The exacerbation of depression, hostility, and social anxiety in the course of

internet addiction among adolescents: a prospective study

Chih-Hung Ko, Tai-Ling Liu, Peng-Wei Wang, Cheng-Sheng Chen,

Cheng-Fang Yen, Ju-Yu Yen

PII: S0010-440X(14)00115-1
DOI: doi: 10.1016/j.comppsych.2014.05.003
Reference: YCOMP 51308

To appear in: Comprehensive Psychiatry

Received date: 1 February 2014

Revised date: 9 May 2014
Accepted date: 12 May 2014

Please cite this article as: Ko Chih-Hung, Liu Tai-Ling, Wang Peng-Wei, Chen Cheng-
Sheng, Yen Cheng-Fang, Yen Ju-Yu, The exacerbation of depression, hostility, and social
anxiety in the course of internet addiction among adolescents: a prospective study, Com-
prehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.05.003

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The exacerbation of depression, hostility, and social anxiety in the course of internet

addiction among adolescents: a prospective study.

Running title: exacerbation of psychiatric symptoms in IA

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Chih-Hung Ko, M.D., Ph.D.,1,2,3 Tai-Ling Liu, M.D.,1 Peng-Wei Wang, M.D.,1

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Cheng-Sheng Chen, M.D.1,3, Cheng-Fang Yen, M.D. Ph.D.1,3, Ju-Yu Yen, M.D.,
Ph.D.1

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Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung

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Medical University, Kaohsiung City, Taiwan 807
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Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung

Medical University, Kaohsiung City, Taiwan 812

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Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung
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Medical University, Kaohsiung City, Taiwan 807

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Department of psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung

Medical University, Kaohsiung, Taiwan 801

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The Corresponding Author:

Ju-Yu Yen, M.D., Ph.D.

Department of Psychiatry, Kaohsiung Municipal Ta-Tung Hospital

Kaohsiung Medical University

No.68, Jhonghua 3rd Rd, Cianjin District, Kaohsiung City 80145, Taiwan

Telephone: 886-7-3121101 Ext. 6822

Fax: 886-7-3134761

E mail: yenjuyu@cc.kmu.edu.tw
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Abstract

Background

In adolescent populations worldwide, internet addiction is prevalent and is often

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comorbid with depression, hostility, and social anxiety of adolescents. This study

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aimed at evaluating the exacerbation of depression, hostility, and social anxiety in the

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course of getting addiction to internet or remitting from Internet addiction among

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adolescents.

Method

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This study recruited 2293 adolescents in grade 7 to assess their depression, hostility,
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social anxiety and internet addiction. The same assessments were repeated one year

later. The incidence group was defined as subjects classified as non-addicted in the
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first assessment and as addicted in the second assessment. The remission group was

defined as subjects classified as addicted in the first assessment and as non-addicted

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in the second assessment.

Results
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The incidence group exhibited increased depression and hostility more than the
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non-addiction group and the the effect of on depression was stronger among

adolescent girls. Further, the remission group showed decreased depression, hostility,

and social anxiety more than the persistent addiction group.

Conclusions

Depression and hostility worsen in the addiction process for the Internet among

adolescents. Intervention of internet addiction should be provided to prevent its

negative effect on mental health. Depression, hostility, and social anxiety decreased in

the process of remission. It suggested the negative consequences could be reversed if

internet addiction could be remitted within a short duration.

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Key words: Internet addiction, depression, hostility, social anxiety, prospective,

adolescents.

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Introduction:

More than 90% of adolescents use the Internet to get information [1]. The

Internet is one of the most powerful media of the 21st century and has revolutionized

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education and social communication in adolescents [2]. For adolescents, the Internet

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is also an important source of health-related information[3]. However, internet

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addiction, which can be defined as the loss of control over internet use and its

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resulting negative consequences, is common in adolescents [4]. Epidemiological

studies reveal that internet addiction occurs in 1.4~17.9% of adolescents in both

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western and eastern populations [5,6,7]. This indicates that internet addiction is a
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major mental health problem in adolescents worldwide. Therefore, a clear

understanding the mental health effects of internet addiction in adolescents is

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essential.

