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      Online Gaming During the COVID-19 Pandemic in India: Strategies for Work-Life Balance

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          Abstract

          The novel coronavirus disease 2019 (COVID-19) pandemic has brought the entire world to a relative standstill, affecting millions worldwide at the time of writing (June 24, 2020) (World Health Organization [WHO] 2020). With the absence of an effective vaccine, public health measures have been implemented by governments worldwide, such as quarantine, closing workplaces (including schools and businesses), and spatial distancing (Nussbaumer-Streit et al. 2020). To combat the spread of COVID-19, the Indian government implemented nationwide lockdown measures and self-isolation policies. In the Indian context, “lockdown” refers to individuals staying at home while completely restricting the movement of the population inside and outside of specific areas except for essential activities (health visits, purchasing for essential items, and providing essential work) (Lippi et al. 2020). As a consequence, the measures have led to occupational and educational disruption and psychological distress for many individuals. One area that has been relatively unaffected during the pandemic is the gaming industry, with user engagement growing considerably during this period (Javed 2020). For example, WinZo Games, an Indian-based gaming company, have reported three times more user engagement and 30% higher traffic in online mobile gaming. Around 35% higher usage has been observed in multi-player modes in comparison with single-user modes, a trend also found elsewhere (Bora 2020). Similarly, Paytm First Games, an Indian mobile-based online gaming platform, reported an almost 200% increase in the user base during the pandemic, with 75,000 new users (Ahaskar 2020). During the lockdown period, there was also an increase in user engagement in online gaming among those aged 25–35 years and a marginal increase in female users (Bora 2020). Gaming has been reported throughout the day, with a peak gaming time from 8pm until midnight (Bora 2020). The reason for the increased uptake in Indian gaming is because many people are now housebound and there are few leisure activities that individuals can participate in. To date, online gaming has played a supporting role in public health efforts to enforce effective spatial distancing during the pandemic and has been supported by the World Health Organization’s collaborative campaign (#PlayApartTogether) with the online gaming industry encouraging individuals to stay at home and limit the spread of the virus (Maden 2020). Research evidence suggests that most engagement in gaming is of positive benefit (Griffiths 2019) and that the benefits can by educational, physical, and therapeutic (Griffiths et al. 2017). Gaming can also help in developing cognitive skills such as reasoning, spatial awareness, and problem-solving (Bowen 2014; Nuyens et al. 2019). However, excessive gaming for protracted periods can be problematic for a minority of individuals. Research evidence suggests that problematic gaming is associated with psychosocial problems such as lack of sleep, low school well-being, concentration problems, impaired life skills, and poor self-control (Männikkö et al. 2020). Extreme engagement in online gaming is also strongly associated with poor academic performance among school-going children and adolescents (Terry and Malik 2018). The literature suggests that multiple factors are associated with problematic gaming such as personality traits (Şalvarlı and Griffiths 2019), anxiety (Adams et al. 2019; Männikkö et al. 2020), entertainment achievement and escapism (Männikkö et al. 2017), game genre (Mihara and Higuchi 2017; Na et al. 2017), and sensation-seeking behaviors (Hu et al. 2017). It has also been speculated that during the COVID-19 pandemic, some individuals may develop an increasing pattern of gaming to relieve psychological distress (King et al. 2020). According to a recent Indian study, gaming behavior increased among college students in the lockdown period (Balhara et al. 2020). Also, due to the lockdown and subsequent occupational and/or educational disruption, individuals may have much more free time and/or may be easily distracted from working at home due to temptations such as online gaming. Subsequently, there is a need for well-balanced and effective strategies to support physical and psychological well-being (King et al. 2020). Individuals usually follow a structured routine or a set of routinized behaviors. These routines can provide life satisfaction and bring more significant meaning to one’s life (Heintzelman and King 2019). Given the apparent considerable increase in online gaming and the occupational and/or educational disruption it may cause for some individuals, it is important to maintain a healthy work/life balance during the COVID-19 crisis. The proposed model of lifestyle balance by Matuska and Christiansen (2008) suggests five