A Study of Internet Addiction and Its Effects on the Mental Health of Medical Students: A Cross-Sectional Study in Western Iran

Background: The internet itself is a harmless technology. However, its overuse and misuse will expose its users to internet addiction. On the other hand, diagnosis of students’mental dysfunction is of prime importance, and their progress and academic success in the future can be prevented by this technology if not properly handled. Methods: In this descriptive and correlational study, the statistical population consisted of all students at Kermanshah University of Medical Sciences, of which 447 students studying in the first and second semesters of the academic year 2017-18 were selected through Cochran's Sample Size Formula and Stratified Random Sampling. As for data collection, the Young's Internet addiction Test (IAT) and Goldberg General Health Questionnaire (GHQ-28) were utilized. Moreover, for data analysis, the descriptive statistics (percentage, mean, standard deviation) and inferential statistics (T-test, Pearson correlation coefficient, and multiple regression analysis) were employed in the environment of SPSS Statistical Software Version 23.0. Results: The results of the present study demonstrated that the total mean score of students’ internet addiction and mental health measured 3.81±0.88 and 2.56±0.33, respectively. The results also indicated that internet addiction correlared positively with depression whereas negatively with mental health (P<0.001). Besides, the results of multiple regression analysis revealed that the five major predictors of vulnerability to internet addictionin university students were as follows: the key reason for using the internet, faculty, depression, the main place for using the internet, and somatic symptoms.

users and the population of countries were specified, it was reported that, of the world's total population measuring 7,264,623,793 people, 3,079,339,857 were using the internet, and the young made up the majority of users (14). While taking into account the many points for its proper and practical use and prevention of mental illness, these statistics underscore the importance of the internet and social networks. Internet addiction is an etymological process of using the internet that creates a psychological state in which the user's behavior is disturbed, thereby leading to a dysfunction in his/her cognitive status (15).
One of the main pillars of the health of societies is mental health, which plays a key role in ensuring the dynamism and efficiency of any society. Moreover, since university students are among the most prestigious layers of societies and seen as future builders in any country, and given that newly arrived students in universities coming from faraway cities are the first who fall victim to internet addiction, their mental health is of particular importance for raising their learning and scientific awareness (16). Furthermore, mental health is a concept that reflects our thinking, feelings and functioning in dealing with life situations (17). Today, the disease patterns are shifting towards noncommunicable diseases, and the rising rate of mental dysfunction and the resultant costs imposed on societies have attracted the attention of health promotion specialists (18). In this regard, the global burden of disease statistics have introduced mental illnesses as one of the three primary causes of lost years of life due to disability (19). According to WHO, mental health is defined as one's ability to communicate with others harmoniously, modify the personal and social environment, resolve conflicts and personal preferences logically, fairly, and appropriately (20). Moreover, according to the statistics announced by WHO, 52 million people of different age groups suffer from severe illnesses worldwide, and 250 million have mild mental dysfunction. In Iran, these statistics are not lower than those in other countries (21). Moreover, the results of the epidemiological studies conducted about the psychiatric dysfunction in Iran are indicative of the variability of the prevalence of dysfunction between 11.9% and 30.2% (22).
As for internet addiction, addressing the mental health of individuals is of prime significance. For example, Fallah (2007) reported that depression was more prevalent among the internet addicts than normal internet users. The results also demonstrated that the internet addicts were more anxious and their mental health was more at risk (23). Lashgarara et al. (2011) concluded that 34% of university students were addicted to the internet based on the Young's categorization (24). In a study performed by Shahbazirad and Mirderikvand (2013), it was shown that the students' internet addiction and mental health were negatively related, and the students' internet addiction was not significancely different from the variables of gender and marital status (16). In another study done by Nastiezaie (2009), the general health of internet addicts was more at risk than the ordinary users (25). In addition, Fonia et al. (2016) found out that there was a significance difference between the internet addiction of male and female students (26). The results of a study conducted by Atash Pour and Kazemi (2003) revealed that the excessive use of the internet reduced the mental health of the users (27). For example, Dargahi and Razavi (2007) showed that 30% of users were addicted to the internet, and all of them were suffering from varying degrees of psychological and social dysfunction (28). Similarly, the role of internet addiction in the mental health of users and the need to pay attention to the matter have been emphasized in studies conducted by Fallah (29), Alavi et al, (5), Mirzaeyan et al, (30) and Taheri Mobarakeh et al, (31).
Given that the student population use the internet very much and they are at high risk of internet addiction (32), paying attention to students' mental health is of prime importance in terms of their future and the country's development (20).
Obviously, universities should do their utmost to boost the mental health, personal growth and well-being of students (33). Therefore, the present study aimed to investigate internet addiction and its effects on the mental health of medical students at Kermanshah University of Medical Sciences.

Study population and design
In this descriptive and correlational study, the statistical population consisted of all students at Kermanshah University of Medical Sciences, of which 447 students studying in the first and second semesters of the academic year 2017-18 were selected through Cochran's Sample Size Formula and Stratified Random Sampling.
Further, the ethical principles employed in the present study included obtaining the necessary permits, retaining the right for the schools under study to either accept or reject to participate in the study, and ensuring the confidentiality and nondisclosure of agreement. Then, the questionnaires were distributed among the target sample. To this end, the objectives of the present study were explained to the target subjects, and informed consent was obtained from all participants before the study began. Not to mention, the exclusion criteria were the samples disinterest in participation in the study and handing over incomplete questionnaires.
Demographic Questionnaire: The first part of the instrument dealt with the demographics and comprised questions on gender, age, marital status, place of residence, faculty, education, having a personal computer, main location and time of using the internet, and the major reason for using the internet.

