This article needs more reliable medical references for verification or relies too heavily on primary sources. Please review the contents of the article and add the appropriate references if you can. Unsourced or poorly sourced material may be challenged and removed. Find sources: "Digital media use and mental health" – news · newspapers · books · scholar · JSTOR (December 2023)

The relationships between digital media use and mental health have been investigated by various researchers—predominantly psychologists, sociologists, anthropologists, and medical experts—especially since the mid-1990s, after the growth of the World Wide Web. A significant body of research has explored "overuse" phenomena, commonly known as "digital addictions", or "digital dependencies". These phenomena manifest differently in many societies and cultures. Some experts have investigated the benefits of moderate digital media use in various domains, including in mental health, and the treatment of mental health problems with novel technological solutions.

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 standardized, although guidelines for safer media use for children and families have been developed. The 2013 fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-11) do not include diagnoses for problematic internet use and problematic social media use; the ICD-11 includes a diagnosis for gaming disorder (commonly known as video game addiction), whereas the DSM-5 does not. Debate over how and when to diagnose these conditions is ongoing as of 2023. The use of the term addiction to refer to these phenomena and diagnoses has been questioned.

Digital media and screen time have changed how children think, interact and develop in positive and negative ways, but researchers are unsure about the existence of hypothesized 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.[1][2][3] Benefits of digital media use in childhood and adolescent development have been found.[4][5] Concerns have been expressed by researchers, clinicians and the public in regard to apparent compulsive behaviors of digital media users, as correlations between technology overuse and mental health problems become apparent.[1][5][6][7]

Terminologies used to refer to compulsive digital-media-use behaviours are not standardized or universally recognised. 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).[8] 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 behavioral addictions.[9][7] The focus on problematic technology use in research, particularly in relation to the behavioural addiction paradigm, is becoming more accepted, despite poor standardization and conflicting research.[10]

Internet addiction has been proposed as a diagnosis since the 1998[11] and social media and its relation to addiction has been examined since 2009.[12] A 2018 Organisation for Economic Co-operation and Development (OECD) report stated there were 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.[13]

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.[14] Gaming disorder, commonly known as video game addiction, has been recognised in the ICD-11.[15][16] 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 using animal models for behavioural addictions.[9]

The utility of the term addiction in relation to the 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.[2][3] 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.[3] 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.[17]

Due to the lack of recognition and consensus on the concepts used, diagnoses and treatments are difficult to standardize 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.[2] Radesky and Christakis, the 2019 editors of JAMA Paediatrics, published a review that investigated "concerns about health and developmental/behavioral risks of excessive media use for child cognitive, language, literacy, and social-emotional development."[18] 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.[19]

Problematic use

See also: Digital Revolution, Social aspects of television, and Television consumption

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.[3] Females are more likely to overuse social media, and males video games.[20] 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).[21]

In 1890, 1 percent of U.S. households owned at least one telephone, while a majority did by 1946 and 75 percent did by 1957.[22][23] In 1908, 1 percent of U.S. households owned at least one automobile, while 50 percent did by 1948 and 75 percent did by 1960.[24][23] In 1948, 1 percent of U.S. households owned at least one television while 75 percent did by 1955,[23] and by 1992, 60 percent of all U.S. households received cable television subscriptions.[25] In 1980, 1 percent of U.S. households owned at least one videocassette recorder while 75 percent did by 1992.[23] From 1970 to 1999, the percentage of U.S. children aged 11–12 with a television in their bedroom grew from 6 percent to 77 percent.[26]

In 2000, a majority of U.S. households had at least one personal computer and internet access the following year.[27] In 2002, a majority of U.S. survey respondents reported having a mobile phone.[28] In September and December 2006 respectively, Luxembourg and the Netherlands became the first countries to completely transition from analog to digital television, while the United States commenced its transition in 2008. In September 2007, a majority of U.S. survey respondents reported having broadband internet at home.[29] In January 2013, a majority of U.S. survey respondents reported owning a smartphone.[30] According to estimates from Nielsen Media Research, approximately 45.7 million U.S. households in 2006 (or approximately 40 percent of approximately 114.4 million) owned a dedicated home video game console,[31][32] and by 2015, 51 percent of U.S. households owned a dedicated home video game console according to an Entertainment Software Association annual industry report.[33][34]

