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Digital media use and mental health
A group of people looking at their smartphones
Digital media use may affect mental health
RelatedScreen time, gaming disorder, problematic Internet use, problematic social media use, problematic smartphone use

The relationships between digital media use and mental health have been investigated by various researchers—predominantly psychologists, sociologists, anthropologists and medical experts—for some years. A significant body of research has explored "overuse" phenomena, commonly known as "digital addictions", or "digital dependencies". These phenomena manifest differently in various 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 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, 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. Scientists, however, are unsure about the direct links between digital media use and mental health outcomes. Those links appear to depend on the individual and the platforms they use. Various large technology firms have made commitments or announced strategies to try to reduce the risks of digital media use.

History and terminology

A child looks into a smartphone
A young boy engaged with a smartphone

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] However, concerns have arisen from researchers, clinicians and the public in regard to apparent compulsive behaviours of digital media users with correlations between technology overuse and mental health problems becoming apparent.[1][5]

Terminology 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).[6] 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.[7] 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.[8]

Internet addiction has been proposed as a diagnosis since the mid-1990s,[9] and social media and its relation to addiction has been examined since 2009.[10] A 2018 OECD (Organisation for Economic Co-operation and Development) report noted the benefits of structured and limited Internet use in children and adolescents for development and education, and that excessive digital media use is associated with mental illness. 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 childhood technology use.[11]

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.[12] Gaming disorder has been recognised in the ICD-11.[13][14] Different recommendations are due in part to the lack of well-established evidence or expert consensus, the differences in emphasis in the classification manuals, as well as difficulties utilising animal models for behavioural addictions.[7]

The utility of the term addiction in relation to overuse of digital media has been questioned, in regard to its suitability as a separate psychiatric entity, or whether it is 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 additional problems.[3] Panova and Carbonell published a review in 2018 that specifically encouraged terminology of "problematic use" in regard to technology behaviours, rather than continuing research based on other behavioural addictions.[15]

Due to the lack of recognition and consensus on the concepts used, diagnoses and treatments are difficult to standardise or develop, especially considering that "new media has been subject to such moral panic".[2] Radeski and Christiakis, 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."[16] 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.[17]

Problematic use

While associations have been observed between digital media use and mental health symptoms or diagnoses, causality has not been established, with nuances and caveats published by researchers often misunderstood by the general public, or misrepresented by the media.[3] Several studies have shown that women are more likely to overuse social media, and men video games.[18] This has led multiple experts cited by Hawi and colleagues to suggest that digital media overuse may not be a singular construct, with some calling to delineate proposed disorders based on the type of digital media used.[19]

The rapid pace of introduction of new technologies between 2008 and 2018 has caused difficulty with timely publishing of evidence-based guidelines,[5] with experts from the fields of psychology and psychiatry calling for further study.[20]

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 ADHD. The studies could not determine if causal relationships exist, with reviewers emphasising the importance of prospective study designs going forward.[1] While overuse of digital media has been associated with depressive symptoms, digital media may also be utilised in some situations to improve mood.[21][22] Symptoms of ADHD have been positively correlated with digital media use in a large prospective study.[23] The ADHD symptom of hyperfocus may cause affected people to overuse digital media such as video games or online chatting.[24]

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; however, 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 developing at both the low and high ends of Internet use.[4] In the United Kingdom, a study of 1,479 individuals of ages 14–24 compared psychological benefits and problems of the largest five 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", followed by Twitter, Facebook, and Snapchat, with Instagram having the lowest rating. The study identified Instagram as having some positive effects including self-expression, self-identity, and community, but these were outweighed by negative effects, including those on sleep, body image, and "fear of missing out".[25]

The relationship between bipolar disorder and technology use has been investigated in a singular survey of 84 participants. The survey found marked variations in technology use based on self-reported mood states. Matthews and colleagues then postulated that for patients with bipolar disorder, technology may be a "double-edged sword", with potential benefits and harms.[26]

