The exacerbation of depression, hostility, and social anxiety in the course of internet addiction among adolescents: a prospective study Chih-Hung Ko, Tai-Ling Liu, Peng-Wei Wang, Cheng-Sheng Chen, Cheng-Fang Yen, Ju-Yu Yen PII: DOI: Reference:
S0010-440X(14)00115-1 doi: 10.1016/j.comppsych.2014.05.003 YCOMP 51308
To appear in:
Comprehensive Psychiatry
Received date: Revised date: Accepted date:
1 February 2014 9 May 2014 12 May 2014
Please cite this article as: Ko Chih-Hung, Liu Tai-Ling, Wang Peng-Wei, Chen ChengSheng, Yen Cheng-Fang, Yen Ju-Yu, The exacerbation of depression, hostility, and social anxiety in the course of internet addiction among adolescents: a prospective study, Comprehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.05.003
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ACCEPTED MANUSCRIPT The exacerbation of depression, hostility, and social anxiety in the course of internet addiction among adolescents: a prospective study.
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Running title: exacerbation of psychiatric symptoms in IA
Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung
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Chih-Hung Ko, M.D., Ph.D.,1,2,3 Tai-Ling Liu, M.D.,1 Peng-Wei Wang, M.D.,1 Cheng-Sheng Chen, M.D.1,3, Cheng-Fang Yen, M.D. Ph.D.1,3, Ju-Yu Yen, M.D., Ph.D.1
Medical University, Kaohsiung City, Taiwan 807 2
Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan 812 Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung
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Medical University, Kaohsiung City, Taiwan 807 Department of psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
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Medical University, Kaohsiung, Taiwan 801
The Corresponding Author: Ju-Yu Yen, M.D., Ph.D. Department of Psychiatry, Kaohsiung Municipal Ta-Tung Hospital Kaohsiung Medical University No.68, Jhonghua 3rd Rd, Cianjin District, Kaohsiung City 80145, Taiwan Telephone: 886-7-3121101 Ext. 6822 Fax: 886-7-3134761 E mail: [email protected]
ACCEPTED MANUSCRIPT Abstract Background
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In adolescent populations worldwide, internet addiction is prevalent and is often
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comorbid with depression, hostility, and social anxiety of adolescents. This study aimed at evaluating the exacerbation of depression, hostility, and social anxiety in the
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course of getting addiction to internet or remitting from Internet addiction among adolescents.
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Method
This study recruited 2293 adolescents in grade 7 to assess their depression, hostility, social anxiety and internet addiction. The same assessments were repeated one year
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later. The incidence group was defined as subjects classified as non-addicted in the first assessment and as addicted in the second assessment. The remission group was
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defined as subjects classified as addicted in the first assessment and as non-addicted
Results
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in the second assessment.
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The incidence group exhibited increased depression and hostility more than the non-addiction group and the the effect of on depression was stronger among adolescent girls. Further, the remission group showed decreased depression, hostility, and social anxiety more than the persistent addiction group. Conclusions Depression and hostility worsen in the addiction process for the Internet among adolescents. Intervention of internet addiction should be provided to prevent its negative effect on mental health. Depression, hostility, and social anxiety decreased in the process of remission. It suggested the negative consequences could be reversed if internet addiction could be remitted within a short duration.
ACCEPTED MANUSCRIPT Key words: Internet addiction, depression, hostility, social anxiety, prospective,
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adolescents.
ACCEPTED MANUSCRIPT Introduction: More than 90% of adolescents use the Internet to get information [1]. The
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Internet is one of the most powerful media of the 21st century and has revolutionized
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education and social communication in adolescents [2]. For adolescents, the Internet is also an important source of health-related information[3]. However, internet
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addiction, which can be defined as the loss of control over internet use and its resulting negative consequences, is common in adolescents [4]. Epidemiological
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studies reveal that internet addiction occurs in 1.4~17.9% of adolescents in both western and eastern populations [5,6,7]. This indicates that internet addiction is a major mental health problem in adolescents worldwide. Therefore, a clear
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understanding the mental health effects of internet addiction in adolescents is essential.
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Epidemiological studies agree that internet addiction in adolescents is associated with depressive symptoms and social anxiety [5,8,9]. The same association
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has also been reported in college students [10]. However, the causal relationship
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between internet addiction and depression and social anxiety could not confirmed in previous cross-section studies.
Social anxiety is generally lower during online
interaction than during face-to-face interaction, especially in subjects with high social anxiety [11]. Depressive subjects also experience lower social anxiety and hostility during online interaction [11,12]. Thus, we hypothesized that adolescents who have depression or social anxiety often use the Internet relieve their depressive or social anxiety symptoms. In our previous study, which analyzed the same data of this presenting study, the baseline severity of depression or social anxiety predicted internet addiction at the 2-year follow up [13]. However, no studies have investigated whether internet addiction contributes to depression and social anxiety.
ACCEPTED MANUSCRIPT Although an earlier path analysis study demonstrated that problematic internet use is a predictor of depression [14], this conclusion was not based on a prospective
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study. A recent study reported that adolescents with problematic internet use had a
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higher incidence of depression at the 9-month follow-up compared to non-addicted controls, but anxiety did not significantly differ [15]. This indicates that internet
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addiction contributes to depression. Another prospective study revealed spontaneous remission in adolescents with internet addiction [16], which is consistent with the
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clinical experience of the authors. If the addiction status changes, the addiction status observed in the initial survey cannot be considered an unchanged predictor of depression or anxiety. Thus, causal relationships should be interpreted cautiously in
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prospective studies in which predictors, e.g., internet addiction, change in the course of the investigation.