Epidemiological studies agree that internet addiction in adolescents is

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associated with depressive symptoms and social anxiety [5,8,9]. The same association

has also been reported in college students [10]. However, the causal relationship
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between internet addiction and depression and social anxiety could not confirmed in
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previous cross-section studies. Social anxiety is generally lower during online

interaction than during face-to-face interaction, especially in subjects with high social

anxiety [11]. Depressive subjects also experience lower social anxiety and hostility

during online interaction [11,12]. Thus, we hypothesized that adolescents who have

depression or social anxiety often use the Internet relieve their depressive or social

anxiety symptoms. In our previous study, which analyzed the same data of this

presenting study, the baseline severity of depression or social anxiety predicted

internet addiction at the 2-year follow up [13]. However, no studies have investigated

whether internet addiction contributes to depression and social anxiety.

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Although an earlier path analysis study demonstrated that problematic internet

use is a predictor of depression [14], this conclusion was not based on a prospective

study. A recent study reported that adolescents with problematic internet use had a

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higher incidence of depression at the 9-month follow-up compared to non-addicted

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controls, but anxiety did not significantly differ [15]. This indicates that internet

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addiction contributes to depression. Another prospective study revealed spontaneous

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remission in adolescents with internet addiction [16], which is consistent with the

clinical experience of the authors. If the addiction status changes, the addiction status

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observed in the initial survey cannot be considered an unchanged predictor of
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depression or anxiety. Thus, causal relationships should be interpreted cautiously in

prospective studies in which predictors, e.g., internet addiction, change in the course
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of the investigation.

In Gentile et al., adolescents who played online games were classified into four
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groups in terms of their pathological internet gaming behavior: a stop group, a start

group, a stay group, and a never group.. Comparisons showed that the start group,
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who started with a pathological condition during follow-up, ultimately showed higher
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depression, anxiety, and social phobia compared to the never group, who had never

been pathological gamers. The authors further showed that the stop group, who no

longer exhibited pathological internet gaming behavior during follow-up, had lower

depression, anxiety, and social phobia compared to the stay group, who continued to

exhibit such behavior[17]. Based these results, the authors suggested that depression

and anxiety result from pathological online gaming activity. They demonstrated a

practical way to perform a detailed study of changes in comorbid psychiatric

symptoms in the four groups of pathological gamers. However, since the initial

investigation did not assess depression, anxiety, and social phobia, the study did not
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confirm whether these symptoms really changed during the follow-up periods. Thus,

depression and social anxiety must be compared prospectively in courses of internet

addiction among adolescents. Such studies would provide essential information for

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understanding whether internet addiction contributes to depression or social anxiety.

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Aggressive behaviors such as cyber bullying and extreme behaviors such as

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internet suicide have been associated with excessive internet use [18] and with

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internet addiction [19]. Hostility has also been associated with internet addiction [12,

13, 20]. Although hostility decreased after getting online, subjects with internet

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addiction increased expressive hostility when getting online [12]. Adolescents with
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internet addiction reportedly have higher hostility [5] and more aggressive behaviors

[20]. These results indicate that subjects with high hostility may have a higher
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vulnerability to internet addiction. This claim is supported by our previous study,

which analyzed the same data set considered here. At the 2-year follow, adolescents
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with high hostility were more likely to get internet addiction [13]. These results are

also consistent with social learning theory, which suggests that violence in media
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increases hostility and aggression [21]. Since longitudinal studies have identified both
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biological and environmental factors that affect behavioral traits in adolescents [22],

an improved understanding of whether internet addiction increases hostility is needed

Internet addiction is more common in males than in females [13]. Further,

hostility is the best predictor of internet addiction in males whereas the presence of

ADHD symptoms is the best predictor in females [13]. This suggests a gender

difference in associative factors or comorbidity in adolescent internet addiction [9].

Gender differences in the preferred online activity have also been reported. For

example, in adolescents with internet addiction, online gaming is the most common

internet activity in males but not in females [23]. Gender differences in the online
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experience and in the vulnerability to comorbidity might contribute to differences in

the effect of internet addiction on psychiatric symptoms.

Thus, the aims of this study were 1) evaluating the change of depression,

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hostility, and social anxiety in the course of internet addiction or remitting from it;

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and 2) exploring the gender difference in incidence or remission effect of internet

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addiction on the progression of depression, hostility, and social anxiety.