Screen time

Main article: 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, with a curvilinear relationship found with both depressive symptoms and overall well-being.[5] A 2017 United Kingdom large-scale study of this "Goldilocks hypothesis"—of avoiding both too much and too little digital media use[27]—was described as the "best quality" evidence to date by experts and NGOs reporting to a 2018 UK parliamentary committee. That study concluded that modest digital media use may have little adverse affects, and even some positive associations in terms of well-being.[28]

Proposed diagnostic categories

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

Gaming disorder has been considered by the DSM-5 taskforce as warranting further study, and has been included in the ICD-11.[12] Concerns have been raised by Aarseth and colleagues over this inclusion, particularly in regard to stigmatisation of heavy gamers.[29]

Christiakis has asserted that Internet addiction may be "a 21st century epidemic".[30] In 2018, he commented that childhood Internet overuse may be a form of "uncontrolled experiment[s] on [...] children".[31] 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.[32] Another perspective by Musetti and colleagues suggested "reconsidering the Internet as an environment rather than as a tool, [... exploring] the Internet's role in cognitive ecology, as well as the inadequacy of treating the Internet as a tool and thus of the current Internet-addiction model".[33]

Social media addiction while excluded from the DSM-5 is under consideration as a mental disorder.[34][35] 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'."[36]

Internet sex addiction, also known as cybersex addiction, has been proposed by Stein and Parashar 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.[37][38] It may be considered a form of problematic Internet use.[39]

Related phenomena

Silhouette of a man gambling online

Online problem gambling

Main article: 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 differences in the cohorts between Internet and land-based problem gamblers.[40]

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, and a variety of emotional responses, including being scared, frustrated, angry or depressed.[41]

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 modest increases were shown in the United States and Brazil.[42]

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.[43] A 2018 review found that while the literature is sparse and inconclusive, overall, heavy media multitaskers also have poorer performance in several cognitive domains.[44] One of the authors commented that the data does not "unambiguously show that media multitasking causes a change in attention and memory", but that it is not efficient, and one may argue to multitask less on digital media.[45]

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.[46] 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.[47][48] The Canadian Paediatric Society produced a similar guideline. Ferguson, a psychologist, has criticised these and other national guidelines for not being evidence-based.[49] Other experts have recommended addressing potential underlying problems rather than arbitrarily enforcing screen time limits, as commented in a 2017 UNICEF Office of Research literature review.[3]

A number of different methodologies of assessing pathological Internet use have been developed, mostly self-report questionnaires, however none have been universally recognised as a gold standard.[50] For gaming disorder, both the American Psychiatric Association[51] and the World Health Organization (through the ICD-11)[13] have released diagnostic criteria.

There is some limited evidence into the effectiveness of cognitive behavioural therapy and family-based interventions for treatment. Medications have not been shown to be effective in randomised controlled trials.[46] A 2016 study of 901 adolescents suggested mindfulness may assist in preventing and treating problematic Internet use.[52] 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 risk of harm online.[28] Treatment centres have proliferated in some countries, and China and South Korea have treated digital dependence as a public health crisis, with 300 and 190 nationwide centres opened, respectively.[53] Other countries have also opened treatment centres.[54][55]

A review published in Dao investigated Internet addiction and its effects on well-being from a philosophical perspective. They suggested possible amelioration by reflecting on ancient Eastern and Western philosophies, as they "may give us inspiration to confront the challenges of technological enslavement in general". They recommended revisiting the ancient wisdom from both Daoist and Stoic philosophies, "as a way of restoring the importance of a reflective mind for the purpose of enhancing our individual and collective well-being".[56]

NGOs, support and advocacy groups provide resources to people overusing digital media, with or without codified diagnoses,[57][58] including the American Academy of Child and Adolescent Psychiatry.[59][60]

Mental health benefits

People using phones while walking
Smartphones and other digital devices are ubiquitous in many societies

Individuals with mental illness can develop social connections over social media, that develop a sense of social inclusion in online communities.[4] Sufferers of mental illness may share personal stories in a perceived safer space, as well as gaining peer support for developing coping strategies.[4] People with mental illness are likely to report avoiding stigma and gaining further insight into their mental health condition using social media. However, 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 LGBTQI community. Furthermore, in children, educational benefits of digital media use are well established.[4]

Other disciplines

As public awareness of the potential effects of digital media on mental health increases, scholars in several disciplines continue to work on assessment, improving understanding, and developing innovative solutions.

