Risk factors of depressive and anxiety symptoms in Chinese adolescent girls: a cross-sectional study

Abstract

Depression and anxiety are common in adolescence girls. This study aims to examine the prevalence and risk factors associated with depressive and anxiety symptoms in Chinese adolescent girls. A cross-sectional study was conducted in six provinces in the eastern, central, and western regions of China. A total of 4,658 adolescence girls aged 10–19 years old was included in this study. Depressive and anxiety symptoms were assessed by the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorders-7(GAD-7), respectively. Logistic regression models were used to estimate the effects of sociodemographic, academic pressure, physical/mental violence, interpersonal relationship, and lifestyle on depressive and anxiety symptoms. In our study, the prevalence rates of depressive and anxiety symptoms were 6.0% (279/4658) and 2.6% (122/4658), respectively. The multivariable logistic regression models show that risk factors including education level of junior high school and above, suffering from physical/mental violence, having academic pressure, having poor interpersonal relationship problems significantly increase the risk of both depressive and anxiety symptoms (P < 0.05), while additionally shorter night time sleep duration significantly increases the risk of depression symptoms (OR = 1.46. 95%CI:1.08–1.97, P = 0.01). The prevalence of depressive and anxiety symptoms are 6.0% and 2.6%, respectively among Chinese adolescent girls, with certain sociodemographic, academic pressure, and interpersonal relationship problem being the risk factors of depressive and anxiety symptoms.

Introduction

Adolescence is the phase from 10 to 19 years old characterized by rapid physical growth and sexual maturation with social, emotional and cognitive developments. Adolescence is also a key stage of physiology and psychology development, during which development of mood disorders can also be common. Up to half of all mental health conditions before 14 years of age being depression or anxiety, and one in five adolescents having a mood disorder worldwide according to the WHO¹. More than 13% of adolescents were diagnosed mental disorder, of which 40% were anxiety and depression². A meta-analysis including 41 studies of participants aged 4 to18 years in 27 countries found an overall prevalence of mental disorders to be 13.4%, of which 65% was anxiety, and 26% was depression. Another systematic review of 87 studies across 44 countries also found the prevalence of adolescent anxiety to be in between 6.5% and 7.2%³. Among American young adults, 20% had anxiety symptoms and 21% had depression symptoms in 2019⁴. In China, anxiety prevalence was estimated to be 7% among 50,361 students from 5 provinces⁵. A meta-analysis of 51 studies in China indicated that the pooled prevalence of depressive symptoms among adolescents in Chinese secondary schools was 24.3%⁶. The WHO reports that depressive and anxiety disorders were two of the top five causes of living with disability in 10–19 year-old girls⁷. Psychiatric disorders account for a significant proportion of the global burden of disease⁸. If the mental health disorders left untreated may severely affect development, including educational and social achievements⁹. What’s more, depression might also cause severe health problems. For instance, in adolescents, depression is a major risk factor for suicide, and more than one-half of adolescent suicide victims are reported to have a depressive disorder at the time of death¹⁰. In adolescents, psychiatric disorders not only cause personal and family suffering, but also leads to serious social and educational maladjustments, such as an increased rate of substance abuse, eating disorders, and criminality, as well as predicting negative outcomes in adulthood¹¹. The burden of depression on adolescents’ health and social functioning could be severe and influence their adult life.

Risk factors for psychiatric disorders range from the biological, genetic, and perinatal to the gender of the child, parental attachment, and trauma, as well as demographic and socioeconomic factors. Among the environmental risk factors associated with psychiatric disorders, research has shown that alcohol consumption, smoking, physical/mental violence, physical activity, night time sleep duration, and interpersonal variables might increase the probability of the individual developing depression and anxiety^12–16. Compared with boys, girls have shown to have a higher prevalence of anxiety and depressive problems^17–19. Despite its prevalence, however, mental health remains stigmatized, with only small number of adolescents received treatment in China, highlighting the need for urgent attention. Therefore, the aim of this study is to assess the prevalence and risk factors of depressive and anxiety symptoms in Chinese adolescent girls.

