Internet addiction is about to become a new psychological disorder that apparently leads to depression-and one that can be treated with psychotropic drugs.
We're about to create a new Prozac generation-and this time, in the queue for powerful drugs are the adolescents and young adults who 'excessively' surf the Internet, use Facebook or text on their smartphones. From next year, Internet addiction will be classified as a psychological problem that causes depression-one that can be treated with powerful psychotropic drugs such as Prozac, Ritalin and Valium.
Anyone who spends more than 38 hours a week on the Internet, uses Facebook, e-mails or texts on their mobile phones can be defined as an Internet addict-and that probably includes most teenagers for a start.
Next year, the prestigious American Psychiatric Association (APA) will recognize Internet addiction (IA) as a cause of depression. According to the APA's governing body, IA has "all the characteristics of a compulsive-impulsive spectrum disorder that may be treated with powerful psychotropic drugs". The 'problem' is featured in the next edition of the APA's standard work, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which is the reference work for all psychiatrists, to be published next year.
Anyone suspected of being an Internet addict could be prescribed a psychotropic drug, and it won't just be teenagers who fall into this new category. Researcher Tony Dokoupil points out that the "gap between an Internet addict and John Q Public is thin to non-existent. By that definition [of 38 hours' usage a week] we are all addicts now, many of us by Wednesday afternoon, Tuesday if it's a busy day" (Newsweek, July 16, 2012).
It could be a rich harvest for the drugs industry. A survey of regular Internet users found that the average time spent online each day was around two hours, although that falls well short of the five hours of an Internet addict, with education and information-gathering cited as the main usage by 62 per cent. Most needed to use the Internet every day, although 43 per cent admitted they stayed online longer than they anticipated. Overall, nearly 4 per cent of participants could be defined as Internet addicts (Ind Psychiatry J, 2010; 19: 94-100).
The average person of any age sends or receives around 400 texts a month-and that's four times the number recorded in 2007-while the average teenager processes 3700 texts each month.
However, the psychiatrist with prescription pad primed still has a problem. Jerald Block of the American Journal of Psychiatry, the official journal of the APA, points out that nobody sees a psychiatrist for IA. This is not surprising, as no one, other than a few researchers and academics, even knows it exists as a syndrome or necessarily sees it as a problem.
Instead, they seek psychiatric help for a known problem, such as depression, anxiety or aggressive behavior. In fact, 86 per cent of 'Internet addicts' have some other problem, and the average addict has 1.5 other, recognized, diagnoses (Am J Psychiatry, 2008; 165: 306-7).
Indeed, Internet addiction appears to be seen in association with a range of psychiatric problems, such as mood swings, anxiety and substance abuse, and could involve psychological, neurobiological and cultural factors.
However, there's no evidence to suggest that psychotropic medication could help, say researchers from the University of Iowa (CNS Drugs, 2008; 22: 353-65).
A Korea move
Psychiatrists and government health officials in South Korea don't seem to have the same misgivings. They have already identified 168,000 children and adolescents who need psycho-tropic drugs for their Internet addiction, and 50,000 may require hospital care.
The government has trained more than a thousand counsellors, and 190 hospital and special treatment centres have been set up to treat the nation's Internet addicts.
In fact, Internet addiction has become one of South Korea's most serious public health issues. Its escalation-which has put it on a par with drug abuse, cigarette smoking and obesity-is mysterious, and even those most militantly opposed to Internet use can point to only 10 heart attacks suffered by visitors at Internet caf'es, and a murder that was triggered by someone who confused a cyberworld game with reality as possible reasons for the crime.
The South Korean government says that Internet addiction is escalating. The average high school student there spends about 23 hours each week playing computer games, which means that another 1.2 million children will soon fall into the 'Internet addiction' net and be in line for a psychotropic.
There are even bigger spoils to be had in China, South Korea's neighbour. There, around 10 million children are estimated to be Internet addicts, and the Chinese government has introduced laws to discourage more than three hours of PC gaming a day, thereby criminalizing 'excessive' Internet use.
