD [
33]. The risk of GD may be higher as they utilize the internet and digital devices during their study at university. In addition to that, due to the COVID-19 pandemic, many colleges have shifted their learning environment to a virtual learning environment in which the student utilization of the internet and technology may influence their online gaming consumption [
34]. GD has many negative implications, particularly on the player’s mental health. Previous studies have shown that GD is associated with many mental health-related issues, such as stress [
27,
35], depression [
30,
35,
36], anxiety [
30,
35], loneliness [
37], suicidal ideation [
38], and lower life satisfaction [
35] as well as lower academic achievement [
36]. Furthermore, GD may affect an individual’s physical health, as playing for a long time was associated with musculoskeletal symptoms [
39] and headache [
40] and led to the emergence of digital eye strain, a syndrome associated with the prolonged use of digital screens [
41].
A scoping review showed that various factors of GD (including social isolation) interplay across the lifespan, leading to the deterioration of quality of life [
42]. We aimed to examine the mechanisms of associations between anxiety, sleep quality, and online gaming to explain depression during the COVID-19 pandemic in the present study. Numerous studies indicate a high prevalence of depression, anxiety, and insomnia during the pandemic, in particular, among university students [
43,
44,
45]. Moreover, insomnia, anxiety, and depression were intercorrelated among university students during COVID-19 [
46]. Therefore, this is essential to understand the specific pattern of these associations in relation to online gaming, which also increased during the global time of crisis [
47,
48,
49]. These associations were analyzed using mediation analysis. Mediation analyses were conducted previously in the same context as our research. A report analyzed the role of bedtime procrastination in mediating smartphone addiction, depression, and anxiety in Chinese participants, mostly undergraduates. Their findings indicated that participants with smartphone addiction are prone to procrastinating their bedtime, depression, and anxiety [
50]. In another study, it was reported that anxiety and depression partially mediate insomnia and emotional stability [
51]. Insomnia is linked to depression biologically [
52,
53] and psychologically [
54,
55]. In clinical settings composed of healthy adults, a three-night consecutive awakening was linked to a significant reduction in mood, suggesting a potential mechanism of the depression–insomnia relationship since a good mood promotes resilience to stress and strengthens coping mechanisms [
56]. Additionally, anxiety and depression are highly comorbid [
57]. About 45% of depressed individuals experience anxiety [
58]. Therefore, it was reasonable to consider insomnia and anxiety as mediators for depression.
According to the biopsychosocial model of health, well-being is determined by various factors derived from the biological, psychological, and social areas of human life [
59,
60]. In the present study, we will consider the effect of the interplay between biological (gender), behavioral (game addiction, sleep quality), and psychological factors (anxiety) on depression as one of the indicators of subjective well-being.
Since online gaming, internet and smartphone addiction are related to each other [
61,
62,
63], sharing criteria of behavioral addiction, we can assume that similar mediation to previous studies will be found in our research. This study aims to examine the mediating role of sleep quality and anxiety on the relationship between gaming addiction and depression among first-year students from King Saud University. Since female sex is a significant risk factor for anxiety, depression, and insomnia [
64,
65,
66], while gaming disorder is more prevalent among men [
67,
68,
69], gender differences will be also considered in this study.
4. Discussion
The present study examined the mechanisms of associations between depression, anxiety, sleep quality, and online gaming. We found that female students scored significantly higher than males in anxiety and depression. Furthermore, this study found that depression is positively and strongly correlated to anxiety. Both anxiety and depression are positively and moderately associated with sleep quality, and gaming is positively but weakly related to depression, anxiety, and sleep quality. Furthermore, the health sciences and nursing tracks showed significantly lower sleep quality than undergraduates from other tracks. Our multiple regression analysis indicated that about a 64% variance of depression is explained by many predictors, including anxiety, sleep quality, gaming, painkiller use, and gender. In addition, the mediation models showed that the association between gaming and depression is mediated indirectly by sleep quality, and sleep quality may be mediated directly by anxiety.
Our descriptive analysis revealed that the study participants exhibited a high risk of developing mental disorders. Indicators of anxiety, depression, and GD were present in around one-third of the participants. Risks of insomnia were reported to be in the majority of the sample. Insomnia is defined as a persistent condition of reduced sleep quantity or quality due to difficulties initiating or maintaining sleep [
85]. At the same time, anxiety is an affective condition characterized by nervousness, worry, and tension. It is usually accompanied by physical symptoms, including but not limited to dizziness, sweating, and elevated blood pressure [
86]. Multiple notions could interpret the mean scores from our descriptive statistics findings. First, this could be attributed to the fact that the first year of university is a determinate transition state [
9] as well as stressors related to class re-entry following the outbreak of the COVID-19 pandemic. Additionally, some changes might have been adapted since the start of the pandemic [
87]. For instance, people have been spending more time on screens [
88], and these changes might have adapted even after the COVID-19 pandemic. Other factors that might contribute to these findings are recent changes in the young population’s lifestyle. Notably, multiple observations were reported on excessive gamer lifestyles, including increased nighttime activity, altered sleep–wake cycles, and altered eating habits [
89].
