A Review of Research on Problematic Internet Use and Well-Being

With Recommendations for the U.S. Air Force

by Joshua Breslau, Eyal Aharoni, Eric R. Pedersen, Laura L. Miller

This Article

RAND Health Quarterly, 2015; 5(1):20


This article reviews the scientific literature on the epidemiology, prevention, and treatment of problematic Internet use (PIU) with the goal of informing Air Force policies aimed at mitigating PIU’s negative impact on operations and the mental health of Airmen. The study is motivated by a recent RAND study estimating that 6 percent of Airmen have PIU. Individuals with PIU, similar to people with substance addictions, suffer from excessive and compulsive online activities, symptoms of tolerance and withdrawal, and functional impairment. PIU is also strongly associated with other mental health problems including major depression. However, at present there is no single accepted definition of PIU, and no up-to-date estimates of the prevalence of PIU in the general U.S. population are available. A range of prevention and treatment approaches have been developed, but none has been rigorously tested in clinical trials. Prevention programs rely on workplace Internet policies and strategies to help individuals self-regulate their Internet use. Treatment approaches that have proven feasible and acceptable to patients with PIU include adaptations of cognitive-behavioral therapy, an evidence-based treatment for depression and anxiety, to the specific symptoms of PIU. Based on our findings, we recommend: (1) increasing awareness of PIU among organizational leadership and mental health professionals, (2) incorporating content related to PIU into existing trainings related to mental health, (3) providing support for self-regulation of Internet use on the job by incorporating PIU management principles into Internet use policies, and (4) continuing monitoring of the emerging scientific literature on PIU.

For more information, see RAND RR-849-AF at https://www.rand.org/pubs/research_reports/RR849.html

Full Text

Just as the Internet was becoming part of everyday life in the mid-1990s, mental health professionals started seeing patients who were so absorbed in their online activities that they were neglecting their important social relationships, their work responsibilities, and even their health. To some clinicians and researchers, it seemed that online activities could lead to dysfunctional behavior. Others even suggested that people could become “addicted” to the Internet, just as they become addicted to gambling or alcohol. As Internet use exploded in the ensuing decades, concern with what has been called problematic Internet use (PIU) or Internet addiction has also grown.

PIU is of concern to the Air Force because it presents new policy challenges. On the one hand, PIU may be particularly likely to emerge among the young adult male demographic of most Airmen. In fact, a 2012 RAND survey estimated that 6 percent of Airmen have PIU using a validated assessment tool. On the other hand, since PIU is a newly emerging condition, little is known about why it occurs, the severity of the impairment it causes, and strategies for preventing and treating it. Indeed, knowledge of PIU is uncommon even among mental health professionals. This report seeks to inform the development of Air Force policies aimed at mitigating PIU's impact on operations and the mental health of Airmen.

How Is PIU Defined, and How Prevalent Is It?

Although a variety of terms and measures have been used to assess PIU, it is commonly defined by symptoms associated with addiction, including excessive and compulsive use, tolerance, withdrawal, and impairment. Individuals with PIU use the Internet compulsively, continuing a pattern of excessive use despite adverse consequences or self-imposed limits. They develop tolerance, so their use becomes increasingly intensive or prolonged, and they have anxiety and other withdrawal symptoms when they cannot be online. Their everyday functioning is impaired, resulting in reduced productivity, friction with friends and family, and failure to perform basic activities. The specific problem activities vary widely. For example, for some, online gaming is the primary difficulty; for others it may be social media, chat rooms, pornography, or gambling.

Although PIU is broadly recognized as a highly problematic behavior pattern that warrants clinical attention, there is no consensus that it constitutes a distinct clinical diagnosis. Like other behavioral addictions, PIU is considered a disorder by some researchers and clinicians, but it is not recognized as such in the American Psychiatric Association's official catalog of disorders, the Diagnostic and Statistical Manual of Mental Disorders, Version 5 (DSM-5). This does not mean that most psychiatrists think that PIU is not a potentially serious condition warranting clinical attention. Many view PIU as a set of behaviors that may reflect an underlying psychiatric disorder such as depression. More research is needed in this area to determine whether PIU should be considered a distinct disorder with a unique etiology and treatment approach. Internet Gaming Disorder was included in an appendix to DSM5 for conditions that warrant additional research and clinical experience prior to consideration for inclusion as an official disorder.

The prevalence of PIU is difficult to gauge. The research to date has used small and often very specialized samples, different assessment tools, and inconsistent definitions and criteria. Also, because Internet penetration has expanded so rapidly, studies quickly become out of date. The most reliable study we found put the prevalence of PIU at less than 1 percent of the U.S. population in 2004, and this decade-old study was conducted well before the steep rise in the adoption of broadband Internet access, computer tablets and smartphones, and the rapid expansion of social media and smartphone “apps.” As noted earlier, the 2012 RAND survey of U.S. Air Force military personnel estimated that 6 percent of Airmen may be struggling with PIU.

What Are the Risk Factors and Consequences?

It is unclear whether excessive Internet use results in the social and psychological issues associated with it or whether those issues make an individual vulnerable to PIU. However, it is clear that PIU does not often occur in isolation, and a variety of likely risk factors have been identified, including social withdrawal, victimization, emotional instability, aggression, anxiety, depression, substance abuse, and suicidal behavior.

The consequences of PIU can be life altering: for example, marital conflict or child neglect due to a spouse or parent spending free time engaging in cybersex or hanging out in chat rooms; financial difficulties because a compulsive shopper can now make purchases online 24 hours a day; ruined college careers because a student chooses gaming over studying and attending class; unemployment due to a worker's inability to stay off social media during work hours; and physical ills caused by sitting at a computer too long and not sleeping, eating, exercising, or even bathing sufficiently.