Screen time and mental health

See also: Criticism of Facebook § Psychological/sociological effects, and Social media and suicide

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 and reviewers emphasized the importance of future prospective study designs.[1] While overuse of digital media has been associated with depressive symptoms, digital media may also be used in some situations to improve mood.[35][36] Symptoms of ADHD have been positively correlated with digital media use in a large prospective study.[37] The ADHD symptom of hyperfocus may cause affected individuals to overuse video games, social media, or online chatting, however the correlation between hyperfocus and problematic social media use is weak.[38]

A 2016 review by Chassiakos, Radesky, and Christakis identified benefits and concerns in adolescent mental health regarding digital media use. It found 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 the risk of depression increasing at both the low and high ends of internet use.[4]

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.[7] 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".[39]

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.[40]

In February 2019, experimental psychologists Amy Orben and Andrew K. Przybylski published a specification curve analysis of data from the Monitoring the Future survey, the Millennium Cohort Study, and the Youth Risk Behavior Surveillance System that included a total of 355,358 subjects in Nature Human Behaviour to examine the correlational evidence for negative effects of digital technology on adolescent well-being and found that digital technology use accounted for only 0.4% of the variance and that such a small change did not require public policy changes and that the weight given to digital screen time in scientific and public discourse is outsized.[41] In May 2019, Orben and Przybylski published a subsequent specification curve analysis in Psychological Science of three nationally representative samples from data sets including 17,247 subjects from the Republic of Ireland, the United States, and the United Kingdom including time-use diary studies and found little evidence for substantial negative associations for digital screen engagement and adolescent well-being and noted that correlations between retrospective self-reports and time diaries are too low for retrospective self-reports to be useful.[42]

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.[6]

A research study done on urban adolescents in China revealed that more than a quarter of adolescents in China were exposed to over 2 hours of screen time per day. They found that screen time and physical activity was independently associated with mental health. Specifically, an increase in screen time and decrease in physical activity contributed to an additional risk for mental health productivity by increasing depressive anxiety symptoms and life dissatisfaction.[43]

A 2017 UK large-scale study of the "Goldilocks hypothesis"—of avoiding both too much and too little digital media use[44]—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.[45]

Social media and mental health

A 2022 umbrella review found there had been a "staggering increase" in recent studies looking at the relationship between mental health and social media use.[46] Excessive time spent on social media may be more harmful than digital screen time as a whole. The review reported that several of the review-level articles published between 2019 and mid-2021 found a "substantial" association between social media use and mental health issues, but most found only a weak or inconsistent relationship.[46][47][48] One of the 2020 meta studies finding only a small negative association between social media use and negative mental health outcomes still described it as significant.[49] A systematic review published in 2023 found there is nuanced evidence for a relationship between social media usage and flourishing, with the potential for this positive association to become stronger.[50]

The 2019 Orben and Przybylski study has been much cited, and influential in supporting the view that there is little evidence to link digital usage with negative mental health outcomes. The study attracted responses from psychologists Jean Twenge, Andrew B. Blake, Jonathan Haidt, and W. Keith Campbell. They accepted that they could reach the same conclusion if they analysed the data in the same way that Orben and Przybylski had chosen to do so. But they found much stronger evidence of a negative association if they focused on social media, rather than digital screen time in the broadest sense, which includes watching TV and playing video games. Using the same data as Orben and Przybylski, they found an especially strong negative association between social media and mental health if they focussed just on the effect social media usage has on girls.[51][52]

A study by The Lancet Child & Adolescent Health in 2019 showed a relationship between social media use by girls and an increase in their exposure to bullying plus a reduction in sleep and exercise.[53]

A US study done in 2019 found an association between social media and depression in adolescence. Based on the upward social comparison, it may be that repeated exposure to idealized images lowers adolescents' self-esteem, triggers depression, and enhances depression over time. Furthermore, heavier users of social media with depression appear to be more negatively affected by their time spent on social media, potentially by the nature of the information that they select (e.g., blog posts about self-esteem issues), consequently potentially maintaining and enhancing depression over time.[54] A 2022 meta-study also found a significant association between social media use and depression, with the association especially high for adolescent girls.[55]

