Psychiatry

Interpersonal and Biological Processes

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/upsy20

Smartphone Addiction and Quality of Sleep among

Indian Medical Students

Surobhi Chatterjee & Sujita Kumar Kar

To cite this article: Surobhi Chatterjee & Sujita Kumar Kar (2021): Smartphone
Addiction and Quality of Sleep among Indian Medical Students, Psychiatry, DOI:
10.1080/00332747.2021.1907870

To link to this article: https://doi.org/10.1080/00332747.2021.1907870

Published online: 15 Apr 2021.

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Psychiatry, 00:1–10, 2021 1
Ó Washington School of Psychiatry
ISSN: 0033-2747 print / 1943-281X online
DOI: https://doi.org/10.1080/00332747.2021.1907870

Smartphone Addiction and Quality of Sleep among

Indian Medical Students
Surobhi Chatterjee and Sujita Kumar Kar

Background: Smartphone is an indispensable miracle of artificial intelligence in

the hands of global netizens. Medical students overburdened and sleep-deprived
due to the curricular demands can have serious health effects due to further sleep
deprivation caused by problematic smartphone use, affecting their work profi­
ciency as practicing physicians. This study aimed to evaluate the association of
smartphone addiction and quality of sleep among medical students across all
semesters, along with other background variables.
Methodology: This cross-sectional study was conducted on 224 medical stu­
dents of a tertiary care teaching hospital in North India using a self-administered
questionnaire with four parts –Socio-demographic characteristics, General health
questionnaire (GHQ-12), Smartphone addiction scale-short version (SAS-SV),
and Pittsburgh sleep quality index (PSQI).
Results: The prevalence of smartphone addiction is was found out to be
33.33% in females and 46.15% in males. In the study, 63.39% were poor
sleepers as assessed by their PQSI scores, and 62.05% reported poor health
status as per their GHQ scores. There was a positive correlation between overall
PQSI scores and smartphone use duration per day, SAS-SV scores, and GHQ
scores.
Conclusion: The high prevalence of excessive smartphone usage among med­
ical students is a cause for concern and is detrimental to their health and sleep
quality. The research addresses current lacunae in correlating smartphone addic­
tion with smartphone usage before sleeping and right after waking up. Risky
behavior adoption and pervasive mood changes associated with excessive smart­
phone use are addressed with equal representation across semesters. The study
recommends increasing self-awareness for help-seeking to regulate smartphone
usage and providing counseling services for students in their formative years.

The age of artificial intelligence has iPhone during its launch “not as way of com­
given a remarkable asset to capable minds – munication but a way of life” (Michelson,
smartphones. It was fore-sighted to describe 2014). Over the last two decades, this