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In Gentile et al., adolescents who played online games were classified into four groups in terms of their pathological internet gaming behavior: a stop group, a start
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group, a stay group, and a never group.. Comparisons showed that the start group,
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who started with a pathological condition during follow-up, ultimately showed higher depression, anxiety, and social phobia compared to the never group, who had never been pathological gamers. The authors further showed that the stop group, who no longer exhibited pathological internet gaming behavior during follow-up, had lower depression, anxiety, and social phobia compared to the stay group, who continued to exhibit such behavior[17]. Based these results, the authors suggested that depression and anxiety result from pathological online gaming activity. They demonstrated a practical way to perform a detailed study of changes in comorbid psychiatric symptoms in the four groups of pathological gamers. However, since the initial investigation did not assess depression, anxiety, and social phobia, the study did not
ACCEPTED MANUSCRIPT confirm whether these symptoms really changed during the follow-up periods. Thus, depression and social anxiety must be compared prospectively in courses of internet
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addiction among adolescents. Such studies would provide essential information for
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understanding whether internet addiction contributes to depression or social anxiety. Aggressive behaviors such as cyber bullying and extreme behaviors such as
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internet suicide have been associated with excessive internet use [18] and with internet addiction [19]. Hostility has also been associated with internet addiction [12,
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13, 20]. Although hostility decreased after getting online, subjects with internet addiction increased expressive hostility when getting online [12]. Adolescents with internet addiction reportedly have higher hostility [5] and more aggressive behaviors
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[20]. These results indicate that subjects with high hostility may have a higher vulnerability to internet addiction. This claim is supported by our previous study,
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which analyzed the same data set considered here. At the 2-year follow, adolescents with high hostility were more likely to get internet addiction [13]. These results are
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also consistent with social learning theory, which suggests that violence in media
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increases hostility and aggression [21]. Since longitudinal studies have identified both biological and environmental factors that affect behavioral traits in adolescents [22], an improved understanding of whether internet addiction increases hostility is needed Internet addiction is more common in males than in females [13]. Further, hostility is the best predictor of internet addiction in males whereas the presence of ADHD symptoms is the best predictor in females [13]. This suggests a gender difference in associative factors or comorbidity in adolescent internet addiction [9]. Gender differences in the preferred online activity have also been reported. For example, in adolescents with internet addiction, online gaming is the most common internet activity in males but not in females [23]. Gender differences in the online
ACCEPTED MANUSCRIPT experience and in the vulnerability to comorbidity might contribute to differences in the effect of internet addiction on psychiatric symptoms.
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Thus, the aims of this study were 1) evaluating the change of depression,
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hostility, and social anxiety in the course of internet addiction or remitting from it; and 2) exploring the gender difference in incidence or remission effect of internet
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addiction on the progression of depression, hostility, and social anxiety.
ACCEPTED MANUSCRIPT Methods Participants
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In September, 2005, the participants in this study were recruited from ten junior
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high schools distributed throughout southern Taiwan (four located in urban areas, four located in suburban areas, and two located in rural areas). The participants included
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students in eight randomly selected classes in each school. Research assistants visited the students in their classrooms and explained the study objectives and procedures.
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Signed consent to participation in the initial investigation was received from 2,293 students (1,179 males and 1,174 females; mean age, 12.36 ± 0.55 years). The Institutional Review Board of Kaohsiung Medical University Hospital approved this
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study and confirmed its compliance with the ethical standards established by the 1964 Declaration of Helsinki and its subsequent amendments.
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Instruments
Chen Internet Addiction Scale (CIAS). The 26-item CIAS uses a 4-point Likert scale
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to assesses five dimensions of internet-related problems. The CIAS rates the severity
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of internet addiction from 26 to 104, which represent low to high severity, respectively. The internal reliability of the scale and the subscales in the original study ranged from 0.79 to 0.93 [24]. According to the diagnostic criteria of internet addiction [25], a cutoff point marked by the scores 63/64 provides the best combination of diagnostic accuracy (87.6%), sensitivity (67.8%), and specificity (92.6%) [26]. Accordingly, subjects with CIAS scores of 64 or higher were classified as the internet addiction group in this study. Center for Epidemiological Studies Depression Scale (CES-D): The 20-item Mandarin Chinese version [27] of the CES-D [28] is a self-administered test of the frequency of depressive symptoms within the previous week in which high scores
ACCEPTED MANUSCRIPT indicate increased severity of depression. The CES-D in the present study had a Cronbach alpha of 0.78.
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The Buss-Durkee Hostility Inventory- Chinese Version- Short Form (BDHIC-SF).
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The 20-item, 5-point Likert-type BDHIC-SF assesses four dimensions of the hostility construct, including hostility cognition, hostility affection, expressive hostility
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behavior, and suppressive hostility behavior. The coefficient of internal consistency (Cronbach alpha) was 0.93, and the four-week test-retest reliability was 0.80. Higher
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scores indicate higher hostility [29].
The brief version of Fear of Negative Evaluation Scale (FNE) evaluates the cognitive symptoms of social phobia. The BV-FNE is a brief, 5-point Likert-type, 12-item version of the FNE that has demonstrated a high correlation with the original
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scale (r=0.96), a high internal consistency (α=0.90), and a good 4-week test-retest
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reliability coefficient (0.75) [30]. Here, the FNE was used to evaluate cognitive symptoms of social phobia.
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Study procedure and statistical analysis
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After receiving approval of this study by the Institutional Review Board of Kaohsiung Medical University Hospital, the CIAS, CESD, BDHIC-SF, and FNE were administered in the initial assessment. The same scales were administered again year later. The objective of the study was to evaluate the effects of internet addiction on the change in depression, hostility, and social anxiety. In the adolescents classified as the non-addiction group in the initial investigation, those classified as addicted and non-addicted at the 1-year follow up were defined as the incidence group and the non-addiction group, respectively. In the adolescents classified as the addiction group in the initial investigation,
ACCEPTED MANUSCRIPT those classified as addicted and non-addicted at the 1-year follow up were defined as the persistence group and the remission group, respectively. In each group, changes in
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CIAS, CESD, BDHIC-SF, and FNE scores were evaluated by paired t-test. A
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repeated-measures, two-way ANOVA analysis of CESD, BDHIC-SF, and FNE scores was performed as a function of the time course (within-subject effect) and incidence
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of internet addiction (incidence group versus non-addiction group; between-subject effect) with gender and age covariates among subjects without internet addiction in
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the initial investigation. The same analysis was further used to evaluate CESD, BDHIC-SF, and FNE as a function of the time course (within-subject effect) and remission of internet addiction (remission group versus persistence group;
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between-subject effect) in the subjects who revealed internet addiction in the initial investigation. All statistical analyses were performed using the SPSS software
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package. A p-value less than 0.05 was considered statistically significant.
ACCEPTED MANUSCRIPT Results The 1863 adolescent students (943 males and 920 females) who completed the CIAS
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were classified into four groups. The missing rate did not differ by gender (X2=2.55).
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Of these, 1520 participants completed the CESD, BDHIC-SF, and FNE in the initial assessment and in the 1-year follow up. Of the 1382 participants (647 males and 735
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females) who did not have internet addiction in the initial assessment, paired t-test showed that both the non-addiction group (572 males and 695 females) and the
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incidence group had increased hostility and social anxiety in the 1-year follow up (Table 1, Figs. 1A, 1B). The repeated two-way ANOVA further demonstrated that the incidence group (75 males and 40 females) had a larger increase in CESD and
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BDHIC-SF scores compared to the non-addiction group at the 1-year follow up (Table 2; Figs.1A, 1B). Further, the interaction of gender and incidence group effect
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significantly predicted the progression of depression. Further analysis demonstrated that the effect of incidence on progression of depression was significantly larger in
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girls than in boys (Table 2 and Fig. 2).
