Psychotic depression with suicidality in the context of internet gaming disorder and chronic cannabis use.

A man in his 20s was admitted after a serious suicide attempt (hypnotic overdose) following months of severe depression and social withdrawal. In the preceding 2 weeks, after a 2-day forced break from gaming due to a brief, mild, self-limited illness during which COVID-19 testing was not performed and loss of in-game status, he developed derealisation and paranoid ideas that others were 'non-playable characters'. His history revealed compulsive online gaming (approximately 10 hours/day) and chronic cannabis use, and urine toxicology was positive for cannabis. He was treated with antipsychotics and antidepressants, a short course of benzodiazepines, psychoeducation and family work, with plans for cannabis abstinence and gaming restriction. Psychotic symptoms and suicidality remitted over 4 weeks. At follow-up, up to 3 months, clinical stability was maintained, urine toxicology was negative for cannabis and symptom measures improved. This case illustrates a clinically important temporal and phenomenological association between severe depression, problematic gaming, cannabis use and psychotic decompensation while emphasising that causality cannot be inferred from a single case.