الفهرس 
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Abstract
During the 1980s, Using of the Internet developed quickly, by 1995 the Internet had become a mainstream communication vehicle (Shaffer et al., 2000). Meanwhile the number of Internet users has expanded dramatically across the world by 5billion users in March 2021, which counts for 65.6 % of the world population (Internet World Stats, 2021). The region with the highest active social networking penetration is Western Europe (79%). Most popular social network based on global audience size is Facebook. (Internet World Stats, 2021).
Compulsive social media use According to the DSM-5, a person is diagnosed as having Internet Gaming Disorder (IGD) if there is a fulfillment of 5 (or more) of the 9 criteria (preoccupation, tolerance, withdrawal, persistence, escape, problems, deception, displacement, and conflict) during 12 months. Since social-media use disorder and IGD both relate to internet use, researchers refer to nine IGD criteria of DSM-5 for constructing diagnostic tools and establishing internet / social media addiction (Ellison&Boyd 2013).
High school and university students are at highest risk for internet dependence. University-aged students are less likely to be monitored and supervised by parents, which may affect the content/restrictions of use. Excessive Internet use could be a risk factor for adolescents’ engagement in NSSI and suicidal behaviors (Xueyan et al., 2020). Daily use of the Internet for more than five hours was closely related with higher levels of depression and suicide among adolescents and People diagnosed with Internet addiction exhibited a higher level of impulsivity than healthy controls and people diagnosed with pathological gambling (Lee et al., 2012).
Neuropathology of adolescent Internet revealed that they reacted differently to impulsivity and disembodiment-related stimuli compared to normal adolescents. The association between IAD and the nicotinic acetylcholine receptor subunit alpha 4 (CHRNA4) gene rs1044396 polymorphism has been investigated. Excessive Internet use may affect this neurotransmitter system of the brain in much the same way as other addictive substances and behaviors (Montag et al.,2012).
Mental illnesses like depression, anxiety and psychological distress are associated with internet addiction. Youth with ASD have higher levels of compulsive internet use and video gameplay compared to healthy peers. Adolescents with internet addiction also reportedly have high social anxiety (Yen et al., 2012). There is growing evidence showing high rates of social media use among individuals with mental disorders.
Self-harm and suicide are major public health problems in adolescents, Suicide was the second leading cause of death among young people aged 15-29 years, after road injury (WHO Global Health Estimates, 2019).
University students, especially during the first year, are exposed to a variety of stressors that may trigger or exacerbate mental health problems, including not only academic burden but also those deriving from the change of environment, such as leaving the parental home, affective isolation, financial hardship, adaptation to methods of instruction very different from the high school, or worries about the future (Tosevski et al., 2010).
Also, internet overuse and exposure to negative information and images about suicide may cause de individuation, reducing self-awareness and concern with social evaluation, leading to a decreased sensitivity towards self-harm Thus, these related studies above indicate that excessive Internet use could be a risk factor for adolescents` engagement in NSSI and suicidal behaviors (Lin et al., 2013).
This study aimed for detecting the relationship between compulsive internet use and the psychological impact on medical students regarding depressive symptoms, self harm behavior and suicidal ideation.
This was a Cross- sectional study which was conducted through online platforms. Participants were 350 students recruited from the two Facebook groups in the preclinical years in faculty of medicine Ain Shams University
The students were enrolled to semi structured interview. Consisted of validated and translated to Arabic questionnaires:
1. Compulsive Internet Using Scale (CIUS) to assess the pattern of social media use.
2. Patient Health Questionnaire-9 (PHQ-9) to assess depressive symptoms
3. The Self-Injury Questionnaire-Treatment Related (SIQ-TR) to assess the self injurious behavior.
4. Suicide Probability Scale (SPS) to assess the suicidal ideation
Study results:
1) Socio-demographic Data:
Our study included 350 participants, all of them are medical students in preclinical years faculty of medicine Ain Shams University. About third quarter of the sample were females 72.3 % (n=253),where 27.7% (n=97) were males
About 71.4% (n=250) of the participants were from urban areas, while 28.6% (n=100) were from rural areas as shown in (figure 5).
