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 Table of Contents  
INVITED PERSPECTIVE/VIEWPOINT
Year : 2021  |  Volume : 37  |  Issue : 2  |  Page : 172-177

Problematic substance and internet use among medical students


Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Submission02-Jun-2021
Date of Acceptance06-Jun-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Dr. Anju Dhawan
Department of Psychiatry and NDDTC AIIMS, Ansari Nagar, New Delhi 110029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_150_21

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  Abstract 


Problematic substance use and internet use negatively impact student's well-being. The prevalence of these addictive disorders is high among medical students and is being linked to several medical and psychiatric complications. It also impacts the social fabric of the campus and poses a security hazard to all. Risk factors for these disorders include psychological stress, peer pressure, and a reduced scope for social interactions. Primary preventive programs include health promotion strategies, formulation of a strong campus alcohol and drug policy, and taking steps to reduce drug availability. It is important to create a screening and referral system so that at-risk students can get access to timely interventions. Prevention of excessive internet use to requires focus on pro-social interactions among students and a bigger push for healthy lifestyle for students. At-risk students might require interventions that try to correct cognitive distortions regarding internet use and work on building emotional regulation.

Keywords: Internet addiction, medical students, substance use


How to cite this article:
Singh S, Dhawan A. Problematic substance and internet use among medical students. Indian J Soc Psychiatry 2021;37:172-7

How to cite this URL:
Singh S, Dhawan A. Problematic substance and internet use among medical students. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Nov 28];37:172-7. Available from: https://www.indjsp.org/text.asp?2021/37/2/172/320212




  Introduction Top


Preventing problematic substance use and Internet use by medical students is an important component of student wellness. Knowledge about nature and the impact of psychoactive substance use is a part of undergraduate training. One can also expect medical students to know that physical and psychological problems can arise due to prolonged internet use. Despite this awareness, and due to the various risk factors embedded into medical training programs and otherwise, the rate of problematic substance use and excessive internet use is growing in this community. Constantly evolving social landscapes within the campus and the increasing preference of the online mode for personal and academic interactions pose added risk.[1]


  Section I: Substance Use among Medical Students Top


Magnitude of the problem

A review of substance use among medical students across various regions of the world (including Americas, Europe, and Asia; most studies being from Europe and America) showed that alcohol use is the most common, with risky or harmful alcohol use occurring in one-fourth; and tobacco use (mostly by smoking route) occurring in about one-sixth of the students. Lifetime cannabis use occurred in more than 30% of the students, with almost 10% being current users.[2],[3] Unprescribed use of pharmaceuticals, particularly stimulants, and sedatives are higher than that in the general population.[4] In a multicentric study from India, the prevalence of alcohol and tobacco use among undergraduate students was 16.6%, and 8.0% respectively, whereas the prevalence was 31.5% and 14.5%, respectively, for postgraduates.[5]

Risk and protective factors for substance use

As is the case with most young adults, medical students try drugs out of curiosity, for an occasional celebration, to deal with stressors such as broken relationships and family issues. Reduced socialization and amplification of peer pressure due to social media are additional risk factors for many campus locations.[1] A longitudinal assessment of medical students showed that prior substance use is an important risk factor while age, spirituality, and religiosity are protective factors.[6] Studies in medical students in India and other parts of the world show that males are at a greater risk, except in the case of sedative use.[5] The risk of substance use increases with seniority in college. The use of sedatives and stimulants is primarily linked to exam-related stress.[2]

Impact on student wellness

Repercussions of substance use include academic fallout, i.e. missed classes, poor academic performance, withdrawal from routine activities and coursework, and increased possibility of course dropout.[7] Other complications of substance use are progression to substance use disorder, development of medical complications, and psychiatric comorbidities. There is a greater risk of overdose and self-harm attempts under the influence of substances. The chronic, long-term complications might not become evident during the training years; however, acute complications such as fights, unintentional injuries, overdose, risky behavior such as driving under influence, and unsafe or unwanted sexual behavior can arise out of problematic substance use.[8] In a multicentered study of university students from the United Kingdom, it was seen that 10% of students who used drugs or alcohol had committed substance-related crimes in the past 1-year; associated factors being male gender, going out to socialize, frequent use of nightclubs, and poor physical or mental health.[7] The impact on peers cannot be minimized and sometimes they might suffer unintended injuries and discomfort as innocent bystanders.