ADHD

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This article needs more reliable medical references for verification or relies too heavily on primary sources. Please review the contents of the article and add the appropriate references if you can. Unsourced or poorly sourced material may be challenged and removed. Find sources: "Digital media use and mental health" – news · newspapers · books · scholar · JSTOR (December 2023)

Main articles: Attention deficit hyperactivity disorder, Like button, and Suicide in the United States § Health or Disability

See also: Criticism of Facebook § Facebook addiction, Facebook like button, Human multitasking, Law of effect, Mobile phones and driving safety, Problematic smartphone use, Problematic social media use, and Texting while driving

In September 2014, Developmental Psychology published a meta-analysis of 45 studies investigating the relationship between media use and ADHD-related behaviours in children and adolescents and found a small but significant relationship between media use and ADHD-related behaviours.[56] In March 2016, Frontiers in Psychology published a survey of 457 post-secondary student Facebook users (following a face validity pilot of another 47 post-secondary student Facebook users) at a large university in North America showing that the severity of ADHD symptoms had a statistically significant positive correlation with Facebook usage while driving a motor vehicle and that impulses to use Facebook while driving were more potent among male users than female users.[57] In June 2018, Children and Youth Services Review published a regression analysis of 283 adolescent Facebook users in the Piedmont and Lombardy regions of Northern Italy (that replicated previous findings among adult users) showing that adolescents reporting higher ADHD symptoms positively predicted Facebook addiction, persistent negative attitudes about the past and that the future is predetermined and not influenced by present actions, and orientation against achieving future goals, with ADHD symptoms additionally increasing the manifestation of the proposed category of psychological dependence known as "problematic social media use."[58]

In July 2018, the Journal of the American Medical Association published a two-month longitudinal cohort survey of 3,051 U.S. teenagers ages 15 and 16 (recruited at 10 different Los Angeles County, California secondary schools by convenience sampling) self-reporting engagement in 14 different modern digital media activities at high-frequency. 2,587 subjects had no significant symptoms of ADHD at baseline with a mean number of 3.62 modern digital media activities used at high-frequency and each additional activity used frequently at baseline positively correlating with a significantly higher frequency of ADHD symptoms at follow-ups. 495 subjects who reported no high-frequency digital media activities at baseline had a 4.6% mean rate of having ADHD symptoms at follow-ups, as compared with 114 subjects who reported 7 high-frequency activities who had a 9.5% mean rate at follow-ups and 51 subjects with 14 high-frequency activities who had a 10.5% mean rate at follow-ups (indicating a statistically significant but modest association between higher frequency of digital media use and subsequent symptoms of ADHD).[59][60][61] In October 2018, PNAS USA published a systematic review of four decades of research on the relationship between children and adolescents' screen media use and ADHD-related behaviours and concluded that a statistically small relationship between children's media use and ADHD-related behaviours exists.[62]

In April 2019, PLOS One published the results of a longitudinal birth cohort study of screen-time use reported by parents of 2,322 children in Canada at ages 3 and 5 and found that compared to children with less than 30 minutes per day of screen-time, children with more than 2 hours of screen-time per day had a 7.7-fold increased risk of meeting criteria for ADHD.[63] In January 2020, the Italian Journal of Pediatrics published a cross-sectional study of 1,897 children from ages 3 through 6 attending 42 kindergartens in Wuxi, China that also found that children exposed to more than 1 hour of screen-time per day were at increased risk for the development of ADHD and noted its similarity to a finding relating screen-time and the development of autism (ASD).[64] In November 2020, Infant Behavior and Development published a study of 120 3-year-old children with or without family histories of ASD or ADHD (20 with ASD, 14 with ADHD, and 86 for comparison) examining the relationship between screen time, behavioural outcomes, and expressive/receptive language development that found that higher screen time was associated with lower expressive/receptive language scores across comparison groups and that screen time was associated with behavioral phenotype, not family history of ASD or ADHD.[65]

