The present study was a observational type of case-control study which conducted in the Department of Biochemistry, of FH Medical College and Hospital Etmadpur, Agra with the collaboration of Santosh Medical College and Hospital Ghaziabad from December 2018 onwards and thesis work is still under progress. Total number of 150 subjects in age range of 18 years and above irrespective of sex which were enrolled according to the protocol criteria of study design, among the staff/students, residents of FH medical college and any patient’s attendants coming in OPD of the medical college. A total of 75 individuals were cases, selected and the other 75 individuals were controls. Sample was taken according to prevalence rate of 4.4% of global population 2015 according to World Health Organisation (WHO), it was calculated by prevalence formula which came out to be 65 required number of cases but to be more effective, 10 extra was taken in each group [23]. All subjects, consent was taken prior to this study. A detailed history of every participant regarding the present or past was taken. This study included staff members, students, residents, patient’s attendants coming in Out Patient Department (OPD) of medical college. All of them were apparently healthy (not suffering from acute infections/fever). Pregnant females, people on any kind of therapy, person with any disorders (diabetes, hypertension, autoimmune diseases, infection, and acute medical or any other surgical condition) were excluded. This study was approved by ethical committee of Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh (EIC/FN:SU/2018/1456).

Two types of pre-defined and tested scales were used in this study. Evaluation of the smart phone addiction was done by Smart Phone Addiction Scale Short Version (SAS-SV) made by Dr. Kwon and associates. It is a set of 10 questions. The SAS-SV scores of gender and self-evaluation of smart phone addiction (p=0.001) shows a cut-off value of 31 (boys), a cut-off value of 33 (girls) [24]. The depression was evaluated by Hamilton Depression Rating scale (HAM-D), which contains set of 21 questions but only 17 were used as last ones are of extreme depression related. This scale can evaluate various levels of depression depending on scores. Scoring was evaluated as (0-7=Normal, 8-13=Mild Depression, 14-18=Moderate Depression, 19-22=Severe Depression, >23=Very Severe Depression) [25]. During personal interview use of smart phone/cell phone duration was asked to fill on daily basis in hours, this parameter was observed as Time in the result formation. Informed consent, both in English as well as vernacular language, was taken from the participants included in the study. First personal interrogation and both scale study was done and then blood sampling for laboratory investigations was conducted, taking all necessary precautions. The blood sample (approx. 4ml) was centrifuged after clot formation to perform the following biochemical investigations. Biochemical investigations was done after meeting the criteria of this study (Depression and addiction of mobile phone simultaneously). Human CRP-assay kit was used for the quantitative analysis of CRP in human serum. STP and SUA was measured on semi-autoanalyser CHEM 7 by regular kits.

After all data collected the statistical analysis was done using the SPSS 17.0 program (SPSS Inc., Chicago, IL, USA) in Windows 10 Ultimate. The statistical analysis of the data includes descriptive tests and analytical parametric tests, as well as binary logistic regression tests and correlations. The descriptive statistics performed to report the analysis of the data as mean and standard deviations. The independent t-test was used to compare the parametric variables between the genders. Pearson correlation was used to determine the strength of the relationships between the examined variables.

In this study 75 cases and 75 controls subjects analysed the question of research. Cases were those who were addicted to their smart phones/cell phones according to SAS-SV (depicted as SPAS) and were also in depression (on HAMD basis). Group statistics are explained in [Table/Fig-1]. Mean age in cases were 21.68±2.32 years and 28.61±9.97 years among controls. SUA, STP, CRP levels of cases were 5.17±1.72 mg/dL, 7.23±0.82 gm/dL, 2.66±2.79 mg/L, for controls UA, STP, CRP levels 5.48±1.53 mg/dL, 7.18±0.85 gm/dL, 2.56±4.41 mg/L. Average time of cell phone use by all participants in hours was found to be 5.12±2.36 hours, 2.53±1.73 hours among cases and controls, respectively.

