Journal of Affective Disorders 313 (2022) 56–71

Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Review article

Effects of different interventions on internet addiction: A meta-analysis of

random controlled trials
Xueqing Zhang a, 1, Jianghui Zhang a, 1, Kexin Zhang a, Juan Ren a, b, Xiaoyan Lu a, Tianli Wang a,
Huayu Yang a, Haiyun Guo a, Guojing Yuan a, Zhihui Zhu a, Jiahu Hao c, Ying Sun c, Puyu Su c,
Linsheng Yang a, *, Zhihua Zhang a, d, **
a
Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei 230032, China
b
The Second Hospital of Anhui Medical University, Hefei 230601, China
c
Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, Hefei 230032, China
d
Center for Evidence Based Medicine, Anhui Medical University, Hefei 230032, China

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To evaluate the effects of different interventions on Internet addiction (IA), a meta-analysis and
CBT network meta-analyses were performed.
Internet addiction Methods: We searched PubMed, Cochrane, Embase, Web of Science, PsycINFO, ProQuest, CNKI, WanFang, VIP
Interventions
database, and CBM from their inception to August 2021 to identify randomized controlled trials (RCTs) where
Meta-analysis
Network meta-analysis
the effects of interventions on IA were assessed. The risk of bias was evaluated according to the Revised Cochrane
RCT risk-of-bias tool for randomized trials (RoB2). The R studio Software and Stata 14.0 were used to perform
traditional meta-analysis and network meta-analyses.
Results: A total of 59 RCTs including 3832 participants were incorporated into meta-analysis. The results of the
traditional meta-analysis of 24 studies showed that CBT, group counseling, sports intervention, and Internet-
based intervention could significantly reduce IA levels (SMD = − 1.90, 95%CI: − 2.26 to − 1.55, P < 0.01, I2
= 85.9%) as compared to no-treatment control groups. Network meta-analyses based on different scales showed
that combined interventions had the highest probability of being the best interventions for IA (SUCRA = 91.0 %
based on IAT; SUCRA = 89.0 % based on CIAS).
Discussion: Most interventions have significant effects on the treatment of IA. Compared with single in­
terventions, combined interventions showed a more pronounced improvement in Internet addiction symptoms.

1. Introduction
With the development and popularization of the Internet over the
past decade, Internet overuse and its negative effects have raised global
concerns (Mylona et al., 2020). According to the report of the China
(China Internet Network Information Center (CNNIC), 2021), the
number of Internet users in China has reached 1.11 billion by June 2021,
with an Internet penetration rate of 71.6 %. Excessive use of the Internet
will bring a series of physical and mental problems to young people,
including eating disorders, obesity, insomnia, daytime sleepiness, eye
fatigue (Balhara YPS et al., 2018; El Asam et al., 2019), attention deficit,
and hyperactivity disorder (ADHD) (Kawabe et al., 2019), social phobia
and hostility, depression (Bickham, 2021), anxiety disorder (Seki et al.,
2019). Excessive usage of the Internet is associated with a psychiatric
condition known as Internet addiction (Zhang et al., 2018b).
The term “Internet Addiction (IA)”, first coined by Dr. Ivan Goldberg
in 1995 (Moreno et al., 2011), was used to describe “the pathological
and compulsive use of the Internet”. In 2013, “Internet Gaming Disor­
der” was included in the fifth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5) as a potential new diagnosis
(American Psychiatric Association (APA), 2013); In 2018, “Internet
Gaming Disorder” was officially subsumed under mental disorders in the
11th revision of the International Classification of Diseases (ICD-11)
(World Health Organization (WHO), 2018). IA has become a serious

* Corresponding author. L. Yang, Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei 230032, China.
** Correspondence to: Z. Zhang, Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei 230032, China.
E-mail addresses: yanglinsheng@ahmu.edu.cn (L. Yang), zhangzh@ahmu.edu.cn (Z. Zhang).
1
Xueqing Zhang, Jianghui Zhang contributed equally and should be considered as co-first author.