Astonishingly, there is hardly any evidence to support the theory that excessive Internet use causes depression, or worse. The one headline-grabbing study published in 2011 that 'proved' that Facebook, the world's most popular social platform, caused depression has since been discredited.
The American Academy of Pediatrics (AAP) had issued a report that concluded that excessive Facebook use could lead to depression, and advised adolescents in particular to severely limit their time on the platform.
But researchers from the University of Wisconsin say the AAP had been alarmist. Their own research, involving 190 students at the university, found no association between Face-book and depression, let alone as a cause. Parents shouldn't worry as long as their children's behaviour and mood haven't changed, and they still have friends and their schoolwork is consistent, they say (J Adolesc Health, 2012; doi: 10.1016/j.jadohealth. 2012.05.008).
And you won't ever discover that the Internet causes depression because there's no link, say researchers from the Missouri University of Science and Technology. They carried out a 'fly-on-the-wall' study, which came up with the conclusion that the Internet doesn't cause depression, but is a symptom of it. In fact, the way people use the Internet can help to diagnose depression, say the researchers.
They collected data on Internet usage unobtrusively and anonymously-making their study one of the first to collate a true picture rather than relying on participants' honesty when completing a survey form. In all, 216 students participated and remained anonymous through-out. Before beginning the study, the students were tested for depression, and the researchers noted that those who were depressed used the Internet differently. The depressed students used file-sharing services, sent more e-mails and chatted online more than the other students; they were also more likely to watch videos and play games. Overall, the depressed students used the Internet randomly, frequently switching between applications, which suggested poor concentration levels, one clear sign of depression (IEEE Technol Soc Mag, 2012; accepted for publication).
As the Missouri researchers discovered-and as many other hundreds of researchers have also found-there is an association between excessive Internet use and depression. In fact, there is an association to even worse social problems, such as suicide, substance abuse and aggressive behaviour.
But an association doesn't prove a cause. Instead, the Internet and its many digital manifestations is the comfort zone for the already depressed and socially maladroit.
Researchers at the University of Leeds came to this conclusion when they looked at the Internet usage of 1319 people, 18 of whom were identified as Internet addicts. The IA group were far more depressed than non-addicts, and all fell into the moderate-to-severe category of depression.
"Those who show symptoms of IA are likely to engage proportionately more than the normal population in sites that serve as a replacement for real-life socializing," the researchers concluded (Psychopathology, 2010; 43: 121-6).
A similar conclusion was reached when researchers analyzed the mental well-being of 722 online gamers. Those who were in front of their screens the most also had more severe depression and social phobia. However, although women spent less time gaming, they suffered more acute depression and social phobia. Again, the study does not necessarily prove that excessive Internet use causes depression; instead, it again demonstrates that those who are more depressed sit longer in front of their screens (BMC Psychiatry, 2012; 12: 92).
Study after study has seen a similar association, such as the one that discovered that, of
the 307 university students monitored, 4 per cent had IA and 12 per cent had moderate-to-severe depression (BMC Med, 2011; 9: 77).
German researchers confirmed such findings when they profiled 30 Internet addicts-who they call 'pathological Internet users' (PIUs)-and compared them with 31 intensive Internet users who were not 'pathological' in their use. Half of the PIUs had a preexisting psychiatric disorder, such as anxiety, compared
with 12.9 per cent in the
non-PIU group (Psychiatr Prax, 2008; 35: 80-3).
It gets worse
It's not just depression that's associated with Internet addiction. One analysis of previously published studies discovered an association with anxiety, ADHD (attention-eficit/hyperactivity disorder), obsessive-compulsive symptoms and also hostility/aggression (Psychopathology, 2012, July 31; Epub ahead of print).
Others have established an association with substance abuse and even suicidal thoughts. In a study of 275
high-school students in Florence, Italy, 5.4 per cent were classified as Internet addicts, and they were also more likely to drink excessive coffee,
have submissive relationships, gamble, and have patterns of starvation and bingeing (CNS Spectr, 2006; 11: 966-74).