Surobhi Chatterjee is an MBBS student at King George’s Medical University, Lucknow, India. Sujita Kumar Kar,
MD (PSY), is Associate Professor in the Department of Psychiatry, King George’s Medical University, Lucknow, India.
Address correspondence to Sujita Kumar Kar, Department of Psychiatry, King George’s Medical University,
Shahmina Road, Chowk, Lucknow 226003, U.P., India. E-mail: drsujita@gmail.com.
2 Chatterjee and Kar
electronic gadget has incorporated features of
nearly every possible arena a being’s mind can
dwell upon, be it navigation, complex arith­
metic tasks, socializing, commercial purposes,
or educational sphere, the list is endless and
everything just at a fingertip away. Though the
importance of smartphones in our lives cannot
be denied, their impact on an individual’s per­
sonality and behavior are certainly intriguing
and a subject that needs immediate attention.
It is estimated that there were nearly
2.5 billion smartphone users across the
world in 2019. As per India’s official Telecom
Statistics in 2019, the internet subscribers with
smartphone access in India have almost
tripled from 251.59 million in 2014 to
636.73 million in 2019 (Government of
India, 2019).
According to the latest version of the
Diagnostic and statistical manual of mental
disorders (DSM-5), gambling addiction
(behavioral addiction) has been categorized
as a “substance-related and addictive disor­
der” (American Psychiatric Association,
2013). Smartphone addiction also shares
several common characteristics to DSM-5
substance-related disorder criteria, including
the four major factors: compulsive behavior,
impairment of function, withdrawal, and
tolerance(American Psychiatric Association,
2013). The nonproductive overuse of smart­
phones (Problematic Smartphone Use),
along with excessive dependence and toler­
ance, often described as smartphone addic­
tion, is among the most prevalent forms of
addictions in younger generations (Soni
et al., 2017).
Sleep quality is an important indicator
of health (Aguirre, 2016; Baglioni et al.,
2016). Evidence suggests that smartphones
adversely affect sleep quality (Christensen
et al., 2016; Demirci et al., 2015). In 2019,
a meta-analysis found that the majority of the
studies (n = 31) reported a prevalence of
smartphone addiction using SAS-SV ques­
tionnaire, between 10 and 30%, among chil­
dren and young adults, with the median being
23.3% as well as a significant association of
smartphone use with sleep quality, depres­
sion, anxiety, stress and day-to-day func­
tional impairment (Sohn et al., 2019).
Though research evaluating the per­
ceived stress and sleep pattern usage pattern
are present (Dharmadhikari et al., 2019), the
pervasive behavioral changes and risky
behaviors adopted by medical students due
to excessive smartphone usage is less docu­
mented in India even though studies suggest
that emotional deregulation is predictive of
all addictive behaviors (Estévez et al., 2017).
The role of smartphone usage just before
sleeping on subjective sleep quality is also
reported as a limitation in some studies
(Dharmadhikari et al., 2019). The subjective
academic performance is a critical input also
included in the study to understand better
the varying effects of sleep on medical stu­
dents’ functioning (Kumar et al., 2019). As
there is a rampant increase in smartphone
use, its impact needs to be evaluated periodi­
cally. There are gross variations in the inter­
net use patterns among students across the
geographical regions. Similarly, the use of
internet use is also changing time to time
(with time there is progressive increase in
use of internet, due to rampant digitaliza­
tion). Hence, there is a need to understand
the association of smartphone use and sleep
quality among medical graduates in
a rapidly evolving digital era.
MATERIALS AND METHODS
This cross-sectional study was con­
ducted among the undergraduate medical stu­
dents of a tertiary care teaching hospital in
North India from August to October 2019.
Participants who gave written informed con­
sent and used a smartphone for at least
12 months were selected. Those who had
a known history of significant medical illness
that leads to low quality of sleep or had any
diagnosed psychiatric disorder were excluded
from the study. The study questionnaire had
four sections. The first section was a socio-
Smartphone Addiction and Sleep Quality among Medical Students
demographic questionnaire which had ques­
tions regarding the socio-demographic back­
ground of students like age, gender, present
address, socio-economic status, year (semester)
of study, and also questions assessing proble­
matic smartphone use (PSU) like duration and
length of smartphone use, purposes for using
a smartphone, smartphone use in risky situa­
tions, neglect of duties and sleepover smart­
phone use, distress in a network-deficient area
and behavioral changes over time spent on the
smartphone (anxiety/irritability when asked to
restrict smartphone usage/guilt due to excessive
use). The second part included General Health
Questionnaire (GHQ- 12), which was devel­
oped and validated by Williams and Goldberg
(1988), and it is a self-administered question­
naire designed to detect persons that are symp­
tomatic or at risk of developing the common,
non-psychotic mental health problems asso­
ciated with depression, anxiety, somatic symp­
toms, and social dysfunction. The GHQ score
was chosen over the simple Likert scale of
0-1-2-3, as this particular method is believed
to help eliminate biases. A higher score indi­
cates poor mental health and vice versa. A cut
off score of ≤3 is considered healthy. (Gold­
berg, 1988) The third part of the questionnaire
was the Smartphone Addiction Scale-Short