https://doi.org/10.1016/j.jad.2022.06.013
Received 28 January 2022; Received in revised form 25 May 2022; Accepted 16 June 2022
Available online 26 June 2022
0165-0327/© 2022 Elsevier B.V. All rights reserved.
X. Zhang et al.
issue in many countries, and its prevalence is evolving in America and
Western European countries. Problematic Internet use usually involves
adolescents and young adults, its prevalence can be as high as 25–30 %
in these age groups (Kapus et al., 2021). Given that the severity of IA
among adolescents is higher than in other age groups, various IA in­
terventions have been developed and implemented for adolescents.
1.1. IA interventions
Recently, more and more studies have investigated the effects of
psychological, sports, and drug interventions on IA and psychopatho­
logical symptoms. There is no widely recognized categorization scheme
for psychological interventions, the term is generally applied to a broad
range of types of interventions, which include Cognitive Behavioral
Therapy (CBT) (Stevens et al., 2019), family intervention (Wei et al.,
2014), sandplay therapy, group counseling (Zhang and Lu, 2009) and
routine intervention. While behavioral therapies have been widely
recognized as an effective way to treat IA, adjuvant therapies such as
sports intervention have also attracted research attention. Previous
research had shown that exercise has physical benefits, such as
strengthening cardiopulmonary function and promoting blood circula­
tion, and nervous system function. It can also significantly reduce IA (Li
et al., 2020). In addition, psychotropic drugs typically used to treat
depression or ADHD can also be used as interventions for IA (Song et al.,
2016). Electrotherapy such as Transcranial direct current stimulation
(tDCS) was also known as an intervention for IA. tDCS is a method of
brain stimulation involving passing a weak current (1–2 mA) across the
cortex using at least two electrodes. It has considerable potential as an
intervention due to its relative cost, portability, safety, and ease of use
compared to other methods of neuromodulation (Chase et al., 2020).
Nowadays, to achieve a better effect of the intervention, many re­
searchers will combine the above two or even three interventions to
treat IA, which is collectively known as combined interventions.
1.2. The previous study
Several types of research assessed the effect of different interventions
on IA. Wölfling K (Wolfling et al., 2019) found that short-term CBT was
effective and that combining CBT and drug therapy could lead to
augmented effects. Zhang (Zhang et al., 2020) explored the intervention
effect of solution-focused group counseling. The results found that the
experimental group experienced more significant changes than the
control group in IA.
There were also some qualitative reviews (Greenfield, 2018; Jor­
genson et al., 2016; Zajac et al., 2020; Zajac et al., 2017) and meta-
analyses to assess the effect of interventions (Chun et al., 2017; Liu
et al., 2017; Malinauskas and Malinauskiene, 2019). Chun J found that
CBT was effective for treating IA and the effect of the combined inter­
vention was substantial. On the contrary, Malinauskas combined 6 RCTs
and the results did not support that CBT had a significant effect on the
severity of IA. Group counseling appeared to be the predominant and
effective modality for treating IA. However, the included studies were
limited, and insufficient samples were not powerful enough to support
the results in the previous meta-analyses.
According to the results of traditional meta-analyses, we can know
which types of interventions were effective by combining the effect
quantity. However, there was a lack of pairwise comparison to rank the
interventions. For scholars, how to choose the best intervention to
perform research was still unknown. So, a network meta-analysis needs
to be performed. Both Qiao (Qiao et al., 2020) and Wu (Wu et al., 2019)
performed network meta-analyses. Qiao found that combined inter­
vention ranked first among all interventions. The second was the family
intervention. But Wu indicated that the best intervention was sports
intervention. Wu et al. ranked 4 interventions in order: sports inter­
vention, group counseling, routine intervention, and CBT. However, Wu
only included 4 common interventions and insufficient samples were not
57
Journal of Affective Disorders 313 (2022) 56–71
powerful enough, so the results were limited. Although Qiao included
more interventions and performed detailed results, the studies based on
different evaluation scales were not divided into different network meta-
analyses. It would affect the homogeneity of the results. So far, there
were few network meta-analyses performed to rank the efficacy of the
various interventions on IA based on different evaluation scales. The
reliable evidence for the best intervention on IA needed further
exploration.
1.3. The present study
Assessment tools of IA varied between studies and used various
evaluation scales. Among the various evaluation measures of IA, the
Internet Addiction Test (IAT), and Young Diagnostic Questionnaire
(YDQ) have been the most widely used internationally. In addition,
Revised Chen Internet Addiction Scale (CIAS-R) was also widely used in
China. These three scales had a high degree of authority and credibility
internationally. This study sought to assess the effect of various in­
terventions on IA and rank the efficacy of interventions based on these
three evaluation scales through meta-analyses and network meta-
analyses. Our target is to search, objectively analyze and evaluate
existing evidence to provide evidence for health professionals and
researchers.
2. Methods
This study was conducted according to the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page
et al., 2021). The review protocol was registered with the International
Prospective Register of Systematic Review (PROSPERO)
(CRD42021294087).
2.1. Search strategy
To retrieve potential articles, we searched PubMed, Cochrane,
Embase, Web of Science, PsycINFO, ProQuest, CNKI, WanFang, VIP
database, and CBM from their inception to August 2021. We used key
terms related to IA and interventions. The following search strategy was
used: (“Internet addiction” OR “Internet-addicted” OR “Internet
depend” OR “Internet overuse” OR “Internet addiction disorder” OR
“Compulsive internet” OR “Problematic internet” OR “Pathological
internet” OR “Excessive internet” OR “Addictive internet” OR “Video
game addiction” OR “Internet gaming disorder” OR “Online game
addiction” OR “Cybersex addiction” OR “Internet sex addiction” OR
“Social network addiction” OR “Facebook addiction”) AND (“Random­
ized controlled trial” OR “Controlled clinical trial” OR “Random” OR
“Placebo” OR “Clinical trials as topic” OR “Trial” OR “Intervention” OR
“Treat” OR “Therapy” OR “Program” OR “Workshop” OR “Train”).
Searches were limited to studies published in English and Chinese.
2.2. Eligibility criteria
The included studies in the meta-analysis had to meet the following
inclusion criteria: (1) studies were journaled papers, unpublished mas­
ter's thesis, or Ph.D. thesis; (2) participants were diagnosed with IA; (3)
the objective of the study was to assess the effect of interventions on IA;
(4) study design was limited to randomized controlled trial (RCT); (5)
the severity of IA was diagnosed using the Internet Addiction Test (IAT),
Young Diagnostic Questionnaire (YDQ), or Revised Chen Internet
Addiction Scale (CIAS-R).
Exclusionary criteria: (1) studies were not published in English or
Chinese; (2) the data on the severity of IA were incompleted or not re­
ported; (3) the study was a single-arm pre-post comparison study; (4) the
full text of the study was unavailable.
Two researchers (Xueqing Zhang and Jianghui Zhang) indepen­
dently screened and selected all of the studies. When disagreements
X. Zhang et al.
Identification of new studies via databases and registers
Records identified from:
Detabases(n=10)
Registers(n=5918)
Records screened (n=5333)
Reports assessed for eligibility
(n=468)
Studies included in meta analysis
(n=59)
Fig. 1. PRISMA flow diagram.
between the two independent researchers occurred, a third reviewer
evaluated the original study so as to reach a consensus.
2.3. Data extraction
Data were independently extracted by two researchers using a pre­
designed table. The following data were extracted: author, published
year, sample size, sample characteristics, interventions, intervention
duration, and outcome measures of the severity of IA.
The main details of evaluation scales were as follows: (a) Internet
Addiction Test (IAT) (Young et al., 1999): The IAT is composed of 20
items with a 5-point scale (1 = “very rarely”, 5 = “very frequently”). IAT
scores range from 20 to 100, with higher scores indicating higher levels
of IA. Scores over 50 indicated a tendency of IA. (b) Young Diagnostic
Questionnaire (YDQ) (Young, 1998): The YDQ includes 8 items. YDQ
scores range from 0 to 8, with higher scores indicating higher levels of
IA. Scores over 5 indicated a tendency of IA. (c) Revised Chen Internet
Addiction Scale (CIAS-R) (Chen et al., 2003): The CIAS-R includes 26
items with a 4-point scale (1 = “total non-conformity”, 4 = “total con­
formity”). The scores range from 26 to 104, with higher scores indicating
higher levels of IA. Scores over 64 indicated a tendency of IA. In our
study, all participants with confirmed IA reached the cut-off score for IA
diagnosis for each evaluation scale the study used.
2.4. Quality assessment
Two reviewers independently evaluated the methodological quality
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Journal of Affective Disorders 313 (2022) 56–71
Records removed before screening:
Duplicate records (n=585)
Records excluded (n=4865)
Records excluded:
(1)studies were not published in
English or Chinese (n=60)
(2)the data of the severity of internet
addiction were incompleted or not
reported (n=194)
(3)the study was a single-arm pre-post
comparison study (n=53)
(4)the measurement scales were not
Internet Addiction Test (IAT), Young
Diagnostic Questionnaire (YDQ), or
Revised Chen Internet Addiction
Scale (CIAS-R) (n=69)
(5)the full text of the study was
unavailable (n=33)
of all included studies. The Revised Cochrane risk-of-bias tool for ran­
domized trials (RoB2) was used to assess the risk of bias. The RoB2 in­
cludes five domains: (1) Risk of bias arising from the randomization
process; (2) Risk of bias due to deviations from the intended in­
terventions (effect of assignment to intervention); (3) Missing outcome
data; (4) Risk of bias in the measurement of the outcome; (5) Risk of bias
in the selection of the reported result. Each domain has several signaling
questions which used to assess the quality of studies. The risk of bias can
be assessed as “low risk of bias”, “some concerns” and “high risk of bias”
in each domain.
2.5. Data analysis
All meta-analyses were performed using R studio Software and Stata
14.0. The outcome variables were continuous random variables and
were assessed using different scales, so the Standard Mean Difference
(SMD) was used to combine the effect quantity (Andrade, 2020; Shah
et al., 2020). Heterogeneity of effect sizes across studies was assessed
using Cochran's Q and I2 statistics. Subgroup analyses were performed
by the language of publication (English or Chinese), sample size, char­
acteristics of participants, outcome measurements, intervention mea­
sures, and intervention duration. Sensitivity analysis was conducted by
excluding each study and rerunning the meta-analysis. To assess the risk
of publication bias, the funnel plots, Egger's test, and Begg's test (α =
0.05) were performed.
The network meta-analysis was performed using the Bayesian
random effect model (Yi et al., 2015; Zhang et al., 2014). The geometry
X. Zhang et al. Journal of Affective Disorders 313 (2022) 56–71