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Methods

Participants

In September, 2005, the participants in this study were recruited from ten junior

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high schools distributed throughout southern Taiwan (four located in urban areas, four

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located in suburban areas, and two located in rural areas). The participants included

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students in eight randomly selected classes in each school. Research assistants visited

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the students in their classrooms and explained the study objectives and procedures.

Signed consent to participation in the initial investigation was received from 2,293

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students (1,179 males and 1,174 females; mean age, 12.36 ± 0.55 years). The
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Institutional Review Board of Kaohsiung Medical University Hospital approved this

study and confirmed its compliance with the ethical standards established by the 1964
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Declaration of Helsinki and its subsequent amendments.

Instruments
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Chen Internet Addiction Scale (CIAS). The 26-item CIAS uses a 4-point Likert scale

to assesses five dimensions of internet-related problems. The CIAS rates the severity
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of internet addiction from 26 to 104, which represent low to high severity,

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respectively. The internal reliability of the scale and the subscales in the original study

ranged from 0.79 to 0.93 [24]. According to the diagnostic criteria of internet

addiction [25], a cutoff point marked by the scores 63/64 provides the best

combination of diagnostic accuracy (87.6%), sensitivity (67.8%), and specificity

(92.6%) [26]. Accordingly, subjects with CIAS scores of 64 or higher were classified

as the internet addiction group in this study.

Center for Epidemiological Studies Depression Scale (CES-D): The 20-item

Mandarin Chinese version [27] of the CES-D [28] is a self-administered test of the

frequency of depressive symptoms within the previous week in which high scores
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indicate increased severity of depression. The CES-D in the present study had a

Cronbach alpha of 0.78.

The Buss-Durkee Hostility Inventory- Chinese Version- Short Form (BDHIC-SF).

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The 20-item, 5-point Likert-type BDHIC-SF assesses four dimensions of the hostility

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construct, including hostility cognition, hostility affection, expressive hostility

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behavior, and suppressive hostility behavior. The coefficient of internal consistency

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(Cronbach alpha) was 0.93, and the four-week test-retest reliability was 0.80. Higher

scores indicate higher hostility [29].

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The brief version of Fear of Negative Evaluation Scale (FNE) evaluates the
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cognitive symptoms of social phobia. The BV-FNE is a brief, 5-point Likert-type,

12-item version of the FNE that has demonstrated a high correlation with the original

scale (r=0.96), a high internal consistency (α=0.90), and a good 4-week test-retest
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reliability coefficient (0.75) [30]. Here, the FNE was used to evaluate cognitive
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symptoms of social phobia.

Study procedure and statistical analysis

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After receiving approval of this study by the Institutional Review Board of

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Kaohsiung Medical University Hospital, the CIAS, CESD, BDHIC-SF, and FNE were

administered in the initial assessment. The same scales were administered again year

later.

The objective of the study was to evaluate the effects of internet addiction on the

change in depression, hostility, and social anxiety. In the adolescents classified as the

non-addiction group in the initial investigation, those classified as addicted and

non-addicted at the 1-year follow up were defined as the incidence group and the

non-addiction group, respectively.

In the adolescents classified as the addiction group in the initial investigation,

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those classified as addicted and non-addicted at the 1-year follow up were defined as

the persistence group and the remission group, respectively. In each group, changes in

CIAS, CESD, BDHIC-SF, and FNE scores were evaluated by paired t-test. A

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repeated-measures, two-way ANOVA analysis of CESD, BDHIC-SF, and FNE scores

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was performed as a function of the time course (within-subject effect) and incidence

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of internet addiction (incidence group versus non-addiction group; between-subject

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effect) with gender and age covariates among subjects without internet addiction in

the initial investigation. The same analysis was further used to evaluate CESD,

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BDHIC-SF, and FNE as a function of the time course (within-subject effect) and
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remission of internet addiction (remission group versus persistence group;

between-subject effect) in the subjects who revealed internet addiction in the initial
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investigation. All statistical analyses were performed using the SPSS software

package. A p-value less than 0.05 was considered statistically significant.

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Results

The 1863 adolescent students (943 males and 920 females) who completed the CIAS

were classified into four groups. The missing rate did not differ by gender (X2=2.55).