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In the subjects who had internet addiction in the initial investigation (104 males and 34 females), CESD and BDHIC-SF scores were significantly decreased in the remission group (52 males and 19 females) but not in the persistence group (52 males and 15 females) did not, during the one-year follow-up (Table 1). The repeated two-way ANOVA revealed that the decrease in CESD, BDHIC-SF, and FNE scores was larger in the remission group than in the persistence group (Table 3; Figs. 1D, 1E).
ACCEPTED MANUSCRIPT Discussion In subjects who became internet-addicted, depression increased during the 1-year
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follow up. The increase in the severity of depression was larger than that in the
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control group during the same period. In line with previous report [22], this result indicates that, during the process of addiction to the internet in adolescents,
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depression is exacerbated. In the process of addiction to the internet, adolescents may experience negative consequences of internet addiction such as impaired academic
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performance, conflict with parents [31], and social isolation. They might also experience a sense of rejection by their parents, isolation from their peers in the real world, and low self-esteem in school.
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Interpersonal theory [32] suggests that these interpersonal difficulties can worsen interpersonal security and increase the risk of depression. However, the need for
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self-esteem and reassurance can be met by internet activity such as online gaming or by using communication tools for mass social interaction. The combination of
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real-world rejection and online reassurance further increases their addiction to the
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internet. Further, excessive internet use occupies the limited free time they have for social interaction such as religious activities and for recreational activities, which can provide feelings of competence or social support. Since social support, personal competence and religion are known to have important effects in protecting adolescents from depression [33], the attenuation of these protective factors in real life might increase the risk of depression. In contrast, online activity reportedly decreases social anxiety and hostility, particularly in depressive subjects [11,12]. To compensate for feelings of inadequate social support, interpersonal security, or personal competence, adolescents may increase their online interaction to increase their self-esteem through approval from others or through achievements in online
ACCEPTED MANUSCRIPT gaming. However, the present study demonstrated that exacerbates rather than diminishes depression. The data suggest that the attempt to escape depression and
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real-world concerns through online interaction results in a vicious cycle that
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exacerbates depression, but not a recovery process. Thus, any preventive schedule for internet addiction should be implemented at the youngest possible age to minimize its
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exacerbating effects on depression.
Another exacerbating factor in depression was the interaction term of gender and
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incidence effect. Further stratified analysis demonstrated that, in the incidence group, the effects of internet addiction were more severe in girls than in boys. That is, adolescent girls are more vulnerable to the effects of the internet addiction process on
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the progression of depression. An earlier study of interpersonal vulnerability to depression in adolescent girls suggested that reassurance-seeking combined with poor
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relationships with peers contributes to depression [34]. Thus, real-world interpersonal difficulties resulting from internet addiction have contributing effects on depression
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that are larger in adolescent boys than in of adolescent girls. A previous report
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suggested that perceived parental conflict contributes to depression in adolescent females [35]. Parents of adolescents with internet addiction usually impose controls on internet use, which results in conflict. In this case, the individual with internet addiction has high perceived parental conflict and low family satisfaction [31]. Thus, internet addiction in female adolescents might exacerbate depression by disturbing family relationships and by increasing interpersonal difficulties. Since female adolescents are also more vulnerable to depression compared to their male counterparts [36], female adolescents might be more vulnerable to the negative effects of internet addiction on depression. Thus, treatment for adolescents with internet addiction, particularly females, should pay effort to prevent the exacerbation of
ACCEPTED MANUSCRIPT depression. This prospective study also revealed that adolescents in remission from internet
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addiction at the 1-year follow-up had decreased depression. The decrease in
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depression during this period was larger than that in the persistence group, which indicates that depression in adolescents with internet addiction can improve if
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remission from internet addiction occurs within a short time. In adolescents in remission from internet addiction, the negative consequences of internet addiction
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may be attenuated by the increased free time available for family members and peers to provide social support and interaction. Another possible attenuating factor is the approval expressed by parents or teachers who observe their improved control of
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internet use. As interpersonal problems such as insecurity or rejection diminish, the risk of depression is attenuated. Thus, maintaining remission status is essential for
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improving depression in subjects with internet addiction. The incidence group of subjects who had changed from non-addicted to addicted
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status at the 1-year follow up revealed increased hostility. The increase in hostility
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was also larger than that in the non-addiction group who did not acquire an internet addiction during the same period. Since hostility significantly increased during the course of addiction, the increase was not attributable to preexisting hostility alone. Based on the theory of media violence, the short-term risk of aggression is increased by the effects of playing online games with violent content, such as priming, arousal, and mimicry. Long-term exposure to violent themes in online games have a desensitizing effect that increases the long-term risk of violent behavior [37]. The anonymizing and deindividuating effects on online interaction [38] also increase the risk of hostility and aggressive behavior. The media violence effect is likely to promote hostility in the course of internet addiction. This finding is in line with a
ACCEPTED MANUSCRIPT previous report suggesting that adolescents with internet addiction have a higher than normal risk of exhibiting aggressive behavior [20].
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Aside from media violence, internet addiction is associated with frustration
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intolerance [39]. Since frustration is associated with hostility among young adolescents [40], the frustration intolerance of adolescents with internet addiction
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might contribute to the progression of hostility in the course of their addiction. During the follow-up period of this prospective study, the remission group
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revealed a larger decrease in hostility compared to the persistence group. According to interpersonal theory [41], hostility develops through identification, internalization, and introjection [42]. In the process of identification, criticism received by the parents
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of adolescents is directed toward others. For example, the internalization process may cause an adolescent child to expect others to exhibit the same dismissive, coercive,
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and blaming behaviors that they observe in their parents. They might also continue to display the cold, wary, and defensive stance that complements this expected treatment
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from others. Finally, the introjection process causes people to treat themselves in the
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same ways they are treated by key developmental figures. Adolescents with internet addiction often lose their control over internet activities such as online gaming and communication. Most parents feel powerless to supervise and get into criticism to their children.
The adolescents may identify with the criticism, internalize it,
interject their own interpretation of the criticism, or interject the criticism to their parents, teachers, and peers. Thus, the addiction to internet might result in a impaired family relationships [31]. This vicious cycle may thus increase hostility in adolescents with internet addiction. In contrast, adolescents who are in remission from internet addiction tend to receive positive feedback and approval of the change from parents or teachers. The
ACCEPTED MANUSCRIPT improved reciprocal interaction interrupts the vicious cycle and relieves the progression of hostility. Comparison of the results observed in the incidence and internet addiction has a temporal effect on hostility if
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remission groups suggests that
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remission from internet addiction is achieved within a short period. Since long-term hostility can have both negative psychosocial consequences, e.g., interpersonal
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difficulty, and negative physical consequences, e.g., cardiovascular disorder [42], remission status should be achieved as early as possible in adolescents with internet
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addiction.
