3.4.4. Support Communities and Significant Others of Problematic Internet Users

In addition to supporting professionals (i.e., the second policy option) and users (i.e., the third policy option), communities (i.e., the fourth policy option) also need attention. The preventive actions for this group are the following:


These problems usually affect families, education or workplace organizations, and communities. Thus, basic information, education, social, and clinical support can help individuals in the immediate context of problem users with community support. The EU should consider facilitating information provision to healthcare providers to support general practitioners when taking care of communities in health settings. Moreover, the implementation of actions, programs, and services for information, early detection, and facilitation of support and treatment routes for future problem users and their significant others are options to develop. For instance, at a school and community level, actions to promote prevention can be provided together with those for other related problems (e.g., substance use disorders and cyberbullying).

#### **4. Discussion**

This timely European literature review provides an overview of the currently available research on Internet use-related addiction problems in this region in the period between gaming addiction recognition by the APA and the WHO (i.e., April 2013–April 2018). It has used a public health approach and a preventative perspective to offer a set of policy options and preventive actions. The aims, therefore, were to use a cross-cultural approach across the EU to identify the problematic users' profiles for risk management in community and clinical settings; to ascertain how Internet addiction problems have been researched in Europe within the period when gaming disorder was officially recognized by health organizations; to understand the scope of their harm implications; and, at a public health level, which preventive actions can be extracted and policy options proposed.

An update of these problems at an individual level in the EU has been provided as Internet use-related addiction problems seem to have increased world-wide in the past two decades [6,18,19], with an estimated global prevalence of 6% [18]. Low rates have generally been reported in European regions in school community sample studies (e.g., via meta-analyses and cross-cultural studies) published between 2012 and 2015 (with an average of a 2.5% prevalence [18–21]). However, this review has highlighted the prevalence is growing, as GIA in similar adolescent and young community samples is now approximately 4%–10% [23,29]. Indeed, a recent cross-cultural study has indicated that the prevalence of PIU in Europe is relatively higher than previously indicated, although this observation is based on an adult community sample (i.e., where prevalence rates ranged from 14% to 55% [51]). However, caution is needed to be considered a cause for concern in the present general population due to the highlighted conceptual and methodological issues in the respective studies of these addiction problems.

On the other hand, another indicator that requires attention and has appeared in this review is the higher rates of GIA and online gaming addiction in European clinical samples [36,37,40] compared with community samples [23,29], which range between 69%–91% for both addiction problems. This is in line with Carbonell et al.'s [52] and Lopez-Fernandez's [53] bibliometric studies of IA and other specific online addiction problems published in the last two decades. It seems increasing world-wide Internet use is accompanied by an increasing number of publications on Internet addiction problems. However, it also seems clear gaming addiction has surpassed IA, probably due to IGD recognition by the APA [5] within the period studied, which was the starting point for this review and attracted the attention of clinicians and researchers who deal with these health problems and have published their findings since. The fact that the number of publications on gaming disorders in Europe, and internationally, is increasing may be due to the official recognition of gaming addiction as a disorder, which is indicated by the number of recent reviews [54–59]. Furthermore, neurological functions have commonalities and differences across these two behavioral addictions [54].

The number of studies included in this literature review, however, is scarce compared to other previous international reviews on GIA and IGD [5,6,16,21,54–58]. One explanation is that these health concerns are less prevalent in Europe relative to Asian regions, which is supported by the scientific literature. However, this does not mean that the precautionary principle cannot be applied [10], and almost no reviews have analyzed papers cross-culturally using different languages [6]. In the reviewed European samples, no study from Eastern Europe has been identified, and the regions that have seen more publications are both Southern and Western Europe for GIA, and Northern regions for gaming addiction. This is consistent with a previous cross-cultural study on dependent mobile phone use [60]. In that case, the Northern and Southern regions were the ones with heaviest online mobile use (the Northern countries especially for gaming), and the Eastern regions had lower rates. France appeared as one of the countries with the highest problematic mobile phone use, although Spain has seen a larger number of publications on Internet use-related addiction problems in the period studied.