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Of these, 1520 participants completed the CESD, BDHIC-SF, and FNE in the initial

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assessment and in the 1-year follow up. Of the 1382 participants (647 males and 735

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females) who did not have internet addiction in the initial assessment, paired t-test

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showed that both the non-addiction group (572 males and 695 females) and the

incidence group had increased hostility and social anxiety in the 1-year follow up

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(Table 1, Figs. 1A, 1B). The repeated two-way ANOVA further demonstrated that the
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incidence group (75 males and 40 females) had a larger increase in CESD and

BDHIC-SF scores compared to the non-addiction group at the 1-year follow up (Table
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2; Figs.1A, 1B). Further, the interaction of gender and incidence group effect

significantly predicted the progression of depression. Further analysis demonstrated

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that the effect of incidence on progression of depression was significantly larger in

girls than in boys (Table 2 and Fig. 2).

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In the subjects who had internet addiction in the initial investigation (104 males
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and 34 females), CESD and BDHIC-SF scores were significantly decreased in the

remission group (52 males and 19 females) but not in the persistence group (52 males

and 15 females) did not, during the one-year follow-up (Table 1). The repeated

two-way ANOVA revealed that the decrease in CESD, BDHIC-SF, and FNE scores

was larger in the remission group than in the persistence group (Table 3; Figs. 1D, 1E).
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Discussion

In subjects who became internet-addicted, depression increased during the 1-year

follow up. The increase in the severity of depression was larger than that in the

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control group during the same period. In line with previous report [22], this result

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indicates that, during the process of addiction to the internet in adolescents,

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depression is exacerbated. In the process of addiction to the internet, adolescents may

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experience negative consequences of internet addiction such as impaired academic

performance, conflict with parents [31], and social isolation. They might also

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experience a sense of rejection by their parents, isolation from their peers in the real
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world, and low self-esteem in school.

Interpersonal theory [32] suggests that these interpersonal difficulties can worsen
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interpersonal security and increase the risk of depression. However, the need for

self-esteem and reassurance can be met by internet activity such as online gaming or
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by using communication tools for mass social interaction. The combination of

real-world rejection and online reassurance further increases their addiction to the
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internet. Further, excessive internet use occupies the limited free time they have for
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social interaction such as religious activities and for recreational activities, which can

provide feelings of competence or social support. Since social support, personal

competence and religion are known to have important effects in protecting

adolescents from depression [33], the attenuation of these protective factors in real

life might increase the risk of depression. In contrast, online activity reportedly

decreases social anxiety and hostility, particularly in depressive subjects [11,12]. To

compensate for feelings of inadequate social support, interpersonal security, or

personal competence, adolescents may increase their online interaction to increase

their self-esteem through approval from others or through achievements in online

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gaming. However, the present study demonstrated that exacerbates rather than

diminishes depression. The data suggest that the attempt to escape depression and

real-world concerns through online interaction results in a vicious cycle that

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exacerbates depression, but not a recovery process. Thus, any preventive schedule for

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internet addiction should be implemented at the youngest possible age to minimize its

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exacerbating effects on depression.

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Another exacerbating factor in depression was the interaction term of gender and

incidence effect. Further stratified analysis demonstrated that, in the incidence group,

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the effects of internet addiction were more severe in girls than in boys. That is,
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adolescent girls are more vulnerable to the effects of the internet addiction process on

the progression of depression. An earlier study of interpersonal vulnerability to

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depression in adolescent girls suggested that reassurance-seeking combined with poor

relationships with peers contributes to depression [34]. Thus, real-world interpersonal

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difficulties resulting from internet addiction have contributing effects on depression

that are larger in adolescent boys than in of adolescent girls. A previous report
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suggested that perceived parental conflict contributes to depression in adolescent

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females [35]. Parents of adolescents with internet addiction usually impose controls

on internet use, which results in conflict. In this case, the individual with internet

addiction has high perceived parental conflict and low family satisfaction [31]. Thus,

internet addiction in female adolescents might exacerbate depression by disturbing

family relationships and by increasing interpersonal difficulties. Since female

adolescents are also more vulnerable to depression compared to their male

counterparts [36], female adolescents might be more vulnerable to the negative effects

of internet addiction on depression. Thus, treatment for adolescents with internet

addiction, particularly females, should pay effort to prevent the exacerbation of

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depression.