Adolescents with internet addiction also reportedly have high social anxiety [5,11], which is another predictor of internet addiction [13]. Communication
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apprehension, which is the fear or anxiety associated with communication with another person, reportedly contributes to social anxiety [43]. In online interaction,
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social cues that provoke communication apprehension, e.g., facial expressions and body language, may be difficult or impossible to perceive. Thus, social anxiety tends
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to be lower during an online interaction than during a face-to-face interaction [11],
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particularly in subjects with high social anxiety. This study did not reveal a significant change in social anxiety during the process of internet addiction, which suggests that social anxiety is neither exacerbated nor improved by internet addiction. On the other hand, social anxiety decreased more in the remission group than among the persistence group. If adolescents could remit from internet addiction, they might regain more chances to maintain interactions with other than those who maintain addiction to the internet. Thus, they have more chance to practice social interaction in real life and really improve their social anxiety. This result might suggest regaining social interaction in the real world but not escaping to online interaction, could attenuate social anxiety..
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Clinical implications of the results:
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The results of this study suggest that, during the progression of internet addiction,
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adolescents are likely to exhibit exacerbated depression and hostility. Both depression and hostility are prognostic indicators of poor mental or physical health. To attenuate
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these exacerbating effects internet addiction on depression or hostility, effective policies are needed to prevent internet addiction in adolescents. However, because the
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Internet is an essential tool for adolescents, total prohibition or aggressive limitation might not be the best policy. Education to develop the skills needed for effective and constructive internet use is needed. Further studies are also needed to determine how
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to advise parents and teachers in setting effective policies for regulating internet use by their adolescent children and students. Since this study revealed that remission
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from internet addiction improves depression, hostility, and social anxiety, the negative mental health consequences of internet addiction can be minimized by achieving
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remission status as early as possible. Thus, effective interventions should be
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developed and implemented as early as possible in adolescents with internet addition to minimize depression, hostility, and social anxiety. This study has two limitations that should be considered when interpreting its findings. Firstly, the diagnoses of internet addiction were based solely on self-reported data. Future studies should also gather information from parents and teachers to support the self-reported scale. Secondly, the severity of internet addiction, depression, hostility, and social anxiety constantly changed during the course of the study. Although increased depression was demonstrated in the incidence group, we could not determine whether the addiction status preceded the exacerbation of depression. Future studies should apply a shorter follow-up period to establish clear temporal and
ACCEPTED MANUSCRIPT causal relationships. Conclusion
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This study revealed the negative mental health consequences of internet
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addiction. That is, depression and hostility increase in the course of internet addiction. However, subjects in remission from internet addiction 1 year later showed
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improvements in depression, hostility, and social anxiety. This indicates that remission from internet addiction has beneficial mental health effects in this age group. Thus,
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prevention and intervention programs should provided as early as possible to
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adolescents with internet addiction.
ACCEPTED MANUSCRIPT Acknowledgements The study was support by grants from the National Scientific Council
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(NSC94-2413-H-037-006-SSS), Kaohsiung Municipal Hsiao-Kang Hospital
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(KMHK-101-009) and Kaohsiung Medical University Hospital (KMUH100-0R50). Conflicts of interest: the authors have no personal, professional, or ethical conflicts
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of interest in the publication of this study.
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[31] Yen JY, Yen CF, Chen CC, Chen SH, Ko CH. Family factors of internet addiction and substance use experience in Taiwanese adolescents. Cyberpsychol Behav 2007;10:323-9.
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[32] Sullivan HS. The interpersonal theory of psychiatry. New York: Norton; 1953. [33] Calles JL Jr. Depression in children and adolescents. Prim Care 2007;34:243-58. [34] Prinstein MJ, Borelli JL, Cheah CS, Simon VA, Aikins JW. Adolescent girls' interpersonal vulnerability to depressive symptoms: a longitudinal examination of reassurance-seeking and peer relationships. J Abnorm Psychol 2005;114:676-88. [35] Constantine MG. Perceived family conflict, parental attachment, and depression in African American female adolescents. Cultur Divers Ethnic Minor Psychol 2006;12:697-709. [36] Weller EB, Kloos A, Kang J, Weller RA. Depression in children and adolescents: does gender make a difference? Curr Psychiatry Rep 2006;8:108-14. [37] Huesmann LR. The impact of electronic media violence: scientific theory and
ACCEPTED MANUSCRIPT research. J Adolesc Health 2007;41:S6-13.
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[38] Douglas KM, McGarty C. Identifiability and self-presentation: computer-mediated communication and intergroup interaction. Bri J Soc Psychol 2001;40:399-416.
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[39] Ko CH, Yen JY, Yen CF, Chen CS, Wang SY. The association between Internet addiction and belief of frustration intolerance: the gender difference. Cyberpsychol Behav 2008;11:273-8. [40] Rabinowitz S, Melamed S, Feiner M, Weisberg E, Ribak J. Hostility and hearing
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protection behavior: the mediating role of personal beliefs and low frustration tolerance. J Occup Health Psychol 1996;1:375-81. [41] Benjamin LS. Interpersonal reconstructive therapy (IRT): Promoting change in nonresponders. New York: Guilford Press; 2003.
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[42] Smith TW, Glazer K, Ruiz JM, Gallo LC. Hostility, anger, aggressiveness, and coronary heart disease: an interpersonal perspective on personality, emotion, and health. J Pers 2004;72:1217-70.
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[43] McCroskey JC. Oral communication apprehension: a summary of recent theroy and research. Hum Commun Res 1997;4:78-96.
ACCEPTED MANUSCRIPT Figure legends Fig. 1 Comparison of depression, hostility, and anxiety between subjects with and
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without internet addiction at the 1-year follow up.
Legend
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At the 1-year follow up, depression and hostility were increased more in the incidence
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group in comparison with non-addiction group. Depression, hostility, and social anxiety decreased more in the remission group in comparison with persist group. Assessment instruments: depression, Center for Epidemiological Studies Depression
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Scale (CES-D);hostility, Buss-Durkee Hostility Inventory- Chinese Version- Short
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Form (BDHIC-SF); social anxiety, brief version of Fear of Negative Evaluation Scale
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(FNE).
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Fig. 2 Depression at 1-year follow up. Comparison of female and male subjects who did not have internet addiction in the first investigation. Legend: The incidence group had increased depression, more significantly among female, at the 1-year follow up. . Depression was assessed by the Center for Epidemiological Studies Depression Scale (CES-D).
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Fig. 1
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Fig. 2
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Table 1 The t-test and paired t-test for depression, hostility, and social anxiety among incidence, remission, persistence and non-addiction group.
