In this blog post we will provide a description of Problematic Internet Use, describe screening measures existing in the field and key unanswered questions, provide clinical patients examples, introduce COST project, suggest a design of an upcoming study, describe applications (“apps”) available for intervention, and will seek patient advocates feedback for the proposed study design, screening measures development and feedback on different digital apps available.

Overview

Problematic Internet Use (PIU) refers to a range of repetitive impairing behaviors, such as excessive video gaming, cybersex, online buying, gambling, streaming, social media use, online searching for health-related info and inability to control the amount of time spent interfacing with digital technology. The reported prevalence of ‘internet addiction’ ranges from 1% to 36.7% (Young 1999, Ko, Yen et al. 2012).

PIU is characterized by over-importance of internet driven activity in one’s life and negative impact to one’s social and emotional life and financial well-being.

Although more studies are needed, cognitive dysfunction relating to decision-making and impulse control might be implicated in the pathogenesis of PIU (Chamberlain, Ioannidis et al. 2018). It is possible that PIU can also occur as a stand-alone problem and thus account for impaired quality of life and decline in relationships quality (Finkenauer, Pollmann et al. 2012).

Currently, following tools are being used to assess PIU: Young’s Internet Addiction Test, the Problematic Internet Use Questionnaire (PIUQ) and the Compulsive Internet Use Scale (CIUS) (Young 1999, Demetrovics, Szeredi et al. 2008, Meerkerk, Van Den Eijnden et al. 2009). More screening tools, assessing impact of PIU components and notably excessive social media use on mental and physical well-being are needed.

Clinical Examples

PIU is often under recognized, and only when specific questions are asked patients start to become more mindful about their patterns of internet use. Some patients report that once they start to look for information on their smartphone for the topic, which particularly interests them, they just cannot stop and proceed till the battery of the phone runs out. Others might spend most of weekly paycheck on internet auctions just for the sake of bidding online for the products they would later not need or return to the seller. Excessive social media use can also be harmful, especially when adolescents join groups and online communities, which would push them to do things classified as risky behavior (for example, excessively lose weight following daily posts on social media, or go to the rooftop of the building and take pictures in dangerous poses).

In a recent analysis of 2006 patients, 181 (9.0%) of which had moderate to severe problematic internet use,  it was found that attention-deficit hyperactivity disorder (ADHD) and social anxiety disorder were associated with high PIU scores in young participants (age ≤ 25), whereas generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD) were associated with high PIU scores in the older participants respectively (Ioannidis, Chamberlain et al. 2016). A recent survey of 1258 students conducted at five universities in Japan concluded that  factors which might predict PIU include female sex, older age, depression, anxiety traits, poor sleep quality and  ADHD tendencies (Kitazawa, Yoshimura et al. 2018).  Tsitsika et al. reported prevalence of PIU to be 14.1% in European countries among 14–17-year old students (N = 13.284) and also emphasized association of PIU with excessive weight and obesity (Tsitsika, Andrie et al. 2016).

Even though the direction of causality remains unclear, PIU is also reported to be associated with substance-use disorders (SUDs) and other physical health disorders, related to sedentary life style (Carli, Durkee et al. 2013, Carter, Rees et al. 2016, Ioannidis, Chamberlain et al. 2016).

COST Project

Currently 22 European countries and the US participate in the COST Action “European Network for Problematic Usage of the Internet” to jointly promote new approaches to study problematic usage of the internet and other related mental and physical disorders.

Suggested Study Design

More clinical trials using digital health care interventions are needed to further investigate factors driving PIU onset and development and determine its physical health correlates.

• Aim 1: Among health care users we will identify individuals with PIU.
  • We will contact, consent and screen for clinically relevant PIU in as many as possible healthcare users.
  • We will determine PIU prevalence
• Aim 2: Define cognitive-behavioral characteristics, levels of depression, anxiety, quality of life and physical well-being in individuals with PIU
  • Ask the respondents to perform key online clinical questionnaires.
  • Perform correlational analyses between PIU metrics and key physical and mental well-being indices.
  • We will determine prevalence of PIU comorbidities
• Aim 3: Define whether utilization of mobile app interventions and providing feedback to patients about their time spent online and on the phone could reduce PIU incidence and its physical and mental health comorbities.