Table 1
The detailed characteristics of the included studies.
Number Author/year Location sample size Participants Type of intervention Frequency Outcome
(Language) and times measurements

1 (Ma and He, Anhui, China EG:49 CG:49 college students EG: CBT CG: no intervention – IAT
2011) (Chinese)
2 (Chen et al., Chongqing, China EG:12 CG:23 college students EG: CBT CG: no intervention 7 weeks CIAS
2011) (Chinese)
3 (Ma and Xinjiang, China EG:14 CG:14 cases from EG: CBT CG: no intervention 8 weeks CIAS
Liang, 2015) (Chinese) hospital
4 (Wang, 2009) Guangzhou, China EG:14 CG:14 cases from EG: CBT CG: no intervention 6 weeks YDQ
(Chinese) hospital
5 (Ming, 2014) Shandong, China EG:60 CG:60 college students EG: CBT CG: no intervention 40 weeks IAT
(Chinese)
6 (Li, 2009) Ningxia, China EG:44 CG:48 cases from EG: CBT CG: no intervention 8–10 weeks YDQ, CIAS
(Chinese) hospital college
students
7 (Guo et al., Jiangxi, China EG:14 CG:14 college and middle EG: CBT CG: routine intervention 8 weeks CIAS
2008) (Chinese) school students
8 (Chen and Wu, Fujian, China EG:52 CG:52 cases from EG: CBT CG: routine intervention – CIAS
2018) (Chinese) hospital
9 (Zhao et al., Shandong, China EG:65 CG:65 cases from EG: CBT CG: routine intervention 16 weeks CIAS
2016) (English) hospital
10 (Cao et al., Hunan, China EG:26 CG:31 middle school EG: CBT CG: routine intervention 8 weeks YDQ, CIAS
2007) (Chinese) students
11 (Yang et al., Sichuan, China EG:15 CG:14 college students EG: Electro-Acupuncture (EA) CG: CBT 45 days IAT
2017) (English)
12 (Cheng and Jiangxi, China EG:25 CG:25 college and middle EG: EEG biofeedback training CG: CBT 12 weeks IAT
Luo, 2017) (Chinese) school students
13 (Huang, 2014) Sichuan, China EG:15 CG:14 college students EG: tDCS CG: CBT 20 times IAT
(Chinese)
14 (Park et al., Republic of Korea EG:12 CG:12 cases from EG: VRT CG: CBT 4 weeks IAT
2016) (English) hospital
15 (Lee et al., Republic of Korea EG:14 CG:12 community EG: tDCS CG: sham tDCS 5 days IAT
2021) (English) residents
16 (Jeong et al., Republic of Korea EG:13 CG:13 community EG: tDCS CG: sham tDCS 4 weeks IAT
2020) (English) residents
17 (Zhong, 2020) Jiangxi, China EG:32 CG:32 cases from EG: tDCS CG: sham tDCS 4 weeks IAT
(Chinese) hospital
18 (Kawabe et al., Iran (English) EG:24 CG:24 college students EG: group-based positive psychology CG: no 1 week IAT
2019) intervention
19 (Zhang and Jiangsu, China EG:12 CG:13 college students EG: group counseling CG: no intervention 8 weeks YDQ
Lu, 2009) (Chinese)
20 (Kong et al., Jiangsu, China EG:36 CG:35 college students EG: group counseling CG: no intervention 8 weeks IAT
2011) (Chinese)
21 (Peng and Li, Gansu, China EG:28 CG:28 middle school EG: group counseling CG: no intervention 8 weeks YDQ
2015) (Chinese) students
22 (Chen et al., Zhejiang, China EG:30 CG:31 college students EG: group counseling CG: no intervention 8 weeks YDQ
2010) (Chinese)
23 (Lu et al., Guizhou, China EG:16 CG:17 college students EG: group counseling CG: no intervention 5 weeks IAT
2021) (Chinese)
24 (Gao et al., Jilin, China EG:35 CG:34 college students EG: sport intervention CG: no intervention 8 weeks IAT
2012) (Chinese)
25 (Li, 2017) Zhejiang, China EG:10 CG:10 primary school EG: group counseling CG: no intervention 8 weeks CIAS
(Chinese) students
26 (Qiu, 2018) Henan, China EG:31 CG:31 middle school EG: group counseling CG: no intervention 4 times CIAS
(Chinese) students
27 (Lan, 2014) Hubei, China EG:10 CG:10 college students EG: group counseling CG: no intervention 4 weeks CIAS
(Chinese)
28 (Li, 2020) Jiangsu, China EG:12 CG:12 college students EG: group counseling CG: no intervention 8 weeks CIAS
(Chinese)
29 (Chi, 2012) Jilin, China EG:10 CG:10 college students EG: group counseling CG: no intervention 8 weeks IAT
(Chinese)
30 (Guan et al., Jiangsu, China EG:20 CG:25 college students EG: group counseling CG: routine intervention 4 weeks CIAS
2012) (Chinese)
31 (Song et al., Henan, China EG:60 CG:60 college students EG: group counseling CG: routine intervention 20 weeks CIAS
2020) (Chinese)
32 (Xu and Xu, Hubei, China EG:20 CG:20 middle school EG: group counseling CG: routine intervention 1 month CIAS
2018) (Chinese) students
33 (Liu et al., Jiangsu, China EG:80 CG:80 college students EG: group counseling CG: routine intervention 4 weeks IAT
2010) (Chinese)
34 (Ge et al., Chongqing, China EG:12 CG:12 middle school EG: group counseling CG: routine intervention 5 weeks CIAS
2014) (Chinese) students
35 (Nam et al., Republic of Korea EG:15 CG:15 cases from EG: bupropion CG: escitalopram 12 weeks IAT
2017) (English) hospital
36 Republic of Korea EG:25 CG:25 cases from EG: bupropion CG: placebo 12 weeks IAT
(English) hospital
(continued on next page)

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X. Zhang et al. Journal of Affective Disorders 313 (2022) 56–71

Table 1 (continued )
Number Author/year Location sample size Participants Type of intervention Frequency Outcome
(Language) and times measurements