-4.70*** -3.81***
58.60±13.28 66.74±11.88 32.17±6.32 33.35±6.38
-7.01*** -1.85
Remission
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(N=71)
17.06*** 0.79 3.04** 6.37***
52 19 12.32±0.47 20.93±12.48 17.27±12.94
2.72** 7.64*** 1.33 2.10*
68.00±12.40 60.83±12.52 32.86±6.87 31.28±6.33
X or t
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55.06±13.34 56.70±13.64 31.36±6.25 32.03±6.46
-4.59***
D
Hostility (1st) (1st) Hostility (2nd) Social anxiety (1st) Social anxiety (2nd)
-0.69
75 40 12.36±0.48 17.97±9.79 22.57±11.67
Paired t
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572 695 12.32±0.47 15.23±9.22 15.40±10.19
(N=115)
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Male Female Age Depression (1st) Depression (2nd)
Paired t
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(N=1267)
Incidence
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Non addiction
Adolescents with IA at first (Mean±SD)
CR I
Adolescents without IA at first (Mean±SD)
Persistence Paired t
2.36* 4.19*** 1.91
Depression: assessed by Center for Epidemiological Studies Depression Scale (CES-D) Hostility: assessed by The Buss-Durkee Hostility Inventory- Chinese Version- Short Form (BDHIC-SF) Social anxiety: assessed by the brief version of Fear of Negative Evaluation Scale (FNE) 1st: the score in the first evaluation 2nd: the score in the follow-up evaluation one year later *: p
S0010-440X(14)00115-1 doi: 10.1016/j.comppsych.2014.05.003 YCOMP 51308
To appear in:
Comprehensive Psychiatry
Received date: Revised date: Accepted date:
1 February 2014 9 May 2014 12 May 2014
Please cite this article as: Ko Chih-Hung, Liu Tai-Ling, Wang Peng-Wei, Chen ChengSheng, Yen Cheng-Fang, Yen Ju-Yu, The exacerbation of depression, hostility, and social anxiety in the course of internet addiction among adolescents: a prospective study, Comprehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.05.003
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ACCEPTED MANUSCRIPT The exacerbation of depression, hostility, and social anxiety in the course of internet addiction among adolescents: a prospective study.
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Running title: exacerbation of psychiatric symptoms in IA
Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung
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Chih-Hung Ko, M.D., Ph.D.,1,2,3 Tai-Ling Liu, M.D.,1 Peng-Wei Wang, M.D.,1 Cheng-Sheng Chen, M.D.1,3, Cheng-Fang Yen, M.D. Ph.D.1,3, Ju-Yu Yen, M.D., Ph.D.1
Medical University, Kaohsiung City, Taiwan 807 2
Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan 812 Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung
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Medical University, Kaohsiung City, Taiwan 807 Department of psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
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Medical University, Kaohsiung, Taiwan 801
The Corresponding Author: Ju-Yu Yen, M.D., Ph.D. Department of Psychiatry, Kaohsiung Municipal Ta-Tung Hospital Kaohsiung Medical University No.68, Jhonghua 3rd Rd, Cianjin District, Kaohsiung City 80145, Taiwan Telephone: 886-7-3121101 Ext. 6822 Fax: 886-7-3134761 E mail: [email protected]
ACCEPTED MANUSCRIPT Abstract Background
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In adolescent populations worldwide, internet addiction is prevalent and is often
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comorbid with depression, hostility, and social anxiety of adolescents. This study aimed at evaluating the exacerbation of depression, hostility, and social anxiety in the
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course of getting addiction to internet or remitting from Internet addiction among adolescents.
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Method
This study recruited 2293 adolescents in grade 7 to assess their depression, hostility, social anxiety and internet addiction. The same assessments were repeated one year
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later. The incidence group was defined as subjects classified as non-addicted in the first assessment and as addicted in the second assessment. The remission group was
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defined as subjects classified as addicted in the first assessment and as non-addicted
Results
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in the second assessment.
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The incidence group exhibited increased depression and hostility more than the non-addiction group and the the effect of on depression was stronger among adolescent girls. Further, the remission group showed decreased depression, hostility, and social anxiety more than the persistent addiction group. Conclusions Depression and hostility worsen in the addiction process for the Internet among adolescents. Intervention of internet addiction should be provided to prevent its negative effect on mental health. Depression, hostility, and social anxiety decreased in the process of remission. It suggested the negative consequences could be reversed if internet addiction could be remitted within a short duration.
ACCEPTED MANUSCRIPT Key words: Internet addiction, depression, hostility, social anxiety, prospective,
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adolescents.
ACCEPTED MANUSCRIPT Introduction: More than 90% of adolescents use the Internet to get information [1]. The
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Internet is one of the most powerful media of the 21st century and has revolutionized
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education and social communication in adolescents [2]. For adolescents, the Internet is also an important source of health-related information[3]. However, internet
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addiction, which can be defined as the loss of control over internet use and its resulting negative consequences, is common in adolescents [4]. Epidemiological
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studies reveal that internet addiction occurs in 1.4~17.9% of adolescents in both western and eastern populations [5,6,7]. This indicates that internet addiction is a major mental health problem in adolescents worldwide. Therefore, a clear
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understanding the mental health effects of internet addiction in adolescents is essential.
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Epidemiological studies agree that internet addiction in adolescents is associated with depressive symptoms and social anxiety [5,8,9]. The same association
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has also been reported in college students [10]. However, the causal relationship
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between internet addiction and depression and social anxiety could not confirmed in previous cross-section studies.
Social anxiety is generally lower during online
interaction than during face-to-face interaction, especially in subjects with high social anxiety [11]. Depressive subjects also experience lower social anxiety and hostility during online interaction [11,12]. Thus, we hypothesized that adolescents who have depression or social anxiety often use the Internet relieve their depressive or social anxiety symptoms. In our previous study, which analyzed the same data of this presenting study, the baseline severity of depression or social anxiety predicted internet addiction at the 2-year follow up [13]. However, no studies have investigated whether internet addiction contributes to depression and social anxiety.
ACCEPTED MANUSCRIPT Although an earlier path analysis study demonstrated that problematic internet use is a predictor of depression [14], this conclusion was not based on a prospective
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study. A recent study reported that adolescents with problematic internet use had a
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higher incidence of depression at the 9-month follow-up compared to non-addicted controls, but anxiety did not significantly differ [15]. This indicates that internet
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addiction contributes to depression. Another prospective study revealed spontaneous remission in adolescents with internet addiction [16], which is consistent with the
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clinical experience of the authors. If the addiction status changes, the addiction status observed in the initial survey cannot be considered an unchanged predictor of depression or anxiety. Thus, causal relationships should be interpreted cautiously in
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prospective studies in which predictors, e.g., internet addiction, change in the course of the investigation.