aspects (i.e., health and physical safety; having rewarding and self-affirming relationships; feeling interested, engaged, challenged, and competent; creating meaning and positive personal identity; and organizing time and energy to meet personal goals). These and other aspects are briefly looked at in turn, in relation and gaming and occupational and/or educational balance. Many factors, such as good nutrition, exercise, safety practices, adequate sleep, managing stress, and avoiding addictive substances, can have beneficial effects on health (Matuska and Christiansen 2008). Given the significance of spatial distancing and nationwide lockdown in India at the time of writing, participation in a variety of activities across various mediums is needed to maintain psychological well-being. Engaging in gaming can be time-consuming and has been associated with increased consumption of sweet drinks (Turel et al. 2017), but maintaining a healthy diet is essential. Also, excessive online gaming is associated with physical inactivity, obesity, musculoskeletal problems (pain in hands, wrist, neck, and back), and visual problems (Ayenigbara 2018; Zirek et al. 2020). At present, there is much uncertainty as to what will happen regarding the COVID-19 pandemic, due to the ever-changing characteristics of the virus (Lippi et al. 2020). This is causing immense psychological distress and fear among some individuals all over the world (Ahorsu et al. 2020; Liu et al. 2020; Pakpour and Griffiths 2020; Xiang et al. 2020). Such psychosocial effects can lead to emotional distress, anxiety, depression, substance use disorders, and behavioral addictions (Pfefferbaum and North 2020). Subsequently, engagement in gaming can be a healthy way to relieve stress and modify mood (Lee et al. 2017), especially during times of crisis. However, excessive engagement in gaming and unhealthy coping strategies can prove challenging in developing a healthy daily routine. Here, we recommend the following strategies to maintain occupational and/or educational balance in times of challenge due to lockdown following the COVID-19 pandemic. Manage stress effectively—Stress management has a key impact on health and well-being, and it is important to incorporate healthy coping strategies such as regular exercise, deep breathing, yoga, or meditation in daily routines to decrease stress and elevate mood. It is vital to pay attention to the body signals, having personal time, space, and reflecting. Engagement in gaming reduces stress but it is imperative not to use this to the neglect of all other stress-relieving activities. Get adequate sleep—Sleep hygiene is essential and can be helped by maintaining a sleep diary for duration and time of sleep. Individuals should (i) have a specific time they go to bed, (ii) avoid gaming before bedtime, (iii) ensure electronic gaming devices are not kept in the bedroom, and (iv) should make sure the bedroom is noise-free with dim light. Adequate sleep is important for psychological well-being and physical functioning. Optimizing circadian rhythms and managing the sleep-wake cycle contributes to enhanced energy levels. Engage in physical activity—Gaming can often displace physical activity, so it is very important to engage in physical activity to elevate mood and maintain health. Physical activity is an important outcome of health and well-being. Engaging in outdoor activities, walking, gardening, jogging, and any other activity that can be done in a safe and spatially distanced way. To avoid prolonging engagement in gaming, individuals need to set time restraints for gaming, incorporate frequent breaks, stretch, maintain good posture with a straight back, keep the head and neck upright, and consciously blink eyes. Engage in good nutrition and eating habits—It is very common to snack while gaming. Snacking healthy food is important, and gamers should eat meals at regular meal times (and not skip meals) and, like sleep, monitor their eating behavior. Have rewarding and self-affirming relationships—Good social support and emotional support can be protective factors for maintaining an individual’s good health (Reblin and Uchino 2008). Furthermore, positive relationships and social support predict life satisfaction (Siedlecki et al. 2014). However, problematic online gaming is highly associated with cyberbullying and aggression (Mcinroy and Mishna 2017), which can have a major impact on an individual’s offline social relationships. Forming or renewing real social relationships is necessary. In the modern busy work schedule, individuals often find it hard to spend quality time with their family and socialize with friends. Capitalizing on the current situation, given that a significant proportion of the world’s individuals are confined to their homes, for some it is an ideal time to reconnect with family and strengthen existing friendships. This can be done both in and outside of online gaming (Griffiths 2020). Moreover, having a socially supportive environment has been associated with psychological well-being. Family