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Digital media use and mental health

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Digital media use and mental health
Smartphone usage may affect mental health
RelatedScreen time, gaming disorder, internet addiction disorder, problematic social media use, problematic smartphone use

Digital media use has been investigated in terms of mental health symptoms and diagnoses from many perspectives. A significant body of research has explored "overuse" phenomena, commonly known as "digital addictions", or "digital dependencies". They have been under study and analysis for some years, predominantly by psychologists, sociologists, anthropologists and medical experts. These phenomena behave differently in various societies and cultures. Some experts have investigated benefits of moderate digital media use in various domains.

The delineation between beneficial and pathological use of digital media is not comprehensively codified, with no widely accepted diagnostic criteria, and consideration that overuse may be a manifestation of underlying psychiatric disorders. Prevention and treatment of pathological digital media use is also not standardised, however guidelines for safer media use for children and families have been developed. The diagnoses of internet addiction disorder, social media addiction, and gaming disorder have not been included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), whereas the International Classification of Diseases (ICD-11) solely recognises gaming disorder. This remains under considerable debate and discussion amongst experts. The terminology of "addiction" in relation to these phenomena and diagnoses has also come under question.

Digital media and screen time have altered the ways that children think, interact and develop; in some cases in a positive way, and sometimes in a negative way. While mental health problems have occurred throughout human history, scientists are unclear as to the direct links between digital media use and mental health outcomes. They appear to depend on the individual, and the platforms used. Various large technology firms have made commitments or announced strategies they assert may reduce risks of digital media use.

History and terminology

The complex, multifaceted 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 from researchers, clinicians and the public have arisen 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 agreed, and 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 internet addiction disorder).[6] Unrestrained use of technological devices may affect developmental, social, mental and physical well-being and result in symptoms akin to other behavioural addictions.[7]

Internet addiction has been proposed as a diagnosis since the mid 1990s, [8] and social media and its relation to addiction has been examined since 2009.[9] A 2018 OECD report noted the benefits of structured, 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.[10]

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

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.[11] Gaming disorder has been recognised in the International Classification of Diseases (ICD-11).[12][13] Different recommendations are in part due 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.[14]

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 because of drawing parallels with substance use behaviours, and careless use of the term may cause additional problems.[3] 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 editor 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."[15] Due to the ready availability of multiple technologies to children worldwide, the problem is bi-directional, as taking away digital devices may also have a detrimental effect, in areas such as learning, family relationship dynamics, and overall development.[16][17][18]

Problematic digital media use

Whilst 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.[19][20] This has led Király and Andreassen 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]

Psychological and psychiatric perspectives

The rapid pace of introduction of new technologies in the period 2008–2018 has caused difficulty with timely publishing of evidence-based guidelines,[5] with experts from the fields of psychology and psychiatry calling for further study.[21]

Mental health relationships

A systematic map of reviews published in 2019, which rated most reviews medium or high quality, also showed mental health associations of problematic internet use, with depression and anxiety most often found, as well as hostility, aggression and ADHD.[1] While overuse of digital media has been associated with depressive symptoms, digital media may also be utilised in some situations to improve mood.[22][23] Symptoms of ADHD have been positively correlated with digital media use in a large prospective study.[24] The ADHD symptom of hyperfocus may cause affected people to overuse digital media such as video games or online chatting.[25]

A 2016 technical report by Chassiakos, Radesky, and Christakis identified benefits and concerns in adolescent mental health in regard to digital media use. It showed that the amount of time spent on social media is not the key factor – rather how that time is spent. A decline in well being and life satisfaction was found in older adolescents who passively consumed social media, however, these were not shown in those who were more actively engaged. The report also found the 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]

The relationship between bipolar disorder and technology use has been investigated in a singular study, without generalisable results. In this study, Matthews and colleagues 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 review 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 wellbeing.[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, Social media addiction, and Internet addiction disorder
See also: Problematic smartphone use and Nomophobia

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

Christiakis, amongst other medical experts, has asserted that internet addiction may be "a 21st century epidemic",[30] and 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 6.0%.[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, whilst excluded from the DSM-V, is under consideration as a mental disorder.[34][35] A 2015 review concluded there was a link suggested 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]