Solutions

The solution lies in designing campus-based staged preventive interventions depending on the seriousness of the problem. The interventions need to be holistic, multimodal and with participation from all stakeholders i. e., administrative authorities (hostel, academic, and security), teaching community, student bodies, health professionals, and parents. A policy and action plan document has been developed for the medical students at All India Institute of Medical Sciences (AIIMS) and a few other universities. [9],[10],[11]

The first step in designing an effective program is to create a guidance document, i. e., a formal campus alcohol and drug policy that guides all interventions and creates accountability among various stakeholders to meet the objectives. These objectives could include the following:

  • To provide a safe, healthy, working, and learning environment
  • To prevent substance abuse on the campus
  • To facilitate early treatment seeking for substance use problems
  • To manage cases of substance abuse or dependence with sensitivity and discretion.


A pragmatic approach to meeting these objectives is to focus more on substance use that is problematic, i. e., use which is leading to individual complications, disrupting campus harmony, or substance use that is impacting the academic performance of students. Overall, the interventions can be divided into the following:

Primary prevention programs

Research on effective programs indicates that the evidence available is equivocal in most cases; however, some steps are effective universal strategies.[12]

  • An important step is to promote a macro environment at the campus that precludes problematic substance use. Pro-social, recreational, and creativity-enhancing activities are encouraged. An environment is created in the student community to reduce the valence of risk factors for substance use such as stress, isolation, sedentary lifestyle, and high interpersonal sensitivity. A culture of volunteerism needs to be nurtured so that the students themselves plan activities for their community that encourage healthy lifestyles
  • Another important aspect of improving the macro environment is to limit the availability of substances on the campus. This is where a consistent, well-enforced drug policy comes handy. The next step is to publicize the rules and penalties and to ensure that disciplinary actions are taken with certainty. At the same time, it is important to keep a high threshold for such interventions, i. e., they should be taken to prevent more serious problems arising due to substance use. The aim is not to create a sense of fear or undue supervision among students, but to assure them of a safe environment. The spectrum of punishment could range between fines, adverse entry into academic files, restriction from entry into hostels or canteens, suspension from academic programs, and action as per the national (Indian) Penal Code. These rules and related penalties must be known to the students upon admission to the institution and well-publicized. Any scope for inconsistent application of these policies and procedures needs to be corrected. This would include taking measures such as strengthened security on the campus, and conveying a clear message to hostel and canteen staff that supplying substances to students will lead to termination
  • Planning awareness measures is a component of the primary prevention strategy but it needs to be done carefully. The involvement of student bodies is essential, the content needs to be in student's own voices. In addition, messages reinforcing the harms due to substance use need to come from multiple sources to have an impact.


To conclude, a health promotion strategy coupled with a rigorously implemented supply reduction strategy is a key primary campus intervention.

Secondary and tertiary prevention programs

These include timely interventions for at-risk students, identification and referral of those with problems due to substance use, and ensuring adequate psychosocial and medical support. Self-referral is ideal and involves creating awareness about the availability of help through orientation sessions. Self-screening can be publicized through periodic e-checkups using validated self-report tools such as the WHO-alcohol smoking and substance involvement screening tests such as the WHO's alcohol, smoking and substance involvement screening test and alcohol use disorder identification test, or drug abuse screening test. Students can also be trained to identify problem signs in their peers. It is important to ensure confidentiality and a secure referral system. Hostel authorities can be trained to look for red flags and plan a referral for better care. The following two programs have shown effectiveness in campus setting:

  • Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based mechanism that can be utilized by the student wellness services. In addition, it is useful for the identification of those needing intensive interventions. Studies indicate that it leads to increased service utilization by college students for substance use-related issues[13]
  • Brief alcohol screening and intervention of college students (BASICS) is an effective program that targets moderate to heavy drinkers in the college campus. The program involves a self-report questionnaire and two 50 min interviews. The components involve gathering of information, providing personalized feedback regarding drinking patterns, providing data on prevalence as to correct norms, and finally a menu of options to help deal with the situation. This intervention is effective at 1-year follow-up[14]
  • Intensive treatment: In some cases, intensive treatment might be needed, and this can then be handled by the mental health professionals at the institute.


The steps program of the University of Albany is a widely replicated campus-wide initiative that has successfully used multimodal, evidence-based strategies to reduce substance use-related problems on the campus.[15]

[Box 1] outlines suggested components of a campus intervention for substance abuse prevention among medical students.