(Han and
Renshaw,
2012)
37 (Zhou et al., Hunan, China EG:32 CG:32 cases from EG: sertraline hydrochloride drug therapy; CG: 8 weeks CIAS
2016) (Chinese) hospital placebo
38 (Fu and Liu, Changchun, China EG:42 CG:42 college students EG: football training intervention CG: no 16 weeks IAT
2016) (Chinese) intervention
39 (Wen and Shijiazhuang, EG:40 CG:40 college students EG: short-term high-intensity exercise 8 weeks CIAS
Chen, 2020) China (Chinese) combined with nutritional intervention
CG: no intervention
40 (Yu, 2017) Guangzhou, China EG:26 CG:26 college students EG: sports intervention CG: no intervention 8 weeks IAT
(Chinese)
41 (Fang and Dai, Bohai, China EG:24 CG:24 college students EG: positive psychological intervention CG: no 8 weeks IAT
2019) (Chinese) intervention
42 (Su et al., Beijing, China EG1:17 college students EG: internet-based intervention CG: no 4 weeks YDQ
2011) (English) EG2:12 intervention
EG3:14 CG:16
43 (Deng et al., Hunan, China EG:28 CG:28 cases from EG:“School, family and society” behavior 3 months YDQ
2014) (Chinese) hospital intervention model
CG: routine intervention
44 (Zhang et al., Guangzhou, China EG:30 CG:30 cases from EG: sandplay therapy CG: routine intervention 12 weeks IAT
2018a) (Chinese) hospital
45 (Wei et al., Shandong, China EG:60 CG:60 cases from EG: family intervention CG: routine 20 weeks IAT
2014) (English) hospital intervention
46 (Li et al., Shandong, China EG:50 CG:50 cases from EG: systematic nursing intervention CG: routine 3 months IAT
2016) (Chinese) hospital intervention
47 (Lu et al., Shandong, China EG:60 CG:60 cases from EG: family intervention CG: routine 5 months IAT
2013) (Chinese) hospital intervention
48 (Zhang and Guangzhou, China EG1:10 college students EG1: dance psychotherapy EG2: group 10 sessions IAT
Wang, 2015) (Chinese) EG2:10 CG:10 counseling CG: Sandplay therapy
49 (Liu et al., Shandong, China EG:60 CG:61 community EG: logotherapy-based mindfulness 8 times CIAS
2021) (English) residents intervention + routine intervention
CG: routine intervention
50 (Xiao et al., Guangzhou, China EG:19 CG:19 cases from EG: routine intervention + acupuncture 8 weeks CIAS
2018) (Chinese) hospital treatment CG: routine intervention
51 (Bong et al., Republic of Korea EG:67 CG:71 primary and EG: CBT+ music therapy CG: CBT 8 weeks IAT
2021) (English) middle school
students
52 (Hong et al., Republic of Korea EG:25 CG:25 cases from EG: CBT + PE CG: CBT 8 weeks IAT
2020) (English) hospital
53 (Cheng et al., Guangxi, China EG1:12 college students EG1: CBT+ hypnotherapy EG2: CBT CG: no 8 weeks IAT
2015) (Chinese) EG2:12 CG:11 intervention
54 (Wu et al., Shandong, China EG:40 CG:36 cases from EG: paroxetine combined with buspirone drug 6 weeks IAT
2006) (Chinese) hospital therapy + CBT
CG: paroxetine combined with buspirone drug
therapy
55 (Cao, 2009) Shandong, China EG:21 CG:21 cases from EG: paroxetine combined with buspirone drug 8 weeks IAT
(Chinese) hospital therapy + family intervention CG: paroxetine
combined with buspirone drug therapy
56 (Song et al., Zhejiang, China EG:20 CG:20 cases from EG: sertraline hydrochloride drug therapy + 17 weeks IAT
2017) (Chinese) hospital group counseling CG: sertraline hydrochloride
drug therapy
57 (Liao, 2010) Jiangxi, China EG:142 middle school EG: CBT+ Chinese and western medicine + 1 years YDQ
(Chinese) CG:142 students family intervention CG: routine intervention
58 (Tang, 2018) Hunan, China EG:26 CG1:24 cases from EG: CBT+ tDCS CG1: tDCS CG2: CBT 8 weeks CIAS
(Chinese) CG2:27 hospital
59 (Ye, 2010) Sichuan, China EG:37 CG1:39 cases from EG: CBT+ tDCS CG1: tDCS CG2: CBT 8 weeks IAT
(Chinese) CG2:36 hospital, college
students

EG: experimental group; CG: control group; VRT: virtual reality therapy; CBT: Cognitive Behavioral Therapy; tDCS: transcranial direct current stimulation.

of the network was summarized in a network plot. The Surface under the
cumulative ranking curve (SUCRA) was calculated to rank the efficacy of
the various interventions. SUCRA ranges from 0 % to 100 %, with 100 %
indicating that intervention is certain to be the best and 0 % indicating
that intervention is certain to be the worst. A node-splitting method was
used to evaluate the inconsistency between direct and indirect com­
parisons. p values were used to identify the presence of inconsistency. If
p > 0.05, a consistent model was used for network meta-analysis,
otherwise an inconsistent model was used. To check the publication
bias of studies, a network funnel plot was generated and the symmetry of
the graph was tested.
3. Results
3.1. Study selection
The detailed process of meta-analysis is shown in Fig. 1. The number
of potentially relevant studies identified through the literature search
was 5918 (1152 in PubMed, 109 in Cochrane, 169 in Embase, 291 in
Web of Science, 129 in PsycINFO, 143 in ProQuest, 1655 in CNKI, 713 in
VIP, 495 in WanFang, and 1062 in CBM). After exclusion of duplicate
search results, we screened 5333 studies for eligibility, of which 4865
were excluded based on titles and abstracts. Consequently, 468 studies

60
X. Zhang et al.
Fig. 2. Risk of bias summary.
Fig. 3. Effect of interventions on Internet addiction.
were assessed in full-text screening. Of these, 59 studies fulfilled inclu­
sion criteria. The reasons for the excluded studies were as follow: (1)
studies were not published in English or Chinese (n = 60); (2) the data on
the severity of IA were incompleted or not reported (n = 194); (3) the
study was a single-arm pre-post comparison study (n = 53); (4) the
measurement scales were not IAT, YDQ, or CIAS-R (n = 69); (5) the full
text of the study was unavailable (n = 33).
3.2. Study characteristics
The characteristics of the included studies are shown in Table 1. The
included 59 studies encompassed 3832 participants. Of the included
studies, 11 studies were published in English, and 48 studies were
published in Chinese. A total of 24 studies used no treatment controls as
control groups. Most studies recruited their participants from univer­
sities (n = 24), or primary and middle schools (n = 10). Some studies
recruited participants from clinics (n = 22). Others recruited partici­
pants from local communities (n = 3). For outcome measures, 32 studies
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Journal of Affective Disorders 313 (2022) 56–71
used IAT to assess the severity of IA, 20 studies used CIAS, 9 studies used
YDQ, and 2 studies used both CIAS and YDQ to assess the severity of IA.
3.3. Methodological quality assessment
We conducted a methodological quality assessment for 59 studies.
According to the summary of the risk of bias, 77.97 % of studies were
assessed as “some concerns” (46 of 59 studies), 16.95 % of studies were
assessed as “low risk bias” (10 of 59 studies), and 5.08 % of studies were
assessed as “high risk bias” (3 of 59 studies). Further information about
the risk of bias assessment and risk of bias summary can be found in
Additional file 1, Fig. 2.
3.4. Meta-analysis: effect of interventions compared with blank controls
A meta-analysis of 24 studies (25 pairwise comparisons, n = 1398)
using no-treatment control groups was performed. Overall results of the
meta-analysis are presented in Fig. 3. Compared with no-treatment
X. Zhang et al. Journal of Affective Disorders 313 (2022) 56–71

