# WikiJournal Preprints/Digital media use and mental health

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This article is an unpublished pre-print undergoing public peer review organised by the WikiJournal of Medicine.
First submitted: 8 Jun 2019 Reviewer comments
QID: Q99557809
Suggested (provisional) preprint citation format: Digital media use and mental health, Wikidata Q99557809
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This is an open access article distributed under the Creative Commons Attribution ShareAlike License, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited.
Jackie Koerner contact João Peschanski contact Rachel Wexelbaum contact

## Article information

Author: Anon until publication

## Abstract

The delineation between beneficial and pathological use of digital media has not been established. There are no widely accepted diagnostic criteria, although some experts consider overuse a manifestation of underlying psychiatric disorders. The prevention and treatment of pathological digital media use is also not standardised, although guidelines for safer media use for children and families have been developed. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) does not include diagnoses for problematic internet use, problematic social media use, and gaming disorder (commonly known as video game addiction), whereas the eleventh revision of the International Classification of Diseases (ICD-11) recognises gaming disorder. Experts are still debating how and when to diagnose these conditions. The use of the term addiction to refer to these phenomena and diagnoses has also been questioned.
Digital media and screen time have changed how children think, interact and develop in positive and negative ways, but scientists are unsure about the existence of hypothesised causal links between digital media use and mental health outcomes. Those links appear to depend on the individual and the platforms they use. Several large technology firms have made commitments or announced strategies to try to reduce the risks of digital media use.

## History and terminology

The relationship between digital technology and mental health has been investigated from many perspectives. Benefits of digital media use in childhood and adolescent development have been found. Concerns have been expressed by researchers, clinicians and the public in regard to apparent compulsive behaviours of digital media users, as correlations between technology overuse and mental health problems become apparent.
Terminologies used to refer to compulsive digital-media-use behaviours are not standardised or universally recognized. They include "digital addiction", "digital dependence", "problematic use", or "overuse", often delineated by the digital media platform used or under study (such as problematic smartphone use or problematic internet use). Unrestrained use of technological devices may affect developmental, social, mental and physical well-being and may result in symptoms akin to other psychological dependence syndromes, or behavioural addictions. The focus on problematic technology use in research, particularly in relation to the behavioural addiction paradigm, is becoming more accepted, despite poor standardisation and conflicting research.
Internet addiction has been proposed as a diagnosis since the mid-1990s, and social media and its relation to addiction has been examined since 2009. A 2018 Organisation for Economic Co-operation and Development (OECD) report noted the benefits of structured and limited internet use in children and adolescents for developmental and educational purposes, but that excessive use can have a negative impact on mental well-being. It also noted an overall 40% increase in internet use in school age children between 2010 and 2015, and that different OECD nations had marked variations in rates of childhood technology use, as well as differences in the platforms used.
The Diagnostic and Statistical Manual of Mental Disorders has not formally codified problematic digital media use in diagnostic categories, but it deemed internet gaming disorder to be a condition for further study in 2013. Gaming disorder (commonly known as video game addiction) has been recognised in the ICD-11. Different recommendations in the DSM and the ICD are due partly to the lack of expert consensus, the differences in emphasis in the classification manuals, as well as difficulties utilising animal models for behavioural addictions.
The utility of the term addiction in relation to overuse of digital media has been questioned, in regard to its suitability to describe new, digitally mediated psychiatric categories, as opposed to overuse being a manifestation of other psychiatric disorders. Usage of the term has also been criticised for drawing parallels with substance use behaviours. Careless use of the term may cause more problems—both downplaying the risks of harm in seriously affected people, as well as overstating risks of excessive, non-pathological use of digital media. The evolution of terminology relating excessive digital media use to problematic use rather than addiction was encouraged by Panova and Carbonell, psychologists at Ramon Llull University, in a 2018 review.
Due to the lack of recognition and consensus on the concepts used, diagnoses and treatments are difficult to standardise or develop. Heightened levels of public anxiety around new media (including social media, smartphones and video games) further obfuscate population-based assessments, as well as posing management dilemmas. Radesky and Christakis, the 2019 editors of JAMA Paediatrics, published a review that investigated "concerns about health and developmental/behavioural risks of excessive media use for child cognitive, language, literacy, and social-emotional development." Due to the ready availability of multiple technologies to children worldwide, the problem is bi-directional, as taking away digital devices may have a detrimental effect, in areas such as learning, family relationship dynamics, and overall development.