time is important; having conversations, engaging in offline games, and participating in household chores can also help reduce stress and further strengthen relationships. For children and adolescents, parents need to monitor a child’s game time and encourage more engagement in offline activities. Engage in challenging activities—Work is an important way of interacting with the environment, fulfilling roles and responsibility, and developing mastery, which increases the sense of competence and self-efficacy. Participating in online gaming can also enhance positive emotions and bring about happier moods (Russoniello et al. 2009) by feeling entertained (Männikkö et al. 2017). However, problematic online gaming is associated with low social competence and self-esteem (Kuss and Griffiths 2012). Therefore, it is important for individuals to invest in exploring new leisure activities and skills and/or restarting old ones to be engaged and productive. As mentioned earlier, participation in an array of physical activities, social activities, as well as cognitive-based activities with the component of challenge will be helpful. Exploration and participation in meaningful and gratifying activities such as painting, gardening, puzzles, and other activities should be encouraged. Create meaning and positive personal identity—To create meaning and positive personal identity, individuals engage in a wide range of activities. During the pandemic, it is recommended that individuals be mindful when participating in gaming. Online gaming provides a platform to create a unique identity. For instance, in role-playing games, the player is free to choose gender, race, background, and physical appearance. The gaming industry has designed games and avatars, and some gamers form deep attachments to their game character (King et al. 2010). However, for a minority, there is a risk of developing internet gaming disorder (IGD) where the individual can experience physical, emotional, and self-identity disturbances (Stavropoulos et al. 2019). Even though gaming provides an opportunity to escape the present reality, it is recommended that individuals find meaning and identity in their everyday events. The COVID-19 crisis has given many individuals sufficient time to reflect on their career, goals, inspiration, motivations, and drives. Consequently, participating in a variety of activities (including physical, creative, cognitive, and expressive activities) to maintain psychological well-being and overall health is highly recommended. Organize time and energy to meet personal goals—Due to the current pandemic, millions of individuals are facing an occupational and/or educational imbalance. For some, this will cause stress associated with infringement on personal freedom, complete disruption of structured routines, and engagement in activities susceptible to behavioral addiction (Pfefferbaum and North 2020). In addition, the allocation of time for day-to-day activities can become challenging and may cause occupational and/or educational disruption for individuals (Whiteford 2000). Individuals who engage in excessive gaming will find the activity time-consuming, leading to less available time to engage in other activities. This could lead to delaying or completely avoiding necessary activities. When these routines are disrupted due to excessive engagement in online gaming, it may lead to occupational and/or educational imbalance inducing stress, anxiety, and various mental health issues (Brown and Hollis 2013). This occupational imbalance or disruption can further lead to occupational and/or educational deprivation, paving the way to associated mental health issues. It is recommended that individuals make a more active choice of time use. Engagement in a variety of goal-directed healthy habits (which can include gaming) and maintaining positive relationships (which can be with others in and outside of gaming) is essential. It is important to plan a routine, use planners, keep a record of time spent on gaming, and using apps such as digital well-being and timers. Appropriate time use is highly related to individual well-being. Final Thoughts As lockdowns are eased in India and elsewhere, the minority who have used gaming as an unhealthy coping mechanism (where there is an over-dependence on gaming as a means of escapism from reality) may suffer from mental health issues. For some, the impact of the pandemic may lead to the persistence of excessive gaming and result in negative consequences. Mental health experts such as psychiatrists, psychologists, occupational therapists, and social workers must continue to monitor the psychosocial needs of individuals and deliver the needed psychosocial support wherever and whenever they can (Pfefferbaum and North 2020). The general population, especially vulnerable groups, requires the utmost mental health care during this pandemic. Early identification of the vulnerable population should begin as early as possible to help overcome the mental health issues caused by the COVID-19 pandemic.

