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The dark side of the web

The Internet and social media have had obvious benefits for many doctors, from being able to follow the latest medical research online to connecting with colleagues across the globe.

Significant numbers of doctors use platforms such as Twitter and as the Medical Independent (MI) exclusively revealed in our last issue (8 December), the HSE’s new strategy for outpatient services envisions a substantial increase in the use of telemedicine by doctors and patients.

However, cautious voices have also emerged from within medicine, noting the negative impact the Internet and social media can have on their work and on patients.

Recent controversies over ‘fake news’ during the US election cycle reflect similar concerns in the medical sector. The public is increasingly obtaining information on vaccination and other medical matters from the Internet, but not always from officially certified medical websites. This year, the Health Products Regulatory Authority (HPRA) published data which found that 24 per cent of people use the Internet to source information on medicines. This phenomenon has been recognised within the HSE (see panel).

And while many doctors may have embraced social media, some have also described their experience of embracing it a little too intensely.

Writing in MI in August, GP Dr Peter Sloane described how he had quit social media. He went from being a “serious ‘Social Media Guru’” to closing down his social media accounts.



“Over a two-month period, I made a very detailed appraisal of why I used social media, what I was giving to it, and what it was giving to me. I began to ask myself hard questions about how much of my time it was occupying,” wrote Dr Sloane.

Dr Sloane has no regrets about his decision. “I came to the realisation that it wasn’t of benefit to my future. I stopped it… in doing so, I believe I’ve made a huge investment!”

Many people find their time swallowed-up by social media, as in Dr Sloane’s experience. However, in a separate realm are those for whom Internet use is a serious problem requiring medical support.

Addiction

Consultant Psychiatrist Dr Colin O’Gara, who is Head of Addiction Services at St John of God Hospital, Dublin, has seen increasing numbers of patients presenting with problems associated with Internet usage.

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Dr Colin O’Gara

Dr O’Gara has much experience in the area of ‘process addictions’. These are addictions that do not require a substance and include gambling, shopping, Internet use and online gaming.

‘Parents give them tablets and phones to play with and then the child might end up quite addicted

He is seeing “a variety of problems that have their root in the easy availability of the Internet on a variety of devices. Nowadays, it is pretty much all mobile devices.”

The Internet has become a platform that has had a significant impact on other process addictions, such as gambling, shopping and sex.

“I do not get referrals specifically for social media addiction,” Dr O’Gara tells MI. “However, what I would see are referrals where people utilise social media platforms to engage in another process problem. So, for example, it would be compulsive contact with individuals [online] where there is a sexual component to it.

“That can be highly problematic. It is not sexual addiction in its true sense, in that there is no physical contact, but [it can be] very damaging. Another example would be the case of Internet shopping and from the people I see, it is not gender-specific. So, we would see people who would have their home cluttered with unnecessary items.

“You could have a particular item of clothing, like a pair of trousers, and this person would have over 20 pairs of trousers in one particular room and then another room with another 20 or so pairs.

“The key here is that there is no mental disorder, such as bipolar affective disorder. There is absolutely no evidence of that… you have rational, lucid thinking and an acknowledgement that the behaviour is harmful [and] that it is causing problems for the individual themselves and people around them. But they have great difficulty in stopping.

“You might ask, what is the attraction there? A lot of the online sites have an auction process, which is where the attraction comes from.  It is a form, to my mind, of gambling, because with some people there is a thrill involved in seeing whether they get to purchase the item or not. That can be significantly problematic.”

Acceptance

Dr Kimberly Young is a US-based psychologist and an expert in Internet addiction disorder. She has written a number of books about Internet addiction and is the Founder and Director of the Centre for Internet Addiction in the US.

Deciphering online fact from fiction

One thing is for certain — people increasingly source medical information online. This year’s HPRA survey found that four out of 10 (43 per cent) people use the Internet to find information on “wider health matters”.

What is less certain is the quality of the information sourced.

In October, MI interviewed Dr Brenda Corcoran from the HSE National Immunisation Office about the difficulties posed by the campaign against the HPV vaccine, which has had a prominent profile online.

“I don’t think it’s peculiar to vaccines. I do think there are lot of issues in general society that the general public are questioning and they are turning away from experts, if you like, and trying to find out information for themselves,” Dr Corcoran told MI.

“And obviously, that is something that everyone is entitled to do, but they need to get that vaccine information from scientifically-accurate sites, and that is the challenge.”

Earlier this month, American science journalist Ms Deborah Blum spoke at an event organised by Science Foundation Ireland, warning of the role that reporting on the Internet and elsewhere can play in feeding public scepticism towards science and medicine.