## Problematic use

Though associations have been observed between digital media use and mental health symptoms or diagnoses, causality has not been established; nuances and caveats published by researchers are often misunderstood by the general public, or misrepresented by the media. Females are more likely to overuse social media, and males video games. Following from this, problematic digital media use may not be singular constructs, may be delineated based on the digital platform used, or reappraised in terms of specific activities (rather than addiction to the digital medium).

### Mental health

A 2019 systematic map of reviews suggested associations between some types of potentially problematic internet use and psychiatric or behavioural problems such as depression, anxiety, hostility, aggression and attention deficit hyperactivity disorder (ADHD). The studies could not determine if causal relationships exist, reviewers emphasising the importance of future prospective study designs. While overuse of digital media has been associated with depressive symptoms, digital media may also be utilised in some situations to improve mood. Symptoms of ADHD have been positively correlated with digital media use in a large prospective study. The ADHD symptom of hyperfocus may cause affected people to overuse digital media such as video games or online chatting.
A 2016 technical report by Chassiakos, Radesky, and Christakis identified benefits and concerns in adolescent mental health regarding digital media use. It showed that the manner of social media use was the key factor, rather than the amount of time engaged. A decline in well-being and life satisfaction was found in older adolescents who passively consumed social media, but these were not apparent in those who were more actively engaged. The report also found a U-shaped curvilinear relationship in the amount of time spent on digital media, with risk of depression increasing at both the low and high ends of internet use. A 2018 review into the Chinese social media platform WeChat found associations of self-reported mental health symptoms with excessive platform use. However, the motivations and usage patterns of WeChat users affected overall psychological health, rather than the amount of time spent using the platform. In the United Kingdom, a study of 1,479 individuals aged 14–24 compared psychological benefits and problems for five large social media platforms: Facebook, Instagram, Snapchat, Twitter and YouTube. It concluded that YouTube was the only platform with a net positive rating "based on the 14 health and wellbeing-related questions", and the other platforms measured had net negative ratings, Instagram having the lowest rating. The study identified Instagram as having some positive effects including self-expression, self-identity, and community, but found that these were outweighed by the negative effects, specifically on sleep, body image, and "fear of missing out".
A report published in Clinical Psychological Science in 2018 featured two cross-sectional surveys of 506,820 American high school students, and found that use of digital media was associated with higher rates of depressive symptoms and suicidality. They concluded that more time engaged with electronic devices, and less time on "non-screen activities" (such as in-person social interaction, sports/exercise, homework, and attending religious services) was correlated with depressive symptoms and suicide-related outcomes (suicidal ideation, plans, and attempts), especially among girls. A later report in the same publication questioned the survey's research methodology, citing "inaccurate research measurements, negligible correlations between the main variables, [and] insufficient and inadequate statistical analyses".
The relationship between bipolar disorder and technology use has been investigated in a singular survey of 84 participants for Computers in Human Behavior. The survey found marked variations in technology use based on self-reported mood states. The authors of the report then postulated that for patients with bipolar disorder, technology may be a "double-edged sword", with potential benefits and harms.

### Screen time

A systematic examination of reviews, published in 2019, concluded that evidence, although of mainly low to moderate quality, showed an association of screen time with a variety of health problems including: "adiposity, unhealthy diet, depressive symptoms and quality of life". They also concluded that moderate use of digital media may have benefits for young people in terms of social integration, a curvilinear relationship found with both depressive symptoms and overall well-being. A 2017 United Kingdom large-scale study of this "Goldilocks hypothesis"—of avoiding both too much and too little digital media use—was described as the "best quality" evidence to date by experts and non-government organisations (NGOs) reporting to a 2018 UK parliamentary committee. That study concluded that modest digital media use may have few adverse affects, and some positive associations in terms of well-being.