Methods

Study design and participants

The National Survey of Women’s Health, a community-based cross-sectional study, was conducted in six provinces of China: eastern (Jiangsu and Shandong provinces), central (Hunan and Anhui provinces), and western areas (Shanxi and Sichuan provinces). In each province, we selected one urban area and one rural area. Adolescent girls aged 10–19 years old were recruited and enrolled using a multi-stage stratified cluster sampling method in each urban and rural areas, which included three stages: (1) First stage: One county/district was selected from each stratum as a sample county/district. (2) Second stage: Within each selected sample county/district, one administrative village/neighborhood committee was selected from each stratum. (3) Third stage: In the sampled villages (neighborhood committees), all eligible participants meeting the age criteria were enrolled household-by-household in sequential order until the designed sample size was achieved, with a response rate of no less than 80%. If the target sample size was not met in the selected village (neighborhood committee), adjacent villages (neighborhood committees) were included until the required sample size was fulfilled. Face-to-face interviews were conducted to collect information on demographic characteristics (including age, place of residence, level of education, living arrangement, etc.), lifestyle factors (including night time sleep duration, alcohol consumption, smoking, physical activity, etc.), symptoms of depression and anxiety (assessed by The Patient Health Questionnaire-9 [PHQ-9] and Generalized Anxiety Disorder [GAD-7]), and school performance (including experience of physical/mental violence, academic pressure, interpersonal relationship, etc.) using a structured questionnaire. 4,658 adolescent girls were included in this study.

The study had been approved by the Ethical Review Committee of the Chinese Center for Disease Control and Prevention (ethic code: 201810), and both the participants and their parents provided a written informed consent. All the data used for this study were entered and stored without any individual identifiers, such as full name, citizen’s ID number, contact information, etc. The data were used anonymously and did not reveal identity information of the participants. The study was performed in accordance with Declaration of Helsinki.

Patient and Public Involvement: Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

Measurements

Assessment of depressive and anxiety symptoms

PHQ-9 and GAD-7 were used to assess depressive and anxiety symptoms during the past 14 days separately^20,21. The PHQ-9 contains 9 items and GAD-7 had 7 items. The answer to each item employed a 4-point response scale: ‘not at all’ (0), ‘various days’ (1), ‘more than half of the days’ (2) and ‘nearly every day’ (3). The sum of the scores ranges from 0 to 27 for PHQ-9, and 0 to 21 for GAD-7. Having depressive symptoms was defined as a PHQ-9 score ≥ 10²². Having anxiety symptoms was defined as a GAD-7 score ≥ 10²³..

Assessment of independent factors

Independent factors including demographic characteristics (age, place of residence, level of education, and living arrangement), night time sleep duration, lifestyle factors (alcohol consumption, smoking, and physical activity), experience of physical/mental violence, academic pressure, and interpersonal relationship (with parents, classmates, and teachers). Place of residence refers to whether lived in urban or rural area, which reflect the social economic environment of the adolescent girls. Living arrangement refers to living with parents, living with grandparents/relatives, living in a dormitory, and living with others. Level of education include primary school, junior high school and above. Night time sleep duration was categorized into ≤ 7 h and > 7 h. Regular physical activity (such as swimming, walking, jogging, etc.) is defined as physical activity of at least 30 min per time and no less than 3 times per week.

Answers to other variables including smoking, alcohol consumption, academic pressure, interpersonal relationships, and physical/mental violence were recorded as either “yes” or “no”. Examples of questions asked are: “Do you currently smoke cigarettes?”, “Do you drink alcohol?”, “Do you experience academic pressure?”, “Do you experience interpersonal relationship problems with your classmates, parents, or teachers?”, and “Have you ever experienced mental or physical violence?”.

Statistical analysis

Continuous variables were expressed by mean ± SD; skewed variables were expressed by median (IQR). Categorical variables (e.g., residence place, level of education, living arrangement, night time sleep duration, lifestyle factors, experience of physical/mental violence, academic pressure, and interpersonal relationship) were expressed by number (percentage). Comparisons between groups were performed by Chi-square tests or Fisher exact test as appropriate. Logistic regression models were used to assess the association between risk factors and depressive or anxiety symptoms. The variables with P < 0.1 in the univariable logistic regression model were selected into the multivariable logistic regression. In the multivariable logistic regression, we further adjusted for clustering and stratification. SPSS 20.0 software was used for statistical analyses, and two-sided P < 0.05 was considered statistically significant.

Results

Demographic characteristics

Among the 4,658 participants in our study, the average age was 13.58 ± 2.81 years old. 49.8% of the participants were from rural areas. 0.7% were of ethnical minorities. All the participants were students, of which 63.6% was attending junior high school and above. Most participants were living with parents (77.7%), 12.9% in dormitory, and 9.0% with grandparents or relatives (Table 1, 2).

Table 1.

Demographic characteristics of participants.

