Adolescent suicide constitutes a severe global public health challenge and ranks as the second leading cause of mortality for individuals aged 10-24 years globally [1]. This crisis is particularly acute in China, where recent epidemiological data reveal a disturbing divergence in suicide trends. While rates have declined in most age groups, they have steadily increased since 2011 among children aged 5-14 years and have risen sharply since 2017 among adolescents aged 15-24 years [2]. This alarming pattern underscores an urgent imperative to identify and understand the novel and modifiable risk factors driving this specific demographic shift.

In parallel, the proliferation of digital media has spurred clinical and research concern regarding internet gaming disorder (IGD) and its potential role in adolescent psychopathology [3-8]. A growing body of primarily cross-sectional evidence consistently links IGD to suicidal behaviors [9-11]. Systematic reviews encompassing diverse cultural contexts have established a reliable association between IGD and heightened suicidal ideation [12], with further studies corroborating a link to suicidal attempts [13-15]. Clinical case reports provide a mechanistic glimpse, suggesting that crises leading to suicidality in adolescents with IGD are often precipitated by conflicts over gaming or attempts to restrict access [16,17].

Theoretical models posit that the IGD-suicidality association might be bidirectional. The integrated motivational-volitional model of suicidal behavior provides a useful framework for conceptualizing how IGD may be linked to suicidal ideation and suicidal attempt [18]. It distinguishes three phases: a premotivational phase involving environmental and personal risk factors, a motivational phase in which feelings such as defeat and entrapment give rise to suicidal ideation, and a volitional phase that determines whether individuals act on these thoughts. In the premotivational phase, excessive gaming and its consequences, such as stressful life events, academic impairment, family conflict, social withdrawal, and sleep disturbance, may increase chronic stress and defeat experiences [19,20]. In the motivational phase, adolescents with IGD may use gaming as an escape-oriented coping strategy for negative affect; although this may provide short-term relief, it may also delay problem solving, weaken resilience and emotional regulation, and deepen feelings of entrapment [21-23], thereby increasing vulnerability to suicidal ideation. In the volitional phase, the transition from suicidal ideation to suicidal attempt may be facilitated by behavioral dysregulation, impulsivity, and impaired executive control, which are commonly linked to IGD [24-26]. In addition, prolonged exposure to video games, especially violent games, may desensitize players to pain, thereby increasing pain tolerance and the “acquired capability” for suicide necessary for suicidal attempts [27-29].

In the opposing direction, theoretical frameworks like the compensatory internet use model and the interaction of person-affect-cognition-execution (I-PACE) model support a reverse pathway, positing that suicidality may precipitate IGD [30,31]. These frameworks suggest that preexisting psychological distress, including suicidal ideation, may drive adolescents to engage in gaming as a maladaptive coping mechanism to escape aversive emotional states, thereby increasing vulnerability to disordered use. This proposed bidirectionality is empirically precedented; longitudinal studies have indicated a reciprocal relationship between IGD and depression [32,33], suggesting that a similar dynamic may exist for the more severe outcome of suicidal behavior.

Despite this compelling theoretical rationale, a critical empirical gap persists. The vast majority of extant literature is limited by its cross-sectional design, which is inherently incapable of establishing temporal precedence or causality. While a handful of longitudinal studies have begun to emerge, these studies have predominantly examined a one-way relationship, positioning IGD only as a predictor of future suicidality, thereby overlooking the potential reverse association [34-38]. This narrow focus overlooks the clinically crucial possibility that suicidality may itself be a potent risk factor for the development of IGD. A hint of this complex interplay was observed in our recent longitudinal network analysis of depressive symptoms and IGD, which identified suicidal ideation as a central bridge symptom within the IGD-depression network [33]. However, this finding was incidental, as the study was not designed to formally test the hypothesis that baseline suicidal behaviors prospectively predict the new onset of IGD.

To address this research gap, we conducted a large-scale, school-based, 2-wave prospective cohort study among Chinese adolescents. We aim to move beyond correlation and unidirectional assumptions to explicitly test for a bidirectional relationship. This study has two primary objectives: (1) to determine if baseline IGD predicts the new onset of suicidal behaviors after 1 year, adjusting for critical mental health confounders (ie, depression, anxiety, sleep disturbance, and externalizing problems); and (2) to test the reverse hypothesis, examining if baseline suicidal behaviors predict subsequent incident IGD. By elucidating the temporal dynamics of this relationship, our findings have the potential to inform more nuanced and effective early intervention and prevention strategies for both suicidal behavior and IGD.

This large 2-wave cohort study provides longitudinal evidence that IGD and suicidal outcomes are prospectively linked in both directions among Chinese adolescent gamers. Baseline IGD was associated with higher risks of incident suicidal ideation and suicidal attempt over 1 year, while baseline suicidal ideation and suicidal attempt were also associated with subsequent incident IGD. These associations remained evident after sequential adjustment for demographic, lifestyle, and mental health covariates, although the estimates were attenuated after mental health factors were added. By examining suicidal ideation and suicidal attempt separately and testing both temporal directions within the same cohort, this study extends prior work that has largely been cross-sectional or focused only on IGD as a predictor of later suicidality [34-38,53,54]. The findings suggest that IGD and suicidal outcomes may constitute interrelated targets for adolescent mental health screening and prevention.