Table 2
Subgroup analysis to assess the effect of interventions on Internet addiction.
Variable Number of trials Sample size Meta-Analysis Heterogeneity
a
EG CG SMD Lower Upper p I2(%) Q pb

All 25 704 694 − 1.90 − 2.26 − 1.55 – 85.9 169.94 <0.01

Language of publication
English 2 67 40 − 2.74 − 5.54 0.07 0.54 95.3 21.31 <0.01
Chinese 23 637 654 − 1.84 − 2.20 − 1.49 85.1 147.17 <0.01
Sample size
≤40 10 151 134 − 1.39 − 1.68 − 1.09 0.03 14.8 10.57 0.31
41–80 10 314 313 − 2.14 − 2.79 − 1.49 90.7 97.09 <0.01
>80 5 239 247 − 2.24 − 3.05 − 1.42 92.0 50.23 <0.01
Population type
College students 18 495 477 − 2.06 − 2.52 − 1.60 0.06 87.1 131.61 <0.01
Primary and middle school students 4 81 81 − 1.30 − 1.69 − 0.90 19.3 3.72 0.29
Others 3 128 136 − 1.73 − 2.67 − 0.79 90.5 21.16 <0.01
Outcome measurement
YDQ 5 157 136 − 1.38 − 2.13 − 0.63 0.02 86.8 30.21 <0.01
IAT 11 334 332 − 2.42 − 2.94 − 1.90 83.8 61.50 <0.01
CIAS 9 213 226 − 1.57 − 2.12 − 1.03 82.1 44.57 <0.01
Intervention measure
Cognitive Behavioral Therapy (CBT) 7 263 279 − 2.10 − 2.81 − 1.38 0.26 90.7 64.31 <0.01
Group counseling 12 245 247 − 1.70 − 2.24 − 1.17 83.7 67.52 <0.01
Sports intervention 5 153 152 − 2.21 − 2.98 − 1.45 84.6 25.90 <0.01
Internet-based intervention 1 43 16 − 1.34 − 1.96 − 0.71 – 0.00 –
Intervention duration
< 8 weeks 6 119 102 − 1.72 − 2.51 − 0.93 0.73 82.2 28.12 <0.01
≥8 weeks 17 505 512 − 1.87 − 2.27 − 1.47 84.8 104.92 <0.01
Not mentioned 2 80 80 − 2.65 − 4.85 − 0.45 96.0 24.95 <0.01
Risk of bias
Some concerns 19 466 448 − 1.85 − 2.27 − 1.43 0.57 84.6 116.94 <0.01
Low risk of bias 6 238 246 − 2.06 − 2.80 − 1.31 90.5 52.77 <0.01

EG: experimental group; CG: control group; YDQ: Young Diagnostic Questionnaire; IAT: Internet Addiction Test; CIAS: Revised Chen Internet Addiction Scale; Pa value
for the between-subgroup difference; Pb value for the heterogeneity within subgroups by Q test.
0.0
0.1
0.2
Standard Error

0.3
0.4
0.5
0.6

−4.0 −3.5 −3.0 −2.5 −2.0 −1.5 −1.0 −0.5

Standardised Mean Difference

Fig. 4. Funnel plot for the publication bias of internet addiction.

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X. Zhang et al. Journal of Affective Disorders 313 (2022) 56–71

Fig. 5. Network plot based on the IAT scale. The size of the circles is weighted according to the number of trials available for each intervention. The interventions
for which direct comparisons were available are linked with a line. The thickness of connections varies according to the number of studies involved in a comparison.

control groups, we found that interventions had significant effects on there was no significant group difference among different types of par­
reducing the total scores of IA (SMD = − 1.90, 95%CI: − 2.26 to − 1.55). ticipants (p>0.05). With regard to intervention measures, there was no
The I2 statistic showed substantial heterogeneity (I2 = 85.9 %, p < 0.01). significant group difference among different interventions (p > 0.05).
With regard to intervention duration, the total scores of IA had no sig­
3.4.1. Subgroup analysis nificant group difference between studies in which intervention lasted
We subsequently stratified our analysis based on the language of <8 weeks or >8 weeks (p > 0.05). With regard to the risk of bias, there
publication sample size, population type, outcome measurement, was no significant group difference between studies that had “some
intervention measure, intervention duration, and risk of bias. The results concerns” or “low risk of bias” (p > 0.05).
of the subgroup analyses are presented in Table 2. All the results of subgroup analyses revealed that the combined effect
According to the results, significant differences were observed both size had significant effects on reducing the total scores of IA. Based on
in the sample size subgroup (p = 0.03) and the outcome measurement the sample size subgroup, the I2 statistic showed lower heterogeneity in
subgroup (p = 0.02). With regard to the language of publication, the the group of sample size ≤40 (I2 = 14.8 %, p = 0.31) when compared
total scores of IA had no significant group difference between studies with overall heterogeneity (I2 = 85.9 %, p < 0.01). Based on the pop­
published in English and Chinese (p>0.05). About the population type, ulation type subgroup, the I2 statistic showed low heterogeneity in the

Table 3
Results of network meta-analysis based on the IAT scale.
No intervention

-16.08(-23.28, -8.85) CBT

-1.25(-13.86, 11.43) 14.78(1.69, 27.90) Routine intervention

-13.38(-20.36, -6.51) 2.71(-6.87, 12.17) -12.13(-24.48, 0.15) Group counselling

-13.20(-20.36, -6.09) 2.89(-7.37, 12.81) -11.90(-26.07, 2.07) 0.21(-8.68, 9.07) Sport intervention

-19.27(-26.89, -11.34) -3.19(-10.08, 3.95) -18.08(-31.58, -4.02) -5.92(-15.75, 4.52) -6.09(-16.33, 4.65) Electrotherapy

-9.33(-24.02, 5.42) 6.67(-9.69, 23.30) -8.04(-26.66, 10.90) 4.01(-10.29, 18.67) 3.89(-10.59, 18.77) 9.95(-6.76, 26.45) Sandplay therapy

