Assessing clinical trials of Internet addiction treatment: A systematic review and CONSORT evaluation

Abstract

Although there is ongoing debate concerning the clinical status of Internet addiction, and the quality of the extant literature in this emerging field is not optimal, several clinical trials of both pharmacological and psychological treatments for Internet addiction have been published in recent years. A systematic review investigating the reporting quality of eight treatment studies is presented. Reporting quality was defined according to the 2010 Consolidating Standards of Reporting Trials (CONSORT) statement. An evaluation of the reviewed studies highlighted several key limitations, including (a) inconsistencies in the definition and diagnosis of Internet addiction, (b) a lack of randomization and blinding techniques, (c) a lack of adequate controls or other comparison groups, and (d) insufficient information concerning recruitment dates, sample characteristics, and treatment effect sizes. It is concluded that improvements in future studies' design and reporting would be of significant benefit to both researchers and clinicians, and to the overall positioning of Internet addiction in the behavioral addiction field.

Introduction

There is ongoing debate as to whether ‘Internet addiction’ constitutes a true addiction and should therefore be recognized as a psychiatric disorder in the forthcoming DSM-V (Block, 2008, Warden et al., 2004). Although it is well established that a significant number of individuals report psychological problems associated with excessive Internet use, the extent and severity of these problems may be somewhat overestimated because of the relatively low methodological quality of many studies in this area. Most studies have utilized inconsistent criteria to identify Internet addicts and/or have applied recruitment methods that may have caused serious sampling bias (Byun et al., 2009). More specifically in relation to Internet addiction criteria used in most studies, Griffiths (2008) asserts the main problems with the measures used is that they tend to (i) have no measure of severity, (ii) have no temporal dimension, (iii) overestimate the prevalence of problems, and (iv) take no account of the context of Internet use.

Reviews by Griffiths (2000a) (Widyanto & Griffiths, 2006) have also argued that those working in the Internet addiction field need to distinguish between addictions on the Internet, and addictions to the Internet. Griffiths argues most ‘Internet addicts’ are not addicted to the Internet itself, but use it as a medium to fuel other addictions. He has also used case study evidence to argue that some very excessive Internet users may not have any negative detrimental effects as a consequence of their behavior and therefore cannot even be classed as addicted (Griffiths, 2010). In short, a gambling addict who uses the Internet to gamble is a gambling addict not an Internet addict (Blaszczynski, 2006). The Internet is just the place where they conduct their chosen (addictive) behavior. However, Griffiths, 2000b, Griffiths, 2001, Suler, 2001 have also observed that some behaviors engaged on the Internet (e.g., cybersex, cyberstalking, etc.) may be behaviors that the person would only carry out on the Internet because the medium is anonymous, non face-to-face, and disinhibiting.

For these reasons, it is often argued that problematic Internet behaviors may be more appropriately conceptualized within existing known psychopathologies such as depression or anxiety (Blaszczynski, 2006, Shaffer et al., 2000, Wood, 2008). Nevertheless, a number of researchers have argued that Internet addictions do exist (Beard, 2005, Davis, 2001, Griffiths, 2000a, King and Delfabbro, 2009, Young, 1996) and can arise from unhealthy involvement in a range of online activities. These activities may include browsing websites, online information gathering, downloading or trading files online, online social networking, online video gaming, online shopping, online gambling, and various online sexual activities such as viewing pornography or engaging in simulated sexual acts.

While there is no consensus as to the clinical status of Internet addiction, there appears to be significant demand for treatment for Internet-related problems, particularly in China, Taiwan and South Korea, where the estimated prevalence of Internet addiction problems among adolescents ranges from 1.6% (Kim et al., 2006) to 11.3% (Geng, Su, & Cao, 2006). The South Korean government has reportedly established a network of over 140 counseling centers for treatment of Internet addiction and has introduced treatment programs at almost 100 hospitals (Kim, 2008). In addition, numerous ‘boot camp’-style programs for Internet-addicted adolescents have emerged in both China and Korea (Koo, Wati, Lee, & Oh, 2011). In Western countries, clinics specializing in the psychological treatment of computer-based addictions have also emerged, including: the Center for Online and Internet Addiction located in Bradford, Pennsylvania, United States; the Computer Addiction Study Center, McLean Hospital, Belmont, Massachusetts, United States; the Broadway Lodge residential rehabilitation unit located in Somerset, England; and the Smith & Jones 12-step (Minnesota Model) clinic located in Amsterdam, Holland (King, Delfabbro, & Griffiths, 2010a). Additionally, there are some online providers of treatment services for Internet addiction (e.g., www.netaddiction.com; www.netaddictionrecovery.com; www.onlineaddiction.com.au), many of which are modeled on 12-step self-help treatment philosophies including specific types of groups such as Online Gamers Anonymous.

Available evidence suggests that, internationally, many individuals with Internet-related problems have received some form of treatment from a mental health or medical service provider. However, very few studies have examined the effectiveness of any such treatments, including counseling, psychotherapy, or pharmacological interventions (Griffiths, 2008, Huang et al., 2010). The number of studies in this area is not as large as the number of studies examining the general features and correlates of Internet addiction, or as the number of studies of psychological treatment for other behavioral addictions, such as pathological gambling. To date, there has been no published critical evaluation or systematic review of the Internet addiction treatment literature. From a research-practitioner perspective, this may make it difficult for some to evaluate the comparative efficacy of certain treatments for Internet addiction. Further, the lack of scientific review in this area may hinder the development of a shared view of Internet addiction and its classification within the broader psychological community.

The aim of this paper was to conduct a comprehensive review of the literature on clinical interventions for Internet addiction. This review aimed to evaluate the quality of reviewed studies using the CONSORT (Consolidating Standards of Reporting Trials) statement, which is a recognized ‘gold standard’ for assessing the reporting quality of clinical trials (Altman et al., 2001). The relevant content of each reviewed study is matched to the CONSORT statement to assess its compliance. It should be noted that this review was not necessarily intended to discern the most efficacious treatment available for Internet-related problems, because the treatment administered in each study was evaluated only in terms of its adherence to the relevant CONSORT indicators of reporting quality, such as how well the treatment was described, how well it was administered (i.e., treatment protocol) and by whom (i.e., care providers/centers), and whether some form of blinding procedure was employed. However, identification of higher quality treatment studies through this process may be of some practical benefit to clinicians.