Version (SAS-SV). The SAS-SV is a 10-item
self-report validated scale that addresses the
following five domains: (1) “daily-life distur­
bance,” (2) “withdrawal,” (3) “cyberspace-
oriented relationship,” (4) “overuse,” and (5)
“tolerance.” For each item, opinions are
expressed on a 6-point Likert scale ranging
from 1 (strongly disagree) to 6 (strongly
agree). A score of ≥31 in Male students and
≥33 in female students is considered significant
(Kwon et al., 2013). The fourth section of the
questionnaire consisted of the Pittsburgh sleep
quality index (PQSI) to assess students’ sleep
quality and quantity. A total of 9 individual
items with 19 sub-sections generate seven
“component” scores, including subjective
sleep quality, sleep latency, sleep duration,
habitual sleep efficiency, sleep disturbances,
use of sleeping medication, and daytime
3
dysfunction over the last month. The sum of
scores for these seven components yields one
global PSQI score. In each component, the
scores varied from 0 to 3. Students who got
a Pittsburgh sleep quality index (PSQI) global
score of less than five are classified as having
“good sleep,” and those who score equal to or
more than five as ones having “poor sleep”
(Buysse et al., 1989).
Procedure
A written informed consent was
obtained from all the participants. Participants
were explained about the purpose of the study
and the method of responding to the question­
naire. They were explained about the anonym­
ity and confidentiality of their responses and
identifying particulars. Each respondent was
identified with a unique code ID, which was
used for tabulating and evaluating all the infor­
mation. The names of the students were not
used in data interpretation. Their responses
were stored in a password-protected file,
accessed only by the authors of the study.
The questionnaire was also pre-tested
on a sample of undergraduate nursing students
who were randomly selected. However, they
were not included as the respondents in the
present study. The purpose of the pre-testing
was to determine the appropriateness of the
questionnaire for the target respondents.
Sample Size and Sampling
Characteristics
The estimated sample size required for
the study was 216 to obtain a confidence
interval level of 95%, α-error of 5%, *Pre­
valence 19.85% (Gedam et al., 2017) with
a population size of 1250. The Study popu­
lation of medical students with 250 students
per year over 5 years
Thus, the respondents recruited for the
present study were considered sufficient for
generalization to be made to the theoretical
population of young medical students in
India’s university setting. The present research
4 Chatterjee and Kar
work was initiated only after taking proper
approval of the Institutional Ethics Commit­
tee (Reference code no- 95th ECM II B IMR-
S/P7). The study was funded by the University
Research Cell as an intramural research grant.
Descriptive Analysis
A descriptive analysis was performed to
determine the distributional characteristics of all
the variables studied, including the students’
level of psychological health. The totals,
means, standard deviation, along with the mini­
mum and maximum values on the age, duration
of use every day, GHQ, SAS-SV, PSQI, were
calculated. The independent t-test analysis was
also performed to determine if these scores
would vary across the two genders. Chi-square
tests were also performed to analyze the varia­
bility of qualitative variables. Pearson’s correla­
tion coefficient was used for assessing the
relation between GHQ, SAS-SV score, and
PQSI score. The p-value of < .05 was considered
significant. Data were analyzed using IBM Sta­
tistical Package for the Social Sciences version
23 through institutional access.
RESULTS
Out of 280 students, 30 students were
excluded based on the exclusion criteria. Out
of 250 students, only 224 returned a filled
questionnaire, which formed the sample of
the study. The mean age of students was
TABLE 1. Socio-Demographic Characteristics of the Participants
Total (n = 224)
AGE in years (MEAN ± SD) 21.085 ± 1.792
EDUCATION
(IN SEMESTER)
2nd 56
5th 56
7th 56
9th 56
21.085 ± 1.792 years. The mean age of
male students was 20.747 ± 1.933 years,
and the mean ages of female students were
21.375 ± 1.614 years (Table 1). There were
104 (46.42%) males and 120 (53.57%)
female students, 56 (25%) from each of 2nd
semester (1st year), 5th semester (2nd year),
7th semester (Pre-final year), and 9th seme­
ster (Final year). Fifty-six students from each
of this semester were included for an equita­
ble and unbiased assessment.
In this study, the total mean dura­
tion of smartphone usage is shown to be
2.60 ± 0.94 years, with the mean duration of
usage in male students being 2.43 ± 0.97 years
and the mean duration of usage in female stu­
dents as 2.74 ± 0.89 years. Most of the students
were using a smartphone for the past 3–5 years,
comprising 80 (35.86%) students out of the
224 interviewed. Female students had
a smartphone for a longer length of time as
compared to male students.
The Daily smartphone usage of the
students is 4.62 ± 2.03 hours (in hours/
day). On average, the male students used
a smartphone for 4.5 ± 2.39 hours in a 24-
hr day, whereas the females used it for
4.65 ± 1.93 hours. Thus there was no sig­
nificant difference among gender and smart­
phone usage. Out of those interviewed, 124
students (55.60% of total students) reported
that they used a smartphone for 3–5 hours
a day (Table 2).
The mean GHQ score was divided
among people having favorable GHQ scores
Females
Males (n = 104) (n = 120) Test of significance
20.747 ± 1.933 21.375 ± 1.614 t = 2.649
df = 222
p = .008
37 19 Chi-square = 23.71
31 25 p = .00002
18 38
15 41
Smartphone Addiction and Sleep Quality among Medical Students 5