“While some aspects of science ‘denialism’, such as rejection of climate change by our President-elect, can seem US-centric, I think we see aspects of this in every country,” said Ms Blum.

“The anti-vaccine movement is stronger in parts of Europe than in the US and the anti-GMO movement tends to be so hostile as to reject even small and rational moves by that field of science.

“And this trend is not a small, worrisome one but a real danger if we consider that people are turning away from very credible evidence that could help us save lives and protect the planet,” she said.

At a press briefing in May, the HPRA ruled out playing a role in certifying health websites. At the briefing, MI asked HPRA Chief Executive Ms Lorraine Nolan whether the HPRA could play a possible role.

“In general, it’s not within our remit to be approving what sites give correct information,” said Ms Nolan. “We would always invite patients to use our own website. It is up-to-date and current and it gives all the correct information.”

Ms Nolan said websites established by official organisations like the HSE and the Department of Health could also be trusted.

MI asked the Department whether it had any policy or concerns regarding patients accessing medical information from non-official sites online. The Department directed us towards the HSE Press Office. MI asked the HSE about this issue, as well as the provision of addiction services for those impacted by issues related to Internet addiction. The Executive had not responded to MI by the time of our print deadline.

In October, the Medical Council published a patient information booklet that focuses on a number of areas, including telemedicine and the Internet.

See the Medical Council patient information booklet at www.medicalcouncil.ie/News-and-Publications/Reports/Working%20with%20Your%20Doctor.html.

Over the last two decades, she has noticed some significant developments in the perception of the problem within medicine.

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Dr Kimberly Young

“I started studying Internet addiction in 1995 and yes, the medical community has changed [its view]. It’s widely accepted in parts of Asia and Europe,” she tells MI.

“The United States has lagged behind in its total acceptance of the disorder, although Internet Gaming Disorder is something more recognised in the US.”

With Internet access on our phones and laptops and a fundamental aspect of many people’s working day, some observers have noted that its ubiquitous nature increases the difficulty in diagnosis.

“Yes, it is harder to diagnose because of the widespread use of technology,” agrees Dr Young. “This is especially true with young children. Parents give them tablets and phones to play with and then the child might end up quite addicted.  I also see that we need very clear guidelines on how parents work with children at home with technology. I’ve developed very clear guidelines [see www.netaddiction.com].”

In Ireland, Dr O’Gara also finds that the all-encompassing nature of the Internet can pose difficulties in terms of definition and health provision.

“One of the biggest challenges the field has is the actual utility of some of the diagnostic categories, and the definition of [the] diagnostic categories,” says Dr O’Gara.

“Process addictions are really going to have a challenge in regards to that. Because again, on the spectrum we have something like exercise, gaming itself, gambling, shopping and tanning. There is good literature on the different aspects of why tanning has become a significant problem for some people.  And then of course you have sex, which is a biological norm. So where is the dividing line, the cut-off?”

Gaming Disorder

The inherent problems around providing clear diagnostic categories may be one of the reasons why Internet addiction and Internet Gaming Disorder did not attain full recognition in the Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM-5) published by the American Psychiatric Association in 2013.

Although not without its critics, the DSM is one of the two most widely-used manuals in the mental health sector, alongside the International Classification of Diseases (ICD).

Internet Gaming Disorder was listed in the DSM-5 within a section titled ‘Conditions for further study’. However, Gambling Disorder was included, the first time a process addiction has been recognised in the manual.

“I think the reason it [Internet Gaming Disorder] did not get in was that the evidence was not conclusive,” Dr O’Gara tells MI.

“But I guess it is more about the volume and quality of the data needed. Certainly, in the case of gambling, it was the convergence of data from mainly neurobiological studies, particularly functional MRI scans, some genetic data and then psychological tests, as well as the obvious clinical observations. In the case of gambling, there is a wealth of evidence there.

“Probably because the prevalence isn’t as high [for online gaming] in Western societies compared to Asian countries, I would have thought that is why we have not got there yet with Internet Gaming Disorder.”

However, Dr O’Gara says there is increasing online gaming in the West. He believes “as a result, we will see the increase in prevalence of difficulties”.

Patients addicted to online games known as Massively Multiplayer Online games (MMOs) are being seen more frequently by those working in the addiction field. “There is no doubt in my mind that a certain proportion of individuals who’ll engage in this activity will run into very severe difficulty,” says Dr O’Gara.