[Table/Fig-2] depicts the Levene’s test for equality of variances and according to t-test, the variable age was found significant. Time spend on smart phone use was statistically significant between cases and controls, but in this study CRP, UA and STP were insignificant between cases and controls when equal variances are assumed.

Present study had 33 males and 42 females in cases and 43 males and 32 females in controls. [Table/Fig-3] shows statistics of males and females of cases. Mean age (22.55±2.86 years) of males were more than females (21±1.5 years) in this study. Time duration of smart phone was also higher among males than females that are (5.21±2.99 hours, 5.05±1.75 hours, respectively). It shows that means males are using phone for much longer duration. Smart phone addiction score was found higher in females than males (M=37.64±5.05, F=37.83±5.13) as calculated from SAS-SV. HAMD scores were also higher among females (M=11.7±3.34, F=12.62±3.53), which explains females are more in depression in this study. STP was more in males than females (M=7.3±0.85 gm/dL, F=7.18±0.8 gm/dL). SUA levels were higher in males than females (M=6.44±1.46 mg/dL, F=4.18±1.16 mg/dL). CRP levels of male and females are as follows (2.65±2.9 mg/L, 2.67±2.74 mg/L) with females on higher side.

When levene’s test of equality of variances was used, significant difference was found between age (p=0.004) and SUA (p=0.001). SPAS scores, HAMD score and other biochemical results were not significant in male and female of cases.

[Table/Fig-4] depicts counts and percentages of individuals in various levels of depression. A total of 54 persons (72%) had mild depression, 15 (20%) had moderate depression, 5 (6.7%) were under severe depression category, 1 (1.3%) was in very severe depression.

[Table/Fig-4]:

Frequency distribution in levels of depression by HAMD.

According to HAMD score in this study, depression was categorised. There were 54 cases in mild depression, 15 in moderate depression, 5 cases were of severe depression and only 1 person was in very severe depression in present study. Mean age in cases of mild depression was 21.41±1.654 years, in moderate depression 23.07±3.845 years, in severe and very severe age was 20.8±1.304, 20 years respectively. It was highest among moderate group. Severe and very severe groups had similar means. Age was least in severe and very severe groups of depression, this is an alarming observation. Age was significantly different between cases and controls overall. This is indicating that young generation is tending towards depression. This factor should be investigated thoroughly in other research models as well.

Duration of cell phone use that is observed as Time is highest in very severe depressed person but mild and moderate groups were similar. Time in mild depression was 5.19±2.533 hours, moderate 5±2.035 hours, severe cases had 4.6±1.673 hours and very severe case had 6 hours duration. Mean SPAS score in mild depression was 37.41±5.075, in moderate cases was 36.2±3.052, in severe depressed cases it was 44.8±4.207 and very severe case had 44. Mean SUA levels in mild cases of depression was 5.28±1.75 mg/dL, moderate cases was 4.91±1.48 mg/dL, severe cases had 4.48±2.05 mg/dL and in very severe case was 7 mg/dL. Again SUA levels was also highest in very severe depressed case. Second highest SUA was found in mild group, it could be because this group has highest number of cases.

Mean of STP in mild cases was 7.24±0.75 gm/dL, moderate cases were 7.3±1.02 gm/dL, severe cases were 7.31±0.67 gm/dL and very severe case was 5.3 gm/dL. STP was found to be least in very severe depressed case and it is likely that person is not taking diet on time and according to body needs. CRP levels in mild depression cases was 2.6402±3.031, in moderate depression cases it was 2.794±2.04, severe case 2.516±2.74, in very severe cases it was 2.4. CRP levels were highest in moderate group but lowest in very severe. But since there was only single person in this category, and biochemical parameters were not significant overall also, this could not be made as point of discussion. On applying ANOVA between groups of depression. SPAS scores were found significant between groups of depression where p-value (0.003). This is very important observation in this study. SUA, STP and CRP were not significant between groups.