(GHQ ≤ 3) and unfavorable GHQ scores a greater proportion of students with an

(GHQ > 3). Students’ mean age having
a GHQ score ≤3 was 20.55 ± 1.81 years,
while students’ mean age having a GHQ score
of > 3 was 21.41 ± 1.70 years. This result was
statistically significant at p < .05, pointing out
that younger students had better GHQ. On
a closer analysis, it was found that the students
in their pre-final and final semesters (7th and
9th semesters) had a more significant number
of people stating unfavorable GHQ than new­
comers (first year) and ones in the 3rd semester.
This could mostly justify the correlation
between increased age and GHQ scores.
Mean SAS-SV score was 26.50 in students
with GHQ≤3 whereas it was 31.21 in students
with GHQ>3, signifying it clearly that ones with
unfavorable GHQ had greater Smartphone
addiction and vice-versa. The mean PQSI score
was 4.82 in students with GHQ≤3, and it was
6.55 in students with GHQ>3, pointing toward
the association of poor PSQI score (> 5) with
unfavorable GHQ scores (> 3) (Table 3).
Duration of smartphone usage has
a significant association with general health
status instead of the length of smartphone
usage per day. Students who used their
smartphone for ≥3 hours (89 students) had
unfavorable GHQ of > 3, whereas the major­
ity of those with a smartphone usage of fewer
than 3 hours reported favorable GHQ (51
students). The most common behavioral
change reported by students who replied
affirmatively when asked regarding any
observed behavioral change within them
was guilt (n = 144, 64.28%), associated
with excessive smartphone use. The least
common behavioral change reported was
the feeling of annoyance (n = 87, 37.8%)
when asked to stop smartphone usage.
On comparing the socio-demographic
characteristics and clinical parameters based
on gender, the SAS-SV score shows that
male students (46.1%) were more addicted
to smartphones than females (33.33%)
based on the cutoff score of > 31 in males
and > 33 in females. Gender-wise, Male stu­
dents (43%) reported that they usually get
anxious in a deficient network area, whereas
female students had a feeling of guilt (39%)
over excessive smartphone use.
The correlation between education,
duration of smartphone use, smartphone
addiction, general health, and sleep quality
was evaluated, which is described in Table 4.

TABLE 2. General Overview of the Smartphone Use and Sleep Quality*

In %
In % Males In % (males/ Females (females/total Test of
Total (n = 224) (n = 104) total males) (n = 120) females) significance

Total duration of 2.60 ± 0.94 2.43±0.97 2.74 ± 0.89 t = 2.493

smartphone use in years df = 222
(Mean ± SD) p = .0134
<1 year 30 13.4 19 18.26 11 9.16 Chi-square
1–3 years 71 31.8 36 34.61 35 29.16 = 6.6778
P = .0829
3–5 years 80 35.8 31 29.80 49 40.83
>5 years 43 19.2 18 17.30 25 20.83
Daily use(in hours/day) 4.62±2.03 4.5±2.3 4.65±1.93 t = 0.5194
Mean ±SD df = 222
p = .6040
<3 hours 32 14.34 17 16.34 15 12.5 Chi-square
3–5 hours 124 55.60 58 55.76 66 55 = 2.828
P = .4189
6–8 hours 59 26.45 24 23.07 35 29.16
>8 hours 9 4.03 6 5.7 3 2.5

*GHQ- General Health Questionnaire, SAS-SV-Smartphone addiction scale short version, PSQI- Pittsburg Sleep Quality Index
6 Chatterjee and Kar

TABLE 3. Comparison of Smartphone Addiction Severity, Sleep Quality and Smartphone Use Duration between
Participants with Low GHQ Scores and High GHQ Scores
GHQ SCORE TEST OF SIGNIFICANCE

<3 >3

SAS-SV (mean ±SD) (n = 78) (n = 146) t = 3.3282df = 222

26.50 ± 10.81 31.21 ± 9.94 p = .001
PSQI(mean ±SD) 4.82 ± 2.69 6.55 ± 3.03 t = 5.4578 df = 222
p < .001
Duration of use (in hrs/day) [mean ±SD] 4.39 ± 2.24 4.65 ± 2.14 t = 0.8668 df = 222
p = .3870
Period of smartphone usage Chi-square = 20.4053.
<1 year 21 9 The p-value = .00014.