Our data suggest that first-year female students have a higher risk of developing depression. Gender difference in depression is considered one of the most robust phenomena in psychiatry and psychology, with more depressed women than men [
90]. In line with this, a systematic review and meta-analysis conducted among healthcare workers during the COVID-19 pandemic found that rates of anxiety and depression were higher for female healthcare workers and nursing staff compared to their male colleagues [
91]. Another report found that more than half of healthcare undergraduate female students and a third of male students have at least moderately high test anxiety [
92]. Overall, sexual dimorphism is well-acknowledged in mood disorders [
93].
Our study track analyses indicated that first-year students in health sciences and nursing tracks showed a trend toward lowered sleep quality and a significant elevation in developing anxiety and depression. First-year university students face numerous stressors, including academic requirements, social adjustments, and time management. Medical students, in particular, may face further challenges, for example, the large study workload, commitment to assessments, and the pressures along with the liability of a clinical environment [
94]. Being a member of the healthcare profession increases the risk of mood disorders. A systematic review and meta-analysis done among healthcare workers during the COVID-19 pandemic showed that at least one in five healthcare professionals report symptoms of depression and anxiety [
95]. In addition, a recent meta-analysis revealed that depression affects approximately one-third of medical students worldwide [
96]. Overall, evidence has indicated that the risk of developing anxiety in medical students is significant compared with nonmedical students [
97].
Our regression analyses indicate that anxiety strongly correlates with depression. Our findings verify existing knowledge. For instance, in a sample of Australian university students, the anxiety–depression comorbidity was more than a third, and in fact, about four times that for anxiety or depression alone. This comorbidity highlights the profound clinical consequences of anxiety and depression [
98]. In line with this, a multicenter-based report indicated a bidirectional association between (1) anxiety and depression promoting insomnia; and (2) insomnia elevating the risk of anxiety and depression [
99]. Additionally, a prospective longitudinal study reported that social anxiety disorder during adolescence is a crucial predictor of subsequent depressive disorders. The study findings indicated that social anxiety–depression comorbidity during adolescence is linked to a subsequent severe major depressive disorder [
100].
Our data show that depression is linked to using painkillers and eye lubricants. Following the inclusion of GD in the WHO classification of diseases (ICD-11), studies have examined some of their consequences on general health. These issues may include musculoskeletal conditions, eyes problems, exhaustion, and headaches [
39,
101], which may increase the utilization of over-the-counter medications to relieve these symptoms, such as painkillers and lubricating eye drops. In line with this, a cross-sectional study in medical school students showed that GD is associated with headaches and less proficiency in time management. A higher prevalence of GD is linked to skipping classes and cognition-related issues [
102]. Another study showed that GD is associated with performance-enhancing drugs; the report indicated that two out of five gamers consumed stimulants, including prescribed and over-the-counter products [
103]. Moreover, a study has shown that playing a video game is associated with anatomical changes in cortical thickness, a brain region critical for decision making and cognitive functions [
104].
In both mediation models, the parallel and serial, GD was the predictor variable, sleep quality and anxiety were mediators, and depression was the outcome. At the same time, gender, and painkiller use were included as confounders. Our findings from the parallel mediation indicate that GD and depression could be partially mediated by poor sleep quality and anxiety. These results provide a mechanistic link between anxiety, sleep quality, and gaming behavior contributing to depression. Additionally, the parallel mediation analysis suggests that sleep quality can be predicted by gaming directly (total effect) and also indirectly through sleep quality and anxiety. In support of this, a systematic review showed that problematic internet use is associated with poor sleep quality [
105].
Although technology is evading, most studies conducted on undergraduate students examining psychological stressors discuss the impact of internet addiction [
63,
106,
107,
108,
109] rather than online gaming, even though a significant portion of the young population using technology are directed toward online gaming [
110]. Predictors of GD were suggested in many studies, including the gender and the age group of the player. Many studies agreed that male gender was positively associated with more GD compared to female gender [
26,
28,
29,
30,
111]. In addition, the purpose of playing online games was different among the two genders, as playing for the purpose of passing time was higher with females whereas more males play for the feeling of achievement and making friends [
111].
A study in the Pakistani general population reported that GD was significantly linked to poor sleep quality [
112]. Similar findings were observed in Indonesian students [
113]. In addition, a study that examined sleep duration in Japanese male adolescent students reported that more than eight hours of sleep duration per night is associated with lower depression/anxiety risks [
114]. Interestingly, a systematic review discussed the biological consequences of gaming addiction. The study examined neuroimaging evidence of neurocircuitry changes that occurred with gaming addiction and compared it with neurological changes with drug abuse [
115], indicating that GD has biological hallmarks of traditional substance-related addictions. In line with this, a previous report examined reward circuitry using functional magnetic resonance imaging during video gaming. Participants were mainly young adults with around eight hours per week of experience in video gaming. The study findings indicated that the orbitomedial prefrontal cortex and the anterior putamen were activated differentially during winning and losin, indicating complex acquisition of reward circuitry while video gaming [
116]. Additionally, the level of dopaminergic release is affected by video gaming [
117].