### Proposed diagnostic categories

Gaming disorder, has been considered by the DSM-5 taskforce as warranting further study (as the subset internet gaming disorder), and has been included in the ICD-11. Concerns have been raised by Aarseth and colleagues over this inclusion, particularly in regard to stigmatisation of heavy gamers.
Christakis has asserted that internet addiction may be "a 21st century epidemic". In 2018, he commented that childhood internet overuse may be a form of "uncontrolled experiment[s] on [...] children". International estimates of the prevalence of internet overuse have varied considerably, with marked variations by nation. A 2014 meta-analysis of 31 nations yielded an overall worldwide prevalence of six percent. A different perspective in 2018 by Musetti and colleagues reappraised the internet in terms of its necessity and ubiquity in modern society, as a social environment, rather than a tool, thereby calling for the reformulation of the internet addiction model.
Some medical and behavioural scientists recommend adding a diagnosis of "social media addiction" (or similar) to the next Diagnostic and Statistical Manual of Mental Disorders update. A 2015 review concluded there was a probable link between basic psychological needs and social media addiction. "Social network site users seek feedback, and they get it from hundreds of people—instantly. It could be argued that the platforms are designed to get users 'hooked'."
Internet sex addiction, also known as cybersex addiction, has been proposed as a sexual addiction characterised by virtual internet sexual activity that causes serious negative consequences to one's physical, mental, social, and/or financial well-being. It may be considered a form of problematic internet use.

### Related phenomena
#### Online problem gambling

A 2015 review found evidence of higher rates of mental health comorbidities, as well as higher amounts of substance use, among internet gamblers, compared to non-internet gamblers. Causation, however, has not been established. The review postulates that there may be differences in the cohorts between internet and land-based problem gamblers.

#### Cyberbullying

Cyberbullying, bullying or harassment using social media or other electronic means, has been shown to have effects on mental health. Victims may have lower self-esteem, increased suicidal ideation, and a variety of emotional responses, including being scared, frustrated, angry or depressed.
According to the EU Kids Online project, the incidence of cyberbullying across seven European countries in children aged 8–16 increased from 8% to 12% between 2010 and 2014. Similar increases were shown in the United States and Brazil.

#### Media multitasking

Concurrent use of multiple digital media streams, commonly known as media multitasking, has been shown to be associated with depressive symptoms, social anxiety, impulsivity, sensation seeking, lower perceived social success and neuroticism. A 2018 review found that while the literature is sparse and inconclusive, overall, heavy media multitaskers also have poorer performance in several cognitive domains. One of the authors commented that the data does not "unambiguously show that media multitasking causes a change in attention and memory", therefore it is possible to argue that it is inefficient to multitask on digital media.

### Assessment and treatment

Rigorous, evidence-based assessment of problematic digital media use is yet to be comprehensively established. This is due partially to a lack of consensus around the various constructs and lack of standardization of treatments. The American Academy of Pediatrics (AAP) has developed a Family Media Plan, intending to help parents assess and structure their family's use of electronic devices and media more safely. It recommends limiting entertainment screen time to two hours or less per day. The Canadian Paediatric Society produced a similar guideline. Ferguson, a psychologist, has criticised these and other national guidelines for not being evidence-based. Other experts, cited in a 2017 UNICEF Office of Research literature review, have recommended addressing potential underlying problems rather than arbitrarily enforcing screen time limits.
Different methodologies for assessing pathological internet use have been developed, mostly self-report questionnaires, but none have been universally recognised as a gold standard. For gaming disorder, both the American Psychiatric Association and the World Health Organization (through the ICD-11) have released diagnostic criteria.
There is some limited evidence of the effectiveness of cognitive behavioural therapy and family-based interventions for treatment. In randomised controlled trials, medications have not been shown to be effective. A 2016 study of 901 adolescents suggested mindfulness may assist in preventing and treating problematic internet use. A 2019 United Kingdom parliamentary report deemed parental engagement, awareness and support to be essential in developing "digital resilience" for young people, and to identify and manage the risks of harm online. Treatment centres have proliferated in some countries, and China and South Korea have treated digital dependence as a public health crisis, opening 300 and 190 centres nationwide, respectively. Other countries have also opened treatment centres.
NGOs, support and advocacy groups provide resources to people overusing digital media, with or without codified diagnoses, including the American Academy of Child and Adolescent Psychiatry.

