Twitch is a leading platform for video game livestreaming, attracting over 2.5 million daily viewers. Despite the popularity of Twitch, few studies have investigated the psychological factors associated with Twitch use. This study explores the psychological antecedents and behavioral outcomes of healthy and problematic Twitch use. In Study 1, the Problematic Use of Twitch Scale was developed using a sample of 1,544 Twitch users (89.05% men; Mage = 25.36 years, SD = 6.42). The unidimensional, six-item scale yielded strong psychometric properties. According to latent profile analysis (LPA), 1.3% of Twitch users could be at risk of problematic use. In Studies 2 and 3, multiple structural equation models were tested on a sample of 525 Twitch users (81.33% men, Mage = 26.57 years, SD = 6.95; 4.8% at risk of problematic use). Results of Study 2 showed that problematic Twitch use was associated with psychological distress while frequent use was not. Maladaptive daydreaming and stronger need to belong also predicted problematic use. In Study 3, reciprocal contact with a favorite streamer predicted purchasing decisions on the platform. These findings indicate that intensive Twitch use, by itself, is not directly associated with psychological concerns. However, a small minority of excessive Twitch users experience mental health difficulties.