This prospective study also revealed that adolescents in remission from internet

addiction at the 1-year follow-up had decreased depression. The decrease in

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depression during this period was larger than that in the persistence group, which

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indicates that depression in adolescents with internet addiction can improve if

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remission from internet addiction occurs within a short time. In adolescents in

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remission from internet addiction, the negative consequences of internet addiction

may be attenuated by the increased free time available for family members and peers

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to provide social support and interaction. Another possible attenuating factor is the
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approval expressed by parents or teachers who observe their improved control of

internet use. As interpersonal problems such as insecurity or rejection diminish, the

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risk of depression is attenuated. Thus, maintaining remission status is essential for

improving depression in subjects with internet addiction.

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The incidence group of subjects who had changed from non-addicted to addicted

status at the 1-year follow up revealed increased hostility. The increase in hostility
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was also larger than that in the non-addiction group who did not acquire an internet
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addiction during the same period. Since hostility significantly increased during the

course of addiction, the increase was not attributable to preexisting hostility alone.

Based on the theory of media violence, the short-term risk of aggression is increased

by the effects of playing online games with violent content, such as priming, arousal,

and mimicry. Long-term exposure to violent themes in online games have a

desensitizing effect that increases the long-term risk of violent behavior [37]. The

anonymizing and deindividuating effects on online interaction [38] also increase the

risk of hostility and aggressive behavior. The media violence effect is likely to

promote hostility in the course of internet addiction. This finding is in line with a
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previous report suggesting that adolescents with internet addiction have a higher than

normal risk of exhibiting aggressive behavior [20].

Aside from media violence, internet addiction is associated with frustration

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intolerance [39]. Since frustration is associated with hostility among young

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adolescents [40], the frustration intolerance of adolescents with internet addiction

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might contribute to the progression of hostility in the course of their addiction.

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During the follow-up period of this prospective study, the remission group

revealed a larger decrease in hostility compared to the persistence group. According to

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interpersonal theory [41], hostility develops through identification, internalization,
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and introjection [42]. In the process of identification, criticism received by the parents

of adolescents is directed toward others. For example, the internalization process may
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cause an adolescent child to expect others to exhibit the same dismissive, coercive,

and blaming behaviors that they observe in their parents. They might also continue to
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display the cold, wary, and defensive stance that complements this expected treatment

from others. Finally, the introjection process causes people to treat themselves in the
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same ways they are treated by key developmental figures. Adolescents with internet
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addiction often lose their control over internet activities such as online gaming and

communication. Most parents feel powerless to supervise and get into criticism to

their children. The adolescents may identify with the criticism, internalize it,

interject their own interpretation of the criticism, or interject the criticism to their

parents, teachers, and peers. Thus, the addiction to internet might result in a impaired

family relationships [31]. This vicious cycle may thus increase hostility in adolescents

with internet addiction.

In contrast, adolescents who are in remission from internet addiction tend to

receive positive feedback and approval of the change from parents or teachers. The
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improved reciprocal interaction interrupts the vicious cycle and relieves the

progression of hostility. Comparison of the results observed in the incidence and

remission groups suggests that internet addiction has a temporal effect on hostility if

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remission from internet addiction is achieved within a short period. Since long-term

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hostility can have both negative psychosocial consequences, e.g., interpersonal

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difficulty, and negative physical consequences, e.g., cardiovascular disorder [42],

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remission status should be achieved as early as possible in adolescents with internet

addiction.

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Adolescents with internet addiction also reportedly have high social anxiety
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[5,11], which is another predictor of internet addiction [13]. Communication

apprehension, which is the fear or anxiety associated with communication with

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another person, reportedly contributes to social anxiety [43]. In online interaction,

social cues that provoke communication apprehension, e.g., facial expressions and
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body language, may be difficult or impossible to perceive. Thus, social anxiety tends

to be lower during an online interaction than during a face-to-face interaction [11],

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particularly in subjects with high social anxiety. This study did not reveal a significant
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change in social anxiety during the process of internet addiction, which suggests that

social anxiety is neither exacerbated nor improved by internet addiction.

On the other hand, social anxiety decreased more in the remission group than

among the persistence group. If adolescents could remit from internet addiction, they

might regain more chances to maintain interactions with other than those who

maintain addiction to the internet. Thus, they have more chance to practice social

interaction in real life and really improve their social anxiety. This result might

suggest regaining social interaction in the real world but not escaping to online

interaction, could attenuate social anxiety..

