Commentary on ‘The association between problematic internet use and depression,suicidal ideation and bipolar disorder in Korean adolescents’

The paper by Park et al. (2012) is a timely and important contribution to the growing – though often still speculative – field of ‘internet psychology’, particularly as it applies to those of school age. In little more than a decade, there has been increasing public, clinical and research interest in the broad field of ‘cybersafety and well-being’, which includes issues such as cyberbullying, inappropriate website access by young people, and problematic internet use (PIU) – popularly dubbed ‘internet addiction’. As a marker of the academic interest, at least three international journals are dedicated to the field of internet psychology: the first and leading one, Cyberpsychology, Behaviour, and Social Networking was established in 1997, with mainstream psychiatry journals, including the Australian & New Zealand Journal of Psychiatry, now regularly publishing articles investigating PIU (e.g. Du et al., 2010; Porter et al., 2010). This would appear noteworthy, given that the status of PIU as a distinct clinical and nosological entity remains unclear (Starcevic, 2010). The DSM-5 Task Force is currently considering placing PIU alongside other, controversial ‘behavioural addictions’ in an Appendix, pending further research and clarification (American Psychiatric Association, 2012), rather than according it the status of a full disorder.

In Park et al.’s (2012) present study, which utilised as subjects a predominantly female population in a high school in the Korean capital, the team investigated the potential associations between PIU and depression, as well as potential links with suicidal ideation and with early-onset bipolar disorder. Standardised and validated questionnaires were utilised, without direct investigator input / interviewing. This broad clinical focus is in line with recently demonstrated associations of PIU with depression, anxiety, low self-esteem and, more tentatively, ADHD (Yen et al., 2009) and Asperger’s disorder (Charlton, 2008). Prominent co-morbidity status adds weight to the conceptualisation of PIU being a ‘complex end-point behaviour’ of many other ‘primary’ problems (made more pertinent given the near-ubiquity of internet access and usage in young people today), rather than a unitary condition in its own right.

The authors found a point prevalence for PIU (definite and probable) of 9.4% of their sample of 795 students. This is broadly in line with most of the international prevalence studies into PIU in young people (though slightly less, the authors note, than in recent Korean studies). The only methodologically sound and valid multicentre, international comparison study to date, by Gentile et al. (2011), also found a prevalence rate similar to that in the present study, though it focused more on problem video-gaming.

This ‘baseline’ data set having been established, the team then investigated potential associations with the three psychopathological domains. Strong associations were found with depression, with a less strong link with suicidal ideation. To this reader at least, it would appear that there is a rather large ‘conceptual leap’ from linking PIU to, for example, suicidal ideation. It is well-recognised that factors such as self-esteem, general well-being and personal stress are associated with PIU (Valkenburg and Peter, 2006) and it is suggested that these latter factors are a key mediating factor in developing subsequent psychopathology. Explicitly exploring these factors could have added more sophistication and subtlety their model – though this would have added to the (already large) number of questionnaires being completed.

Another concern – indeed a feature of almost all similar research – is the lack of specific data on how the subjects were utilising their time online. The World Wide Web is clearly not a unitary phenomenon: almost all of human experience and endeavour can be accessed online, and in a more immediate, intense and personalised form. Current surveys (e.g. the Nielsen online survey; Nielsen, 2011) indicate that social networking is the commonest online activity, followed by gaming, and then general browsing / media viewing. This issue is crucial, as the various activities probably have different sychological and social underpinnings, and thus may require differing approaches to managing resultant compulsive or obsessive habits. For example, it is clear that many video games utilise cognitive methods such as intermittent positive reinforcement to enhance gameplay (and enjoyment) – a very strong form of conditioning which adds to a game’s ‘addictive’ potential. Obtaining an ‘internet usage inventory’ in future population-based research would seem advisable. This last point is also important when exploring gender differences in internet usage, and by extension PIU. Clinical experience, both locally and internationally, suggests that males tend to be attracted to games, and females to social networking (though females have increased dramatically in gaming usage in recent years).

In their path-analysis model of association between the factors studied, the authors are correct in highlighting the transactional nature of the core phenomena: PIU can lead to depression (and, less robustly, to suicidal ideation), but the depression itself can lead to worsening PIU. This ‘vicious cycle’ has been clearly established in other behavioural addictions – most notably pathological gambling – and most likely is a major factor in maintaining problem behaviours despite intervention.

Though the study was located in a Korean setting, which as Park et al. (2012) note has its own particular characteristics (including a dense, urbanised setting, world-leading internet connectivity and a pressured, competitive educational system), there are two major relevancies for Australian specialists to note: first, a recent international Nielsen survey (Nielsen, 2011) put Australian youth as amongst the highest users of ‘social media’ in the world (well ahead of the USA, the UK and all Asian countries); second, the highly multicultural nature of contemporary Australian society – particularly in metropolitan regions – suggests that mental health clinicians should be aware of the possibility of PIU features in their clients. Of course, this by no means implies that PIU is limited to immigrant or non-English-speaking background (NESB) populations, but the well-established stresses in those groups along with concomitant increased rates of mental health issues suggests that a basic ‘internet inventory’ as part of the clinical assessment is often advisable. In summary, and in looking at the future evolution of this complex disorder, the perennial epithet ‘more research is needed’ seems most apt for this 21st-century affliction.

See Research by Park et al., 2013, 47(2): 153–159.