in reducing anxiety (g=.55, [0.17,0.

93]) at
This article has been accepted for publication and
post-test. There was insufficient power to
undergone full peer review but has not been through
the copyediting, typesetting, pagination and determine whether CBT was capable of
proofreading process which may lead to differences reducing time spent gaming. Treatment
between this version and the Version of Record.
Objective: While there is sufficient gains at follow-up were non-significant
Please cite this article as doi: 10.1002/cpp.2341
research and clinical evidence to support across the four treatment outcomes.
the inclusion of gaming disorder in the Conclusions: The pooled findings
latest revision of the International suggest that CBT for IGD is an effective
Classification of Diseases (ICD-11), short-term intervention for reducing IGD
relatively little is known about the and depressive symptoms. However, the
effectiveness of first-line psychological effectiveness of CBT for reducing actual
treatment for gaming disorder or Internet time spent gaming was unclear. Given the
gaming disorder (IGD) as it is listed in the limitations of this evidence base, there is a
DSM-5. This systematic review employed need for more rigorous studies to
meta-analytic techniques to determine the determine the potential long-term benefits
effectiveness of cognitive-behavioral of CBT for IGD.
therapy (CBT) for IGD on four key Public Health Significance
outcomes: IGD symptoms, anxiety, Statement:
depression, and time spent gaming. Given the rise in treatment demand
Method: A database search for Internet gaming disorder (IGD) and
identified 12 independent CBT studies. problematic gaming, it is necessary to
Effect size estimates (Hedges’ g) with determine which treatments are most
associated confidence intervals, prediction effective for whom and under which
intervals and p values, for each pre-post conditions. This review shows that
treatment outcome, were calculated. cognitive-behavioral therapy for IGD,
Study reporting quality was evaluated in which is often considered the first-line
accordance with the Consolidated therapy, can improve IGD symptoms and
Standards of Reporting Trials comorbid depression. However, treatment
(CONSORT) guidelines. Subgroup and gains tend to be short-term and their effect
moderator analyses were undertaken to in reducing time spent gaming is unclear.
investigate potential sources of Programs that target problematic gaming
heterogeneity. may be improved by additional support
Results: CBT demonstrated high beyond the standard program of therapy
efficacy in reducing IGD symptoms (g=.92, sessions. More funding and resources are
[0.50,1.34]) and depression (g=.80, needed to support the development of a
[0.21,1.38]) and showed moderate efficacy
more rigorous evidence base on IGD and
its treatment.
Keywords:
Internet gaming disorder; Gaming
disorder; Meta-analysis; CBT; Treatment;
DSM-5
Original submission date: July 5,
2018. Page count: 37 (inc. 3 pages of
online supplementary material).
The notion that video gaming
should be recognized as an acquired
addictive disorder has received strong
support from within clinical psychology,
psychiatry, and public health. Internet
gaming disorder (IGD) was included in
Section III of the latest Diagnostic and
Statistical Manual (DSM-5) as a condition
warranting further study in 2013 (American
Psychiatric Association, 2013). More
recently, gaming disorder was included in
the latest revision of the International
Classification of Diseases (ICD-11) (World
Health Organization, 2018). While the ICD
and DSM systems differ in their clinical
description of gaming disorder, both
systems state that the disorder has similar
characteristics to gambling disorder (e.g.,
prioritization of gaming over other
activities, loss of control, and functional
impairment). Numerous epidemiological
studies (e.g., Rehbein et al., 2015; Muller
et al., 2015; Haagsma, Pieterse, & therapies,
Peters., 2012; Przybylski et al., 2016)
have reported that the prevalence of
gaming disorder exceeds 1% of the
general population, with much higher
estimates among adolescents (Mentzoni
et al, 2011; Müller et al. 2015; Mak et al.,
2014; van Rooij et al., 2011; King,
Delfabbro, Zwaans, & Kaptsis., 2013).
Currently, little is known on the
effectiveness of psychological treatments
for IGD to inform clinical guidelines.
At an international level, there is
increasing demand for clinical and public
health interventions for gaming-related
problems. Available research suggests
that cognitive-behavioral therapy (CBT)
may be a promising first-line approach
(King et al., 2017; Winkler et al., 2013;
Zajac et al., 2017). Recommendations of
CBT for gaming-related problems appear
to be consistent with recent models of
gaming disorder (i.e., Brand, Young, Laier,
Wölfling, & Potenza, 2016; Dong, &
Potenza, 2014; King & Delfabbro, 2016,
2019). The I-PACE model proposed by
Brand et al., (2016), for example, posits
that IGD is maintained by diminished
cognitive control, which inhibits decision-
making processes resulting in the decision
to play video games. Young and Brand
(2017) argue that CBT techniques may be
particularly useful to target the
maladaptive processes that contribute to
IGD as described in the I-PACE model
other related models of gaming disorder.