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Clinical implications of the results:

The results of this study suggest that, during the progression of internet addiction,

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adolescents are likely to exhibit exacerbated depression and hostility. Both depression

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and hostility are prognostic indicators of poor mental or physical health. To attenuate

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these exacerbating effects internet addiction on depression or hostility, effective

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policies are needed to prevent internet addiction in adolescents. However, because the

Internet is an essential tool for adolescents, total prohibition or aggressive limitation

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might not be the best policy. Education to develop the skills needed for effective and
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constructive internet use is needed. Further studies are also needed to determine how

to advise parents and teachers in setting effective policies for regulating internet use
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by their adolescent children and students. Since this study revealed that remission

from internet addiction improves depression, hostility, and social anxiety, the negative
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mental health consequences of internet addiction can be minimized by achieving

remission status as early as possible. Thus, effective interventions should be

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developed and implemented as early as possible in adolescents with internet addition

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to minimize depression, hostility, and social anxiety.

This study has two limitations that should be considered when interpreting its

findings. Firstly, the diagnoses of internet addiction were based solely on self-reported

data. Future studies should also gather information from parents and teachers to

support the self-reported scale. Secondly, the severity of internet addiction, depression,

hostility, and social anxiety constantly changed during the course of the study.

Although increased depression was demonstrated in the incidence group, we could not

determine whether the addiction status preceded the exacerbation of depression.

Future studies should apply a shorter follow-up period to establish clear temporal and
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causal relationships.

Conclusion

This study revealed the negative mental health consequences of internet

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addiction. That is, depression and hostility increase in the course of internet addiction.

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However, subjects in remission from internet addiction 1 year later showed

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improvements in depression, hostility, and social anxiety. This indicates that remission

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from internet addiction has beneficial mental health effects in this age group. Thus,

prevention and intervention programs should provided as early as possible to

adolescents with internet addiction.

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Acknowledgements

The study was support by grants from the National Scientific Council

(NSC94-2413-H-037-006-SSS), Kaohsiung Municipal Hsiao-Kang Hospital

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(KMHK-101-009) and Kaohsiung Medical University Hospital (KMUH100-0R50).

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Conflicts of interest: the authors have no personal, professional, or ethical conflicts

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of interest in the publication of this study.

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Figure legends

Fig. 1 Comparison of depression, hostility, and anxiety between subjects with and

without internet addiction at the 1-year follow up.

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Legend

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At the 1-year follow up, depression and hostility were increased more in the incidence

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group in comparison with non-addiction group. Depression, hostility, and social

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anxiety decreased more in the remission group in comparison with persist group.
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Assessment instruments: depression, Center for Epidemiological Studies Depression

Scale (CES-D);hostility, Buss-Durkee Hostility Inventory- Chinese Version- Short

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Form (BDHIC-SF); social anxiety, brief version of Fear of Negative Evaluation Scale
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(FNE).
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Fig. 2 Depression at 1-year follow up. Comparison of female and male subjects who
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did not have internet addiction in the first investigation.

Legend: The incidence group had increased depression, more significantly among

female, at the 1-year follow up. . Depression was assessed by the Center for

Epidemiological Studies Depression Scale (CES-D).

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Fig. 1
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Fig. 2
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Table 1 The t-test and paired t-test for depression, hostility, and social anxiety among incidence, remission, persistence and non-addiction group.

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Adolescents without IA at first Adolescents with IA at first
(Mean±SD) (Mean±SD)

I
CR
Non
addiction Incidence Remission Persistence

S
2
(N=1267) Paired t (N=115) Paired t X or t (N=71) Paired t (N=67) Paired t X2 or t

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Male 572 75 17.06*** 52 52 0.35
Female 695 40 19 15

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Age 12.32±0.47 12.36±0.48 0.79 12.32±0.47 12.34±0.53 0.23
Depression (1st) 15.23±9.22 -0.69 17.97±9.79 -4.59*** 3.04** 20.93±12.48 2.36* 21.64±10.28 -0.47 0.37

D
Depression (2nd) 15.40±10.19 22.57±11.67 6.37*** 17.27±12.94 22.19±10.32 2.46*

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Hostility (1st) (1st) 55.06±13.34 -4.70*** 58.60±13.28 -7.01*** 2.72** 68.00±12.40 4.19*** 68.61±10.14 -0.09 0.32
Hostility (2nd)

