A Case-Control Study Investigating the Link Between Prolonged Smartphone-Based Learning and Treatment-Resistant Anxiety in Medical Students

Background: The integration of smartphone-based learning into medical education, accelerated by the COVID-19 pandemic, has raised concerns about its psychological consequences. Prolonged digital academic engagement may sustain cognitive hyperarousal and disrupt sleep architecture, potentially contributing to anxiety disorders that persist despite conventional treatment — a clinically critical but underexplored outcome in student mental health research. Objective: To determine whether excessive smartphone-based academic exposure constitutes an independent risk factor for treatment-resistant anxiety among medical students in the Islamabad region of Pakistan. Methods: A 12-month case-control study enrolled 180 medical students (90 cases with treatment-resistant anxiety defined as GAD-7 ≥ 15 persisting despite ≥ 8 weeks of CBT and/or pharmacotherapy, and 90 anxiety-free controls). Data were collected using the Smartphone-Based Learning Exposure Index (SBLEI; Cronbach's α = 0.86), GAD-7, PHQ-9, and PSS-10. Binary logistic regression identified independent predictors; a dose-response analysis across SBLEI tertiles used one-way ANOVA with Bonferroni correction. Results: Cases reported significantly higher daily smartphone use (7.3 ± 1.6 h vs 4.5 ± 1.3 h; p < 0.001) and lower sleep duration (5.6 ± 1.2 h vs 7.2 ± 1.1 h; p < 0.001). High SBLEI score (AOR = 4.58; 95% CI: 2.33–9.01), daily use exceeding six hours (AOR = 3.72; 95% CI: 1.91–7.23), and sleep below six hours (AOR = 2.84; 95% CI: 1.47–5.49) independently predicted treatment-resistant anxiety. Treatment-resistant prevalence rose from 6.7% in the low-exposure tertile to 96.7% in the highest (p < 0.001). Conclusion: Excessive smartphone-based academic exposure independently and substantially increases the risk of treatment-resistant anxiety in medical students. Structured digital screen-time guidelines, mandatory sleep hygiene education, and integrated mental health support within medical curricula are warranted.