Effects of a manualized Short-term treatment of Internet and Computer game Addiction (STICA)
Final Report Abstract
21.) Summary Presentation of major findings and future implications The present evaluation of a CBT short-term therapy with patients with internet- and computer gaming addiction demonstrated a significant improvement in the main outcome criterion AlCA-S level (Al(^-S<7, resp. not pathological) between active intervention and wait-list control group. Participants of the intervention had a 9.46-fold better chance to achieve a non-pathological state of their online behavior. Education, treatment center and age had no significant effect on outcome. Additional and consistent benefits were found for remission rates, continuous AlCA-S Scores, time spent online, reduction of negative consequences, resp. depression arid improved self-efficacy. Adverse events refened to mental disorders which are frequent in this group, particularly regarding depression. Regarding vital signs and health parameters there were no relevant changes. Smoking and consumption of hard drugs were reduced in both groups. The current study demonstrates the efficacy of short-term CBT for patients with internet- and computer gaming addiction on a broad array of outcome parameters. Recruitment difRcufties in other centers and high drop-out rates may indicate problems of motivation and consistent participation in this male and mostly adolescent group. Fields of further implementation and future research perspectives: Report Synopsis Page 9 of 12 Final Report Synopsis of Study “STICA” DFG-Refercnce: DFG BE 2248/10-1 / DFG-BMBF Sonderprogramm „Klinische Studien“ It is planned to disseminate the clinical experience wrth STICA to other outpatient clinics with a special focus on the treatment of internet addiction. Moreover, it seems possible to apply elements of STICA to inpatient treatment settings, as well as in psychosocial counselling programs. Since STICA is a modular intervention program, it is possible to implement some of its elements during therapeutic interventions for other mental disorders in clients expressing internet addiction as a comorbid health condition. Prior research has demonstrated that especially among patients being treated for cannabis dependency, high rates of comorbid internet addiction are present (Müller et al., 2012). The first findings on the efficacy of STICA in internet addiction are promising. However, there are several aspects that are worth of being further investigated. First, while in general, good effect sizes were obtained, there are also patients that obviously do not respond to the therapy program. Therefore we suggest conducting further subgroup analyses in order to identify variables predictive of response vs. non-response. These analyses can be performed on a quantitative level (data from self-reports) but should also include a qualitative perspective (e.g. by analyzing motivational states of the patients at the beginning). For the latter approach, It is proposed to perform a guided qualitative analysis of the video recordings available. Since STICA has been shown to be largely effective, it is further proposed to test if its applicability can be extended also to adolescents. To that purpose it is planned to perform some adaptations to the program in order to better meet the needs of adolescents suffering from internet addiction and to perform a similar randomized controlled trial including patients aged 12 to 16 years. As has been mentioned above, there are first findings on a potential efficacy of pharmacological intervention in internet addiction (e.g. Winkler et al. 2013). Since a benchmark for a non-pharmacologicai intervention is available now, we can think of running a second randomized controlled trial additionally involving a pharmacological treatment condition (e.g. involving application of SSRI). Unexpected events during the trial Although a feasibility study had been performed prior to this trial, the affiliated study centers were suffering from recruitment problems throughout the trial and none of them reached the previously estimated number of patients. Consequently, the coordinating center in Mainz exceeded the pre-defined number of patients in order to compensate for the recruitment problems in the other centers. Although the multicenter design was preserved, these circumstances led to an imbalance of patients being treated. One reason for these recruitment problems might be found in the inclusion and exclusion criteria. These criteria may have been defined too strictly leading to unexpectedly high rates of exclusion. For example, considerable proportions of patients did not fulfil all of the inclusion criteria (exceeding age, below criteria for self-reported lA/ CA) or fulfilled exclusion criteria (increased depression score, ongoing psychotherapy, need for medication). We recommend conducting future trials with a larger number of affiliated centers in order to be able to compensate for failures of single centers. Unlike some years ago, there is a growing number of hospitals offering outpatient treatment for patients with internet and computer game addiction. Thus, clinical trials with a larger number of participating centers should be feasible. Also, given the high rate of comorbid mental disorders, inclusion criteria (e.g. BDI scores, criteria