	Overall (N = 4,658)	%
Age(years)
10–14	2937	63.1
15–19	1721	36.9
Nationally
Han	4537	99.3
Minorities	31	0.7
Residence
Rural	2292	49.8
Urban	2366	50.2
Level of education
Primary school	1696	36.4
Junior high school and above	2962	63.6
Living arrangement
Living with parents	3619	77.7
Living in a dormitory	602	12.9
Living with grandparents/relatives	420	9.0
Living with others	17	0.4

Table 2.

Comparation between adolescent girls with and without depressive and anxiety symptoms.

Factors	Depressive symptoms		χ2	p	Anxiety symptoms		χ2	p
	Yes (N = 279)	No (N = 4379)			Yes (N = 122)	No (N = 4536)
Age(years)			26.1	< 0.001			9.16	0.002
10–14	136(48.7)	2801(64.0)			61(50.0)	2876(63.4)
15–19	143(51.3)	1578(36.0)			61(50.0)	1660(36.6)
Nationality				0.26				0.44
Han	279(100)	4348(99.3)			122(100)	4505(99.3)
Minorities	0(0)	31(0.7)			0(0)	31(0.7)
Education			66.6	< 0.001			19.9	< 0.001
Primary school	38(13.6)	1658(37.9)			21(17.2)	1675(36.9)
Junior high school and above	241(86.4)	2721(62.1)			101(82.8)	2861(63.1)
Residence			13.1	< 0.001			16.3	< 0.001
Rural	108(38.7)	2184(49.9)			38(31.1)	2254(49.7)
Urban	171(61.3)	2195(50.1)			84(68.9)	2282(50.3)
Living arrangement			3.7	0.30			3.8	0.29
Living with parents	221(79.2)	3387(77.3)			103(84.4)	3505(77.3)
Living in a dormitory	20(7.2)	397(9.1)			8(6.6)	409(9.0)
Living with grandparents/relatives	34(12.2)	567(12.9)			10(8.2)	591(13.0)
Living with others	4(1.4)	28(0.6)			1(0.8)	31(0.7)
Nighttime sleep duration			80.6	< 0.001			22.8	< 0.001
> 7 h	144(51.6)	3320(75.8)			68(55.7)	3396(74.9)
≤ 7 h	135(48.4)	1059(24.2)			54(44.3)	1140(25.1)
Regular physical activity			28.7	< 0.001			13.7	< 0.001
Yes	53(19.0)	1516(34.6)			22(18.0)	1547(34.1)
No	226(81.0)	2863(65.4)			100(82.0)	2989(65.9)
Smoking				0.001				0.006
Yes	9(3.2)	36(0.8)			5(4.1)	40(0.9)
No	270(96.8)	4343(99.2)			117(95.9)	4496(99.1)
Alcohol consumption			54.0	< 0.001				< 0.001
Yes	31(11.1)	127(2.9)			17(13.9)	141(3.1)
No	248(88.9)	4252(97.1)			105(86.1)	4395(96.9)
Suffering from physical/mental violence			161.7	< 0.001			144.8	< 0.001
Yes	63(22.6)	198(4.5)			37(30.3)	224(4.9)
No	216(77.4)	4181(95.5)			85(69.7)	4312(95.1)
Academic pressure			114.7	< 0.001			85.2	< 0.001
Yes	128(45.9)	836(19.1)			66(54.1)	898(19.8)
No	151(54.1)	3543(80.9)			56(45.9)	3638(80.2)
Interpersonal relationship			232.8	< 0.001			129.8	< 0.001
Yes	133(47.7)	592(13.5)			64(52.5)	661(14.63)
No	146(52.3)	3787(86.5)			58(47.5)	3875(85.4)

The prevalence of depressive and anxiety symptoms

In our study, 6.0% (279/4,658) experienced depressive symptoms based on the PHQ-9 scores, while 2.6% (122/4,658) experienced anxiety symptoms based on the GAD-7 scores.

Risk factors for depressive symptoms

Results show that older adolescent girls with an education level of being junior high school and above, shorter night time sleep duration, lack of regular physical activity, alcohol consumption and smoking, suffering from academic pressure and physical/mental violence, as well as having poor interpersonal relationships being more likely to experience depressive symptoms (all p < 0.001, Table 3). After adjusting for confounding factors as well as clustering and stratification, education level of junior high school and above (OR = 3.05, 95% CI: 1.89–4.91, P < 0.001), experience of physical/mental violence (OR = 2.93, 95% CI: 2.02–4.24, P < 0.001), shorter nighttime sleep duration (OR = 1.46, 95% CI:1.08–1.97, P = 0.01), academic pressure (OR = 1.85, 95% CI: 1.37–2.51, P < 0.001), and poor interpersonal relationship (OR = 2.82, 95% CI: 2.08–3.81, P < 0.001) were found to be independent risk factors for depressive symptoms in adolescent girls (Table 3).