Of the studied participants 2% (n=7) of the participants were married while 98% (n=343) were single
Regarding the devices used for social media use smart phones comes first with 86% (n=301), then 9.8% (n=34) laptop, 2.8% (n=10) tablets, 1.4% (n=5) used home computer
2) Description data of students` daily social media use:
Regarding daily social media use 43.7% (n=153) are using social media more than six hours daily. About 27.7% (n=97) were using social media from 4 to 6 hours daily,20.6% (n=72) from 2 to 4 hours, (n=28) 8.0% from 1 to 2 hours daily
Most common accessed platform was Facebook 80.0% (n=280) then Instagram 12.0% (n=42), Twitter 2.9% (n=10), Snapchat.3% (n=1) and other platforms 4.8% (n=17).
3) Assessment of Compulsive social media Use via CIUS
Percentage of participants with mild compulsive social media use was 7.1% (n=25), moderate compulsive social media use was 52.3% (n=183). Severe compulsive social media use was 36.6% (n=128). Results of about 50% of study participants showed that they had moderate to severe compulsive social media use (scored >34-46)
4) Assessment of depression severity among studied participants via PHQ-9
The prevalence of depression in studied students was 40.0% (n=140), 28.9% (n=101), 30.0% (n=105) mild, moderate, and severe depression respectively. Nevertheless, the remaining 1.1% (n=4) didn`t have depressive symptoms. Results of about 50% of study participants showed that they had moderate to severe depression (scored >17-29)
5) Assessment of Self Harm behavior among the studied participants using (SIQ-TR)
*Severity of self harm behavior:
Of the studied sample 17.7% (n=62) were engaged in NSSI, of them 3(3.2%) were at Mild risk, 24 (39%) were at Moderate risk, 35 (57.8%) were at Severe risk. Results of about 50% of study participants showed that they had severe risk of self harm behavior (scored >28-36)
*Characteristics of self harm behavior in the studied participants:
Results showed that duration of self harm behavior among study participants 62.7 % (n=36) were doing NSSI more than a year before the study, 32.2% (n=19) were doing self harm for several months before the study, while 5.1% (n=7) are doing self harm a month before the study
Results showed that 38.6% (n=27) were doing self harm from 1 to 5 days the previous month before the study, 38.6% (n=27) from 6 to 10 days the previous month before the study,15.7 % (n=8) more than 15 days the previous month before the study
Our results showed 73.8% (n=39) didn`t do self harm daily, while 19,7% (n=10) mentioned that they do it from 1 to 2 times daily, 4,9% (n=4) from 3 to 4 times, 1.6 % (n=2) are doing self harm more than five times daily
Results in our sample showed that most common methods of self harm behavior were 52% (n=32) Cutting, 21 % (n= 13) Bruising, 21 % (n=13) Biting, 6% (n=4) were burning themselves
Our results showed that 83.3% of the studied participants reported that the most common areas of self harm behavior were upper extremities (arms, hands, fingers, nails), while 10.2% reported that the most common areas head and neck, breasts and genitalia reported to be the most common areas of self harm by 3.4%, then the area of the Back with 2%. About 1.3% of our sample reported doing self harm in more than one place.
