Problematic Internet Use Before and During the COVID-19 Pandemic in Youth in Outpatient Mental Health Treatment: App-Based Ecological Momentary Assessment Study

BACKGROUND

Youth with existing psychiatric illness are more apt to use the internet as a coping skill. Because many "in-person" coping skills were not easily accessible during the COVID-19 pandemic, youth in outpatient mental health treatment may have been particularly vulnerable to the development of problematic internet use (PIU). The identification of a pandemic-associated worsening of PIU in this population is critical in order to guide clinical care; if these youth have become dependent upon the internet to regulate their negative emotions, PIU must be addressed as part of mental health treatment. However, many existing studies of youth digital media use in the pandemic do not include youth in psychiatric treatment or are reliant upon cross-sectional methodology and self-report measures of digital media use.

OBJECTIVE

This is a retrospective cohort study that used data collected from an app-based ecological momentary assessment protocol to examine potential pandemic-associated changes in digital media youth in outpatient mental health treatment. Secondary analyses assessed for differences in digital media use dependent upon personal and familial COVID-19 exposure and familial hospitalization, as well as factors associated with PIU in this population.

METHODS

The participants were aged 12-23 years and were receiving mental health treatment in an outpatient community hospital setting. All participants completed a 6-week daily ecological momentary assessment protocol on their personal smartphones. Questions were asked about depression (PHQ-8 [8-item Patient Health Questionnaire]), anxiety (GAD-7 [7-item General Anxiety Disorder]), PIU (PIU-SF-6 [Problematic Internet Use Short Form 6]), digital media use based on Apple's daily screen time reports, and personal and familial COVID-19 exposure. The analyses compared screen time, psychiatric symptoms, and PIU between cohorts, as well as between youth with personal or familial COVID-19 exposures and those without. The analyses also assessed for demographic and psychiatric factors associated with clinically significant PIU-SF-6 scores.

RESULTS

A total of 69 participants completed the study. The participants recruited during the pandemic were significantly more likely to meet the criteria for PIU based on their average PIU-SF-6 score (P=.02) and to spend more time using social media each day (P=.049). The overall amount of daily screen time did not differ between cohorts. Secondary analyses revealed a significant increase in average daily screen time among subjects who were exposed to COVID-19 (P=.01). Youth with clinically significant PIU-SF-6 scores were younger and more likely to have higher PHQ-8 (P=.003) and GAD-7 (P=.003) scores. No differences in scale scores or media use were found between subjects based on familial COVID-19 exposure or hospitalization.

CONCLUSIONS

Our findings support our hypothesis that PIU may have worsened for youth in mental health treatment during the pandemic, particularly the problematic use of social media. Mental health clinicians should incorporate screening for PIU into routine clinical care in order to prevent potential familial conflict and subsequent psychiatric crises that might stem from unrecognized PIU.

A pilot study using ecological momentary assessment via smartphone application to identify adolescent problematic internet use

For some youth, pathologic Internet use can cause significant distress and dysfunction, a phenomenon known as Problematic Internet Use (PIU). PIU has been associated with poorer health outcomes in adolescents with existing psychiatric illness but understanding PIU has been challenging due to research methodologies using cross-sectional, self-report data. This study assessed the feasibility of using app-based ecological momentary assessment (EMA) to provide more ecologically-valid data to identify and characterize the relationship between mood symptoms and PIU in adolescents in active mental health treatment. 25 youth (aged 12-23) were recruited to use an EMA app for 6 weeks. 96% of participants completed the study and the majority of participants completed surveys at least once weekly. Youth with anxiety disorders endorsed significantly greater benefit from using the app to monitor PIU. While PIU severity was positively correlated with worsened anxiety and depression, analyses of the temporal relationships between PIU and mood symptoms showed that anxiety symptoms were significantly improved after episodes of PIU. Overall results suggest that app-based EMA may be both acceptable and feasible to understand PIU in this population. Follow-up studies should consider personalization of study protocols and use of digital phenotyping methodology to collect more objective measurements of behavior.

An Assessment of Digital Media-related Admissions in Psychiatrically Hospitalized Adolescents

Background:

Prevalent adolescent digital media use has brought clinical attention to its potential associated risks. While excessive digital media use has been connected to adolescent difficulties with mood and impulsivity, no study has examined digital media’s role in precipitating adolescent psychiatric admissions.

Objective:

Our study aims were to identify and characterize digital media-related admissions in a sample of psychiatrically hospitalized adolescents, and to recognize unique patterns of digital media use within this sample. We hypothesized that adolescents with digital mediarelated admissions would endorse higher amounts of digital media use and problematic online behaviors.