1–3 years 30 41
>3 to 5 years 19 60
>5 years 15 29

GHQ: General Health Questionnaire, SAS-SV: Smartphone addiction scale short version, PSQI: Pittsburg Sleep Quality Index

DISCUSSION reported in India and Korea (Chen et al.,

Our study population consisted of med­
ical students from different semesters. We
found that male medical students (46.15%)
studying in the 2nd and 5th semesters were
at risk of higher usage and more significant
addiction to smartphones than female stu­
dents (33.33%). Similar results were also
2017; Gedam et al., 2017; Nowreen &
Ahad, 2018; Tsimtsiou et al., 2015). On the
other hand, few studies found female students
more addicted to smartphones (Lee et al.,
2017; M. Prasad et al., 2017) whereas some
reported no gender predilection (Kumar et al.,
2019; Prakash, 2017). A separate meta-
analysis (Morrison & Gore, 2010) reports

TABLE 4. Association of Various Clinical Variables*

Duration of smartphone use Education
(in hours/day) PSQI SAS-SV GHQ (in years)

Daily use of r-value = 0.181 r-value = 0.273 r-value = 0.114 r-value = 0.221
smartphone p-value < .001 p-value < .001 p-value = .087 p-value < .001
(in hours/ (extremely (extremely (Non- (extremely
day) significant) significant) significant) significant)
PSQI r-value = 0.181 r-value = 0.285 r-value = 0.384 r-value = −0.050
p-value < .001 p-value < .001 p-value < .001 p-value = .452
(extremely (significant) (extremely (Non-
significant) significant) significant)
SAS-SV r-value = 0.273 r-value = 0.285 r-value = 0.285 r-value = −0.041
p-value < .001 p-value < .001 p-value < .001 p-value = 0.541
(extremely (extremely (extremely (Non-
significant) significant) significant) significant)
GHQ r-value = 0.114 r-value = 0.384 r-value = 0.285 r-value = 0.181
p-value = .087 p-value < .001 p-value < .001 p-value < .001
(Non- significant) (extremely (extremely (extremely
significant) significant) significant)
Education (in r-value = 0.221 r-value = −0.050 r-value = −0.041 r-value = 0.181
years) p-value< .001 p-value = .452 p-value = .541 p-value = .006
(extremely (Non- (Not (significant)
significant) significant) significant)

