Abstract
Behavioral addictions were introduced as novel mental disorders in the International Classification of Diseases, 11th Revision, based on evidence that human behavior itself can become addictive, similar to addiction to substances. However, previous studies on prevention of gaming disorder and unspecified internet use disorder lacked randomization, follow-up measurements, and diagnostic interviews that assessed incidence rates; this trial was intended to fill this gap. To investigate whether the PROTECT (Professioneller Umgang mit technischen Medien [Professional Use of Technical Media]) intervention can reduce the symptom severity and prevent full syndrome and subthreshold onset of gaming disorder and unspecified internet use disorder in at-risk adolescents. A multicenter cluster randomized clinical trial conducted recruitment, screening, intervention delivery, and data collection among at-risk adolescents aged 12 to 18 years in 33 high schools in Germany. Inclusion criteria for the study and symptom severity analyses were elevated symptoms of gaming disorder and unspecified internet use disorder. A subsample that met the inclusion criteria for incidence analyses (no full syndrome of gaming disorder or unspecified internet use disorder, depression, or anxiety at baseline) was analyzed for illness onset. Participants were randomized to either the PROTECT intervention group or the assessment-only control group. Participants were assessed at baseline, 1-month follow-up, 4-month follow-up, and 12-month follow-up between October 1, 2015, and September 30, 2018. Based on intent-to-treat principle, data analyses were conducted from February 8, 2019, to May 7, 2021. PROTECT, a theory-driven, manualized, cognitive behavioral therapy-based indicated preventive group intervention that is delivered in 4 sessions by trained psychologists. It targets changes in addictive reward processing and pathological cognitive mechanisms. The primary outcome was symptom severity (measured by CSAS [Computerspielabhängigkeitsskala], a modified German video game dependency scale with a score range of 0-56 [higher scores indicating greater pathology]) along with incidence rates (assessed by a structured clinical interview) after 12 months. Secondary outcomes were comorbid psychopathology and problem behaviors. A total of 422 at-risk adolescents (mean [SD] age, 15.11 [2.01] years; 229 female participants [54.3%]) were randomized to either the PROTECT intervention group (n = 167; mean [SD] risk score, 29.05 [6.98]) or the assessment-only control group (n = 255; mean [SD] risk score, 26.21 [5.01]) and were included in the symptom severity analyses. Compared with the control group, the PROTECT group showed a significantly greater reduction in symptom severity of gaming disorder or unspecified internet use disorder (γ11 = -0.128; 95% CI, -0.246 to -0.011; P = .03), reflecting a 39.8% vs 27.7% reduction of symptoms with an effect size of Cohen d = 0.67 (baseline vs 12-month follow-up) for the PROTECT group. Differences in incidence rates did not reach statistical significance. The PROTECT group showed a significantly greater decrease in procrastination (γ11 = -0.458; 95% CI, -0.735 to -0.180; P < .001) over 12 months, but no significant differences were found for other secondary outcomes. Results of this trial showed that the PROTECT intervention effectively reduced symptoms of gaming disorder and unspecified internet use disorder over 12 months. The intervention did not change incidence rates of gaming disorder or unspecified internet use disorder. ClinicalTrials.gov Identifier: NCT02907658.
Highlights
Results of this trial showed that the PROTECT intervention effectively reduced symptoms of gaming disorder and unspecified internet use disorder over 12 months
With the release of the International Classification of Diseases, 11th Revision (ICD-11), the World Health Organization recognized that excessive behaviors can become addictive, and such an addiction can be analogous to addictions based on psychotropic substances.[1]
In 1 study, prevalence of gaming disorder and unspecified internet use disorder increased from 2.8% in children aged 11 to 12 years to 9.1% in young adults aged 18 to 21 years,[28] whereas several studies found that prevalence decreased at the end of the third decade of life.[20,25,27]
Summary
With the release of the International Classification of Diseases, 11th Revision (ICD-11), the World Health Organization recognized that excessive behaviors can become addictive, and such an addiction can be analogous to addictions based on psychotropic substances.[1]. Adolescents seem to be vulnerable to developing disorders that are associated with the reward system.[20,25,26,27] In line with this finding, excessive use of video games and the internet is highly prevalent in youth and early adulthood.[23,28,29,30] In 1 study, prevalence of gaming disorder and unspecified internet use disorder increased from 2.8% in children aged 11 to 12 years to 9.1% in young adults aged 18 to 21 years,[28] whereas several studies found that prevalence decreased at the end of the third decade of life.[20,25,27] Findings on the stability of addiction symptoms over 1 year have been mixed, ranging from 28.4%31 to 37.6%32 to 63.3%.33 Those patients whose addictive behaviors persist present a challenge to health care and social systems. The excessive use of video games and internet applications has been growing ( during the ongoing COVID-19 pandemic),[29,36,37] which underlines the need for prevention and early intervention.[38,39,40,41,42,43] Between September 2019 and March 2020, the mean amount of time that adolescents in Germany spent on video gaming increased by 75.0% on weekdays (Monday through Friday) and by 29.3% on weekends.[29]
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