Taiwanese researchers found an association between Internet addiction and conditions like hostility, depression and severe psychiatric problems when they studied the Internet habits of 3662 students (Psychiatry Clin Neurosci, 2008; 62: 9-16).
Heavy Internet users are also more likely to commit suicide, or to at least have suicidal thoughts. One study of 1670 high-school students in Korea concluded that 38.1 per cent of them were "in the early stages of Internet addiction" and 1.5 per cent were heavily addicted. There was a direct association between Internet usage and levels of depression and suicidal thoughts, said the researchers (Taehan Kanho Hakhoe Chi, 2004; 34: 102-10).
The brain changes
And, as if to put the final flourish to the argument, researchers have discovered that Internet addiction changes the physical brain-in particular, gray-matter changes. One magnetic resonance imaging (MRI) study of 18 Internet addicts-who were compared with 15 adolescents who were not frequent Internet users-found that the brain of the addicts had undergone structural changes (Eur J Radiol, 2011; 79: 92-5). A different team of Chinese researchers noted similar changes in the brains of Internet addicts (PLoS One, 2011; 6: e20708), while yet other researchers from China have also detected abnormal white matter in the brains of 17 Internet addicts. They believe the white-matter abnormalities could impair behaviour (PLoS One, 2012; 7: e30253).
However, John Grohol, founder of the PsychCentral Web portal on mental health and an advocate of the Internet, argues that brain changes mean little. "A whole host of activities 'rewire the brain'," he writes, "from learning to drive a car or learning a new foreign language. Every action we take changes our brain chemistry."
Web of deceit
The Internet may not cause depression, much as the drug companies would like it to, but it can be compulsive, addictive and socially isolating, just as television can be, too. However, Internet addicts tend to have addictive personalities, and are likely to be heavy smokers, drinkers or drug-takers, as one study of Greek students discovered. The researchers, from the Technological Educational Institute of Athens, have also coined a new term to describe Internet addicts-'problematic Internet users' (PIUs). PIUs tend to be male, unemployed and to have addictive habits such as smoking, drinking alcohol and/or coffee, and drug use. Their Internet addictions seem to focus on pornographic sites and online games (Cyberpsychol Behav Soc Netw, 2011; 14: 51-8).
German researchers, who prefer the term 'pathological Internet users' (PIUs), reckon that they represent between 1.5 per cent and 8.2 per cent of all users, and they often have preexisting psychiatric disorders such as ADHD and affective disorder (Fortschr Neurol Psychiatr, 2009; 77: 263-71).
Whatever they are called, Internet addicts appear to have an uncontrolled and harmful access to gaming, pornography and e-mails, chat rooms and text messaging. Overuse seems to
be associated with higher levels of aggression and anxiety, say Polish researchers (Postepy Hig Med Dosw [Online], 2009; 63: 8-12).
The extension of Internet behaviours, especially game-playing, into real life for a tiny minority of users has also been recognized by researchers at the Hadassah Medical Organization in Jerusalem. However, nobody truly understands the psychol-ogical mechanisms as to why this happens, so suggesting a treatment is currently not possible (Am J Drug Alcohol Abuse, 2010; 36: 277-83).
It's hard to find any good news about the Internet and texting. Instead, we read a steady flow
of stories about cyberbullying, Internet 'trolls' who leave abusive and upsetting messages, teenagers who spend every waking hour on Facebook or texting, and psychopaths who act out a violent online game in real life.
Now we hear that Internet addiction is a cause of depression, to be treated with powerful drugs.
While all of this is true, and it's also true that the Internet can be isolating and addictive, it all seems to be confusing the medium for the message. As TV presenter Kirstie Allsopp said after she was a victim of abusive 'tweets', to blame Twitter is a little like blaming the existence of paper for the printing of libel.
And, for every case of social isolation, there is one where the Web has helped to bring people closer together. For example, the parents' community website www.mumsnet.com attracts around five million visitors every month who are looking for advice from their virtual extended family about bringing up their children (see box, page 13).