“The prevalence will probably mirror other processes, so you’ll have probably in and around 1 per cent who will have very severe dysfunction, probably then in the area of 5 to 7 per cent who will have elements of harm on the spectrum. So people will be gaming too long, causing friction with people around them, missing opportunities that they might otherwise get involved in [and] possibly some physical impact where they are not keeping a healthy lifestyle, like they should do.”

The reference to physical health points to the wider public health challenge posed by Internet-based addictions.

Sedentary behaviour

The Government’s public health campaign Healthy Ireland (HI) makes no direct reference to excessive gaming or Internet usage as a concern. However, in its most recent survey, HI does focus on “sedentary behaviour” as one of its four key “unhealthy behaviours” (see panel below). The others are binge-drinking, smoking and not eating the recommended amount of fruit and vegetables.

Are you sitting down… perhaps too much?

An indication of the public health impact of excessive Internet usage may be found in the results of the Healthy Ireland Survey 2016.

“In recent years, a number of studies have highlighted a variety of risks associated with sitting for long periods of time,” found the survey.

“These risks include both those associated with physical inactivity, such as obesity and cardiovascular disease, but also other conditions such as chronic back pain, varicose veins and other musculoskeletal disorders.

“At an overall level, people spend an average of 396 minutes (six hours, 36 minutes) sitting across an average day. Men typically spend longer sitting than women, 415 and 376 minutes, respectively. For both men and women, the time spent sitting is typically higher in younger age groups and declines across older groups.

“People spent on average 92 minutes working or studying (including 55 per cent who did not work or study on the previous day), 172 minutes sitting while watching a TV or other screen and 133 minutes sitting while driving, eating or relaxing.”

The 172 minutes of sitting “while watching a TV or other screen” accounted for the largest amount of time sitting every day.

HI defines unhealthy “sedentary behaviour” as sitting for more than eight hours a day.  Evidence shows that Internet Gaming Disorder, where players are using MMOs, increases the amount of time sitting. Gaming was not itemised in the Healthy Ireland Survey 2016, but “sitting while watching a TV or other screen” was the category of sitting that took up most of people’s time on a daily basis.

While the popular perception may be of an isolated gamer in their bedroom, this somewhat ignores the social aspect of MMOs, where players can play with and against other people from around the globe.

“Certainly, the literature would lean towards that [social connection] being a unique element which adds to the attractiveness and ultimately to the addictiveness of the game,” says Dr O’Gara.  “Some commentators suggest that people can live in pretty much alternate worlds. In some countries, particularly in Asia, there are issues with young people basically not leaving their rooms at all.”

The global challenge seems to vary geographically. For instance, in Japan, Internet Gaming Disorder is viewed as an important public health topic. A recent report by the Japanese government concluded that more than half a million young people in Japan live as hikikomori, which is defined by the Japanese Health, Labour and Welfare Ministry as people who have stayed in their home for six months or more without leaving. Experts point to varied causes of the phenomenon, but many mention the role of the Internet and gaming in particular.

“We haven’t had it on the same scale, say, in Ireland or the UK,” says Dr O’Gara.

“But one might be worried with the increase in quality of both Internet speed and then the constant development of the social interactive aspects of these games. Also, the emergence of other platforms into the games-like gambling platforms and possibly even sexual platforms. One can really become completely diverted from what we consider reality into just an inordinate amount of time spent in front of the screen.”

Working in the United States for over two decades, Dr Young believes that the rapidity of change in the online world will keep those working in addiction services busy.

“I think overall, the world has changed related to technology,” she tells MI.

“We need to be much more cautious and raise awareness that people can become addicted and misuse this technology.”

Dr O’Gara notes that while the exact prevalence of this problem in Ireland has not been quantified, reports from schools in particular show that children are sometimes being introduced to Internet-connected technologies as soon as they can speak and there is peer pressure to obtain devices and engage in MMO games.

His own website (www.drcolinogara.com) notes that the “prevalence and popularity of online gaming in young persons in Ireland suggests that the numbers looking for assistance with addiction will not be insignificant”.

Troubled

From his experience working with cases of process addictions impacted by the Internet, Dr O’Gara said the problems are “significant”.

“The key message from a clinical point of view is that these issues are certainly not trivial,” says Dr O’Gara. “People are significantly troubled by them; there is ample evidence to demonstrate the significant loss of control and all the other features that go with addiction.

“People engaging with this sort of behaviour have a very significant effect on people around them. For example, family members are very upset and traumatised by something like overspending [with Internet shopping]; parcels arriving every day from Internet companies. So it is not insignificant from a clinical point of view.”

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