CBT-based intervention may PROTECT against online addiction

PROTECT*, a theory-driven, manualized, CBT**-based intervention targeting internet gaming disorder (IGD) and unspecified internet use disorder (IUD), may help at-risk adolescents fight their battle against behavioural addictions, a study suggests.

“Behavioural addictions were introduced as novel mental disorders in [ICD-11***] based on evidence that human behaviour itself can become addictive, similar to substance addiction,” said the researchers. “However, studies [on IGD and unspecified IUD prevention] lacked randomization, follow-up measurements, and diagnostic interviews that assessed incidence rates. [Our] trial was intended to fill this gap.”

To assess the potential of PROTECT to reduce symptom severity and prevent full syndrome and subthreshold onset of IGD and unspecified IUD, 422 at-risk adolescents (mean age 15.11 years, 54 percent female) were randomized to either the PROTECT (n=167) or the assessment-only programme (n=255 [control]). [JAMA Netw Open 2022;5:e2148995]

As per raw scores, there was an initial increase in symptom severity with PROTECT within the first month, as opposed to a decrease in the control arm. “This paradox reaction could be explained by an elevated awareness of problematic internet behaviour, which was induced by [PROTECT],” the researchers explained.

“It seemed unlikely that the intervention itself was harmful because symptoms significantly decreased at 4 and 12 months,” they continued.

The incremental improvement with PROTECT represented a 40-percent decrease in symptoms over a year vs 28 percent in the control arm, translating to a significantly greater reduction in the severity of IGD and unspecified IUD symptoms with the former vs the latter (γ11=–0.128; p=0.03). “[This suggests] a true effect of [PROTECT] that went beyond mere problem awareness, regression to the mean, or spontaneous remission,” said the researchers.

While fewer participants in the high-risk group within the PROTECT arm developed subthreshold IGD or unspecified IUD than those in the control arm (18 percent vs 30 percent), the power was too low to statistically corroborate the effect, hence the lack of significant reduction in incidence rates of IGD and unspecified IUD (p=0.09).

“[PROTECT] effectively reduced symptoms of [IGD or unspecified IUD] over 12 months, which is a clinically, scientifically, and politically important step in dealing with this newly recognized disorder,” said the researchers. The findings may be used in larger follow-up studies to ascertain its efficacy in reducing incidence rates.

Extra time = high internet usage

The ongoing COVID-19 pandemic has opened the floodgates for excessive internet usage, as work shifted to telecommuting and students attended their classes online. [www.dak.de/dak/bundesthemen/computerspielsucht-2296282.html#, accessed March 31, 2022; J Affect Disord 2020;275:112-118; Am J Addict 2020;29:268-270] The ensuing isolation and cancellation of physically engaging activities created a space for extra unsupervised and unstructured time, noted Dr S Evelyn Stewart from the BC Mental Health & Addictions Research Institute, Vancouver, British Columbia, Canada, in a commentary. [JAMA Netw Open 2022;5:e2149037]

“For many children and youth, the extra time has been filled with internet use and internet gaming … [which] have addictive qualities that could magnify long-term risk,” said Stewart.

A guiding ray of hope

Apart from the comorbid psychiatric disorders, lower life satisfaction, and lower academic achievements associated with IGD and unspecified IUD, Stewart noted physical repercussions tied to it, such as visual and hearing deficits, repetitive strain injuries, sleep deprivation, and nutritional deficits. The lack of motivation to seek treatment also underscores the need for illness onset prevention or early intervention, the investigators added.

“As such, efforts to minimize the impact of these disorders and to rigorously study intervention implications are crucial at this time,” said Stewart. “[The study] exemplified the potential for youth-focused prevention to mitigate the global burden of psychiatric disease given the concurrent onset of mental illnesses during this developmental stage.”

“[This is] a reminder to proactively address subclinical behaviours that are potentially addictive among adolescents. A guiding ray of hope to diminish mental illness in this population may lie in prevention rather than in clinically based interventions after disease onset,” said Stewart.