The European scientific evidence reviewed here published between April 2013–April 2018 identified three potential problems: GIA, online gaming, and gambling disorders at community and clinical levels, which usually affected adolescents and young male adults, except for online gambling (middle-aged adults). This distribution corresponds to previous literature [5,6,16,54–57], specifically as gambling requires financial resources. However, recent empirical European and international studies on IA and gaming addiction show that females are increasingly affected, although they have not been the main study group yet [51,61]. To the best of the authors' knowledge, no review on these problems at an individual person level in the EU has been published yet, and the main findings correspond to the results presented in two previous international reviews on clinical issues related to IA [6,55].

Furthermore, comorbidity seems to be the norm [6,59], and usually includes depression, social anxiety disorder, social phobia, OCD, ADHD, hostility, substance use disorders (e.g., gambling, alcohol, marihuana, nicotine, and cocaine use), eating disorders (e.g., binge eating disorder, bulimia, and obesity), and certain personality traits and personality disorders (e.g., impulsivity, borderline, avoidant personality, or antisocial disorders) [6,55]. However, the present review showed different comorbidities depending on the type of Internet use-related addiction problems, a novel finding which reinforces the independent identities of GIA and gaming addiction [5,24,38,53–59]. In GIA, half of the investigated samples present with comorbid Axis I disorders, which is consistent with previous research [25,27,62]. This suggests a complete psychiatric evaluation is needed for these types of problems. Nevertheless, this review also highlights the need of a psychological evaluation as other emotional, cognitive, and behavioral features have emerged, such as the role of self-esteem [25,32,39], attachment or defense styles [26,60], cognitive coping and disassociation [25,32], and other personality traits and mental disorders [6,25,27,37,41,59] in specific developmental stages (i.e., adolescence [58]). In gaming addiction, however, the spectrum of comorbid disorders is more diverse and severe, especially if gambling is one of the co-occurring disorders, including internalizing and externalizing profiles which need to be considered regarding recovery length [24,35,36,38,39,59]. A European gamer profile has also emerged where environmental factors appear for the etiology, development, and recovery of these problems (e.g., CBT with a systemic approach for adolescent gamers).

At present, research has moved the field forward considerably, resulting in clinicians and researchers recognizing Internet use-related addiction problems across different devices [30,53,60,62] as more scientific research is emerging [5,6,52], and so is the demand for diagnosis and treatment [24,34,36,38,39,41]. The present literature is slightly contradictory, as it has been suggested that the device used to engage in gaming can be associated with the occurrence, course, and prognosis of IGD [62], and it has also been stated that the device does not influence gaming addiction problems [30]. The most alarming studies on gaming addiction and the role of gaming devices come from Asia, and those studies which contradict the findings related to the role of gaming devices in gaming addiction were mainly conducted in Europe.

On the other hand, other contradictions regarding gaming addiction, such as comorbidity or associated symptom experience identified, are the reasons why, together with the low number of prevention research studies in the field [13,16,57,59,63], it seems essential to start addressing possible preventive actions regarding IA and related harms at all levels (i.e., by regions and globally). Simultaneously, qualitative work is needed to address the uniqueness of the phenomenological expression of these types of behavioral addiction problems [64] facilitated through the Internet.

Regarding the policy options, the first one (i.e., no action) has also been put forward in similar preventive studies on substance use disorders. This action is based on the available knowledge on natural recovery, which is considered in the context of IGD as well [65]. However, as almost no follow-up studies have produced evidence on long-term relapse and the natural recovery rates, caution must be applied for this first policy option. The second policy option will aid informing and training professionals and practitioners and is aligned with the few international reviews on IA and prevention. For instance, according to Vondráckov ˇ á and Gabrhelík [16], the improvement of skills in specific professions (i.e., for researchers, counsellors, and teachers) can support preventive action and better intervention plans or, as Kiraly et al. [57] stated, measures are taken to make health services available to gamers who experience problems. The third policy option, related to users, also highlights the need to pay attention to those who are among the highest risk groups, individuals of particular age (e.g., children and youth, especially MMORPG gamers), gender (males), engaged in a general or specific Internet activity, and who experience comorbidity [6,15,16,55,57–59]. The fourth policy option is aimed at supporting communities, including signposting families, schools, institutions, and governments [13,16,57,63,66,67].

Nevertheless, as King et al. [13] highlighted, in Western cultures including Europe, at the moment community-based support derives from non-profit organizations and the private sector; although a few countries are starting to provide support through their national health systems, such as Germany [10]. However, not all measures that have been put into place to prevent Internet and gaming addiction

have obtained effective results [13,57], and there is a bias regarding what is known through the current literature, which is dominated by English language publications from English and Asian regions [13,57]. Thus, the current scientific literature base may not sufficiently reflect what other non-English speaking countries are already doing regarding prevention at all levels (e.g., Switzerland [10]).