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          Most cited references16

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          Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed

          The 2019 novel coronavirus (2019-nCoV) pneumonia, believed to have originated in a wet market in Wuhan, Hubei province, China at the end of 2019, has gained intense attention nationwide and globally. To lower the risk of further disease transmission, the authority in Wuhan suspended public transport indefinitely from Jan 23, 2020; similar measures were adopted soon in many other cities in China. As of Jan 25, 2020, 30 Chinese provinces, municipalities, and autonomous regions covering over 1·3 billion people have initiated first-level responses to major public health emergencies. A range of measures has been urgently adopted,1, 2 such as early identification and isolation of suspected and diagnosed cases, contact tracing and monitoring, collection of clinical data and biological samples from patients, dissemination of regional and national diagnostic criteria and expert treatment consensus, establishment of isolation units and hospitals, and prompt provision of medical supplies and external expert teams to Hubei province. The emergence of the 2019-nCoV pneumonia has parallels with the 2003 outbreak of severe acute respiratory syndrome (SARS), which was caused by another coronavirus that killed 349 of 5327 patients with confirmed infection in China. 3 Although the diseases have different clinical presentations,1, 4 the infectious cause, epidemiological features, fast transmission pattern, and insufficient preparedness of health authorities to address the outbreaks are similar. So far, mental health care for the patients and health professionals directly affected by the 2019-nCoV epidemic has been under-addressed, although the National Health Commission of China released the notification of basic principles for emergency psychological crisis interventions for the 2019-nCoV pneumonia on Jan 26, 2020. 5 This notification contained a reference to mental health problems and interventions that occurred during the 2003 SARS outbreak, and mentioned that mental health care should be provided for patients with 2019-nCoV pneumonitis, close contacts, suspected cases who are isolated at home, patients in fever clinics, families and friends of affected people, health professionals caring for infected patients, and the public who are in need. To date, epidemiological data on the mental health problems and psychiatric morbidity of those suspected or diagnosed with the 2019-nCoV and their treating health professionals have not been available; therefore how best to respond to challenges during the outbreak is unknown. The observations of mental health consequences and measures taken during the 2003 SARS outbreak could help inform health authorities and the public to provide mental health interventions to those who are in need. Patients with confirmed or suspected 2019-nCoV may experience fear of the consequences of infection with a potentially fatal new virus, and those in quarantine might experience boredom, loneliness, and anger. Furthermore, symptoms of the infection, such as fever, hypoxia, and cough, as well as adverse effects of treatment, such as insomnia caused by corticosteroids, could lead to worsening anxiety and mental distress. 2019-nCoV has been repeatedly described as a killer virus, for example on WeChat, which has perpetuated the sense of danger and uncertainty among health workers and the public. In the early phase of the SARS outbreak, a range of psychiatric morbidities, including persistent depression, anxiety, panic attacks, psychomotor excitement, psychotic symptoms, delirium, and even suicidality, were reported.6, 7 Mandatory contact tracing and 14 days quarantine, which form part of the public health responses to the 2019-nCoV pneumonia outbreak, could increase patients' anxiety and guilt about the effects of contagion, quarantine, and stigma on their families and friends. Health professionals, especially those working in hospitals caring for people with confirmed or suspected 2019-nCoV pneumonia, are vulnerable to both high risk of infection and mental health problems. They may also experience fear of contagion and spreading the virus to their families, friends, or colleagues. Health workers in a Beijing hospital who were quarantined, worked in high-risk clinical settings such as SARS units, or had family or friends who were infected with SARS, had substantially more post-traumatic stress symptoms than those without these experiences. 