  Section II: Problematic Internet Use among Medical Students Top


Magnitude of the problem

The issue of problematic internet use among medical students has been in the spotlight in recent years. The global pooled prevalence of internet addiction among medical students is 28.5%–31.8%, but there is significant heterogeneity among studies and variation across regions.[16] The concerning issue is that the prevalence among medical students is 5 times that seen in the general populations. This variation in prevalence is not associated with age, gender, and the severity of internet addiction. In India, a recent survey in this community showed that 8.2% of respondents had problematic internet use.[17]

Risk factors

Regular access to internet, increasing online academic activities, and a generational preference for being online are major, albeit unavoidable risk factors for developing problem internet use. Most interventions designed to manage problematic internet use and internet addiction focus on two main etiological models:

  • The cognitive-behavioral model: it hypothesizes that impaired cognitive process leads to poor coping with real-life issues and this in turn leads to addictive internet use
  • The social skills deficit theory: it explains poor social skills, comorbid psychological problems, and a preference for online social interactions as a cause of excessive preoccupation with the virtual world.


Studies show that loneliness and the need for social desirability can contribute to the development of internet addiction. Lack of social support and real relationships, a “fear of missing out,” poor media literacy (ability to utilize information and media content in an useful and creative manner; using the internet in a way that enhances social and professional functioning) and poor emotional intelligence contribute to the development of internet addiction.[18]

Impact on student wellness

High internet dependency is leading to academic procrastination, higher course dropout rate, poor self-esteem, stress, depressive symptoms, anxiety, and increased risk of clashes between doctors and treatment seekers.[19] Problematic internet use in healthcare professionals and trainees is associated with sleep disturbances, postural problems, headache, eye strain, ocular dryness, musculoskeletal problems, fatigue and psychological issues such as loneliness, anxiety, and an increased severity of depression.[20]

Solutions

Primary prevention methods

College students are an important target group for planning prevention activities. There are many strategies that have been evaluated for their effectiveness; however, there are few bespoke prevention programs for medical students.

  • One effective technique is the use of short informational videos on Internet addiction, presented in an engaging and light-hearted manner.[21] Similarly, training of peers to organize informational sessions in an interactive format is a good approach
  • Primary prevention programs can target multiple risk behaviors (e. g., substance use, poor nutrition, lack of physical activity, sexual health, bullying, excessive internet use, and online gaming) in one program, assuming that reducing one risky behavior reduces other risky behaviors as well. Another approach is to create prevention strategies that are applicable to multiple targets such as individuals, peers, mentors, family, and the campus[22]
  • Some students are at a higher risk of developing problematic Internet use due to their bio-psycho-social and Internet use-related characteristics. Selective and indicated prevention programs can be planned for them based on the risk factors present. The psychopathology involved can be targeted, personality traits such as impulsivity novelty seeking, low emotional stability, introversion, and environmental issues such as loneliness and stress can be targeted/channelized into other activities such as sports, cultural programs, and creative activities. Skills to better cope with stress, better regulate emotions, and reduce hostility with others can be useful
  • Poor control of internet use, internet binges over the weekend, and overindulgence in online gaming lead to a decreased sense of self-efficacy. This can be rectified by training in skills such as better time management, controlled or complete abstinence from addictive websites/applications, and training inability to identify thoughts related to maladaptive internet use. Other specifics of such a training program include keeping a sleep schedule, encouraging participation in group learning and recreational activities, planning free time more minutely, and reducing interpersonal sensitivity. Medical students can be equipped with these skills right from the start
  • An innovative solution being researched is to use artificial intelligence and bio-signal recordings to analyze internet usage, identify problem use, and offer tailored interventions.[23] An environmental strategy is based on discouraging online gaming or online social activity by disincentivizing prolonged Internet usage.[24]


Secondary and tertiary prevention programs

Such interventions can be planned for students who are at risk or are showing signs of Internet or smartphone addiction.

  • Group interventions that include components of cognitive-behavioral therapy, sandplay therapy (a hands-on therapeutic activity where the client uses their imagination to project internal thoughts and emotions onto the sand, water, and miniature objects), and educational interventions are effective in lowering the severity of Internet addiction. The impact is significant when such a group intervention (e.g. ten 2-h group cognitive-behavioral therapy [CBT] sessions on psychosocial training, cognitive restructuring, emotional regulation, and behavior modification) delivered in a collaborative approach to medical university students.[25]



  Conclusions Top


To promote student wellness in campuses, problematic substance, and internet use must be prevented. Multimodal and staged interventions at the campus are effective and could benefit the medical community as a whole in the long run. While many science-based prevention and intervention programs have been formulated for this age group, there is limited research on specific solutions for medical students. A tactful approach toward educational and awareness activities coupled with multi-dimensional prevention programs centered around life-skills training and health promotion are useful for both problematic substance and internet use. All stakeholders need to wholeheartedly participate. Interventions for at-risk students with signs of drug abuse include the SBIRT and BASICS approach, and the group interventions using CBT show evidence in managing problematic Internet use in college students.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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