In the United Kingdom, a study of 1,479 14-24 year olds 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. Instagram was identified by the report to have some positive effects such including self-expression, self-identity, and community, but these were outweighed by its negative effects including on sleep, body image, and "fear of missing out".[37]

Online gambling
Main article: Online gambling § Problem gambling

A 2015 review found evidence of higher rates of mental health comorbidites, as well as higher amounts of substance use, amongst internet gamblers, compared to non-internet gamblers. Causation, however, has not been established. The review postulated that there may differences in the cohorts between internet and land-based problem gamblers.[38]

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, and depressed.[39]

Multitasking with multiple forms of digital media may affect mental health
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 and social anxiety in a single study of 318 participants.[40] A 2018 review found that whilst the literature is sparse and inconclusive, overall, heavy media multitaskers have poorer performance in several cognitive domains.[41] 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.[42]

Assessment and treatment

Rigorous, evidence-based assessment of problematic digital media use is yet to be comprehensively established, partially due to lack of consensus around the various constructs and lack of standardization of treatments.[43] 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 2 hours or less per day.[44][45] The Canadian Paediatric Society produced a similar guideline. Ferguson, a psychologist, has criticised these and other national guidelines for not being evidence-based.[46] 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.[47] For gaming disorder, both the American Psychiatric Association[48] and the World Health Organization (through the ICD-11)[12] 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.[43] A 2016 study of 901 adolescents suggested mindfulness may assist in preventing and treating problematic internet use.[49] A 2019 United Kingdom parliamentary report deemed parental engagement, awareness and support to be essential in developing "digital resilience" for young people, 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.[50] Other countries have also opened treatment centres.[51][52]

A review published in Dao investigated internet addiction and its effects on wellbeing 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."[53]

Non-governmental organisations, support and advocacy groups provide resources to people overusing digital media, with or without codified diagnoses,[54][55] including the American Academy of Child and Adolescent Psychiatry.[56][57]

Digital technology use in mental health care

"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 of cognitive behavioural therapy for depression and anxiety.[58] Research of digital health interventions in young people is preliminary with a meta-review unable to draw firm conclusions due to problems in research methodology,[59] 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".[60] Mindfulness as an online intervention has been shown to have small to moderate effects on mental health; with psychological stress (perceived ability to cope with life demands) showing the highest effect size, and benefits also shown in depression, anxiety, and well-being.[61] 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.[58]

A 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.[62]

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 that effects of social media are very specific to individual locations and cultures. He contended that "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."[63]

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.[64] 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".[65]

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".[66]

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.[67] A study of 1,296 Malaysian adolescent students found an inverse relationship between religiosity and internet addiction tendency in females, but not males.[68]

A subsequent 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. 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 that this may be a new form of digital divide between at risk young people and other young people, with preexisting risks becoming amplified amongst the vulnerable.[69]

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

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".[70] A 2018 neuroscientific review published in Nature found that 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 on 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".[71] Although brain imaging modalities are under study, often findings in relation to behavioural addictions or digital media use 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]

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.[72] In January 2019, Facebook's then head of global affairs, Nick Clegg, responding to criticisms of Facebook and mental health concerns, stated Facebook Inc 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.[73] Facebook and Instagram announced in 2018 new tools that they asserted may assist with overuse of their products.[74] In 2019, Instagram, which specifically has been investigated in one study in terms of addiction,[75] 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.[76]

In 2018, Alphabet Inc released an update for Android smartphones, including a dashboard app enabling users to set timers on application overuse.[77] Apple Inc purchased a third party application and then incorporated it in iOS 12 to measure "screen time".[78] However, journalists have questioned the functionality and motivations of both of these interventions from these corporations for users and for parents.[77][79]

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" and called upon Apple Inc to act, prior to regulators and consumers potentially forcing them to do so.[80][81] 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," planning new features that they asserted may allow them to play a pioneering role in regards to young people's health.[82]

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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 (2018-03-06). 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)
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