Associations in Both Directions Between Internet Gaming Disorder and Suicidal Ideation and Attempts Among Chinese Adolescent Gamers: Two-Wave Prospective Cohort Study.

backgroundInternet gaming disorder (IGD) has been associated with suicidal outcomes in adolescents, but most evidence is cross-sectional or has examined only whether IGD predicts later suicidality. Whether suicidal ideation and suicidal attempts are also associated with subsequent IGD remains unclear.

objectiveThis study aimed to examine prospective associations in both directions between IGD and suicidal ideation and suicidal attempts among Chinese adolescent gamers.

methodsThis school-based, 2-wave prospective cohort study was conducted in Zigong, China, with assessments in November 2021 and November 2022. The analytic sample included 57,985 adolescents who completed both waves and reported gaming in the past 12 months at baseline. Students were recruited through school-based cluster sampling and completed electronic questionnaires during school sessions. IGD was assessed using the 9-item Internet Gaming Disorder Scale-Short Form (IGDS9-SF), with probable IGD defined as a score of 32 or higher. Suicidal ideation referred to serious consideration of suicide during the past month, whereas suicidal attempt was assessed over the lifetime. Both outcomes were assessed at both waves. Incident outcomes were defined among participants without the corresponding outcome at baseline. Logistic regression models estimated cross-sectional and prospective associations with sequential adjustment for demographic, lifestyle, and mental health covariates.

resultsAt baseline, 1333 of 57,985 adolescents had IGD (2.3%, 95% CI 2.2%-2.4%), 8450 had suicidal ideation (14.6%, 95% CI 14.3%-14.9%), and 6666 reported a suicidal attempt (11.5%, 95% CI 11.2%-11.8%). IGD was associated with higher baseline prevalence of suicidal ideation (crude odds ratio [COR] 6.45, 95% CI 5.78-7.20, P<.001; adjusted odds ratio [AOR] 1.50, 95% CI 1.31-1.72, P<.001) and suicidal attempt (COR 5.38, 95% CI 4.81-6.02, P<.001; AOR 1.48, 95% CI 1.29-1.69, P<.001). Prospectively, baseline IGD was associated with incident suicidal ideation (COR 2.49, 95% CI 2.02-3.06, P<.001; AOR 1.38, 95% CI 1.11-1.73, P=.004) and incident suicidal attempt (COR 2.99, 95% CI 2.47-3.61, P<.001; AOR 1.37, 95% CI 1.12-1.68, P=.002). Conversely, baseline suicidal ideation was associated with incident IGD (COR 2.98, 95% CI 2.58-3.45, P<.001; AOR 1.37, 95% CI 1.14-1.64, P<.001), as was baseline suicidal attempt (COR 2.63, 95% CI 2.24-3.08, P<.001; AOR 1.37, 95% CI 1.14-1.64, P<.001).

conclusionsThis study is innovative in testing prospective associations in both directions within an adolescent gamer cohort while examining suicidal ideation and suicidal attempts separately. Unlike previous studies that were predominantly cross-sectional or treated IGD only as a predictor of later suicidality, it identifies suicidal outcomes as prospective predictors of incident IGD. The findings add longitudinal evidence that IGD and suicidality are interrelated prevention targets, although they do not establish causality. In practice, school-based and clinical screening should assess problematic gaming, suicide risk, and co-occurring mental health symptoms together, with timely referral and integrated intervention for adolescents who screen positive in either domain.