In 2015, Preventive Medicine Reports published a multivariate linear and logistic regression study of 7,024 subjects aged 6–17 in the Maternal and Child Health Bureau's 2007 National Survey of Children's Health examining the association between bedroom televisions and screen time in children and adolescents diagnosed with ADHD that found that 59 percent of subjects had a bedroom television, subjects with bedroom televisions averaged 159.1 minutes of screen time per weekday versus 115.2 minutes per weekday for those without, and after adjusting for child and family characteristics, a bedroom television was associated with 25.1 minutes more of screen time per weekday and a 32.1 percent higher probability of average weekday screen time exceeding 2 hours.[66] In July 2021, Sleep Medicine published a correlational study of 374 French children with a mean age of 10.8±2.8 years where parents completed the Sleep Disturbance Scale for Children (SDSC), the ADHD Rating Scale, and a questionnaire about the subjects screen time habits during the morning, afternoon, and evening that found that subjects with bedroom televisions had greater sleep disturbance and ADHD symptoms, that evening screen time was associated with higher SDSC and ADHD scores, and that structural equation modeling demonstrated that evening screen time was directly associated with greater sleep disturbance which in turn was directly associated with greater ADHD symptoms.[67]

In 2021, the journal Globalization and Health Article published a study (Shuaia et. al. 2021) titled Influences of digital media use on children and adolescents with ADHD during COVID-19 pandemic. They explored the influence of digital media on the core symptoms, emotional state, life events, learning motivation, executive function (EF), and family environment of children and adolescents diagnosed with ADHD. They included participants age 8 to 16 who met the criteria for ADHD and included a group who had problematic digital media use (PDMU) and a group who met the ADHD criteria who did not have PDMU. The study analysed the differences between the groups in ADHD symptoms, EF, anxiety, and depression, stress from life events, learning motivation, and family environment were compared respectively. The research concluded that the ADHD children with PDMU displayed more severe symptoms, negative emotions, impairments in executive functioning, difficulties in family functioning, pressure from life events, and a lower learning motivation than those who did not have PMDU. The research suggested that for children and adolescents who struggle with ADHD, it is essential to supervise digital media usage and increase physical exercise for better management of core symptoms and other associated difficulties associated with ADHD.[68]

Researchers Siddharth Sagar, Dr. Navin Kumar published a study in Psychology and Education, titled Usages of Social Media and Symptoms of Attention Deficit Hyperactivity Disorder (ADHD): A Cross-Sectional Study. The study aimed to empirically test the association between social media usage and ADHD. They hypothesized that social media users will significantly differ in demographic variables such as age, gender, and education and that ADHD would be significantly associated with social media usage. The study did suggest that ADHD is significantly associated with addictive or excessive social media use and that addictive social media use was associated with being female, being a young individual, and with undergraduate-aged individuals. It further concluded that ADHD is more prevalent in individuals with high social media usage. The authors suggested this may be due to social media being an ideal outlet for constant touching, fidgeting, and frequent shifts from one activity to another when bored or feeling inattentive. These are common ADHD behaviours (American Psychiatric Association, 2013).[69]

Autism

Main articles: Autism spectrum, Suicide in the United States § Health or Disability, and Video game addiction

See also: Evolutionary psychiatry § Autism spectrum disorder (ASD), PC bang, and Video games in the United States

In April 2018, Child and Adolescent Psychiatric Clinics of North America published a study of data from the American Academy of Child and Adolescent Psychiatry that found that children with ASD surveyed spent 4.5 hours more per day on screen time than typically developing peers, that children with ASD spent most of their free time on screen time as compared with 18% of typically developing peers, and that children with ASD played video games 1 hour more per day than typically developing peers and tended to prefer video games over television. Conversely, more than half of children with ASD surveyed had never played with a friend over electronic media, with only 15% engaging with friends in this way on a weekly basis and 64% using electronic media primarily non-socially (e.g. to play video games alone or with strangers, or surfing gaming web sites).[70]

In October 2018, Evidence-Based Mental Health published a meta-analysis of 47 data sets using a random effects model to examine associations between sleep problems and ASD on 14 subjective and 14 objective sleep parameters and found that as compared with control groups, ASD participants differed significantly on 10 of the 14 subjective parameters and 7 of the 14 objective parameters.[71] In November 2018, the Journal of Autism and Developmental Disorders published a study examining associations between environmental factors physical activity and screen time among 1,380 children with ASD and 1,411 children without ASD and found that the absence of a bedroom television and neighbourhood support for children without ASD were associated with physical activity, while a bedroom television and no parental limits on screen time was associated with screen time for children with ASD.[72]