-20.68(-36.17, -5.12) -4.52(-20.73, 11.06) -19.44(-28.50, -10.30) -7.28(-22.71, 7.95) -7.45(-24.41, 9.41) -1.35(-18.20, 14.80) -11.26(-32.28, 9.73) Family intervention

-16.81(-34.95, 1.07) -0.67(-17.60, 15.66) -15.63(-37.01, 5.63) -3.43(-22.75, 15.60) -3.63(-23.19, 15.63) 2.51(-15.74, 20.11) -7.60(-30.64, 15.85) 3.83(-19.33, 26.94) VRT

-31.56(-40.33, -22.36) -15.47(-22.96, -7.88) -30.27(-42.39, -17.86) -18.14(-28.50, -7.38) -18.34(-29.57, -6.89) -12.28(-21.34, -3.16) -22.24(-39.31, -5.14) -10.88(-25.95, 4.76) -14.74(-32.79, 3.70) Combined intervention

-13.94(-31.83, 3.93) 2.22(-17.15, 21.34) -12.61(-34.81, 9.28) -0.51(-19.66, 18.42) -0.66(-20.08, 18.62) 5.40(-14.24, 24.75) -4.52(-27.92, 18.04) 6.75(-16.81, 30.37) 2.84(-22.59, 28.41) 17.64(-2.29, 37.35) Bupropion

-3.99(-30.60, 22.62) 12.11(-15.68, 39.49) -2.67(-32.16, 27.03) 9.51(-18.21, 36.71) 9.22(-18.36, 36.93) 15.28(-12.99, 42.72) 5.49(-25.23, 35.49) 16.81(-14.07, 47.22) 12.76(-19.00, 45.12) 27.60(-0.69, 55.60) 10.02(-9.78, 29.38) Escitalopram

Sertraline
-24.91(-44.48, -4.54) -8.79(-27.68, 10.81) -23.57(-44.95, -1.98) -11.52(-31.87, 9.54) -11.70(-32.60, 9.68) -5.57(-25.59, 14.39) -15.48(-39.77, 9.11) -4.14(-27.37, 19.22) -8.03(-32.97, 17.56) 6.68(-10.77, 24.64) -10.89(-37.77, 16.42) -20.98(-53.46, 12.86)
Hydrochloride

Paroxetine combined
1.76(-12.46, 16.29) 17.85(4.48, 31.66) 3.10(-13.51, 19.76) 15.16(-0.02, 30.83) 15.01(-0.86, 31.13) 21.07(6.40, 35.68) 11.28(-9.34, 31.61) 22.44(3.57, 41.65) 18.67(-2.56, 40.13) 33.30(22.15, 44.45) 15.74(-7.31, 38.88) 5.76(-24.58, 36.34) 26.78(5.36, 47.54)
with buspirone

CBT = Cognitive Behavioral Therapy; VRT = Virtual Reality Therapy; Bupropion = Bupropion drug therapy; Escitalopram = Escitalopram drug therapy; Sertraline
Hydrochloride = Sertraline Hydrochloride drug therapy; Paroxetine combined with buspirone = Paroxetine combined with buspirone drug therapy.

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X. Zhang et al. Journal of Affective Disorders 313 (2022) 56–71

Fig. 6. Cumulative ranking plot based on the IAT scale.

Fig. 7. Cumulative probability plots based on IAT scale.

group of studies in which participants were primary and middle school that the potential publication bias would not significantly affect the
students (I2 = 19.3 %, p = 0.29). interpretation of the results of this meta-analysis.

3.4.2. Sensitivity analysis 3.5. Network meta-analyses

The results of the leave-one-out approach for assessing sensitivity by
the random-effects model are summarized in Additional file 2. Sensi­
tivity analysis revealed no single study changed the overall results (p <
0.001).
3.4.3. Publication bias
The funnel plot indicates potential publication bias (Fig. 4). How­
ever, we observed no significant publication bias in the Egger's tests (p =
0.129) and the Begg's test (p = 0.123). The collective results indicated
To examine effect differences among different interventions,
network meta-analyses were further performed. We divided the studies
into three categories according to the evaluation scales to ensure
homogeneity.
3.5.1. Comparison of interventions based on the IAT scale
The IAT scale was used in 32 studies including 2034 patients, in
which 14 interventions were assessed. A network plot is shown in Fig. 5.

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X. Zhang et al. Journal of Affective Disorders 313 (2022) 56–71

Table 4 3.5.2. Comparison of interventions based on the CIAS scale

The SUCRA value of interventions based on the IAT scale. The CIAS scale was used in 20 studies including 1263 patients, in
Treatment SUCRA Prbest MeanRank which 7 interventions were assessed. A network plot is shown in Fig. 8.
The results of the network meta-analysis were summarized in
No intervention 18.1 0.0 11.6
Cognitive Behavioral Therapy (CBT) 50.3 0.0 7.5 Table 5. CBT was significantly superior to routine intervention and no
Routine intervention 16.0 0.0 11.9 intervention (P < 0.05). Group counseling and combined intervention
Group counseling 56.2 0.5 6.7 were both significantly superior to routine intervention and no inter­
Sports intervention 57.0 0.9 6.6 vention (P < 0.05).
Electrotherapy 71.0 2.5 4.8
Sandplay therapy 45.8 3.6 8.0
Interventions were reported in order of their efficacy ranking, ac­
Family intervention 67.8 12.9 5.2 cording to the cumulative ranking plot (Fig. 9), cumulative probability
Virtual Reality Therapy (VRT) 53.6 7.8 7.0 plots (Fig. 10) and SUCRA (Table 6).
Combined intervention 91.0 35.5 2.2
Bupropion drug therapy 59.9 10.0 6.2
3.5.3. Comparison of interventions based on the YDQ scale
Escitalopram drug therapy 36.4 5.8 9.3
Sertraline Hydrochloride drug therapy 69.0 20.5 5.0 The YDQ scale was used in 9 studies including 718 patients, in which
Paroxetine combined with buspirone drug 8.0 0.0 13.0 7 interventions were assessed. A network plot is shown in Fig. 11.
therapy The results of the network meta-analysis were summarized in
Table 7. CBT was significantly superior to routine intervention and no
intervention (P < 0.05). School-family-social comprehensive behavior
intervention was significantly superior to routine intervention (P <
0.05).
Intervention measures were reported in order of their efficacy
ranking, according to the cumulative ranking plot (Fig. 12), cumulative
probability plots (Fig. 13) and SUCRA (Table 8).

3.5.4. Consistency of the network

A node-splitting method was used to evaluate the inconsistency be­
tween direct and indirect comparisons. The results are shown in Addi­
tional file 3. We found no significant inconsistency for all outcomes.