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In Gentile et al., adolescents who played online games were classified into four groups in terms of their pathological internet gaming behavior: a stop group, a start
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group, a stay group, and a never group.. Comparisons showed that the start group,
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who started with a pathological condition during follow-up, ultimately showed higher depression, anxiety, and social phobia compared to the never group, who had never been pathological gamers. The authors further showed that the stop group, who no longer exhibited pathological internet gaming behavior during follow-up, had lower depression, anxiety, and social phobia compared to the stay group, who continued to exhibit such behavior[17]. Based these results, the authors suggested that depression and anxiety result from pathological online gaming activity. They demonstrated a practical way to perform a detailed study of changes in comorbid psychiatric symptoms in the four groups of pathological gamers. However, since the initial investigation did not assess depression, anxiety, and social phobia, the study did not
ACCEPTED MANUSCRIPT confirm whether these symptoms really changed during the follow-up periods. Thus, depression and social anxiety must be compared prospectively in courses of internet
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addiction among adolescents. Such studies would provide essential information for
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understanding whether internet addiction contributes to depression or social anxiety. Aggressive behaviors such as cyber bullying and extreme behaviors such as
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internet suicide have been associated with excessive internet use [18] and with internet addiction [19]. Hostility has also been associated with internet addiction [12,
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13, 20]. Although hostility decreased after getting online, subjects with internet addiction increased expressive hostility when getting online [12]. Adolescents with internet addiction reportedly have higher hostility [5] and more aggressive behaviors
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[20]. These results indicate that subjects with high hostility may have a higher vulnerability to internet addiction. This claim is supported by our previous study,
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which analyzed the same data set considered here. At the 2-year follow, adolescents with high hostility were more likely to get internet addiction [13]. These results are
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also consistent with social learning theory, which suggests that violence in media
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increases hostility and aggression [21]. Since longitudinal studies have identified both biological and environmental factors that affect behavioral traits in adolescents [22], an improved understanding of whether internet addiction increases hostility is needed Internet addiction is more common in males than in females [13]. Further, hostility is the best predictor of internet addiction in males whereas the presence of ADHD symptoms is the best predictor in females [13]. This suggests a gender difference in associative factors or comorbidity in adolescent internet addiction [9]. Gender differences in the preferred online activity have also been reported. For example, in adolescents with internet addiction, online gaming is the most common internet activity in males but not in females [23]. Gender differences in the online
ACCEPTED MANUSCRIPT experience and in the vulnerability to comorbidity might contribute to differences in the effect of internet addiction on psychiatric symptoms.
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Thus, the aims of this study were 1) evaluating the change of depression,
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hostility, and social anxiety in the course of internet addiction or remitting from it; and 2) exploring the gender difference in incidence or remission effect of internet
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addiction on the progression of depression, hostility, and social anxiety.
ACCEPTED MANUSCRIPT Methods Participants
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In September, 2005, the participants in this study were recruited from ten junior
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high schools distributed throughout southern Taiwan (four located in urban areas, four located in suburban areas, and two located in rural areas). The participants included
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students in eight randomly selected classes in each school. Research assistants visited the students in their classrooms and explained the study objectives and procedures.
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Signed consent to participation in the initial investigation was received from 2,293 students (1,179 males and 1,174 females; mean age, 12.36 ± 0.55 years). The Institutional Review Board of Kaohsiung Medical University Hospital approved this
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study and confirmed its compliance with the ethical standards established by the 1964 Declaration of Helsinki and its subsequent amendments.
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Instruments
Chen Internet Addiction Scale (CIAS). The 26-item CIAS uses a 4-point Likert scale
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to assesses five dimensions of internet-related problems. The CIAS rates the severity
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of internet addiction from 26 to 104, which represent low to high severity, respectively. The internal reliability of the scale and the subscales in the original study ranged from 0.79 to 0.93 [24]. According to the diagnostic criteria of internet addiction [25], a cutoff point marked by the scores 63/64 provides the best combination of diagnostic accuracy (87.6%), sensitivity (67.8%), and specificity (92.6%) [26]. Accordingly, subjects with CIAS scores of 64 or higher were classified as the internet addiction group in this study. Center for Epidemiological Studies Depression Scale (CES-D): The 20-item Mandarin Chinese version [27] of the CES-D [28] is a self-administered test of the frequency of depressive symptoms within the previous week in which high scores
ACCEPTED MANUSCRIPT indicate increased severity of depression. The CES-D in the present study had a Cronbach alpha of 0.78.
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The Buss-Durkee Hostility Inventory- Chinese Version- Short Form (BDHIC-SF).
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The 20-item, 5-point Likert-type BDHIC-SF assesses four dimensions of the hostility construct, including hostility cognition, hostility affection, expressive hostility
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behavior, and suppressive hostility behavior. The coefficient of internal consistency (Cronbach alpha) was 0.93, and the four-week test-retest reliability was 0.80. Higher
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scores indicate higher hostility [29].
The brief version of Fear of Negative Evaluation Scale (FNE) evaluates the cognitive symptoms of social phobia. The BV-FNE is a brief, 5-point Likert-type, 12-item version of the FNE that has demonstrated a high correlation with the original
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scale (r=0.96), a high internal consistency (α=0.90), and a good 4-week test-retest
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reliability coefficient (0.75) [30]. Here, the FNE was used to evaluate cognitive symptoms of social phobia.
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Study procedure and statistical analysis
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After receiving approval of this study by the Institutional Review Board of Kaohsiung Medical University Hospital, the CIAS, CESD, BDHIC-SF, and FNE were administered in the initial assessment. The same scales were administered again year later. The objective of the study was to evaluate the effects of internet addiction on the change in depression, hostility, and social anxiety. In the adolescents classified as the non-addiction group in the initial investigation, those classified as addicted and non-addicted at the 1-year follow up were defined as the incidence group and the non-addiction group, respectively. In the adolescents classified as the addiction group in the initial investigation,
ACCEPTED MANUSCRIPT those classified as addicted and non-addicted at the 1-year follow up were defined as the persistence group and the remission group, respectively. In each group, changes in
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CIAS, CESD, BDHIC-SF, and FNE scores were evaluated by paired t-test. A
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repeated-measures, two-way ANOVA analysis of CESD, BDHIC-SF, and FNE scores was performed as a function of the time course (within-subject effect) and incidence
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of internet addiction (incidence group versus non-addiction group; between-subject effect) with gender and age covariates among subjects without internet addiction in
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the initial investigation. The same analysis was further used to evaluate CESD, BDHIC-SF, and FNE as a function of the time course (within-subject effect) and remission of internet addiction (remission group versus persistence group;
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between-subject effect) in the subjects who revealed internet addiction in the initial investigation. All statistical analyses were performed using the SPSS software
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package. A p-value less than 0.05 was considered statistically significant.
ACCEPTED MANUSCRIPT Results The 1863 adolescent students (943 males and 920 females) who completed the CIAS
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were classified into four groups. The missing rate did not differ by gender (X2=2.55).