## Mental health benefits

Individuals with mental illness can develop social connections over social media, that may foster a sense of social inclusion in online communities. Sufferers of mental illness may share personal stories in a perceived safer space, as well as gaining peer support for developing coping strategies. People with mental illness are likely to report avoiding stigma and gaining further insight into their mental health condition by using social media. This comes with the risk of unhealthy influences, misinformation, and delayed access to traditional mental health outlets.
Other benefits include connections to supportive online communities, including illness or disability specific communities, as well as the LGBTQI community. Furthermore, in children, the educational benefits of digital media use are well established.

## Other disciplines
### Digital anthropology

Daniel Miller from University College London has contributed to the study of digital anthropology, especially ethnographic research on the use and consequences of social media and smartphones as part of the everyday life of ordinary people around the world. He notes the effects of social media are very specific to individual locations and cultures. He contends "a layperson might dismiss these stories as superficial. But the anthropologist takes them seriously, empathetically exploring each use of digital technologies in terms of the wider social and cultural context."
Digital anthropology is a developing field which studies the relationship between humans and digital-era technology. It aims to consider arguments in terms of ethical and societal scopes, rather than simply observing technological changes. Brian Solis, a digital analyst and anthropologist, stated in 2018, "we've become digital addicts: it's time to take control of technology and not let tech control us".

### Digital sociology

Digital sociology explores how people utilise digital media using several research methodologies, including surveys, interviews, focus groups, and ethnographic research. It intersects with digital anthropology, and studies cultural geography. It also investigates longstanding concerns, and contexts around young people's overuse of "these technologies, their access to online pornography, cyber bullying or online sexual predation".
A 2012 cross-sectional sociological study in Turkey showed differences in patterns of internet use that related to levels of religiosity in 2,698 subjects. With increasing religiosity, negative attitudes towards internet use increased. Highly religious people showed different motivations for internet use, predominantly searching for information. A study of 1,296 Malaysian adolescent students found an inverse relationship between religiosity and internet addiction tendency in females, but not males.
A 2018 review published in Nature considered that young people may have different experiences online, depending on their socio-economic background, noting lower-income youths may spend up to three hours more per day using digital devices, compared to higher-income youths. They theorised that lower income youths, that are already vulnerable to mental illness, may be more passive in their online engagements, being more susceptible to negative feedback online, with difficulty self-regulating their digital media use. It concluded that this may be a new form of digital divide between at-risk young people and other young people, pre-existing risks of mental illness becoming amplified among the already vulnerable population.

### Neuroscience

Dar Meshi and colleagues noted in 2015 that "[n]euroscientists are beginning to capitalise on the ubiquity of social media use to gain novel insights about social cognitive processes". A 2018 neuroscientific review published in Nature found the density of the amygdala, a brain region involved in emotional processing, is related to the size of both offline and online social networks in adolescents. They considered that this and other evidence "suggests an important interplay between actual social experiences, both offline and online, and brain development". The authors postulated that social media may have benefits, namely social connections with other people, as well as managing impressions people have of other people such as "reputation building, impression management, and online self-presentation". It identified "adolescence [as] a tipping point in development for how social media can influence their self-concept and expectations of self and others", and called for further study into the neuroscience behind digital media use and brain development in adolescence. Although brain imaging modalities are under study, neuroscientific findings in individual studies often fail to be replicated in future studies, similar to other behavioural addictions; as of 2017, the exact biological or neural processes that could lead to excessive digital media use are unknown.