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."[61]

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.[62] Brian Solis, a digital analyst, anthropologist and keynote speaker working in the field, in 2018 stated, "we've become digital addicts: it's time to take control of technology and not let tech control us".[63]

Digital sociology

Digital sociology explores how people utilise digital media using various 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".[64]

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. However, some high believers showed different motivations for Internet use, predominantly searching for information.[65] A study of 1,296 Malaysian adolescent students found an inverse relationship between religiosity and Internet addiction tendency in females, but not males.[66]

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 time per day using digital devices, compared to higher income youths.[67] They theorised that these same vulnerable groups 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 this may be a new form of digital divide between at-risk young people and other young people, with pre-existing risks becoming amplified among the vulnerable.[67]

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".[68] 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 called for further study, identifying, "adolescence a tipping point in development for how social media can influence their self-concept and expectations of self and others".[69] Although brain imaging modalities are under study, often findings in relation to behavioural addictions or digital media used in individual studies fail to be replicated in further studies, and as of 2017, the exact biological or neural processes that could lead to excessive digital media use are unknown.[3]

Digital technology use in 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, with some benefits shown with cognitive behavioural therapy for depression and anxiety.[70] 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.[71] However, potential benefits by one review include "the flexibility, interactivity, and spontaneous nature of mobile communications ... in encouraging persistent and continual access to care outside clinical settings".[72] Mindfulness as an online intervention has been shown to have small to moderate effects on mental health. Psychological stress (the perceived ability to cope with life's demands) has shown the highest effect size, and benefits have also been shown in depression, anxiety, and well-being.[73] Smartphone applications have proliferated in many mental health domains, with "demonstrably effective" recommendations from one review encouraging cognitive behavioural therapy, addressing both anxiety and mood, but this would require validating evidence from future randomised controlled trials.[70]

The Lancet commission on global mental health and sustainability report from 2018 evaluated both benefits and harms of technology. It considered the roles of various technologies in mental health, particularly in public education; patient screening; treatment; training and supervision; and system improvement. Digital media use in healthcare is unregulated in most countries.[74]

Response of large technology firms

Various technology firms have implemented changes to mitigate the negative effects of excessive Internet use. 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.[75] 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". It admitted "heavy responsibilities" to the global community, and invited regulation by governments.[76] Facebook and Instagram announced in 2018 new tools that they asserted may assist with overuse of their products.[77] In 2019, Instagram, which has been investigated specifically in one study in terms of addiction,[78] began testing a platform change in Canada to hide the number of "likes" and views that photos and videos receive in an effort to create a "less pressurised" environment.[79] It then continued this trial in Australia, Italy, Ireland, Japan, Brazil and New Zealand.[80] The platform also developed artificial intelligence to counter cyberbullying.[81]

In 2018, Alphabet Inc released an update for Android smartphones, including a dashboard app enabling users to set timers on application overuse.[82] Apple Inc purchased a third-party application and then incorporated it in iOS 12 to measure "screen time".[83] However, journalists have questioned the functionality for users and for parents and companies' motivations for these interventions.[82][84]

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.[85][86] 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 regards to young people's health.[87]

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Further reading

  • Bartlett, Vanessa; Bowden-Jones, Henrietta (2017). Are we all addicts now? : digital dependence. Beales, Katriona, MacDonald, Fiona. [Liverpool]. ISBN 9781786940810. OCLC 988053669. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)CS1 maint: location missing publisher (link)
  • Alter, Adam (6 March 2018). Irresistible : the rise of addictive technology and the business of keeping us hooked. New York. ISBN 9780735222847. OCLC 990286417. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)CS1 maint: location missing publisher (link)
  • Young, Kimberly; de Abreu, Cristiano Nabuco (2017). Internet addiction in children and adolescents : risk factors, assessment, and treatment. New York, NY. ISBN 9780826133731. OCLC 988278461. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)CS1 maint: location missing publisher (link)

External links

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