In February 2021, Frontiers in Psychiatry published a study of 101 children with ASD and 57 children without ASD to examine the relationship between screen time of children with ASD and their development quotients and found that screen time for children with ASD was longer among children with ASD (3.34 ± 2.64 hours) than children without (0.91 ± 0.93 hours) and screen time for children with ASD was positively correlated with the Childhood Autism Rating Scale.[73]

Insomnia

Main articles: Insomnia and Screen time § Sleep

See also: Circadian rhythm, Circadian rhythm sleep disorder, Light effects on circadian rhythm, Obesity, and Obesity in the United States

In May 2019, Sleep Medicine published a study of 2,865 U.S. adolescents at the age 15 follow-up of the Fragile Families and Child Wellbeing Study who completed surveys quantifying personal sleep duration and insomnia symptoms, screen time use of social messaging, web surfing, television or movie watching, and gaming, and depressive systems and the researchers constructed a multiple mediation model while controlling for depressive symptoms at age 9 to identify associations between age 15 screen time, sleep, and depressive symptoms, and found through structural equation modeling that the association for social messaging, web surfing, and television and movie watching, the three sleep variables fully mediated the positive association between screen time and depressive symptoms while for gaming the sleep variables only accounted for 38.5% of the association between gaming and depressive symptoms.[74]

In November 2019, Psychiatry Research published a study of a nationally representative sample of 14,603 U.S. adolescents aged 14–18 years from the 2017 Youth Risk Behavior Survey examining the association between excessive screen time and behaviours and insufficient sleep among adolescents using a logistic regression with insufficient sleep and the excessive screen time behaviours as the outcome and explanatory variables respectively and found that the odds for adolescents engaging in excessive screen time behaviours to be receiving insufficient sleep (controlling for all other predictors) was 1.34 times higher than adolescents not engaging in excessive screen time behaviours, with 74.8% of adolescents in the survey receiving less than 8 hours of sleep on an average school night and 43% engaging in excessive screen behaviours.[75]

In February 2020, Sleep Medicine Reviews published a systematic review of 31 studies examining associations between screen time or movement behaviours (sedentary vs. physical activity) and sleep outcomes in children younger than 5 years following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and that performed a Grading of Recommendations Assessment, Development and Evaluation with subjects stratified by age and found that screen time is associated with poorer sleep outcomes for children under the age of 5, with meta-analysis only confirming poor sleep outcomes among children under 2 years while for movement behaviours evidence was mixed but that physical activity and outdoor play among children 1–4 were favorably associated.[76]

NPD

Main articles: Narcissistic personality disorder, Dark triad, and Like button

See also: Criticism of Facebook § Narcissism, Facebook like button, Fear of missing out, Law of effect, Malignant narcissism, Mass shootings in the United States § Contributing factors, Microblogging, Objectification, Reblogging, Selfie, Slacktivism, Tokenism, Virtue signalling, and White savior

In July 2018, a meta-analysis published in Psychology of Popular Media found that grandiose narcissism positively correlated with time spent on social media, frequency of status updates, number of friends or followers, and frequency of posting self-portrait digital photographs,[77] while a meta-analysis published in the Journal of Personality in April 2018 found that the positive correlation between grandiose narcissism and social networking service usage was replicated across platforms (including Facebook and Twitter).[78] In March 2020, the Journal of Adult Development published a regression discontinuity analysis of 254 Millennial Facebook users investigating differences in narcissism and Facebook usage between the age cohorts born from 1977 to 1990 and from 1991 to 2000 and found that the later born Millennials scored significantly higher on both.[79] In June 2020, Addictive Behaviors published a systematic review finding a consistent, positive, and significant correlation between grandiose narcissism and problematic social media use.[80] Also in 2018, social psychologist Jonathan Haidt and FIRE President Greg Lukianoff noted in The Coddling of the American Mind that former Facebook president Sean Parker stated in a 2017 interview that the Facebook like button was consciously designed to prime users receiving likes to feel a dopamine rush as part of a "social-validation feedback loop".[81]