Our results showed that 47.5% (n=30) of the students reported that they sometimes feel pain during and after self harm, while 41% (n=26) didn`t feel pain at all, Regarding pain intensity during and after self harm, 45.3% felt mild pain, 32.8% never felt pain, 17.2% felt moderate pain
The results of our study showed that when self harm happened, 72.9% (n=41) of participants who self harm reported that they hide the action from others,20.3% (n=14) reported that they realized what happened
Before doing self harm 32.3% reported that they felt happy, 22.6 % were anxious, 12.9% felt nervous,12.9% felt angry of themselves,11.3% were sad
After doing self harm 65.6% reported feeling relieved, 14.8% felt angry towards themselves, 13% felt sad, 3.3% felt bored, and 3.3% felt nervous (Fig.17)
H) Reasons of self harm behavior:
Regarding data described reasons of why students do self harm, 62.2 % (n=39) reported that they self harmed to avoid or suppress negative feelings,11.3% (n=14) to punish themselves, 6.5% (n=6) to avoid or suppress suicidal thoughts
6) Assessment of severity of suicidal risk among study participants via SPS scale (suicidal ideation subscale). reveals that 42% (n=147) reported having suicidal ideation in the last two weeks, while 58% reported not having it. 51.0% (n=75) were in mild suicidal risk, 49.0% (n=72) in moderate and no participants were in severe suicidal risk. Results of about 50% of study participants showed that they had moderate severity of suicidal risk, (scored >11-28)
1) Relation between gender and compulsive use, depression, self harm and suicidal ideation
Table (9) showed significant differences between both genders, with severity of CIUS in males than females (42) versus (39) with p-value = 0.029.
Depression severity (measured by PHQ-9) was significantly higher in females than males. we found that the depression severity in females was higher than that of males, mild to moderate depression 105 (41.5%):35 (36.1%) mild, 79 (31.2%): 22 (22.7%) moderate, was significantly (p < 0.001). while males were higher in severe depression than that of females (36 (37.1%):69 (27.3%)). (p < 0.001).
Also in Suicidal risk severity (measured by SPS) results were higher in males than females (27 (14 – 30) vs 17 (11 – 26) p-value = 0.008. we found that the intense emotions and preoccupation by suicidal thoughts in females (M = 101.05) was significantly (χ2 = 3.104, p < 0.001) higher than that of males (M = 88.37)
2) Relation of daily hours of social media use, compulsive use, depression, self harm and suicidal ideation
Table (10) showed relation of daily hours of social media use with CIUS, PHQ, Self harm questionnaire and SPS. Daily hours spent on social media use were significantly related to compulsive social media use(p <.01).the more hours of use increases the more the students become compulsive users especially when social media use increases more than 6 hours daily, almost all users became compulsive users as shown in figure (21).
Daily hours was significantly related to depression severity (p <.01), The more time spent on social media the more severe results of PHQ are. Students spent more than 6 hours daily were had higher PHQ results in mild, moderate and severe depression. They accounted for 44.4% severe depression compared with 27.8% severe depression in students spent 4-6 hours daily and 12.5% severe depression in students spent 2-4 hours daily as shown in figure (22).
Suicidal ideation severity was also significantly related to daily hours of social media use (p<.01). The longer hours of social media use, the higher SPS results are increased. Of the students using social media more than 6 hours 66.3% had moderate suicidal ideation compared to 39.4% and 12% in users spending 4-6 hours and 2-4 hours respectively
3) Relationship between different social media platforms and compulsive use, depression,self harm and suicidal ideation
Our results showed that there was no relationship between the type of the platform mostly used and CIUS, PHQ, SPS and Self harm.
The main platform used was Facebook 80.0% (n=280) then Instagram 12.0% (n=42), then Twitter 2.9% (n=10), Snapchat.3% (n=1), other platforms 4.8% (n=17).
Regarding CIUS, the platform type didn`t increase the compulsive use with p-value (0.856). In Facebook users 96.4% were compulsive users, Instagram users 95.2% were compulsive users, Twitter 90%, and in other platforms 94.1% were compulsive users.
Platform type didn`t increase depression severity with p-value (0.911).Facebook users were 39.3%, 30%, 29.6% mild, moderate and severe depression respectively. Instagram users were 40.5%, 23.4%, 33.3% mild, moderate and severe depression. Twitter 40%, 20%,40% mild, moderate and severe depression. Other platforms users were 52.9%, 29.4%, 17.6% mild, moderate and severe depression.