In [Table/Fig-5] multiple comparison by Tukey HSD (Honestly Significant Difference) was done, significant differences were found for age of mild and moderate groups of depression. SPAS scores were also significant between severe and mild, and severe and moderate depression. CRP, SUA, STP in all categories was insignificant. [Table/Fig-6] presents correlation of all parameters by Pearson correlation. Here age was found to be correlated with TIME (p-value=0.043) and SUA (p-value=0.003). SPAS scores were associated with depression HAMD scores (p-value=0.023). CRP, SUA, STP were not correlated with any parameters.

A study by Karki S et al., found that the average addiction score among males was 30.23±9.40 and that among females was 28.89±8.63. A higher average addiction score was obtained among males [26]. In present study, males had average addiction score as 37.64±5.05 and females with average score of 37.8±5.13, although not of much difference female scores were higher. Reason behind this attraction may be shopping sites, or social networking/chatting applications as females are already much involved in these activites. A study by Guo N et al., had higher SAS-SV scores for respondents who had symptoms of depression (33.2±10.2 vs. 28.5±10.0; p<0.001) than those with negative screening results [27]. In present study, mobile addiction score for cases vs controls were (37.75±5.06 vs17.43±6.84 p<0.001). Present study proved that depression is in association with mobile addiction. Similarly in study of Dharmadhikari SP et al., out of the 195 students, 90 (46.15%) screened positive for smart phone addiction. These included 45 females and 45 males. An average score of 31.59 (±9.89) by SAS-SV were found [28].

Park SY et al., observed significant changes in the longitudinal studies of relationships among phone use, mobile phone addiction, and depressive symptoms in Korean youth [29]. This was in agreement with present study, where significant correlation was found between depression (HAMD) scores and mobile addiction (SPAS) scores p<0.05 as in [Table/Fig-6]. In [Table/Fig-5], multiple comparisons between severity of depression and mobile addiction were also statistically significant. The possible reason could be intermixed pathways of addiction and depression, anyone can lead to another.

In study of 196 patients with acute ischemic stroke and 100 healthy volunteers; 56 patients (28.6%) were diagnosed for Post Stroke Depression (PSD) by HAMD scale. PSD patients displayed significantly lower levels of UA at baseline as compared to controls [30]. This was similar to present study SUA was lower in cases but not significantly different, possibly due to antioxidant behaviour of SUA.

In study between the First-Episode of Depression (FED) and Recurrent Depressive Disorder (RDD), and healthy controls, no significant differences were observed in reference to acute CRP level and severity of depression. No significant correlation was found between severity of depression and serum concentration of CRP in both the groups [31], this is similar to present study here also CRP levels were insignificant. But in contrast to present study, Köhler-Forsberg O et al., had observed higher and significant association of CRP levels with greater overall Montgomery Aasberg Depression Rating Scale symptom severity (p=0.02), which was significant among women (p=0.02) but not among men (p=0.68) [32]. Also, Song X et al. observed significant differences in total protein (<0.001), albumin, creatinine, UA (<0.001), glucose, creatine kinase and other parameters between the hypertensive depressive cases and only hypertensive [33], which was unlike the present study, where STP was not significant between any groups. Only SUA was found significant between male and females of cases, may be due to similar nutritional status.

This study was done with limited sample size and parameters. Authors did not analyse radiations emitted from cell phones which could also have led to draw important conclusion. BMI or other confounders of depression were not investigated in this study.

In this study, a novel approach of finding cell phone addiction and depression together was investigated with biochemical parameters. Astounding results were found, age was one of the significant parameter of this study and decreasing age of addiction and depression in cases is an alarm to society, scientist and technology experts to reframe their strategies. Females are found in more depression with higher level of behaviour addiction compared to males but statistically were insignificant. Depression and mobile addiction was positively correlated. CRP, STP and SUA were not found significant in this study but further researches are required to investigate them. Severity of depression also had severity of mobile phone addiction again who is hunter and who is hunted remains in question. This gives a bidirectional path which has to be investigated with new perspectives.