for lA) could be extended. Some participants may have underestiiTiated their level of addictive behavior initially. Missing data (e.g. due to drop-outs) occurred in the STlCA-group as well as in the WLC-group. This is a general problem in the field of addictive behavior. Our experience showed that many patients virtio had sought consultation turned out to be highly ambivalent concerning group therapy or lacked commitment to enroll in a treatment trial. In many cases a lack of compliance is most likely related to the specific psychopathology in this group with a low conscientiousness and high procrastination. Some patients refused participation due to the obligatory video recording of the therapy sessions. Secondly, as our design required block randomization to closed groups, patients enrolling had to wait until the full sample size (ideally, N=16) were recruited (control patients faced an additional waiting period of 4 months). These requirements led to further refusers and dropouts. For future studies we recommend to take steps to timely enhance the level of commitment among the treatment seekers (e.g. by initial sessions to enhance motivation by implementing the technique of motivational interviewing) or to offer some kind of stabilization (e.g. online counselling) during the waiting period. Furthermore, the high drop-out rates were also caused by a rather strict a priori definition of therapy commitment (participation in at least 18 therapy sessions). This criterion turned out to be a quite conservative one that led to a loss of statistical power and consequently should be reconsidered in future studies. A last aspect regards unexpected financial challenges. During the course of the trial four trained therapists transferred to other positions and thus were lost as study therapists. This led to an increase of training needed to ensure reliable manualized treatment and minimize bias of assessments (AlCA-C and SCID-training). Increased payment costs were caused because randomization had to be conducted with fewer patients per group to avoid delay and patient refusals resp. drop-outs. Media coverage and other relevant publication outlets regarding STICA: Plenary talk, Dr. K. Wölfling: .Ways out of Addiction - outpatient therapy of Internet Addiction' [.Wege aus der Abhängigkeit - Ambulante Therapie der Intemetsucht“], Annual meeting of The Federal Commissioner for Drugs, [Jahrestagung der Bundesdrogenbeauflragten], Berlin 09.10.2012 Appearance Or. K. Wölfling; talk show jiacht:sicht“ with the topic Digital Gaming Addiction [.Digitale Spielsuchr], Bavarian Television, Munich, 29.08.2016, [http://vww.br.de/mediathek/videoA/ideo/zum-thema-digitale-spielsucht-100.html] Expert hearing, Dr. K. Wölfling: statement at the parliamentary committee of the German Federal Parliament with the topic Expert reoort on the addictive potential of digital media [“Studie zum Suchtpotenzial digitaler Medien*], Berlin 09.06.2016, Bundestags-TV Report Synopsis Page 10 of 12 Final Report Synopsis of Study “STICA'’ DFG-Reference: DFG BE 2248/10-1 / DFG-BMBF Sonderprogramm „Klinische Studien“ (http://www.bundestag.de/dokumente/textarchlv/2016/kw23-pa-bildung-technikfolgen-diskussion/426826l Appointment of Dr. K. Wölfling to the national expert team S2-medical guideline “Internet Addiction" [S2-Leitlinie Intemetabhängigkeit der AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V to be constituted in 2017 Furthermore, it is planned to launch a media conference in spring 2017 in order to present the main results of the trial and to further raise the public consciousness for the problem of internet and computer game addiction.
Publications
- (2012) Effects of a manualized short-term treatment of internet and computer game addiction (STICA): study protocol for a randomized controlled trial. Trials.13. 43
Jäger, S., Müller, K.W., Ruckes, C., Wittig, T., Batra, A., Musalek, M., Mann, K. Wölfling, K. & Beutel, M.E.
(See online at https://doi.org/10.1186/1745-6215-13-43) - (2012). Computerspiel- und Internetsucht: Ein kognitiv-behaviorales Behandlungsmanual. In Buchkremer. G., Batra, A. Reihe: Störungsspezifische Psychotherapie. Stuttgart: Kohlhammer Verlag
Wölfling, K., Jo. C., Bengesser, I., Beutel, M. E. & Müller, K.W.
- (2012). Construction of a clinical interview to assess Internet Addiction: First findings regarding the usefulness of AlCA-C. J Addict Res Ther. S6: 003
Wölfling, K., Müller, K.W. & Beutel, M.E.
(See online at https://doi.org/10.4172/2155-6105.S6-003) - (2013).Therapieansätze bei Computerspiel- und Internetsucht und pathologischem Glücksspiel. Der Nervenarzt 84 (5): 576-83
Wölfling, K., Leménager, T., Peukert, P. & Batra, A.
(See online at https://doi.org/10.1007/s00115-012-3722-3) - (2014). A contribution to the clinical characterization of Internet addiction in a sample of treatment seekers: validity of assessment, severity of psychopathology and type of co-morbidity. Compr Psychiatry. 55(4):770-7
Müller, K.W., Beutel, M.E. & Wölfling K.
(See online at https://doi.org/10.1016/j.comppsych.2014.01.010) - Treatment Outcomes in Patients with Internet Addiction: A Clinical Pilot Study on the Effects of a Cognitive-Behavioral Therapy Program. BioMed research International, 2014
Wölfling, K., Beutel, M. E., Dreier, M., & Müller, K. W.
(See online at https://doi.org/10.1155/2014/425924)