Without doubt, the Internet is a siren call for the
lonely, socially maladroit, the depressed and the psychotic-and these, in the main, become Internet addicts-but it has also been a force for good for the vast majority of users.
However, there is scant evidence to suggest that the Internet causes mental or psychological problems; at worst, it may exacerbate a problem that is already there.
But the idea that this is just cause to drug a whole new generation is frightening for anyone outside of the pharma-ceutical industry, and is far more terrifying a prospect than anything conjured up by the Web.
Factfile: Now for the good news
Computers and the Web can be a force for good, and there's plenty of research to back up this claim.
Combining regular computer use with moderate exercise helps to protect against memory loss. In a study of 926 people aged between 70 and 93, those who exercised regularly and used the computer were less likely to suffer mild cognitive decline, the intermediary stage between normal memory loss with ageing and Alzheimer's. Nearly 38 per cent of those who didn't exercise or use a computer were showing signs of mild cognitive decline compared with just 18 per cent of those who exercised and were on their PC (Mayo Clin Proc, 2012; 87: 437-42).
The Internet also acts as an important support when people feel isolated, or need some friendly advice or sympathy. A study of 1000 women who had suffered a miscarriage discovered that they used website message boards to help them overcome their grief. Astonishingly, many were still coping with the emotional impact up to 20 years later. The most common reason for posting messages was to confirm a feeling that their problem was not unique, researchers from the University of Michigan found (Women's Health Issues, 2011; doi: 10.1016/j.whi.2011.07.006).
In addition, the Internet doesn't just provide psychological support. It can also be used as a therapeutic aid, and it can be as effective as attending group sessions. Tinnitus sufferers who used the Web-based Tinnitus Handicap Inventory therapy programme for 10 weeks saw their 'distress levels' drop to the same measure as those who attended cognitive behavioural sessions (Johannes Gutenberg University Mainz; www.uni-mainz.de/eng/15114.php).
Factfile: Stopping the cyberbully
The Web-and especially the social-networking platform Facebook-has its dark side. Children and adolescents who are singled out for bullying-characterized by offensive remarks left by 'trolls', usually anonymously-can become social outcasts, sometimes leading to suicide or suicidal thoughts.
One case involved an Irish girl, 15-year-old Phoebe Prince, who hanged herself after being tormented by hurtful text messages and posts on Facebook. In another case, teenager Megan Meier committed suicide after the mother of a former friend harassed her.
You might suspect your child is a victim of cyberbullying if he or she:
- shows signs of distress during or after being on the Internet
- becomes protective or secretive about their digital connections
- withdraws from friends and activities
- avoids school and after-school parties
- slips in grades and seems more angry at home
- shows signs of changes in mood, behaviour, sleep or appetite.
If you suspect cyberbullying, talk to your child about any experiences of bullying you suffered when you were at school. This may help your child put the experience in context, and may provide an invitation to start talking.
Practical measures you can carry out include:
- blocking the bully, which can be achieved by changing the computer's settings
- limiting your child's access to computers and mobile phones
- knowing your child's online world by checking their postings and the sites visited
- using the Web to find resources and support groups against cyberbullying.
Factfile: The Web stops depression
Internet-based therapy can help to ease depression, the very condition it's supposed to cause, and its benefits have been established in numerous studies. In one, Internet-based cognitive behavioural therapy worked just as well as a face-to-face session, with the added benefit that patients could choose their own time for the therapy. It's also easier for people to access therapies that often have a long waiting list of patients. The Internet therapy programme helped to ease existing symptoms, and just 10 per cent suffered a relapse, according to a doctoral dissertation by Fredrik Holl"andare at "Orebro University in Sweden.
The Web can also help to prevent depression in the elderly, as several studies have demonstrated. In one, older people who regularly use the Web-dubbed the 'silver surfers'-are one-third less prone to being depressed. A third of over-65s regularly use Facebook and Twitter and, according to University of Alabama researchers, it helps them stay in touch with family and friends (The British Psychological Society, 27 July 2012; www.bps.org.uk/ news/mental-health-benefits-being-silver-surfer).
WDDTY vol 23 no.6