Proposed diagnostic categories

See also: Internet addiction disorder, Internet sex addiction, Nomophobia, Problematic smartphone use, Problematic social media use, and Video game addiction

Gaming disorder has been considered by the DSM-5 task force as warranting further study (as the subset internet gaming disorder), and was included in the ICD-11.[14] Concerns have been raised by Aarseth and colleagues over this inclusion, particularly in regard to stigmatization of heavy gamers.[82]

Christakis has asserted that internet addiction may be "a 21st century epidemic".[83] In 2018, he commented that childhood Internet overuse may be a form of "uncontrolled experiment[s] on ... children".[84] 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.[85] 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.[86]

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.[87][88][7] 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'."[89]

Internet sex addiction, also known as cybersex addiction, has been proposed as a sexual addiction characterized by virtual internet sexual activity that causes serious negative consequences to one's physical, mental, social, and/or financial well-being.[90][91] It may be considered a form of problematic internet use.[92]

Related phenomena

Online problem gambling

Main article: Online gambling § 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.[93]

Cyberbullying

Main article: 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, decreased motivation for usual hobbies, and a variety of emotional responses, including being scared, frustrated, angry, anxious or depressed. These victims may also begin to distance themselves from friends and family members.[94][95][96]

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.[97]

Media multitasking

Main article: 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.[98] A 2018 review found that while the literature is sparse and inconclusive, overall, heavy media multitaskers also have poorer performance in several cognitive domains.[99] 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.[100]

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.[101] 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.[102][103] The Canadian Paediatric Society produced a similar guideline. Ferguson, a psychologist, has criticised these and other national guidelines for not being evidence-based.[104] 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.[3]

Different methodologies for assessing pathological internet use have been developed, mostly self-report questionnaires, but none have been universally recognised as a gold standard.[105] For gaming disorder, both the American Psychiatric Association[106] and the World Health Organization (through the ICD-11)[15] have released diagnostic criteria.

There is some limited evidence of the effectiveness of cognitive behavioral therapy and family-based interventions for treatment. In randomized controlled trials, medications have not been shown to be effective.[101] A 2016 study of 901 adolescents suggested mindfulness may assist in preventing and treating problematic internet use.[107] A 2019 UK 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.[45] 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.[108] Other countries have also opened treatment centres.[109][110]

NGOs, support and advocacy groups provide resources to people overusing digital media, with or without codified diagnoses,[111][112] including the American Academy of Child and Adolescent Psychiatry.[113][114]

A 2022 study outlines the mechanisms by which media-transmitted stressors affect mental well-being. Authors suggest a common denominator related to problems with the media's construction of reality is increased uncertainty, which leads to defensive responses and chronic stress in predisposed individuals.[115]

Mental health benefits

Smartphones and other digital devices are ubiquitous in many societies.

Individuals with mental illness can develop social connections over social media, that may foster a sense of social inclusion in online communities.[4][5] People with mental illness may share personal stories in a perceived safer space, as well as gaining peer support for developing coping strategies.[4][5]

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.[4]

Other benefits include connections to supportive online communities, including illness or disability specific communities, as well as the LGBTQIA community.[5] Young cancer patients have reported an improvement in their coping abilities due to their participation in an online community.[116] The uses of social media for healthcare communication include providing reducing stigma and facilitating dialogue between patients and between patients and health professionals.[117]

Furthermore, in children, the educational benefits of digital media use are well established.[4] For example, screen-based programs can help increase both independent and collaborative learning. A variety of quality apps and software can also decrease learning gaps and increase skill in certain educational subjects.[118]

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."[119]

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.[120] 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".[121]

Digital sociology

Digital sociology explores how people use 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".[122]

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.[123] A study of 1,296 Malaysian adolescent students found an inverse relationship between religiosity and internet addiction tendency in females, but not males.[124]

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.[125] They theorized that lower-income youths, who 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.[125]

Neuroscience

Dar Meshi and colleagues noted in 2015 that "[n]euroscientists are beginning to capitalize on the ubiquity of social media use to gain novel insights about social cognitive processes".[126] 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.[127] 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.[3]

Impact on cognition

There is research and development about the cognitive impacts of smartphones and digital technology. A group reported that, contrary to widespread belief, scientific evidence does not show that these technologies harm biological cognitive abilities and that they instead only change predominant ways of cognition – such as a reduced need to remember facts or conduct mathematical calculations by pen and paper outside contemporary schools. However, some activities – like reading novels – that require long focused attention-spans and do not feature ongoing rewarding stimulation may become more challenging in general.[128][129] How extensive online media usage impacts cognitive development in youth is under investigation[130] and impacts may substantially vary by the way and which technologies are being used – such as which and how digital media platforms are being used – and how these are designed. Impacts may vary to a degree such studies have not yet taken into account and may be modulatable by the design, choice and use of technologies and platforms, including by the users themselves.