What Strategies Are Used for Prevention and Treatment?

Comprehensive prevention and treatment strategies include individuals at risk for PIU, their employers, and their clinicians. The following approaches have support in the existing literature:

Individuals at risk: Self-regulation strategies are likely to be the front line of PIU prevention. These include self-monitoring, committing to limited usage, and rewards for meeting goals. Many online tools are available for purchase and free of charge to block access to certain sites, limit usage of a site, or provide usage statistics. Because many job duties require Internet access, people need strategies to regulate their use of the specific websites associated with their problem.

Employers: Most employers already have Internet policies in place aimed at keeping workers productive. The standard response to violations has been discipline or termination, not taking into account the potential role of PIU in the employee's behavior. But some companies are developing “cyber wellness” programs designed to increase employee, supervisor, and management awareness of PIU issues, reduce incidents, and decrease the employer's liability in the case of a terminated employee claiming that the rules for Internet use were not clear or that he or she had a mental health problem.

Mental health clinicians: Over the past 25 years, clinicians have developed treatments for PIU based on existing and proven treatments for depression, anxiety disorders, and substance use disorders. However, the effectiveness of these treatments for PIU specifically has yet to be tested in rigorous clinical studies. The treatments show promise, but their use should be closely monitored and adjusted as the research grows richer. Among the more promising treatment candidates is cognitive-behavioral therapy, which is successful at treating anxiety disorders or depression. Principles of substance abuse treatment are also incorporated into treatments, including abstinence and “harm reduction”—reducing or limiting use, often after temporary abstinence. Harm reduction typically is more attractive and feasible than abstinence because Internet access is so essential to work and daily communication. In the absence of proven PIU-specific treatments, for now clinicians should consider PIU symptoms as potential manifestations of underlying disorders which can be treated using established methods.

Our Recommendations

Until the research on PIU matures, policies that promote education and awareness, self-monitoring, and efficient and private access to wellness services represent judicious steps toward successfully managing, and preventing this potentially debilitating condition. The overall goal of our recommendations is to shift the culture regarding Internet use in the Air Force so that the mental health aspects of Internet use, i.e., PIU and its common mental health comorbidities, are given appropriate priority in the operational awareness of leaders, workplace policies, and mental health treatment.

Increase awareness: Organizational leadership and mental health professionals should be trained to consider PIU as a factor influencing Airmen's behavior. Training should cover the signs of PIU and its association with mental health problems, as well as protocols for unobtrusive mental health referral. Content related to PIU should be included in existing commander handbooks and broader training programs related to Airmen's mental health and well-being.

Provide support on the job: As in the civilian sector, the Air Force could benefit by incorporating knowledge of PIU into Internet use policies. The Air Force as well as civilian employers should focus on voluntary monitoring; educational, prevention, and treatment services; and self-monitoring support. They should carefully weigh the pros and cons of more onerous policies that would broadly restrict Internet access and adversely affect overall productivity. They should also exercise caution when disciplining violators, taking into account that some may be in need of professional mental health services. Leaders should also recognize that while some Airmen may require Internet access to perform their duties, there are potential hazards to allowing access to the “drug of choice” for the Internet “addict,” and that restrictions on access to selected problematic sites may be warranted. Relatively minor adjustments to workplace environment or work responsibilities may be sufficient to help some individuals with PIU remain on-task and productive.

Employ promising treatment approaches: Mental health treatment should be considered in cases where PIU persists despite attempts to help an individual self-regulate Internet use. Until more is known about tailoring treatment approaches to PIU, mental health professionals can follow civilian providers' lead in providing cognitive-behavioral therapy and elements of substance abuse treatment to Airmen suffering the consequences of PIU and associated disorders. Mental health practitioners should consider clinical assessments of PIU in their patients to help detect problems that might not otherwise surface. They are also likely to benefit from continuing education programs focused on PIU, as well as ensuring that they have a basic understanding of common technologies and associated terms (e.g., avatar, sexting, Internet troll) so they can better understand the experiences of the Airmen they are treating.

Continue to investigate PIU in the Air Force: Further investigation is sorely needed to understand PIU in the general population and in the military in particular. In the Air Force, a cost-effective method could include performing a quantitative assessment to measure PIU, perhaps as part of biennial Air Force Community Assessment surveys. This instrument offers the opportunity to assess prevalence as well as the relationship between PIU scores and other indicators of well-being. We recommend using language more broad than “Internet,” as addiction-like behaviors regarding computer, smartphone and video game use more generally hold as much relevance for the military as the more narrowly focused term “Internet.” Otherwise, measures can underestimate the problem if respondents do not think of time in an online game or on their smartphones as being “on the Internet.”

Qualitative exploration to determine what PIU looks like in the military population could also provide context-specific information that would help develop better strategies to address it. For example, does PIU often follow a life event or begin during a certain military experience? Does it tend to start before Airmen join the service? What obstacles exist to overcoming PIU? How much do military leaders, chaplains, and mental health professionals know about it, and how do they attempt to address it? The results of a qualitative study could identify

  • targeted topics to include in the large-scale survey to assess prevalence and track PIU over time
  • misconceptions and counterproductive behaviors among personnel attempting to address PIU
  • interest in or need for continuing education on the topic for military counselors
  • military-specific examples of PIU for use in educational and training materials
  • points of vulnerability where special outreach may be warranted (e.g., postdivorce, postcombat, during assignments to remote locations).

The research reported here was commissioned by the Air Force Office of the Surgeon General (AF/SG) and conducted within the Manpower, Personnel, and Training Program of RAND Project AIR FORCE.

RAND Health Quarterly is produced by the RAND Corporation. ISSN 2162-8254.