Self harm severity wasn`t increased by the platform type, with p-value (0.323). Facebook users had 42.9%,57.1% moderate and severe scores of self harm questionnaire. Instagram users were 71.4%, 28.6% moderate and severe. Twitter users were 100% severe, while other platforms had 33.3%, 66.7% moderate and severe self harm severity.
Platform type didn`t affect Suicidal ideation severity with p-value (0.495).Facebook users had 51.4%, 48.6% mild and moderate SPS scores. Instagram users had 45.8%, 54.2% mild and moderate SPS scores. Twitter users had 100% moderate scores. Other platforms users had75%,25% mild and moderate SPS scores.
Correlation between Facebook, Instagram and items of CIUS:
Table 12 reveals Correlation between Facebook, Instagram and each item of CIUS scale. Reported positive correlation between using Facebook platform and 2 items of the scale, Using SM while in bad mood and continue to use the SM despite intention to stop.
4) Correlations between Compulsive social media use, Depression, Self harm questionnaire and Suicidal ideation, reveals positive correlation between Compulsive social media use, Depression, Suicidal ideation.
Compulsive social media use (CIUS) had positive correlation with depression (PHQ) and suicidal ideation (SPS) p-value.000 and.000 respectively. Depression (PHQ) had significant correlation with compulsive use (CIUS), self harm and Suicidal ideation (SPS) with p-value.000,.006 and.000 respectively.
Self harm had significant correlation with depression (PHQ) and suicidal ideation (SPS) with p-value.006 and.040 respectively. Finally suicidal ideation (SPS) had significant correlation with compulsive social media use (CIUS), depression (PHQ) and self harm with p-value.000,.000 and.040 respectively.
The highest correlations were found between depression and suicidal ideation (p<.01) and between compulsive use and suicidal ideation (p<.01)
Our results found that compulsive social media use is a big problem endangers mental health of medical students in preclinical years mild compulsive social media use was 7.1%, moderate compulsive social media use was 52.3%. Also, severe compulsive social media use was 36.6% Compulsive social media use was related to depression and suicide in those students. These findings provide an early warning signal that deserve special attention, otherwise may endanger their own life, affect their mental health and impair the students` academic achievement.
Discussion:
Students at preclinical stage are more prone to psychological stressors, a study on freshman medical students in Malaysia found that those in pre-clinical years had a 2.5 times greater likelihood of developing anxiety than those in clinical years (Abdel-Salam et al., 2019).
Multiple factors played role in psychological stressors in the preclinical medical education. It may be due to the transitional phase from secondary school, adjustment to a new life, competitive environment, excessive educational content, individual personality, and fear of inadequacy (Abdallah et al., 2014).
Our study showed that 43.7 % of the sample spent more than 6 hours on social media daily, consistent with the previous research that showed that medical students in Turkey spent about 6 to 8 hours daily on social media in 2020 (Kocak et al., 2021). However some studies shows different results, as in study done in Bangladesh showed that only 14.3% of the students spent more than three hours daily on social media (Saha & Guha, 2021).
We found that mild severity compulsive social media users were 7.1%, moderate compulsive social media users were 52.3%. And severe compulsive social media users were 36.6%, comparable with another study done in Egypt in 2021 and found internet addiction severity among medical students to be 43.4%, 57.7% moderate and severe respectively (Shehata and Abdeldaim, 2021). Also, there was another study showed the prevalence of 39.5% severe users of Internet and 31.5% of the moderate users reported by Kumar and Mondal, in a study in multiple colleges of Kolkata in 2018 (Kumar and Mondal, 2018).
However, some studies have also shown lower prevalence of internet addiction, as in a study on Iranian medical students, the prevalence of internet addiction was 10.8% (Ghamari et al., 2011).
We found significant differences between genders, regarding CIUS, as it was found to be higher in males than females. Those study results were similar to results of Anand and colleagues in south India who also found males are higher than females in compulsive social media use (Anand et al., 2018).