3.5.5. Risk of bias across studies

Fig. 8. Network plot based on the CIAS scale. The size of the circles is weighted The publication bias was illustrated by funnel plots (Fig. 14). Ac­
according to the number of trials available for each intervention. The in­ cording to the network meta-analysis, the funnel plots appeared slightly
terventions for which direct comparisons were available are linked with a line. asymmetric.
The thickness of connections varies according to the number of studies involved
in a comparison.
4. Discussion

In the figure, each node represents a treatment. Connections between In this research, 59 RCTs from 10 databases were included. A
nodes indicate direct comparisons. Node size and the thickness of con­
nections represent the number of studies.
The results of the network meta-analysis are summarized in Table 3.
Combined intervention was significantly superior to Sandplay therapy,
electrotherapy, sports intervention, group counseling, routine inter­
vention, and CBT (P < 0.05). In addition, CBT was significantly superior
to routine intervention and paroxetine combined with buspirone drug
therapy (P < 0.05).
Interventions were reported in order of their efficacy ranking, ac­
cording to the cumulative ranking plot (Fig. 6), cumulative probability
plots (Fig. 7), and SUCRA (Table 4). The rank of each intervention is
shown on the histogram, which indicates the probability of being ranked
in that position. Lower ranks indicate a better intervention effect.

Fig. 9. Cumulative ranking plot based on the CIAS scale.

Table 5
Results of network meta-analysis based on the CIAS scale.
No intervention

-9.81(-16.58, -3.10) CBT

2.18(-5.08, 9.72) 11.98(6.32, 18.08) Routine intervention

-12.04(-18.09, -6.18) -2.31(-9.71, 5.17) -14.26(-21.27, -7.54) Group counselling

-13.09(-26.68, 0.56) -3.32(-18.49, 11.98) -15.29(-31.01, 0.23) -1.01(-15.95, 13.87) Sports intervention

-10.33(-24.34, 3.72) -0.55(-13.09, 12.01) -12.48(-25.58, 0.39) 1.80(-12.59, 15.81) 2.83(-16.65, 22.38) Electrotherapy
Combined
-16.55(-26.33, -6.42) -6.72(-15.07, 1.91) -18.70(-26.16, -11.29) -4.42(-14.20, 5.50) -3.36(-20.25, 13.92) -6.17(-18.79, 6.54)
intervention

CBT = Cognitive Behavioral Therapy.

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X. Zhang et al. Journal of Affective Disorders 313 (2022) 56–71

Fig. 10. Cumulative probability plots based on CIAS scale.

traditional meta-analysis based on 24 studies was performed to assess

Table 6 the effect of interventions compared with no-treatment control groups.
The SUCRA value of interventions based on the CIAS scale. To make pairwise comparisons between interventions, network meta-
Treatment SUCRA Prbest MeanRank analyses based on different scales were performed. The RoB2 was used
No intervention 13.7 0.0 6.2
to assess the methodological quality. Here are the main findings of our
Cognitive Behavioral Therapy (CBT) 51.0 0.6 3.9 research.
Routine intervention 4.6 0.0 6.7
Group counseling 65.6 6.6 3.1 4.1. Meta-analysis
Sports intervention 69.4 29.2 2.8
Electrotherapy 56.8 9.8 3.6
Combined intervention 89.0 53.8 1.7 We performed a meta-analysis based on 24 RCTs (25 pairwise com­
parisons, n = 1398) to assess the effect of interventions on IA. Compared
with no-treatment control groups, results showed that all of the in­
terventions (CBT, group counseling, sports intervention, and Internet-
based intervention) had significant effects on reducing the total scores
of IA. The total effect size was − 1.90, 95%CI: − 2.26 to − 1.55. This result
was similar to Chun J (− 1.84, 95%CI: − 2.11 to − 1.56) (Chun et al.,
2017). According to subgroup analyses based on sample size and

Fig. 11. Network plot based on the YDQ scale. The size of the circles is weighted according to the number of trials available for each intervention. The interventions
for which direct comparisons were available are linked with a line. The thickness of connections varies according to the number of studies involved in a comparison.

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X. Zhang et al. Journal of Affective Disorders 313 (2022) 56–71

Table 7
Results of network meta-analysis based on the YDQ scale.
No intervention

-2.52 (-4.59, -0.44) CBT

-0.73(-3.32, 1.93) 1.79(0.13, 3.44) Routine intervention

-1.24(-2.55, -0.03) 1.29(-1.21, 3.68) -0.51(-3.47, 2.37) Group counseling

School-family-social comprehensive
-3.67(-6.91, -0.19) -1.13(-3.82, 1.63) -2.93(-5.09, -0.74) -2.42(-5.88, 1.24)
behavior intervention

Intenet-based
-2.33(-4.55, -0.18) 0.19(-2.87, 3.24) -1.62(-5.10, 1.80) -1.10(-3.59, 1.46) 1.34(-2.8, 5.29)
intervention

Combined
-2.22(-5.51, 1.12) 0.29(-2.39, 2.92) -1.51(-3.61, 0.57) -0.99(-4.54, 2.68) 1.44(-1.62, 4.40) 0.11(-3.87, 4.14)
intervention

CBT = Cognitive Behavioral Therapy.

Fig. 12. Cumulative ranking plot based on the YDQ scale.

Fig. 13. Cumulative probability plots based on YDQ scale.

outcome measurement, results indicated significant group differences. A
total of 4 interventions have a significant effect on reducing the total
scores of IA, but there was no significant group difference among these
interventions. In addition, significant differences were not observed
when stratified by the language of publication, population type,
intervention duration, and risk of bias (p > 0.05). Due to the small
number of studies and the substantial heterogeneity, the results must be
regarded as preliminary.

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X. Zhang et al. Journal of Affective Disorders 313 (2022) 56–71