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Of these, 1520 participants completed the CESD, BDHIC-SF, and FNE in the initial assessment and in the 1-year follow up. Of the 1382 participants (647 males and 735
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females) who did not have internet addiction in the initial assessment, paired t-test showed that both the non-addiction group (572 males and 695 females) and the
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incidence group had increased hostility and social anxiety in the 1-year follow up (Table 1, Figs. 1A, 1B). The repeated two-way ANOVA further demonstrated that the incidence group (75 males and 40 females) had a larger increase in CESD and
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BDHIC-SF scores compared to the non-addiction group at the 1-year follow up (Table 2; Figs.1A, 1B). Further, the interaction of gender and incidence group effect
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significantly predicted the progression of depression. Further analysis demonstrated that the effect of incidence on progression of depression was significantly larger in
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girls than in boys (Table 2 and Fig. 2).
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In the subjects who had internet addiction in the initial investigation (104 males and 34 females), CESD and BDHIC-SF scores were significantly decreased in the remission group (52 males and 19 females) but not in the persistence group (52 males and 15 females) did not, during the one-year follow-up (Table 1). The repeated two-way ANOVA revealed that the decrease in CESD, BDHIC-SF, and FNE scores was larger in the remission group than in the persistence group (Table 3; Figs. 1D, 1E).
ACCEPTED MANUSCRIPT Discussion In subjects who became internet-addicted, depression increased during the 1-year
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follow up. The increase in the severity of depression was larger than that in the
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control group during the same period. In line with previous report [22], this result indicates that, during the process of addiction to the internet in adolescents,
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depression is exacerbated. In the process of addiction to the internet, adolescents may experience negative consequences of internet addiction such as impaired academic
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performance, conflict with parents [31], and social isolation. They might also experience a sense of rejection by their parents, isolation from their peers in the real world, and low self-esteem in school.
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Interpersonal theory [32] suggests that these interpersonal difficulties can worsen interpersonal security and increase the risk of depression. However, the need for
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self-esteem and reassurance can be met by internet activity such as online gaming or by using communication tools for mass social interaction. The combination of
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real-world rejection and online reassurance further increases their addiction to the
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internet. Further, excessive internet use occupies the limited free time they have for social interaction such as religious activities and for recreational activities, which can provide feelings of competence or social support. Since social support, personal competence and religion are known to have important effects in protecting adolescents from depression [33], the attenuation of these protective factors in real life might increase the risk of depression. In contrast, online activity reportedly decreases social anxiety and hostility, particularly in depressive subjects [11,12]. To compensate for feelings of inadequate social support, interpersonal security, or personal competence, adolescents may increase their online interaction to increase their self-esteem through approval from others or through achievements in online
ACCEPTED MANUSCRIPT gaming. However, the present study demonstrated that exacerbates rather than diminishes depression. The data suggest that the attempt to escape depression and
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real-world concerns through online interaction results in a vicious cycle that
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exacerbates depression, but not a recovery process. Thus, any preventive schedule for internet addiction should be implemented at the youngest possible age to minimize its
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exacerbating effects on depression.
Another exacerbating factor in depression was the interaction term of gender and
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incidence effect. Further stratified analysis demonstrated that, in the incidence group, the effects of internet addiction were more severe in girls than in boys. That is, adolescent girls are more vulnerable to the effects of the internet addiction process on
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the progression of depression. An earlier study of interpersonal vulnerability to depression in adolescent girls suggested that reassurance-seeking combined with poor
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relationships with peers contributes to depression [34]. Thus, real-world interpersonal difficulties resulting from internet addiction have contributing effects on depression
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that are larger in adolescent boys than in of adolescent girls. A previous report
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suggested that perceived parental conflict contributes to depression in adolescent females [35]. Parents of adolescents with internet addiction usually impose controls on internet use, which results in conflict. In this case, the individual with internet addiction has high perceived parental conflict and low family satisfaction [31]. Thus, internet addiction in female adolescents might exacerbate depression by disturbing family relationships and by increasing interpersonal difficulties. Since female adolescents are also more vulnerable to depression compared to their male counterparts [36], female adolescents might be more vulnerable to the negative effects of internet addiction on depression. Thus, treatment for adolescents with internet addiction, particularly females, should pay effort to prevent the exacerbation of
ACCEPTED MANUSCRIPT depression. This prospective study also revealed that adolescents in remission from internet
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addiction at the 1-year follow-up had decreased depression. The decrease in
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depression during this period was larger than that in the persistence group, which indicates that depression in adolescents with internet addiction can improve if
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remission from internet addiction occurs within a short time. In adolescents in remission from internet addiction, the negative consequences of internet addiction
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may be attenuated by the increased free time available for family members and peers to provide social support and interaction. Another possible attenuating factor is the approval expressed by parents or teachers who observe their improved control of
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internet use. As interpersonal problems such as insecurity or rejection diminish, the risk of depression is attenuated. Thus, maintaining remission status is essential for
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improving depression in subjects with internet addiction. The incidence group of subjects who had changed from non-addicted to addicted
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status at the 1-year follow up revealed increased hostility. The increase in hostility
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was also larger than that in the non-addiction group who did not acquire an internet addiction during the same period. Since hostility significantly increased during the course of addiction, the increase was not attributable to preexisting hostility alone. Based on the theory of media violence, the short-term risk of aggression is increased by the effects of playing online games with violent content, such as priming, arousal, and mimicry. Long-term exposure to violent themes in online games have a desensitizing effect that increases the long-term risk of violent behavior [37]. The anonymizing and deindividuating effects on online interaction [38] also increase the risk of hostility and aggressive behavior. The media violence effect is likely to promote hostility in the course of internet addiction. This finding is in line with a
ACCEPTED MANUSCRIPT previous report suggesting that adolescents with internet addiction have a higher than normal risk of exhibiting aggressive behavior [20].
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Aside from media violence, internet addiction is associated with frustration
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intolerance [39]. Since frustration is associated with hostility among young adolescents [40], the frustration intolerance of adolescents with internet addiction
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might contribute to the progression of hostility in the course of their addiction. During the follow-up period of this prospective study, the remission group
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revealed a larger decrease in hostility compared to the persistence group. According to interpersonal theory [41], hostility develops through identification, internalization, and introjection [42]. In the process of identification, criticism received by the parents
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of adolescents is directed toward others. For example, the internalization process may cause an adolescent child to expect others to exhibit the same dismissive, coercive,
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and blaming behaviors that they observe in their parents. They might also continue to display the cold, wary, and defensive stance that complements this expected treatment
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from others. Finally, the introjection process causes people to treat themselves in the
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same ways they are treated by key developmental figures. Adolescents with internet addiction often lose their control over internet activities such as online gaming and communication. Most parents feel powerless to supervise and get into criticism to their children.