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56.70±13.64 66.74±11.88 7.64*** 60.83±12.52 68.73±11.13 3.91***
Social anxiety (1st) 31.36±6.25 -3.81*** CE
32.17±6.32 -1.85 1.33 32.86±6.87 1.91 32.42±6.31 -0.75 -0.39
Social anxiety (2nd) 32.03±6.46 33.35±6.38 2.10* 31.28±6.33 33.00±5.73 1.67
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Depression: assessed by Center for Epidemiological Studies Depression Scale (CES-D)

Hostility: assessed by The Buss-Durkee Hostility Inventory- Chinese Version- Short Form (BDHIC-SF)
Social anxiety: assessed by the brief version of Fear of Negative Evaluation Scale (FNE)
1st: the score in the first evaluation
2nd: the score in the follow-up evaluation one year later
*: p<0.05; **: p<0.01; ***: p<0.001
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Table 2 The repeated-measure two-way ANOVA for severity of depression, hostility,

and social anxiety as a function of time course and incidence effect among subjects
without Internet addiction in the initial investigation.
Within-subject analysis
Mean
Partial η2

T
Variables Df F
square

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Adolescent without IA at first

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Depression
Time 1 2.08 0.05 0.000

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Time by age 1 18.01 0.43 0.000
Time by gender 1 678.49 16.20*** 0.012
Time by Incidence 1 1397.28 33.36*** 0.024
Time by gender by Incidence 1 217.19 5.19* 0.004

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Depression stratified by gender
Female without IA at first
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Time 1 9.91 0.22 0.000
Time by age 1 42.98 0.95 0.001
Time by Incidence 1 1073.52 23.66*** 0.031
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Male without IA at first

Time 1 1.89 0.05 0.000
Time by age 1 0.54 0.01 0.000
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Time by Incidence 1 359.61 9.48** 0.014

Hostility
0.000
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Time 1 38.63 0.50

Time by age 1 1.27 0.02 0.000
Time by gender 1 135.12 1.76 0.001
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Time by Incidence 1 2338.09 30.48*** 0.022

Time by gender by Incidence 1 64.88 0.85 0.001
Social anxiety
Time 1 11.01 0.56 0.000
Time by age 1 17.78 0.91 0.001
Time by gender 1 1.82 0.09 0.000
Time by Incidence 1 9.34 0.48 0.000
Time by gender by Incidence 1 1.39 0.07 0.000
Depression: assessed by Center for Epidemiological Studies Depression Scale
(CES-D); Hostility: assessed by The Buss-Durkee Hostility Inventory- Chinese
Version- Short Form (BDHIC-SF); Social anxiety: assessed by the brief version of
Fear of Negative Evaluation Scale (FNE); Time: the follow-up versus the initial
investigation; incidence group: incidence group versus non-addiction group.
*: p<0.05; **: p<0.01; ***: p<0.001
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Table 3 The repeated-measure two-way ANOVA for severity of depression, hostility,

and social anxiety as a function of time course and remission group effect among
subjects with Internet addiction in initial investigation respectively.
Within-subject analysis
Mean
Partial η2

T
Variables Df F
square

P
Adolescents with IA at first

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Depression
Time 1 52.64 0.82 0.006

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Time by age 1 53.56 0.83 0.006
Time by gender 1 363.05 5.64* 0.041
Time by remission 1 308.75 4.79* 0.035

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Time by gender by remission 1 10.04 0.16 0.001
Hostility
Time 1 30.25 0.36 0.003
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Time by age 1 39.43 0.46 0.003
Time by gender 1 297.41 3.50 0.026
Time by remission 1 669.94 7.88** 0.056
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Time by gender by remission 1 3.27 0.04 0.000

Social anxiety
Time 1 0.68 0.03 0.000
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Time by age 1 0.59 0.03 0.000

Time by gender 1 18.33 0.81 0.006
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Time by remission 1 96.10 4.24* 0.031

Time by gender by remission 1 14.50 0.64 0.005
Depression: assessed by Center for Epidemiological Studies Depression Scale
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(CES-D); Hostility: assessed by The Buss-Durkee Hostility Inventory- Chinese

Version- Short Form (BDHIC-SF); Social anxiety: assessed by the brief version of
Fear of Negative Evaluation Scale (FNE); Time: the follow-up versus the initial
investigation; remission: remission group versus persistence group.
*: p<0.05; **: p<0.01

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