This review also has its limitations, including the strategy applied to identify the included studies. For instance, the period of five years selected, and the number of databases used can be considered short and small, but both decisions have a rationale (i.e., recognition of gaming addiction, and disciplinary and interdisciplinary scientific search engines associated with the aims, respectively). Preliminary findings are relevant as they have shown, for example, the emergence of clinical research in online addiction problems in Europe with its specificities (e.g., gamer profile and specific comorbidity depending on internet use-related problems). However, in this emergent field, other literature reviews have also been undertaken with even shorter periods of analysis for relevant reasons and with a larger or smaller number of databases (e.g., internet use-related to self-harm and suicidal behaviour using Medline, Cochrane, and PsychINFO, and covering four years [68], or the utility of magnetic resonance imaging to study IA using Scopus, which covered a three year period [69]). The keywords applied did not take into consideration other possible Internet addiction problems which are currently being researched in Europe (e.g., cybersex). However, the identified limited number of studies produced preliminary findings to achieve the present aims to obtain an overview of the status quo in Europe regarding these problems from a cross-cultural and preventive perspectives, with a qualitative analysis using the lens of harm minimization to develop a set of policy options with preventive actions. Future research should first extend a similar procedure to non-European countries and also collect grey literature with non-English language publications to produce a holistic perspective of the policy options and prevention actions and consequences of what kinds of initiatives are already taken in several countries, which can be useful at local and global levels. Thus, this review offers a brief and timely snapshot of scientific studies in the recent period where gaming addiction has been officially recognized. Indeed, it is the first review on these problems at a European level using a preventive approach. However, methodological improvements can aid more robust future research, which should apply methods and procedures to compute other quantitative inter-rater reliability measures to complement the qualitative inter-rated reliability obtained through sharing and comparing coding agreements in iterative rounds until arriving at a consensus and theoretical saturation of findings (e.g., the Cohen's Kappa coefficient [70]), and complementary quality checks of the procedure (e.g., the Critical Appraisal Skills Programme (CASP) [71]). The included studies' findings have been synthesized and analyzed in detail in the present literature review to provide an overview regarding these emerging addiction problems in Europe, which can be used with caution as the present literature review constitutes a qualitative narrative synthesis, for international comparisons, and to translate some of the identified policy options into preventive actions.

#### **5. Conclusions**

In summary, the most prevalent Internet addiction problems appeared to be generalized Internet addiction and online gaming addiction in the EU between April 2013 and April 2018, both of which tend to present with specific comorbid disorders. More clinical studies compared to non-clinical studies were identified and analyzed which shows the emergence of and need for action, public health, and prevention. Gaming and gambling addictions were usually more severe problems compared to generalized Internet addiction. In addition, gambling appears to be more severe than gaming. However, the current scientific literature base does not report much prevention work in Europe (and internationally). A set of preventive recommendations and policy options have been formulated, which can support future harm minimization actions.

*Int. J. Environ. Res. Public Health* **2020**, *17*, 3797

**Author Contributions:** Conceptualization, O.L.-F.; methodology, O.L.-F. and D.J.K.; formal analysis, O.L.-F. and D.J.K.; investigation, O.L.-F. and D.J.K.; resources, O.L.-F.; data curation, O.L.-F. and D.J.K.; writing—original draft preparation, O.L.-F.; writing—review and editing, O.L.-F. and D.J.K.; visualization, O.L.-F.; supervision, O.L.-F. and D.J.K.; project administration, O.L.-F.; funding acquisition, O.L.-F. and D.J.K. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by the European Parliament through the Scientific Foresight Unit (STOA), Directorate for impact assessment and European added value, grant number SQM 02Y066 (EPRS/STOA/SER/17/226N; ED number 03210-01-00/5218/107321).

**Acknowledgments:** We would like to acknowledge the contribution of the European Parliament through the Science and Technology Options Assessment (STOA) Panel and thank them for their invitation to develop this research project: Gianluca Quaglio, Damir Plese, and Emilia Bandeira Morais. To Nottingham Trent University for facilitating the development of the project, which included a research assistant in the data collection: Bailey Foster.

**Conflicts of Interest:** The authors declare no conflict of interest.