An apparent advantage of CBT over other
including pharmacological
treatment, is its ability to target and modify
maladaptive cognitions that underlie
gaming behaviors that generate harm
and/or distress. Another benefit of CBT is
that it may be more equipped to address
comorbid conditions in the context of IGD. the first-line therapy approach and most
IGD is significantly associated with (75%) reportedly did not prescribe
depression (Wang, Cho, & Kim, 2018), medication for IGD. IGD has been treated
general anxiety (Bargeron, & Hormes, by a range of clinical and health-related
2017), social anxiety (Wei, Chen, Huang, practitioners using the same techniques
& Bai, 2012), attention deficits (Yen et al., (King et al., 2017), and therefore clinician
2017), other addictive behaviors (van Rooj training and expertise may be potential
et al., 2014), elevated stress (Batthyany, sources of heterogeneity in the treatment
D., Müller, K. W., Benker, F., & Wölfling, literature. most recent meta-analysis of
2009), sleep problems (Dworak, Schierl, treatment for gaming disorder by Winkler
Bruns, & Strüder, 2007), maladaptive et al. (2013) compared the effectiveness
coping (Betthyany et al. 2009), loneliness of pharmacological (n=3) and
(Lemmens, Valkenberg, & Peter, 2011), psychological (n=13) interventions for
and suicidal ideation (Rehbein, Psych, ‘Internet addiction’ (including gaming
Kleimann, Mediasci, & Mößle, 2010). The disorder). Both intervention types were
known effectiveness of CBT for many of reportedly ‘highly effective’ (g=1.61) from
these comorbidities and other issues pre- to post-treatment. Although Winkler et
suggests that CBT may be a strong first- al. referred to positive long-term treatment
line therapy candidate for IGD. There may benefits, very few studies (n=4) included a
also be some cost-benefit considerations if follow-up assessment. CBT was
existing CBT programs can be adapted to considered the most beneficial treatment
accommodate IGD-specific content. for reducing depressive symptoms and
The substantial demand for time spent gaming compared to other
treatment of IGD and problematic gaming psychological interventions. It is timely to
(Nakayama & Higuchi, 2015), in re-evaluate the literature and these
combination with a lack of standard conclusions given that information is most
treatment guidelines and inconsistent useful when it is current and includes
classification approaches and evidence that may inform a new
measurement tools (King, Haagsma, consensus on this topic (Moher et al.,
Delfabbro, Griffiths, & Gradisar, 2013; 2008).
Rodda et al., 2018), has led to widespread 1.2. The present review
uncertainty and inconsistent approaches Current recommendations of CBT
to treatment. A recent survey of 289 for IGD have not taken into consideration
psychiatrists reported that 43% were not the important issue of sample
confident in their ability to manage IGD in heterogeneity, such as differences in
their practice (Dullur & Hay, 2017). participant age and gender, among other
Psychological treatment was considered methodological differences. It is necessary
to clarify which IGD treatments are most excluded if they did not include pre-post
effective for whom and under which outcome data which was necessary for the
conditions. The present meta-analytic analysis. Studies published from 2007 to
review will evaluate the effectiveness of
cognitive-behavioral treatment for gaming
disorder. This review will refer to gaming
disorder as ‘IGD’ given that this
terminology predominates the research
literature and most measurement tools for
gaming disorder are based on the DSM-5
conceptualization. CBT has the strongest
preliminary support for IGD treatment
despite the evidence of inconsistent
findings and some methodological
concerns (King et al., 2017; Winkler et al.
2013). Since Winkler et al.’s (2013) meta-
analytic review, additional studies have
been published, thereby allowing for an
updated empirical evaluation which also
includes examination of potential sources
of study heterogeneity. The presented
meta-analysis will evaluate the short- and
long-term effectiveness of CBT in relation
to four key outcomes: IGD
symptomatology, anxiety symptoms,
depression symptoms, and time spent
gaming. These therapy outcomes were
chosen to be consistent with Winkler et
al.’s (2013) meta-analysis.
2. Methods
2.1.Identification and selection of studies
Figure 1 provides an outline of the
study selection process according to
PRISMA guidelines (Moher, Liberati,
Tetzlaff, & Altman, 2009). Studies were
identified for inclusion if they included a
CBT intervention for IGD. Studies were