A recent review reported that GD is linked to structural and functional changes in neuronal populations, particularly the fronto-striatal region. This region is physiologically implicated in modulating both compulsive behavior and attention. Further, the core pathology of GD includes psychological dependence. Additionally, individuals with GD exhibited personal features similar to traditional substance-related addicts, including the reduced personal capacity to evaluate risks, aggression, and impulsivity [
89]. In line with this, another study underlined the addictive potential of problematic online gaming compared to other online activities. Further, it suggests that comorbidities of psychopathologies or addictions are relatively common. In fact, it is viewed as a typical rather exceptional condition [
118], indicating the link between GD, insomnia, and depression is beyond passing the time, and it suggests the association is due to psychological addiction.
On the other hand, the serial model showed that depression could be predicted by gaming indirectly by sleep quality in a simple mediation. This could be attributed to gaming to sleep quality and anxiety then to depression. However, a direct path between gaming and anxiety was insignificant, suggesting anxiety cannot mediate the gaming–depression association. A study showed that excessive use of social networks is associated with poor sleep quality and elevated everyday cognitive failures. The study findings indicated that the use of social networks–cognitive failures is mediated by sleep quality [
115].
In line with this, studies showed that online gaming is related to sleep deprivation and decreased sleep quality [
119,
120,
121]. Furthermore, gaming addiction increases symptoms of anxiety and depression [
61,
62,
69,
122]. Insomnia increases the risk of both depression and anxiety [
123,
124,
125]. Moreover, a systematic review suggests insomnia is bidirectionally related to anxiety and depression [
126,
127]. Insomnia is linked to depression biologically [
52,
53] and psychologically [
54,
55]. In clinical settings composed of healthy adults, a three-night consecutive awakening was linked to a significant reduction in mood. Bai et al. [
124] evidenced that insomnia plays an essential role in the well-being of people during the COVID-19 pandemic, and prevention of insomnia is critical to reducing anxiety and depression. Insomnia and anxiety were found as predictors of depression previously [
128].
On the other hand, a good mood promotes resilience to stress and strengthens coping mechanisms [
56], suggesting a potential mechanism of the depression–insomnia relationship. Additionally, anxiety and depression are highly comorbid [
57]. About 45% of depressed individuals experience anxiety [
58]. However, research indicated that anxiety precedes depression and contributes to its severity [
129]. Therefore, it was reasonable to consider insomnia and anxiety as mediators for the relationship between gaming addiction and depression.
A previous study indicated that delaying bedtime can indirectly affect anxiety and depression via poor sleep quality [
130]. Some potential reasons for procrastination at bedtime are online gaming and excessive mobile phone or internet use. Indeed, several studies found a partial mediating effect of sleep quality on the relationship between problematic online behavior (i.e., internet addiction, social media, or mobile phone overuse) and well-being (especially depression) among university students from Algeria [
131], China [
132,
133], and Nepal [
134]. Moreover, Yu et al. [
135] found a mediating role between insomnia and depression in the association between internet gaming disorder and suicidal ideation among Chinese adolescents. Furthermore, a recent study found both a serial and parallel mediation of anxiety, stress, and sleep quality on the relationship between internet addiction and depression among Serbian medical students [
136,
137].
As far as we know, this is the first report to explore the mechanistic effect of GD on insomnia, anxiety, and depression in first-year students. Moreover, given that exposure to the COVID-19 pandemic has altered mental health, this study is an updated measurement following the return to the typical lifestyle we used to have. Additionally, few studies have examined the impact of GD on the Saudi community. This report is updated and the first to analyze the implications of GD in first-year undergraduate students.
Our findings highlight the need for some interventions. For instance, first-year students, particularly health and medical students, need prioritization to increase awareness of the impact of good sleep quality and GD. Second, given that GD is a key mediator of poor sleep quality and depression, some actions should be taken to help students reduce time spent on gaming and the internet and improve their sleep quality, for instance, conducting a periodical educational workshop about these stressors. In addition, our findings highlight the need to implement a regulation restricting online gaming. A previous experience was implemented in South Korea [
138]. Similarly, in China, a midnight patrol was initiated recently where players have a limited number of games after midnight [
139].
Study Limitations
Although the study findings are significant, some limitations exist. First, the study design is cross-sectional; further verification can be added by conducting a longitudinal study. Second, most participants were females; thus, we may not generalize the study conclusions. Third, the study was conducted at a single center. Moreover, the study was a self-reported survey, and thus reporter bias might exist.