Our findings were partly consistent with previous literature in a different cultural context [34,38]. In a prospective cohort of Mexican college students, baseline IGD was associated with incident suicidal ideation after adjustment for psychiatric disorders, whereas associations with suicide plans and attempts were not statistically significant [34]. In a Korean adolescent cohort, high risk of IGD predicted subsequent suicidality, suicidal ideation, and suicide plans or attempts among boys, but not among girls [38]. These studies, together with our findings in a large Chinese adolescent sample, suggest that the prospective association between IGD and suicidal outcomes may have relevance across different cultural contexts. However, the pattern of findings has not been uniform. Differences in age range, cultural setting, outcome definition, follow-up design, statistical power, and the number of suicidal attempt events may partly explain the weaker or sex-specific associations reported in previous studies [34,38]. Compared with these earlier cohorts, the present study included a substantially larger sample, providing more precise estimates of the prospective associations with both suicidal outcomes [34,38]. These results also align with a broader literature on the positive association between digital addiction and suicidality [37,55,56], suggesting that addictive engagement with digital platforms may represent an emerging and clinically relevant risk marker for adolescent suicidal risk. From a prevention perspective, these findings support the need to assess problematic digital behaviors, including IGD, alongside conventional mental health risk factors in school-based and clinical screening.

The sequential adjustment models helped clarify the contribution of shared mental health factors to the observed associations. The estimates were substantially attenuated after depression, anxiety, sleep disturbance, hyperactivity and inattention, and conduct problems were added to the models, suggesting that these factors may explain part of the overlap between IGD and suicidal outcomes. Prior studies have linked these psychiatric and behavioral characteristics to IGD, suicidal outcomes, or both, indicating that they may represent shared vulnerabilities or potential pathways connecting the 2 domains [57,58]. Cross-sectional studies have also provided preliminary evidence that mental health and psychosocial factors may mediate the associations between IGD and suicidal outcomes. Yu et al [54] reported that insomnia and depression serially mediated the association between IGD and suicidal ideation, while other studies found that sleep disturbance partially mediated the association between IGD and suicidal behaviors [10,59]. Additional cross-sectional evidence suggests that reduced psychosocial resources and greater psychosocial difficulties, including lower resilience and social support and higher social anxiety and loneliness, may constitute further indirect pathways linking IGD with suicidal ideation [53]. Collectively, these findings support the plausibility of indirect pathways, particularly those involving sleep disturbance and depressive symptoms [10,53,54,59]. However, because the present 2-wave study did not formally test mediation, we could not determine whether these variables functioned as confounders, mediators, or markers of shared vulnerability. The fully adjusted estimates should therefore be interpreted as associations conditional on the measured covariates rather than as total effects. Although the adjusted associations were modest, they remain relevant to clinical and school-based prevention given the severity of suicidal outcomes, the modifiable nature of IGD, and the feasibility of screening for both conditions in adolescent populations.

The most novel contribution of this study is the longitudinal evidence that suicidal outcomes predict the subsequent onset of IGD. Although the precise mechanisms remain unclear, several potential explanations warrant consideration. First, according to the compensatory internet use model [30], adolescents may turn to online gaming as a form of escape-oriented coping when experiencing psychological distress, including suicidal ideation. Repeated reliance on gaming to escape negative emotional states may contribute to excessive and dysregulated gaming, thereby increasing vulnerability to IGD [60-62]. Previous studies have identified escapism as an important gaming motivation associated with both psychological distress and problematic gaming, supporting this interpretation [60-62]. Second, gaming may also serve social motives. Problematic gamers have been reported to endorse stronger social, escape, coping, and fantasy motives than nonproblematic gamers [62]. One possible explanation is that adolescents experiencing suicidal distress may increasingly use gaming environments to seek social connection or validation, thereby increasing their gaming engagement. This interpretation is indirectly supported by a network study by Yang et al [63], in which the item “Do you frequently make new friends online?” showed the strongest association with adolescent suicide risk within the internet addiction symptom network. These mechanisms remain hypotheses because the present study did not assess gaming motives, online social interactions, or the proposed intermediate processes.

This study has several strengths, including its large sample size, prospective design, and adjustment for multiple mental health factors relevant to both IGD and suicidal outcomes. Several limitations should also be noted. First, all measures were based on self-report, which may have introduced recall bias and social desirability bias. Second, the 2-wave, 1-year design limited temporal inference and temporal resolution. Although we examined prospective associations in both directions, 2 waves were insufficient to characterize dynamic reciprocal processes or to separate within-person change from stable between-person differences [64]. The annual interval also lacked the temporal resolution needed to capture short-term fluctuations or acute suicidal crises temporally associated with gaming-related conflict or restriction [16,17]. The findings therefore reflect prospective associations over a 1-year interval rather than dynamic reciprocity or acute effects. In addition, suicidal attempt was assessed as a lifetime item; although incident suicidal attempt was operationalized as no lifetime attempt at baseline and a reported lifetime attempt at follow-up, the exact timing of the attempt during the follow-up interval was not assessed. Third, the sample was drawn from a single Chinese city and was restricted to adolescents who reported gaming in the past 12 months at baseline. The findings therefore apply primarily to adolescent gamers and may not generalize to adolescents without baseline gaming exposure or to populations with different cultural, educational, or mental health service contexts. Fourth, the survey did not collect detailed information on game-related characteristics, such as game genre, violent content, multiplayer format, or social context of play. The findings should therefore be interpreted as associations with overall IGD symptoms rather than effects of specific game types. Finally, school identifiers were removed during data cleaning and were not available for analysis, preventing adjustment for school-level clustering. This may have led to underestimated standard errors and overly narrow CIs. Future studies should use multiwave or intensive longitudinal designs, retain de-identified school-level clustering indicators, and incorporate detailed measures of gaming characteristics, gaming motives, social functioning, and suicide-related mechanisms to clarify when and how IGD and suicidal outcomes become prospectively linked.

In conclusion, this study is innovative in testing prospective associations in both directions within an adolescent gamer cohort while examining suicidal ideation and suicidal attempt 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, suicidal risk, and co-occurring mental health symptoms together, with timely referral and integrated intervention for adolescents who screen positive in either domain.