## Digital mental health care

Digital technologies have also provided opportunities for delivery of mental health care online; benefits have been found with computerised cognitive behavioural therapy for depression and anxiety. Research of digital health interventions in young people is preliminary, with a meta-review unable to draw firm conclusions because of problems in research methodology. Potential benefits according to one review include "the flexibility, interactivity, and spontaneous nature of mobile communications [...] in encouraging persistent and continual access to care outside clinical settings". Mindfulness based online intervention has been shown to have small to moderate benefits on mental health. The greatest effect size was found for the reduction of psychological stress. Benefits were also found regarding depression, anxiety, and well-being. Smartphone applications have proliferated in many mental health domains, with "demonstrably effective" recommendations listed in a 2016 review encouraging cognitive behavioural therapy, addressing both anxiety and mood. The review did however call for more randomised controlled trials to validate the effectiveness of their recommendations when delivered by digital apps.
The Lancet commission on global mental health and sustainability report from 2018 evaluated both benefits and harms of technology. It considered the roles of technologies in mental health, particularly in public education; patient screening; treatment; training and supervision; and system improvement.

## Industry and government

Several technology firms have implemented changes intending to mitigate the negative effects of excessive use of their platforms, and in Japan, China and South Korea legislative and/or regulatory governmental efforts have been enacted to address the interrelated issues.
In December 2017, Facebook admitted passive consumption of social media could be harmful to mental health, although they said active engagement can have a positive effect. In January 2018, the platform made major changes to increase user engagement. In January 2019, Facebook's then head of global affairs, Nick Clegg, responding to criticisms of Facebook and mental health concerns, stated they would do "whatever it takes to make this environment safer online especially for youngsters". Facebook admitted "heavy responsibilities" to the global community, and invited regulation by governments. In 2018 Facebook and Instagram announced new tools that they asserted may assist with overuse of their products. In 2019, Instagram, which has been investigated specifically in one study in terms of addiction, began testing a platform change in Canada to hide the number of "likes" and views that photos and videos received in an effort to create a "less pressurised" environment. It then continued this trial in Australia, Italy, Ireland, Japan, Brazil and New Zealand. The platform also developed artificial intelligence to counter cyberbullying.
China's Ministry of Culture has enacted several public health efforts from as early as 2006 to address gaming and internet related disorders. In 2007, an "Online Game Anti-Addiction System" was implemented for minors, restricting their use to 3 hours or less per day. The ministry also proposed a "Comprehensive Prevention Program Plan for Minors’ Online Gaming Addiction" in 2013, to promulgate research, particularly on diagnostic methods and interventions. China's Ministry of Education in 2018 announced that new regulations would be introduced to further limit the amount of time spent by minors in online games. In response, Tencent, the owner of WeChat and the world's largest video game publisher, restricted the amount of time that children could spend playing one of its online games, to one hour per day for children 12 and under, and two hours per day for children aged 13–18.
In 2018, Alphabet Inc released an update for Android smartphones, including a dashboard app enabling users to set timers on application use. Apple Inc purchased a third-party application and then incorporated it in w:iOS 12 to measure "screen time". Journalists have questioned the functionality of these products for users and parents, as well as the companies' motivations for introducing them. Alphabet has also invested in a mental health specialist, Quartet, which uses machine learning to collaborate and coordinate digital delivery of mental health care.
South Korea has eight government ministries responsible for public health efforts in relation to internet and gaming disorders, a review article published in Prevention Science in 2018 stating that the "region is unique in that its government has been at the forefront of prevention efforts, particularly in contrast to the United States, Western Europe, and Oceania." Efforts are coordinated by the Ministry of Science and ICT, and include awareness campaigns, educational interventions, youth counselling centres, and promoting healthy online culture.
Two institutional investors in Apple Inc, JANA Partners LLC and the California State Teachers' Retirement System, stated in 2018 that they "believe[d] both the content and the amount of time spent on phones need to be tailored to youths". They called on Apple Inc to act before regulators and consumers potentially force them to do so. Apple Inc responded that they have, "always looked out for kids, and [they] work hard to create powerful products that inspire, entertain, and educate children while also helping parents protect them online". The firm is planning new features that they asserted may allow them to play a pioneering role in regard to young people's health.
Japan's Ministry of Internal Affairs and Communications coordinates Japanese public health efforts in relation to problematic internet use and gaming disorder. Legislatively, the Act on Development of an Environment that Provides Safe and Secure Internet Use for Young People was enacted in 2008, to promote public awareness campaigns, and support NGOs to teach young people safe internet use skills.