These results contradicted with previous study in Turkey pointing out that females were more addicted to social media than men (Deniz& Gürültü, 2016). On the other hand other studies didn`t find any gender difference in social media compulsive use, like a Turkish study in Marmara university (Tutgun-Ünal & Deniz, 2016).
In our study spending more time on the social media was more likely to develop compulsive use than spending less time, consistent with similar studies done on college students in Taiwan and three medical schools across three countries Croatia, India, and Nigeria and found that spending more time on social media is related to compulsive use (Balhara et al., 2015), while another study on Chinese university students found that there was no relationship between daily hours of internet use and internet addiction (Zhang et al., 2014).
We found depression severity among our participants 40.0% mild, 28.9% moderate, 30.0% severe depression. Comparable to a Chinese study on medical students which found (35.1%) had mild depression, (51.4%) had moderate depression, and (13.5%) had severe depression (Sobowale et al., 2014). Unlike a Portuguese study investigating depression and suicidal behavior in medical students the rate was, mild depression (3.1%) of the students and moderate depression (2.4%), (0.7%) had severe depression (Coentre et al., 2016).
We found that the depression severity of females was from mild to moderate, which was significantly higher than that of males. While males were more frequent in severe depression than that of females, the same results were found by Marcus and her colleagues in their study for gender difference in depression severity in internet addiction, they also found females were more mild and moderately depressed than males, who were higher in severe depression (Marcus et al., 2009).
Different results came from a large study done in Sydney in 2014 which find that gender had minimal if any impact on depression severity in internet addiction estimates, against general finding that women have higher rates of lifetime depression (Parker et al., 2014).
Our findings suggest that compulsive use of social media was positively related to depression. The relationship was higher in the moderate and severe depression groups, the same results were found in previous studies (Aboujaoude, 2016). Also, other studies which find a relation between compulsive internet use and depression (Sahin et al., 2013). Although conversely some studies found negative correlations were found between depression and Facebook use (Wright et al., 2013).
Our results showed high frequency of self harm in our sample; it was 17.7%,comparable to 17.1% found by Tang and colleagues on their search on NSSI in medical students in China (Tang et al., 2020). Also Madge and colleagues found an average lifetime prevalence estimate of 17.8% (Madge et al., 2008). Those results are different from a Chinese study found the prevalence of self harm in among Chinese medical students was 9.6% (Wu et al.,2016).
Some authors observe that females are more likely to self-injure than males (Briere & Gil, 1998). Other authors reject this thesis, arguing that females are more likely to disclose their self harm than males, and therefore to be captured by national statistics (Rodham et al., 2004).
Our study reveals that severity of self harm significantly didn`t differ between males and females. Plener and colleagues found no gender difference in the association of problematic internet use with self-harm, which mirrors findings of our results (Plener et al., 2014)
Duration of self harm measured by SIQ-TR. was that 62,7% of participants were doing NSSI. more than a year before the study, comparable to a previous study which found that 60.6 % of the participants were doing self harm more than five times/year during the previous two years (Gatta et al., 2016).
Results in our sample showed that most common methods were 52% Cutting, 21 % Bruising, 21 % Biting, 6% were burning themselves, similar to previous study included large number of patients on young adults self harm behavior which found Cutting the most common means (Hawton et al., 2012). Less common methods include burning, stabbing, swallowing objects, insertion (National Collaborating Centre for Mental Health UK, 2004).
Of the study participants who did NSSI, 83,3% of them most commonly did self harm on upper extremities. Close results were found in a large study in Finland which found 67.2% mostly self harm in upper arms (Laukkanen et al., 2013).
When participants with self harm were asked about pain they reported that 45.3% felt mild pain, 32.8% never felt pain, 17.2% felt moderate pain during and after self harm. Consistant with previous study in Brazil, It found that those who self harm, 45% have reported feeling no pain (Vieira et al., 2016).