8 Health professionals who worked in SARS units and hospitals during the SARS outbreak also reported depression, anxiety, fear, and frustration.6, 9 Despite the common mental health problems and disorders found among patients and health workers in such settings, most health professionals working in isolation units and hospitals do not receive any training in providing mental health care. Timely mental health care needs to be developed urgently. Some methods used in the SARS outbreak could be helpful for the response to the 2019-nCoV outbreak. First, multidisciplinary mental health teams established by health authorities at regional and national levels (including psychiatrists, psychiatric nurses, clinical psychologists, and other mental health workers) should deliver mental health support to patients and health workers. Specialised psychiatric treatments and appropriate mental health services and facilities should be provided for patients with comorbid mental disorders. Second, clear communication with regular and accurate updates about the 2019-nCoV outbreak should be provided to both health workers and patients in order to address their sense of uncertainty and fear. Treatment plans, progress reports, and health status updates should be given to both patients and their families. Third, secure services should be set up to provide psychological counselling using electronic devices and applications (such as smartphones and WeChat) for affected patients, as well as their families and members of the public. Using safe communication channels between patients and families, such as smartphone communication and WeChat, should be encouraged to decrease isolation. Fourth, suspected and diagnosed patients with 2019-nCoV pneumonia as well as health professionals working in hospitals caring for infected patients should receive regular clinical screening for depression, anxiety, and suicidality by mental health workers. Timely psychiatric treatments should be provided for those presenting with more severe mental health problems. For most patients and health workers, emotional and behavioural responses are part of an adaptive response to extraordinary stress, and psychotherapy techniques such as those based on the stress-adaptation model might be helpful.7, 10 If psychotropic medications are used, such as those prescribed by psychiatrists for severe psychiatric comorbidities, 6 basic pharmacological treatment principles of ensuring minimum harm should be followed to reduce harmful effects of any interactions with 2019-nCoV and its treatments. In any biological disaster, themes of fear, uncertainty, and stigmatisation are common and may act as barriers to appropriate medical and mental health interventions. Based on experience from past serious novel pneumonia outbreaks globally and the psychosocial impact of viral epidemics, the development and implementation of mental health assessment, support, treatment, and services are crucial and pressing goals for the health response to the 2019-nCoV outbreak. © 2020 VW Pics/Science Photo Library 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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            Online mental health services in China during the COVID-19 outbreak

            At the start of 2020, the 2019 coronavirus disease (COVID-19), originating from Wuhan in Hubei province, started to spread throughout China. As a result of the rapidly increasing numbers of confirmed cases and deaths, both medical staff and the public have been experiencing psychological problems, including anxiety, depression, and stress.1, 2 Since January, 2020, the National Health Commission of China have published several guideline documents, starting with the notification of principles for emergency psychological crisis intervention for the COVID-19 epidemic on January 26, then the notice on establishing psychological assistance hotlines for the epidemic on February 2, and most recently, guidelines for psychological assistance hotlines during the COVID-19 epidemic on February 7. 3 During the severe acute respiratory syndrome epidemic in 2003, internet services and smartphones were not widely available. Therefore, few online mental health services were provided for those in need. 4 The popularisation of internet services and smartphones, and the emergence of fifth generation (5G) mobile networks, have enabled mental health professionals and health authorities to provide online mental health services during the COVID-19 outbreak. Fast transmission of the virus between people hinders traditional face-to-face psychological interventions. By contrast, provision of online mental health services is safe. To date, several types of online mental health services have been implemented widely for those in need during the outbreak in China. Firstly, as of Feb 8, 2020, 72 online mental health surveys associated with the COVID-19 outbreak could be searched for via the WeChat-based survey programme Questionnaire Star, which target different populations, including medical staff (23 of the surveys), patients with COVID-19 (one survey), students (18 surveys), the general population (nine surveys), and mixed populations (21 surveys); in Hubei province (five surveys), other provinces (15 surveys), all provinces, municipalities, and autonomous regions (36 surveys), and unspecified areas of China (16 surveys). One such multicentre survey involving 1563 medical staff, with our centre at Nanfang Hospital, Southern Medical University (Guangzhou, China) as one of the study sites, found the prevalence of depression (defined as a total score of ≥5 in the Patient Health Questionnaire-9) to be 50·7%, of