Table 3.

Risk factors of depressive and anxiety symptoms.

Risk factors	Depressive						Anxiety
	Model 1			Model 2			Model 1			Model 2
	OR	95%CI	P	OR	95%CI	P	OR	95%CI	P	OR	95%CI	P
Age	1.16	1.11–1.21	< 0.001	0.99	0.92–1.06	0.80	1.14	1.07–1.21	< 0.001	1.02	0.92–1.14	0.68
Junior high school and above	3.86	2.73–5.47	< 0.001	3.05	1.89–4.91	< 0.001	2.82	1.75–4.52	< 0.001	2.11	1.07–4.15	0.03
Nighttime sleep duration	2.94	2.30–3.75	< 0.001	1.46	1.08–1.97	0.01	2.37	1.65–3.40	< 0.001	0.98	0.63–1.54	0.93
No regular physical activity	2.26	1.66–3.07	< 0.001	1.34	0.97–2.69	0.06	2.35	1.48–3.75	< 0.001	1.29	0.78–2.13	0.32
Smoking	4.02	1.92–8.43	< 0.001	1.37	0.55–3.38	0.50	4.80	1.86–12.39	0.001	1.52	0.47–4.95	0.49
Alcohol consumption	4.19	2.77–6.33	< 0.001	1.61	0.97–2.69	0.07	5.05	2.94–8.65	< 0.001	1.76	0.89–3.47	0.10
Suffering from physical/mental violence	6.16	4.50–8.44	< 0.001	2.93	2.02–4.24	< 0.001	8.38	5.57–12.61	< 0.001	3.48	2.17–5.57	< 0.001
Having academic pressure	3.59	2.81–4.60	< 0.001	1.85	1.37–2.51	< 0.001	4.78	3.32–6.87	< 0.001	2.46	1.60–3.78	< 0.001
Having poor interpersonal relationship problems	5.83	4.54–7.49	< 0.001	2.82	2.08–3.81	< 0.001	6.47	4.49–9.32	< 0.001	2.48	1.61–3.82	< 0.001

Risk factors for anxiety symptoms

Similar to depressive symptoms, adolescent girls with older age, education level of junior high school and above, shorter night time sleep duration, lack of regular physical activity, alcohol consumption, smoking, experience of academic pressure, suffering from physical/mental violence, and poor interpersonal relationships were found to be more likely to experience anxiety symptoms (all P < 0.01, Table 3). Multivariable logistic regression showed that education level of junior high school and above (OR = 2.11, 95% CI: 1.07–4.15, P = 0.03), suffering from physical/mental violence (OR = 3.48, 95% CI: 2.17–5.57, P < 0.001), academic pressure (OR = 2.46, 95% CI: 1.60–3.78, P < 0.001), and having poor interpersonal relationships (OR = 2.48, 95% CI: 1.61–3.82, P < 0.001) were independent risk factors for anxiety symptoms (Table 3).

Discussion

In our study, the prevalence rates of depressive and anxiety symptoms among adolescent girls were calculated to be 6.0% and 2.6% respectively. Independent risk factors for both depressive and anxiety symptoms include education level of junior high school and above, suffering from physical/mental violence, having academic pressure, having poor interpersonal relationship problems. For depression symptoms, in addition to the factors mentioned above, shorter night time sleep duration was also found to be independent risk factor. A Chinese meta-analysis of 62 studies with 232,586 participants in total estimated the pooled prevalence of depressive symptoms among children and adolescents to be 22.2%²⁴. A large-scale epidemiological study among 53,421 elementary and junior high school student across China reports that 20% of the students are at risk for depression²⁵. A cross-sectional epidemiological study among 23,005 Chinese children and adolescents aged 8–18 years who attend primary or high school showed that 13.1% of participants experienced depressive symptoms, 22.3% experienced anxiety symptoms²⁶. Another study in Shanghai, China reports that the prevalence rates of anxiety and depression were 15.4% and 17.2% among 1,597 junior high school students aged 10-17²⁷. Globally, the Global School-based Student Health Survey with 67,077 adolescents also reported a depressive symptom prevalence of 28.7%. Therefore, most researches showed that anxiety and depressive disorders were common problems of adolescent mental health, which need to be paid more attention to.