*(Significance is kept at p < .05, extreme significance at p < .001, NA-Not applicable) GHQ- general health questionnaire, PSQI-
Pittsburg sleep quality index, SAS-SV- Smartphone addiction scale-short version score
Smartphone Addiction and Sleep Quality among Medical Students
a definite association between male gender
and internet addiction.
A study was done in the Western part of
India and reported greater addiction to smart­
phone in first-year students than in other
semesters (Domple et al., 2017), consistent
with our study’s findings. In contrast to it, in
Bangladesh, a cross-sectional pilot study
(Uddin et al., 2016) reported that final year
students were significantly more addicted.
Smartphone addiction due to higher
every-day usage is detrimental to sleep qual­
ity and quantity in medical students. This
relationship between over-use of smart­
phones and sleep quality is reported in sev­
eral studies (S. Prasad et al., 2018; Soni
et al., 2017; Tsimtsiou et al., 2015).
Similar to our study, the multivariate
analysis is done in a group of 1,519 adoles­
cents in Switzerland,(Haug et al., 2015)
demonstrated that duration of use and time
provided better indicators for smartphone
addiction than use frequency, similar find­
ings were also reported in several studies
done in India as well (Gedam et al., 2017;
Nowreen & Ahad, 2018).
Higher smartphone addiction rates
lead to more time spent on smartphones at
night, thereby impairing sleep quality. This
positive correlation between PSQI and SAS-
SV scores was also published in several other
Indian studies (M. Prasad et al., 2017;
S. Prasad et al., 2018).
There was a positive correlation
observed between general mental health
and sleep quality in our study. A poor gen­
eral mental health is associated with low
sleep quality and vice-versa. The Iranian
study on 321 medical university students
also reported a correlation between low
sleep quality and poor health (r = 0.506,
p < .001) (Kawyannejad et al., 2019).
Male students in our study who were
more addicted to smartphones and used smart­
phones just before sleeping suffered from low
sleep quality, avoided social interaction, felt
annoyed when asked to restrict smartphone
7
usage, and spent more time playing online and
offline games. They also reported poor aca­
demic subjective assessment and ignorance of
essential activities over smartphone usage;
some of our study’s findings are consistent
with other studies (Lee et al., 2017; Nowreen
& Ahad, 2018; S. Prasad et al., 2018).
It is fairly understood that there is
a vicious cycle of excessive smartphone use,
poor sleep quality, and poor mental health.
Breaking this vicious cycle can improve gen­
eral well-being (Rafique et al., 2020; Tetta­
manti et al., 2020). Preventive strategies
focusing on limiting the excessive use of
smartphones may improve sleep quality
and, in turn, mental well-being.
It needs to be emphasized that smart­
phone addiction and internet addiction,
though inter-changeably used, are separate
entities with several independent variables
(Choi et al., 2015; Jin Jeong et al., 2020).
This is one of the pioneer studies done
to correlate smartphone addiction, sleep
quality, and general health status in medical
students. This cross-sectional study also
focuses on the correlation of smartphone
use with risky behaviors and behavioral
changes like anxiety, annoyance, and guilt.
The study also had an equal number of stu­
dents from first to final year, thus removing
selection bias and skewed interpretation. It
was also a pioneer study that correlated sub­
jective academic performance with smart­
phone addiction and smartphone usage just
before sleeping on subjective sleep quality,
not addressed by our predecessors.
The present study had some limitations,
including (1) the use of a convenience sample
of medical students, the results of which can­
not be generalized for the entire young popu­
lation in India; (2) only a limited number of
health and smartphone usage related charac­
teristics have been evaluated; and (3) smart­
phone usage indicators have been self-
reported rather than objective evaluation.
Thus, future studies with multi-centric and
cohort design are suggested with a higher
8 Chatterjee and Kar
sample size to address the cultural and eco­
nomic differences so that the data could be
extrapolated to the entire population. The
temporal and causative association could be
pin-pointed further by such studies, and the
drawbacks of the present study could be
removed.
There is no precise collection of univer­
sal guidelines applicable to smartphone addic­
tion diagnosis as per DSM 5 or ICD 11.
However, such pioneer studies could likely
aid in having a clear consensus on the subject
like gaming disorder (Panova & Carbonell,
2018).
CONCLUSION
The study delineates the importance of
regulating smartphones’ usage as they are asso­
ciated with risky behaviors, anxiety, guilt, and
other behavioral changes. This study concludes
that medical students are not only addicted but
are also developing significant sleep and beha­
vior problems owing to excessive smartphone
usage, which affects their academic perfor­
mance and can be extremely detrimental in
the near-future. This study can be used for
drafting health policies concerning adolescents
and young adults, with particular emphasis on
medical students. Self-awareness and help-
seeking can only be ensured to students if
encouraged to share their feelings with
unbiased discussion on the topic and are pro­
vided with a healthy support system.
The curriculum also needs to be
revised to address this issue, including pro­
viding regular counseling services and no
smartphone campus days to raise awareness.
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AUTHORS’ CONTRIBUTION
Both the authors collected data, ana­
lysis of the data, writing and editing of the
manuscript.
ETHICAL APPROVAL
The data collection team of investi­
gators had ensured the confidentiality of
the participants. We had followed the
“Declaration of Helsinki”– ethical princi­
ples for medical research involving human
subjects.
DISCLOSURE STATEMENT
No potential conflict of interest was
reported by the authors.
FUNDING
The research was funded by an intra­
mural grant from the University Research
Cell of King George’s Medical University,
Lucknow, U.P., India (as undergraduate
medical student research grant).
INFORMED CONSENT
All participants provided informed
consent online.
ORCID
Sujita Kumar Kar http://orcid.org/
0000-0003-1107-3021
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