Table 8 future, the intervention model for IA will be developed into a compre­
The SUCRA value of interventions based on the YDQ scale. hensive intervention model.
Treatment SUCRA Prbest MeanRank Based on the YDQ scale, the result showed that the best intervention
measure was school-family-social comprehensive behavior intervention
No intervention 1.4 0.0 6.9
Cognitive Behavioral Therapy (CBT) 73.3 1.8 2.6 rather than combined interventions. It's not consistent with the results
Routine intervention 18.4 0.0 5.9 based on IAT and CIAS scales. Among the 59 studies included in this
Group counseling 31.3 0.0 5.1 research, only 9 studies used the YDQ scale as an outcome measure.
School-family-social comprehensive behavior 98.6 93.4 1.1 Among these 9 studies, there was only 1 study using school-family-social
intervention
Intenet-based intervention 66.4 4.8 3.0
comprehensive behavior intervention, and 1 study using the combined
Combined intervention 60.7 0.0 3.4 intervention. Due to the small number of studies, it is disputable
whether the available studies have sufficient scope to enable the types of
comparisons being made and therefore results must be regarded as
4.2. Network meta-analyses preliminary.
In this research, the results showed that the effect of CBT appeared to
According to traditional meta-analysis, we found that all of the in­ be moderate. The cognitive-behavioral model suggests that generalized
terventions had significant effects on reducing the total scores of IA, but thinking might contribute to IA in providing a psychological escape
the result of subgroup analysis showed that there was no significant mechanism to avoid real or perceived problems (Davis, 2001). Its basic
group difference among the four interventions. This result was not concept was to combine behavioral and cognitive psychology to correct
consistent with previous researches (Goslar et al., 2020). This meta- the wrong ideas and cognition of Internet addicts about excessive use of
analysis only compared the interventions with no-treatment control the Internet. The effect of CBT has been confirmed by many studies (King
groups, and there was a lack of pairwise comparison. Therefore, the and Delfabbro, 2014; Vasile, 2020; Zajac et al., 2017), which was
result had some limitations. So far, most researchers performed meta- consistent with our results. Due to feasible research methods and a solid
analyses to assess the total effect of interventions and few studies have theoretical foundation, CBT was widely used in the treatment of psy­
compared interventions pairwise. If we want to rank the intervention chological diseases such as depression and anxiety. In recent years, it has
measures, further network meta-analyses needed to be performed. also been widely used in the treatment of IA. Our research further
We divided the studies into three categories according to the eval­ confirmed that CBT can be a safe and reliable intervention measure for
uation scales to ensure homogeneity. According to the results of a IA.
network meta-analysis based on the IAT scale, combined intervention The effect of drug therapy needs to be further explored. In this
(SUCRA = 91.0 %) ranked as the best intervention for treating IA. Based research, we included 6 studies using drug therapy. However, these 6
on the CIAS scale, combined intervention (SUCRA = 89.0 %) also ranked studies were divided into different network meta-analyses because of the
as the best intervention measure. Based on the YDQ scale, the results different evaluation scales. Due to the small number of studies, the re­
showed that School-family-social comprehensive behavior intervention sults must be regarded as preliminary.
(SUCRA = 98.6 %) may be the best intervention measure for treating IA.
Based on the IAT scale and the CIAS scale, the results were consistent
with Qiao's (Qiao et al., 2020). In our research, there were many types of 4.3. Strengths and limitations
combined intervention measures such as CBT combined with music
therapy (Bong et al., 2021), drug therapy combined with group coun­ Some strengths, as well as limitations regarding this study, need to be
seling (Peng and Li, 2015), CBT combined with drug therapy (Wu et al., mentioned and discussed. To the best of our knowledge, this is the first
2006), CBT combined with electroacupuncture (Tang, 2018; Ye, 2010), network meta-analysis of RCTs based on different evaluation scales of
and other combined intervention measures. Preliminary studies sug­ IA. According to the results, the effect of interventions and relative
gested that combinations of several interventions may be more effective rankings of the different types of interventions could be further
than a single approach (Goslar et al., 2020; Zhou et al., 2020). The confirmed. It provided a further suggestion for future scholars to choose
theoretical foundation of combined intervention measures is that interventions on IA.
physical and cognitive activities might influence brain plasticity through First, in order to reduce bias, a comprehensive and systematic search
distinct and complementary pathways (Gavelin et al., 2021). In the of the published and unpublished literature for potentially relevant
studies was conducted. However, the inclusion of both published and

Fig. 14. Funnel plot for the publication bias of internet addiction. (I): based on the IAT scale. A: No intervention; B: Cognitive Behavioral Therapy (CBT); C: Routine
intervention; D: Group counseling; E: Sports intervention; F:Electrotherapy; G: Sandplay therapy; H: Family intervention; I:Virtual Reality Therapy (VRT); J:
Combined intervention; K:Bupropion drug therapy; L:Escitalopram drug therapy; M:Sertraline Hydrochloride drug therapy; N: Paroxetine combined with buspirone
drug therapy. (II): based on the CIAS scale. A: No intervention; B: Cognitive Behavioral Therapy (CBT); C: Routine intervention; D: Group counseling; E: Sports
intervention; F: Electrotherapy; G: Combined intervention. (III): based on the YDQ scale. A: No intervention; B: Cognitive Behavioral Therapy (CBT); C: Routine
intervention; D: Group counseling; E: School-family-social comprehensive behavior intervention; F: Intenet-based intervention G: Combined intervention.

68
X. Zhang et al.
unpublished literature is advantageous in many ways, and it also created
challenges as most of the unpublished work had not been rigorously
evaluated. To alleviate this problem, two reviewers independently
evaluated the methodological quality of all included studies according
to the RoB2.
Second, in this study, we searched 10 databases using a robust search
strategy and screened citations from retrieved studies, we had to exclude
93 potentially relevant studies because of the language or because we
were not able to retrieve the full text. Finally, we included 59 studies and
11 of them were published in English. Because several interventions
which the studies used were not very common and few studies have been
implemented, we did not include these studies in our meta-analysis.
Some studies were published in English but the evaluation scales were
self-administered questionnaires rather than IAT or YDQ, so we
excluded these studies because their authority and credibility were
questioned, and it may affect the extrapolation of the results. In addi­
tion, China is a large country, with the largest population in the world.
IA represents a major social and public health problem in China, and
many scholars are studying the problems related to IA. Therefore,
studies published in Chinese account for a large proportion of the
included studies, and the extrapolation of the conclusion should be
scrupulous.
Third, the included studies were only published in English and Chi­
nese, and studies published in other languages were not included. The
current situation of IA will be different based on different cultural
backgrounds. It may also lead to some bias in the analysis results.
Finally, the ranking order of interventions was based on mean
SUCRA values, which does not necessarily imply that a higher-ranked
intervention was statistically significantly better than a lower-ranked
intervention. Therefore, the results obtained must be interpreted with
care.
5. Conclusion
Based on the results of our research, we found that all the inter­
vention measures had significant effects on reducing the total scores of
IA. According to the results of network meta-analyses, combined inter­
vention may be the best intervention measure. In the future, we will
further include more new interventions and provide evidence for
scholars to choose appropriate intervention measures.
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jad.2022.06.013.
Ethics approval and consent to participate
Because we reanalyze existing data and no identifiable information
was shared, this study was not required to undergo independent ethical
review.
Availability of data, code, and other materials
All of the data extracted from included studies are publicly available
in PubMed, Cochrane, Embase, Web of Science, PsycINFO, ProQuest,
CNKI, WanFang, VIP database, and CBM.
Funding
This study was supported by The National Natural Science Founda­
tion of China (Grant number: 81973064).
CRediT authorship contribution statement
Xueqing Zhang designed the study. Jianghui Zhang collected the
data. Kexin Zhang, Juan Ren, Xiaoyan Lu, Tianli Wang, Huayu Yang,
Haiyun Guo, Guojing Yuan, Zhihui Zhu, Jiahu Hao, Ying Sun, Puyu Su,
Linsheng Yang contributed to the writing of the manuscript. Zhihua
69
Journal of Affective Disorders 313 (2022) 56–71
Zhang provided support of fund and completed the final editing of the
manuscript.
Conflict of Interest
The authors report no conflicts of interest.
Acknowledgement
None.
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