Methods:

We administered a cross-sectional survey of psychiatrically hospitalized adolescents between 2012 and 2016. Admissions were considered related to digital media use either by adolescent report or documentation in the medical record. Unadjusted comparisons were used to examine relationships between digital media-related psychiatric admissions, online behaviors and suicide-related risk factors.

Results:

68 of 218 participants (31.2%) had digital media-related admissions. The most frequent cause of digital media-related admission was cyberbullying (31.9%). Teens with digital- media related admissions were significantly more likely to sext, use social media, and be cyberbullied; these adolescents were also at increased risk of suicide planning and hopelessness.

Conclusion:

Efforts should be made by mental health clinicians to identify and address online relational conflict, as well as to screen for cyberbullying and sexting. Clinicians should consider that adolescents with digital media-related presentations may be at elevated risk of self-harm, with higher rates of suicide planning and hopelessness compared to hospitalized peers with admissions unrelated to digital media.

Problematic Internet Use and Associated High-Risk Behavior in an Adolescent Clinical Sample: Results from a Survey of Psychiatrically Hospitalized Youth

Problematic Internet use (PIU) is a growing clinical concern to clinicians working in adolescent mental health, with significant potential comorbidities like depression and substance use. No prior study has examined associations between PIU, high-risk behavior, and psychiatric diagnoses specifically in psychiatrically hospitalized adolescents. Here, we analyzed how PIU severity correlated with preadmission Internet habits, psychiatric symptoms, and high-risk behavior in this unique population. We hypothesized that as the severity of PIU increased, so would endorsement of mood symptoms, engagement in risky behaviors, and chances of having comorbid mood and aggression-related diagnoses. We performed a cross-sectional survey on an adolescent psychiatric inpatient unit in an urban community hospital in Massachusetts. Participants were 12-20 years old (n = 205), 62.0 percent female, and of diverse racial/ethnic backgrounds. Relationships between PIU, high-risk symptoms, diagnoses, and behaviors were performed both using chi-square tests and determining Pearson correlation coefficients. Two hundred five adolescents participated in the study. PIU severity was associated with being female (p < 0.005), sexting (p < 0.05), cyberbullying (p < 0.005), and increased suicidality within the last year (p < 0.05). Adolescents with aggressive and developmental disorders, but not depressive disorders, also had significantly higher PIU scores (p ≤ 0.05). In our sample of psychiatrically hospitalized adolescents, PIU severity was significantly associated with both serious psychiatric symptoms and high-risk behaviors, including those related to suicide. Our findings may improve safety assessments in this vulnerable adolescent population by identifying comorbid risks associated with problematic digital media use.

Assessment of Digital Media Use in the Adolescent Psychiatric Evaluation

Digital media (also called "new media") have become an important ecosystem in which adolescents develop biologically, psychologically, and socially. When assessing adolescents in the psychiatric interview, a nuanced understanding of digital media use can inform a more accurate formulation. However, there are few published resources to help the psychiatrist assess the impact of digital media during the initial adolescent interview. The authors propose an innovation on the traditional psychiatric assessment that addresses teen Internet use and digital media habits. Through this enhanced assessment, mental health clinicians can improve upon current interviewing practices of twenty-first century adolescents.

Short communication: vascular smooth muscle cell stiffness as a mechanism for increased aortic stiffness with aging

RATIONALE

Increased aortic stiffness, an important feature of many vascular diseases, eg, aging, hypertension, atherosclerosis, and aortic aneurysms, is assumed because of changes in extracellular matrix (ECM).

OBJECTIVE

We tested the hypothesis that the mechanisms also involve intrinsic stiffening of vascular smooth muscle cells (VSMCs).

METHODS AND RESULTS

Stiffness was measured in vitro both by atomic force microscopy (AFM) and in a reconstituted tissue model, using VSMCs from aorta of young versus old male monkeys (Macaca fascicularis) (n=7/group), where aortic stiffness increases by 200% in vivo. The apparent elastic modulus was increased (P<0.05) in old (41.7+/-0.5 kPa) versus young (12.8+/-0.3 kPa) VSMCs but not after disassembly of the actin cytoskeleton with cytochalasin D. Stiffness of the VSMCs in the reconstituted tissue model was also higher (P<0.05) in old (23.3+/-3.0 kPa) than in young (13.7+/-2.4 kPa).

CONCLUSIONS

These data support the novel concept, not appreciated previously, that increased vascular stiffness with aging is attributable not only to changes in ECM but also to intrinsic changes in VSMCs.