Apps and Tools to Track Time Spent Online

Different apps and software are available to track time being spent on the phone or on the computer. Space app (formerly Breakfree) available on Google Play can not only  assess user’s daily phone usage, but also provides trends of phone use information over the course of 60 days. iOS Moment app can track how many hours per day a person uses iPhone and iPad and to set daily limits. Rescue time program can determine trends in daily online activities, such as use of applications and websites on a personal computer. It also provides a weekly email report with a productivity score, which might help a person to become more mindful about time they spend online.

Online CBT Tools for Depression and Anxiety

Valera health represents a digital intervention, which provides patients with depression and anxiety with self-help tools and connects with health care management team when necessary. myCompass web-based intervention is an Australian public health program, dedicated to individuals with mild-to-moderate mental health problems,  such as depression and anxiety, but also can be useful for physical well-being improvement (for example, diabetes-related distress decrease) (Proudfoot, Clarke et al. 2013, Clarke, Proudfoot et al. 2016).

Wearables and Apps for Behavioral Addictions

Currently, many people use wearable bracelets and smart watches, such as Fitbit  or iWatch not only for step counts, but also to determine disrupted sleep patterns, which are often associated with depression and anxiety symptoms.  Some smart watch manufacturers started to partner with companies providing continuous glucose monitoring (CGM) devices for people with diabetes to enhance their product. These innovations together with data on heart rate, derived from smart watches and Fitbits might help assess individual’s health challenges and provide insights on their better management.

A survey by Kimberly S. Young, international Internet addiction expert and founder of the Center for Internet Addiction, indicated that, among the U.S. Internet-addicted population, about 70% also have another form of addiction–drugs, alcohol, smoking or sex addiction.

The US Food and Drug Administration (FDA) has recently approved a wearable device named Drug Relief for the treatment of opioid withdrawal symptoms, including agitation, anxiety, depression, and opiate cravings. FDA also recently approved an app delivering CBT, named reSET for treatment of alcohol, cocaine, marijuana and stimulant SUDs, as an addition to  traditional outpatient treatment. 

Patient Advocate’s Feedback is Needed to Drive Innovation Further

We welcome patient health advocates, family members and other stakeholders to reach out to us directly to help shape screening tools, participate in a design of a study and develop outcome measures for a global innovative research project related to early detection, treatment and prevention of problematic internet use and its comorbidities.

Excessive use of social media is currently understudied and under recognized. We believe that by providing feedback, i.e. on time spent on these potentially anxiogenic and compulsive activities we may increase their recognition and cut down on their usage. We look forward to hearing from you to hear your story, get your feedback on different digital apps and to jointly develop innovative patient-centered studies, which could really make a change in patients’ quality of life.

You can contact us at [email protected]

References:

1. Carli, V., T. Durkee, D. Wasserman, G. Hadlaczky, R. Despalins, E. Kramarz, C. Wasserman, M. Sarchiapone, C. W. Hoven, R. Brunner and M. Kaess (2013). "The association between pathological internet use and comorbid psychopathology: a systematic review." Psychopathology 46(1): 1-13.
2. Carter, B., P. Rees, L. Hale, D. Bhattacharjee and M. S. Paradkar (2016). "Association Between Portable Screen-Based Media Device Access or Use and Sleep Outcomes: A Systematic Review and Meta-analysis." JAMA Pediatr 170(12): 1202-1208.
3. Chamberlain, S. R., K. Ioannidis and J. E. Grant (2018). "The impact of comorbid impulsive/compulsive disorders in problematic Internet use." J Behav Addict: 1-7.
4. Clarke, J., J. Proudfoot and H. Ma (2016). "Mobile Phone and Web-based Cognitive Behavior Therapy for Depressive Symptoms and Mental Health Comorbidities in People Living With Diabetes: Results of a Feasibility Study." JMIR Ment Health 3(2): e23.
5. Demetrovics, Z., B. Szeredi and S. Rozsa (2008). "The three-factor model of Internet addiction: the development of the Problematic Internet Use Questionnaire." Behav Res Methods 40(2): 563-574.
6. Finkenauer, C., M. M. Pollmann, S. Begeer and P. Kerkhof (2012). "Brief report: examining the link between autistic traits and compulsive Internet use in a non-clinical sample." J Autism Dev Disord 42(10): 2252-2256.
7. Ioannidis, K., S. R. Chamberlain, M. S. Treder, F. Kiraly, E. W. Leppink, S. A. Redden, D. J. Stein, C. Lochner and J. E. Grant (2016). "Problematic internet use (PIU): Associations with the impulsive-compulsive spectrum. An application of machine learning in psychiatry." J Psychiatr Res 83: 94-102.
8. Kitazawa, M., M. Yoshimura, M. Murata, Y. Sato-Fujimoto, H. Hitokoto, M. Mimura, K. Tsubota and T. Kishimoto (2018). "Associations between problematic Internet use and psychiatric symptoms among university students in Japan." Psychiatry Clin Neurosci.
9. Ko, C. H., J. Y. Yen, C. F. Yen, C. S. Chen and C. C. Chen (2012). "The association between Internet addiction and psychiatric disorder: a review of the literature." Eur Psychiatry 27(1): 1-8.
10. Meerkerk, G. J., R. J. Van Den Eijnden, A. A. Vermulst and H. F. Garretsen (2009). "The Compulsive Internet Use Scale (CIUS): some psychometric properties." Cyberpsychol Behav 12(1): 1-6.
11. Proudfoot, J., J. Clarke, M. R. Birch, A. E. Whitton, G. Parker, V. Manicavasagar, V. Harrison, H. Christensen and D. Hadzi-Pavlovic (2013). "Impact of a mobile phone and web program on symptom and functional outcomes for people with mild-to-moderate depression, anxiety and stress: a randomised controlled trial." BMC Psychiatry 13: 312.
12. Tsitsika, A. K., E. K. Andrie, T. Psaltopoulou, C. K. Tzavara, T. N. Sergentanis, I. Ntanasis-Stathopoulos, F. Bacopoulou, C. Richardson, G. P. Chrousos and M. Tsolia (2016). "Association between problematic internet use, socio-demographic variables and obesity among European adolescents." Eur J Public Health 26(4): 617-622.
13. Young, K. S. (1999). "The research and controversy surrounding internet addiction." Cyberpsychol Behav 2(5): 381-383.

Blog Co-Authors:

Dr. Vera Nezgovorova is a clinical research fellow in the Autism, Obsessive Compulsive Spectrum disorders, Anxety and Depression program at Montefiore Medical Center at Albert Einstein College of Medicine, Bronx, NY. She is interested in digital behavioral health interventions, pharmacogenomics and technological advances in healthcare.

Dr. Naomi  Fineberg is the Chair of the COST Action (CA16207) European Network for Problematic Usage of the Internet. She is also the lead psychiatrist in the UK Highly Specialised Service for Obsessive-Compulsive and Related Disorders at Hertfordshire Partnership University NHS Foundation Trust, a visiting professor at the University of Hertfordshire, and current Chair of the World Psychiatric Association Anxiety and Obsessive-Compulsive Disorders Section.

Kyra Citron attends Duke University as a double major in Psychology and Gender, Sexuality, and Feminist Studies. As an advocate and academic, she is interested in an intersectional approach to psychopathology research.
Dr. Jon Grant is a Professor of Psychiatry at the University of Chicago. Dr. Grant completed an undergraduate degree at the University of Michigan, a master's degree at the University of Chicago, a law degree from Cornell University, a medical degree from Brown University, and a masters degree in public health from Harvard University. Dr. Grant is a board-certified psychiatrist.

Dr. Sam Chamberlain is a Welcome Trust Fellow and Honorary Consultant (Board Certified) Psychiatrist, at the University of Cambridge Department of Psychiatry, and Cambridge & Peterborough NHS Foundation Trust, UK. His research focuses on the neurobiology and treatment of addictive, impulsive, and compulsive disorders. Dr. Chamberlain has published widely, and is co-author of several books including ‘Clinical Guide to Obsessive Compulsive and Related Disorders' and ‘Why Can't I Stop? Reclaiming Your Life from a Behavioral Addiction’.