E-sports: What mental health professionals from low & middle-income countries must know

Introduction

Videogame competition typically takes place either alone (player v. machine, or chalking up points or rewards), or between professional players (one-on-one, or in teams) in a context of leagues or tournaments, played online, which can be staged in front of a live audience, streamed, or broadcast on television. ¹ Over the last decade, esports has become very attractive with viewers’ and professional salaries reaching levels comparable to traditional sports. ² ‘E-sports’ popularity is expected to grow further to levels where it may become an indispensable part of modern sports, even as a future sport itself or as a counterculture to modern sports. ³ In richer countries, better infrastructure with respect to internet speed and smartphones has pushed the agenda for mobile gaming. Players can monetize their gaming skills by the help of tournaments and streaming platforms. ⁴

Synonyms which have been interchangeably used in literature include electronic sports, gaming, cybersports, competitive computer gaming, and virtual sports. ⁵ According to the earliest conceptualization by Wagner, ‘eSports’ is an area of sport activity in which people develop and train mental or physical ability by the use of information and communication technology. ⁶ Alternate conceptualisations of esports emphasize the role of electronic systems between the human-computer interface ⁷ or unique cultural features such as executive ownership, absolute power, and commercially vested interest as defining features. ⁸ Despite these attempts, there are no well agreed definitions for ‘esports’.

Although Korea was the first country to recognize esports, many others including China, Germany, Russia, Italy, South Africa have done so in recent years. ⁹ As of March 2022, there are more than 100 countries across the world where esports is represented by professional organisations. ¹⁰ There are estimated 2.2 billion active gamers worldwide, with around 150 million involved in esports. ¹¹ The total prize money for esports tournaments in 2019 was >200 million dollars, with the DOTA 2 International 2019 tournament awarding the largest pool prize of c. 34 million dollars. ¹²

Effect on health

Physical health

Excessive Internet Gaming has been found to be associated with increased sedentary time, decreased physical activity, poor dietary habits, obesity, musculoskeletal pain,^{13, 14} disturbed sleep, ¹⁵ and visual problems. ¹⁶

Behaviors involved with esports such as evening use of light emitting devices, overtraining and stimulant abuse, contribute to sub-optimal sleep among players, ¹⁷ who have been reported to be significantly less involved in physical activity ¹⁸ and have poorer body structure in comparison to recognized athletes. ¹³ Further, the former are likely to complain of frequent physical symptoms including eye fatigue (56%), neck and back (42%), wrist (36%) and hand pain (32%) with few seeking medical help for these problems. ¹⁸ In contrast, high level and elite esports players place significant emphasis on physical training, with majority being physically active, ¹⁹ following pre-designed training paradigms where adequate focus is simultaneously to develop physical as well as mental strength. ²⁰ However, as of now there are no evidence-based preventive interventions extant to address the harm that esports may entail. ²¹

Research suggests that specific types of online games have a relatively high addictive potential for some players, as they offer the possibility to escape their real-life problems. ²⁸ These escape motivations also mediate a relationship between excessive playing time and poor psychological well-being. ²⁹ Though those engaging in esports are primarily motivated by achievement and skill development and maybe also socialization, they nevertheless spend long hours playing to improve their skills. ³⁰ Although excessive gaming is known to become an addiction, no systematic research has explored this question in sufficient detail. ³¹ Further, there are no studies which have looked at mental health correlates of professional esports players. ³² In fact, DSM-5 and ICD-11 have recognized IGD as an important condition requiring further additional research. In addition, ICD-11 has also included a Hazardous Gaming category, referring to a pattern of gaming that considerably increases the risk of harmful physical or mental health consequences to the individual or to others. Although only a fraction of those playing games end up developing problematic use, the absolute numbers are nevertheless bound to be very significant. Presentation to mental health professionals therefore maybe take any of the following forms.

Excessive gaming.

A systematic approach is recommended:

Screening

Using a non-judgmental approach, details must be inquired about regarding the frequency of gaming, the amount of time spent on these activities, neglect of other activities and priorities, risky behaviour associated with gaming or its context leading to functional impairment in personal (psychological/physical), social, education, work and financial domains.

Conclusion

E-sports have seen a phenomenal growth over past two decades and are predicted to play a very important role in youth culture. While its standing as a sporting category remains dubious, the economic rewards of esports continue to attract millions every year. As yet, esports is a poorly researched field from a health perspective. Limited literature available on esports professionals indicate significant associated physical and mental health consequences. ICD-11 and DSM-5 recognition of online gaming as a clinical entity will expose further potential harmful psychological consequences of esports. Although everything about esports is not deleterious, it becomes an absolute necessity for mental health professionals to be updated on this entity, as they are likely to see increased referrals in the near future.