Measured results of the study

A study suggests that in children aged 8–12 during two years, time digital gaming or watching digital videos can be positively correlated with measures intelligence, albeit correlations with overall screen time (including social media, socializing and TV) were not investigated and 'time gaming' did not differentiate between categories of video games (e.g. shares of games' platform and genre), and digital videos did not differentiate between categories of videos.[131][132]

Impact on social life

Worldwide adolescent loneliness in contemporary schools and depression increased substantially after 2012 and a study found this to be associated with smartphone access and Internet use.[133][134]

Mitigation

Industry

Several technology firms have implemented changes intending to mitigate the adverse effects of excessive use of their platforms.

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.[135] 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.[136] In 2018 Facebook and Instagram announced new tools that they asserted may assist with overuse of their products.[137] In 2019, Instagram, which has been investigated specifically in one study in terms of addiction,[138] 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.[139] It then continued this trial in Australia, Italy, Ireland, Japan, Brazil and New Zealand[140] before extending the experiment globally in November of that year. The platform also developed artificial intelligence to counter cyberbullying.[141]

In 2018, Alphabet Inc. released an update for Android smartphones, including a dashboard app enabling users to set timers on application use.[142] Apple Inc. purchased a third-party application and then incorporated it in iOS 12 to measure "screen time".[143] Journalists have questioned the functionality of these products for users and parents, as well as the companies' motivations for introducing them.[142][144] Alphabet has also invested in a mental health specialist, Quartet, which uses machine learning to collaborate and coordinate digital delivery of mental health care.[145]

Two activist investors in Apple Inc voiced concerns in 2018 about the content and amount of time spent by youth. They called on Apple Inc. to act before regulators and consumers potentially force them to do so.[146] 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.[147]

Public sector

In China, Japan, South Korea and the United States, governmental efforts have been enacted to address issues relating to digital media use and mental health.

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.[148] 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.[149][150] 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.[151] Effective 2 September 2023, those under the age of 18 can no longer access the Internet on their mobile device between 10 pm and 6 am without parental bypass. Smartphone usage is similarly capped by default at 40 minutes a day for children younger than eight and at two hours for 16- and 17-year-olds.[152]

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.[148]

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 stated 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."[148] Efforts are coordinated by the Ministry of Science and ICT, and include awareness campaigns, educational interventions, youth counseling centres, and promoting healthy online culture.[148]

In May 2023, the United States' Surgeon general took the rare measure of issuing an advisory on Social media and mental health.[153][154] In October, 41 U.S. states commenced legal proceedings against Meta. This included the attorneys general of 33 states filing a combined lawsuit over concerns about the addictive nature of Instagram and its impact on the mental health of young people.[155][156]

Digital mental health care

Photograph of a screen from the "Wellmind" smartphone application
"Wellmind", a United Kingdom National Health Service smartphone application

Digital technologies have also provided opportunities for delivery of mental health care online; benefits have been found with computerized cognitive behavioral therapy for depression and anxiety.[157] 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.[158] 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".[159] 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.[160] 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 randomized controlled trials to validate the effectiveness of their recommendations when delivered by digital apps.[157]

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.[161] A study in 2019 published in Front Psychiatry in the National Center for Biotechnology Information states that despite proliferation of many mental health apps there has been no "equivalent proliferation of scientific evidence for their effectiveness."[162]

Steve Blumenfield and Jeff Levin-Scherz, writing in the Harvard Business Review, claim that "most published studies show telephonic mental health care is as effective as in-person care in treating depression, anxiety and obsessive-compulsive disorder." The also cite a 2020 study done with the Veterans Administration as evidence of this as well.[163]

See also

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Further reading