anxiety (defined as a total score of ≥5 in the Generalized Anxiety Disorder-7) to be 44·7%, of insomnia to be 36·1% (defined as a total score of ≥8 in the Insomnia Severity Index), and of stress-related symptoms (defined as a total score of ≥9 in the Impact of Events Scale-Revised) to be 73·4%. These findings are important in enabling health authorities to allocate health resources and develop appropriate treatments for medical staff who have mental health problems. Secondly, online mental health education with communication programmes, such as WeChat, Weibo, and TikTok, has been widely used during the outbreak for medical staff and the public. In addition, several books on COVID-19 prevention, control, and mental health education have been swiftly published and free electronic copies have been provided for the public. As of February 8, 29 books associated with COVID-19 have been published, 11 (37·9%) of which are on mental health, including the “Guidelines for public psychological self-help and counselling of 2019-nCoV pneumonia”, published by the Chinese Association for Mental Health. Finally, online psychological counselling services (eg, WeChat-based resources) have been widely established by mental health professionals in medical institutions, universities, and academic societies throughout all 31 provinces, municipalities, and autonomous regions in mainland China, which provide free 24-h services on all days of the week. Online psychological self-help intervention systems, including online cognitive behavioural therapy for depression, anxiety, and insomnia (eg, on WeChat), have also been developed. In addition, several artificial intelligence (AI) programmes have been put in use as interventions for psychological crises during the epidemic. For example, individuals at risk of suicide can be recognised by the AI programme Tree Holes Rescue, 5 by monitoring and analysing messages posted on Weibo, and alerting designated volunteers to act accordingly. In general, online mental health services being used for the COVID-19 epidemic are facilitating the development of Chinese public emergency interventions, and eventually could improve the quality and effectiveness of emergency interventions.
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              Social and emotional support and its implication for health.

              Recent research findings from selected publications focusing on links between social support and physical health are summarized. Current research is extending our understanding of the influences of social support on health. Many epidemiological studies have concentrated on further linking measures of social support to physical health outcomes. A few studies are now moving into newer areas, such as emphasizing health links with support receipt and provision. Researchers are also interested in outlining relevant pathways, including potential biological (i.e. inflammation) and behavioral (i.e. health behaviors) mechanisms. Interventions attempting to apply basic research on the positive effects of social support are also widespread. Although the longer term effects of such interventions on physical health remain to be determined, such interventions show promise in influencing the quality of life in many chronic disease populations. Recent findings often show a robust relationship in which social and emotional support from others can be protective for health. The next generation of studies must explain, however, why this relationship exists and the specificity of such links. This research is in its infancy but will be crucial in order to better tailor support interventions that can impact on physical health outcomes.
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                Author and article information

                Contributors
                kritikaamin@gmail.com
                mark.griffiths@ntu.ac.uk
                deena.dimple@manipal.edu
                Journal
                Int J Ment Health Addict
                Int J Ment Health Addict
                International Journal of Mental Health and Addiction
                Springer US (New York )
                1557-1874
                1557-1882
                10 July 2020
                : 1-7
                Affiliations
                [1 ]Plexus Neuro and Stem Cell Research Center, 503, 3rd A Main Road, 5th Cross, OMBR Layout, Banaswadi, Bangalore, 560043 India
                [2 ]GRID grid.12361.37, ISNI 0000 0001 0727 0669, Psychology Department, , Nottingham Trent University, ; 50 Shakespeare Street, Nottingham, NG1 4FQ UK
                [3 ]GRID grid.411639.8, ISNI 0000 0001 0571 5193, Department of Occupational Therapy, , Manipal College of Health Professions, Manipal Academy of Higher Education, ; Manipal, India
                Article
                358
                10.1007/s11469-020-00358-1
                7351552
                9f23f278-3f74-4dc5-9e87-199996177e0d
                © Springer Science+Business Media, LLC, part of Springer Nature 2020

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

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