Measures
Internet addiction Test (IAT): This 20-item questioonaire was developed by Young (1988) for measuring the internet addiction, which is affected by a variety of aspects in users' lives (12). The questions were scored with five-point Likert Scaling (5 = always, 4 = usually, 3 = most of the time, 2 = sometimes, and 1 = seldom).
Moreover, the minimum and maximum ranges of scores were 20-100. According to the scores, the internet users were grouped into three categories: a score of 20-49 for typical users, a score of 50-79 for at-risk users, and a score of 80-100 for addicted users. It should be noted that the highest scores represent the highest levels of dependency on the internet. According to the latest studies, a score of 50 is considered for internet addiction. Furthermore, the validity of the questionnaire was confirmed by three experts using the content validity index (0.84), and its reliability was confirmed using the test-retest (0.88) by 20 medical students using Cronbach's alpha (0.87) within two weeks. The reliability and validity of this tool have been reported above 90% in previous studies (34)(35)(36)(37)(38).

Sample Characteristics
Of the total of 447 subjects in the present study, 215 students (48.1%) were male and 232 (51.9%) were female. The average age of the subjects was 23.47 ± 4.58, marital status, 360 of the participants (80.5%) were single. In addition, the majority of students were studying bachelor's degrees (202 students or 45.2%), and the majority of students were studying at the medicine school (71 students or 15.9%).
Further, the majority of students were living in dormitories (216 students or 483. %). The results also showed that 356 subjects had their own personal computers (79.6%), and 205 subjects (45.9%) used the interent at their dormitories. It was also revealed that they mainly got conncetd to the interent in the morning or evening (367 subjects or 82.1%), and their main reason for being online was using chat applications (Table 1).   (Table 3). To analyze the relationship between the variables of mental health and internet addiction, a model was used. This model consisted of five major factors: the key reason for using the internet, faculty, depression, the main place for using the internet, and somatic symptoms (Table 4). the students at Dezful University of Medical Sciences, it was found out that 1.8% of female students had internet addiction behaviors, which was higher than that in male students by 0.9% (49). Male students seem to have more internet addiction than girls. On the other hand, with the growing number of girls entering universities, they have the chance to become more familiar with technologies and have a greater chance of using the internet. In fact, the present research, in line with the findings of previous studies, shows that men are more exposed to internet addiction, not because of biological differences between the two genders, but due to different social and environmental factors to which each gender is exposed.
According to the results, it seems that this finding can be an alarm at the increase in this disorder among students, and it is better that proper planning be done in this area in cooperation with university officials.
Based on the results of the present study, the mean score of male students' mental health was higher than that of female students, and no significant difference was seen between gender and mental health. This finding was inconsistent with the results of a study by Ghodasara  was expressed that female students had more mental disorders than male students, which was inconsistent with the results of the present study. It should be noted that the mean score of male students' mental health was higher than that of female students, possibly due to men's ability to communicate with others in society and university, the ability to deal with problems and difficulties and the ability to earn money, as well as the women's excessive emotional dependency on their families and lack of social security in society.
The results of this study revealed that half of the students had poor mental health, and there was a sygnificant difference between the mean scores of depression and internet addiction. These results were consistent with the results of studies done by Nastiezaie (25), Xiuqin et al, (60) and Chung and Wong (61). Kessler et al, (62) concluded that 9.7% of the young aged 18-25 in the USA suffered from depression disorders. The mental health disorders in students cause a sygnificant portion of their mental force to be devoted to such problems, thereby resulting intheir lack of ability and interest to study, disturbing their educational tasks and reducing their motivation, as well as fear, concern, and anxiety.In a study done by Abdollahi   (75) found out that there was a relationship between anxiety and internet addiction. These two findings were consistent with the results of the present study.Depression, as a psychologicaltrauma, seems to lay the groundwork for the internet addicts. Some people resort to the internet to reduce their depression. In this case, the internet may provide a substitute for the joyless lives of depressed people, or they may get depressed as a result of internet addiction. In other words, the internet addicts will experience the negative consequences, such as depression.
In justifying the relationship between depression and internet addiction, it can be expressed that the excessive use of the internet can lead to social isolation and depression throughreducing familial, social and local connection. Therefore, depression may occur as a result of internet addiction, and in this case, the internet addicts experience the resultant negative consequences, such as depression (25).
The results revealed that the five major predictors of vulnerability to internet addiction in university students were as follows: the key reason for using the internet, faculty, depression, the main place for using the internet, and somatic symptoms.

Limitations of the Study
The present study had some limitations. First, the data were collected through a self-reporting method, possibly affecting the accuracy of the results. Second, the subjects' personal differences may also affect the generalizability of the research findings. Hence, it is suggested that further studies be conducted in this respect to draw comparisons towards reaching a consensus on this matter.

Conclusion
According to the findings of the present study, it can be concluded that students' excessive use of the internet leads to depression, anxiety, and reduced mental health, thereby affecting their academic performance. Hence, It is suggested that further monitoring and control be exercised on how the internet is used by  Relationship between mental health and demographic factors in nursing