The adolescents may identify with the criticism, internalize it,
interject their own interpretation of the criticism, or interject the criticism to their parents, teachers, and peers. Thus, the addiction to internet might result in a impaired family relationships [31]. This vicious cycle may thus increase hostility in adolescents with internet addiction. In contrast, adolescents who are in remission from internet addiction tend to receive positive feedback and approval of the change from parents or teachers. The
ACCEPTED MANUSCRIPT improved reciprocal interaction interrupts the vicious cycle and relieves the progression of hostility. Comparison of the results observed in the incidence and internet addiction has a temporal effect on hostility if
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remission groups suggests that
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remission from internet addiction is achieved within a short period. Since long-term hostility can have both negative psychosocial consequences, e.g., interpersonal
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difficulty, and negative physical consequences, e.g., cardiovascular disorder [42], remission status should be achieved as early as possible in adolescents with internet
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addiction.
Adolescents with internet addiction also reportedly have high social anxiety [5,11], which is another predictor of internet addiction [13]. Communication
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apprehension, which is the fear or anxiety associated with communication with another person, reportedly contributes to social anxiety [43]. In online interaction,
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social cues that provoke communication apprehension, e.g., facial expressions and body language, may be difficult or impossible to perceive. Thus, social anxiety tends
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to be lower during an online interaction than during a face-to-face interaction [11],
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particularly in subjects with high social anxiety. This study did not reveal a significant change in social anxiety during the process of internet addiction, which suggests that social anxiety is neither exacerbated nor improved by internet addiction. On the other hand, social anxiety decreased more in the remission group than among the persistence group. If adolescents could remit from internet addiction, they might regain more chances to maintain interactions with other than those who maintain addiction to the internet. Thus, they have more chance to practice social interaction in real life and really improve their social anxiety. This result might suggest regaining social interaction in the real world but not escaping to online interaction, could attenuate social anxiety..
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Clinical implications of the results:
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The results of this study suggest that, during the progression of internet addiction,
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adolescents are likely to exhibit exacerbated depression and hostility. Both depression and hostility are prognostic indicators of poor mental or physical health. To attenuate
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these exacerbating effects internet addiction on depression or hostility, effective policies are needed to prevent internet addiction in adolescents. However, because the
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Internet is an essential tool for adolescents, total prohibition or aggressive limitation might not be the best policy. Education to develop the skills needed for effective and constructive internet use is needed. Further studies are also needed to determine how
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to advise parents and teachers in setting effective policies for regulating internet use by their adolescent children and students. Since this study revealed that remission
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from internet addiction improves depression, hostility, and social anxiety, the negative mental health consequences of internet addiction can be minimized by achieving
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remission status as early as possible. Thus, effective interventions should be
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developed and implemented as early as possible in adolescents with internet addition to minimize depression, hostility, and social anxiety. This study has two limitations that should be considered when interpreting its findings. Firstly, the diagnoses of internet addiction were based solely on self-reported data. Future studies should also gather information from parents and teachers to support the self-reported scale. Secondly, the severity of internet addiction, depression, hostility, and social anxiety constantly changed during the course of the study. Although increased depression was demonstrated in the incidence group, we could not determine whether the addiction status preceded the exacerbation of depression. Future studies should apply a shorter follow-up period to establish clear temporal and
ACCEPTED MANUSCRIPT causal relationships. Conclusion
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This study revealed the negative mental health consequences of internet
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addiction. That is, depression and hostility increase in the course of internet addiction. However, subjects in remission from internet addiction 1 year later showed
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improvements in depression, hostility, and social anxiety. This indicates that remission from internet addiction has beneficial mental health effects in this age group. Thus,
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prevention and intervention programs should provided as early as possible to
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adolescents with internet addiction.
ACCEPTED MANUSCRIPT Acknowledgements The study was support by grants from the National Scientific Council
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(NSC94-2413-H-037-006-SSS), Kaohsiung Municipal Hsiao-Kang Hospital
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(KMHK-101-009) and Kaohsiung Medical University Hospital (KMUH100-0R50). Conflicts of interest: the authors have no personal, professional, or ethical conflicts
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of interest in the publication of this study.
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ACCEPTED MANUSCRIPT Figure legends Fig. 1 Comparison of depression, hostility, and anxiety between subjects with and
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without internet addiction at the 1-year follow up.
Legend
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At the 1-year follow up, depression and hostility were increased more in the incidence
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group in comparison with non-addiction group. Depression, hostility, and social anxiety decreased more in the remission group in comparison with persist group. Assessment instruments: depression, Center for Epidemiological Studies Depression
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Scale (CES-D);hostility, Buss-Durkee Hostility Inventory- Chinese Version- Short
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Form (BDHIC-SF); social anxiety, brief version of Fear of Negative Evaluation Scale
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(FNE).
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Fig. 2 Depression at 1-year follow up. Comparison of female and male subjects who did not have internet addiction in the first investigation. Legend: The incidence group had increased depression, more significantly among female, at the 1-year follow up. . Depression was assessed by the Center for Epidemiological Studies Depression Scale (CES-D).
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Fig. 1
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Fig. 2
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Table 1 The t-test and paired t-test for depression, hostility, and social anxiety among incidence, remission, persistence and non-addiction group.
-4.70*** -3.81***
58.60±13.28 66.74±11.88 32.17±6.32 33.35±6.38
-7.01*** -1.85
Remission
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(N=71)
17.06*** 0.79 3.04** 6.37***
52 19 12.32±0.47 20.93±12.48 17.27±12.94
2.72** 7.64*** 1.33 2.10*
68.00±12.40 60.83±12.52 32.86±6.87 31.28±6.33
X or t
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55.06±13.34 56.70±13.64 31.36±6.25 32.03±6.46
-4.59***
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Hostility (1st) (1st) Hostility (2nd) Social anxiety (1st) Social anxiety (2nd)
-0.69
75 40 12.36±0.48 17.97±9.79 22.57±11.67
Paired t
TE
572 695 12.32±0.47 15.23±9.22 15.40±10.19
(N=115)
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Male Female Age Depression (1st) Depression (2nd)
Paired t
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(N=1267)
Incidence
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Non addiction
Adolescents with IA at first (Mean±SD)
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Adolescents without IA at first (Mean±SD)
Persistence Paired t
2.36* 4.19*** 1.91
Depression: assessed by Center for Epidemiological Studies Depression Scale (CES-D) Hostility: assessed by The Buss-Durkee Hostility Inventory- Chinese Version- Short Form (BDHIC-SF) Social anxiety: assessed by the brief version of Fear of Negative Evaluation Scale (FNE) 1st: the score in the first evaluation 2nd: the score in the follow-up evaluation one year later *: p