The results of our study showed that when self harm happened, 72,9% reported that they hide the action from others, consistant with a study on Finnish students suggested that self-injury is often performed privately, and hidden from others (Rissanen et al., 2008). The main reasons of SH were 62,2 % reported that they did self harm to avoid or suppress negative feelings, In consistent with previous study which found that The most common reasons given were ’to get relief from a terrible state of mind’ (Madge et al., 2008).
According to our findings, NSSI seems to be a multifactorial phenomenon that is related to other psychiatric disorders like depression, similar to previous study of Prinstein and colleagues that found that depressive symptoms strongly and significantly predicted future engagement in NSSI among adolescents (Prinstein et al., 2010); however, Hankin and Abela did not find a significant association between depression and self harm, they concluded that self harm is more related to liable mood not to dysphoric mood, which is more reported in depressive patients (Hankin and Abela, 2011).
Our study results also showed significant relation between suicide and self harm, consistent with earlier studies (Fox et al., 2015). While other study found that this relationship may not exist because NSSI was to reduce negative affect or emotion but not to cause suicidal behaviors (Klonsky, 2007).
Our results showed no relation between compulsive social media use and NSSI, consistent with our results suggested a null association of internet addiction with self-harm (Hsieh et al., 2018). Previous studies have indicated inconsistent results (Oktan, 2015) some studies have suggested that internet addiction is associated with self-harm (Pan et al., 2018), also, discussing online with people who are also interested in NSSI related topics may lead to the encouragement of NSSI (Fortune et al., 2005). Thus, these related studies above indicate that compulsive social media use could be a risk factor for adolescents’ engagement in NSSI.
According to our study results 42% reported having suicidal ideation in the last two weeks, consistent with previous results of cross sectional study on medical students in Oman, which accounted for 33.4% having suicidal ideation (El-Sayed et al., 2018). Other studies found lower prevalence in medical students, one study done in Egypt on medical students of two public colleges revealed that 12.75% of respondents had suicidal ideation, and that first year students tended to score higher than pre-clinical and clinical phase students (Ahmed et al., 2016).
We also found that suicidal ideation is positively related to compulsive social media use, consistent with the same results found by Cheng and colleagues who found social media compulsive use is associated with increased suicidal ideation (Cheng et al., 2021). For example, students may acquire harmful online information about suicide and hold a positive attitude toward suicide, which has been associated with increased risk of Suicidal Ideation (Wang et al., 2019). Compulsive social media use may also increase risk of Suicidal Ideation via reducing social contacts, which result in loneliness, a significant risk for Suicidal Ideation (Teo et al., 2018).
Our study results revealed higher suicidal ideation frequency in males than females, contradicted with previous studies that shows higher suicidal ideation in females than males (Mortier et al., 2018), those studies added that while females, show higher rates of non-fatal suicidal behavior and suicide thoughts, and attempt suicide more frequently than males do, males have a much higher rate of suicide. This is known as the gender paradox in suicide (Schrijvers 2011). Young women may be more likely to engage in help-seeking behaviors (Rickwood et al. 2005). Unlike males (Rhodes et al., 2014).
Although we found that the suicidal ideation severity of females was significantly higher than that of males, in line with the previous studies like the study that assessed suicidal ideation in medical students in Beijing, China (Zhang et al., 2019).
Another finding of interest was to the differences between the main social networks used and compulsive use. Facebook was reported to affect using Social Media while in bad mood and continuing using Social Media despite intention to stop, more than Instagram. These two compulsive characteristics of Facebook in our study goes in the same line with previous study done on university students in Bangladesh showed that Facebook is more addictive than other platforms (Abu sayeed et al., 2020), contrary to other studies on social media addiction which found the social networks most used were Instagram followed by Facebook and there is significance value for having an account on Instagram and a definite diagnosis of social media addiction, they explained that findings with the nature of Instagram as a platform based on photo sharing more than long posts, and that the celebrities, public figures, and bloggers are more represented in Instagram than Facebook so following their updates is easier on Instagram (Pilar et al., 2019).