The risk factors identified in our study are also in line with the previous findings that higher education levels and higher levels of academic pressure were likely to increase the risk of depression and anxiety^5,25,26. This could be due to increased academic pressure as the education progresses, and which has been shown to be associated with depressive and anxiety symptoms^28,29. An examination-centered culture is rooted in Chinese society, thus driving high expectations for adolescents’ educational achievements. Higher learning/testing standards, outcomes, and expectations have led to a rise in academic pressure among students, which in turn increases the risk for mental health problems. The Chinese education system is especially competitive, with only 58% junior high school students able to be admitted to high school in 2018 based on China’s Ministry of Education report³⁰. Students in high school further face the pressure of passing the college entrance exam to be admitted to a university. Overall, students in higher level of education experience more academic pressure, which could contribute to the high prevalence of depressive and anxiety symptoms.

Shorter night time sleep duration was found to be associated with increased risk of depressive symptoms among adolescent girls in our study. A longitudinal study of 421 American adolescents reported that adolescents with short sleep duration (sleep time ≤ 7 h) are more likely to experience depressive symptoms than those with normal sleep duration and without insomnia symptom³¹. Another cross-sectional research show that short night sleep is associated with higher risk of depressive symptoms compared with those who have night sleep duration of 6–8 h³². A study of 90 Australia children aged 6–12 reports that sleeping problems (Children’s Sleep Habits Questionnaire [CSHQ] total scores ≥ 41) have a strong association with generalized anxiety disorder (GAD) symptoms³³. Insufficient sleep time may disturb an individual’s emotional regulation capacity, which further exacerbate his or her depressive symptoms³⁴. Therefore, ensuring sufficient nighttime sleep duration for students are effective ways to prevent the onset and exacerbation of mental health symptoms in adolescents. In addition, previous studies demonstrated that alcohol consumption was associated with mood disorders in a survey of 20,951 secondary school students aged 11–20 in Hong Kong, which concludes that depressive symptoms are associated with a history of alcohol consumption³⁵. Other studies also report that adolescents with depressive symptoms are more likely to have motives for alcohol consumption^7,14,35,36. Physical activity have been reported to be a positive effect on mental health explained by changed brain structure and function^37–44. A systematic review of 114 original articles suggested that physical activity interventions can improve adolescents’ mental health³⁷. Another systematic review with 115,540 adolescents and children from 12 counties also indicated that an achievement of high levels of physical activity (≥ 60 min of moderate-to-vigorous physical activity), low levels of sedentary behavior (≤ 2 h of recreational screen time), and sufficient sleep (9–11 h for children or 8–10 h for adolescents) each day were associated with better mental health among adolescents and children³⁸. The FITKids randomized controlled trial showed that a physical activity intervention enhanced cognitive performance and brain function³⁹. Therefore, schools and families are encouraged to promote adolescents to keep a healthy lifestyle to alleviate the influence of negative emotions on their psychological and behavioral health⁴⁵.

Coinciding with the prior literature, our study indicated that poor interpersonal relationships were one of the risk factors for depressive and anxiety symptoms. A cohort study conducted by Fowler et al. also showed that interpersonal abuse, assaults etc. was correlated with depression severity⁴⁶. Parent-child relationships play a crucial role in shaping adolescent depression. A four-wave longitudinal study reported that higher parent-child relationship quality is associated with lower levels of adolescent depression, while parent-child relationship changes are linked to higher depression, which highlighted the impact and mechanisms of parent-child relationship quality and its effects on depression⁴⁷. Better parental involvement may help minimize adolescents’ ruminative processes and facilitate greater behavioral activation. Better parental presence may also provide strong social support for adolescents when they face challenges, which might have beneficial effects on the reduction of adolescents’ depression and anxiety. Based on this study, we call on families, schools, and society to work together and take measures to safeguard the mental health of adolescents.

Our results showed that suffering from physical/mental violence was more likely to experience both depressive and anxiety symptoms. The relationship between violence exposure and mental health in children and adolescents have been reported by previous studies. A recent meta-analysis including 57 retrospective studies found that individuals who experienced violence (sexual abuse, physical abuse, domestic violence, or emotional abuse) were more likely to development depression by childhood or adolescence than those who didn’t⁴⁸. This indicated that interventions might be necessary even after the slightest exposure of violence to promote optimal adolescents’ development⁴⁹.

The study contains a large sample size of 4,658 from both urban and rural areas in six provinces in eastern, central and western China using validated tools to assess the anxiety and depression symptoms in adolescent girls. However, several limitations must be considered. Firstly, the study was limited by the cross-sectional study design, which could help determine the temporal association but limit its ability to assess the causal relationship between risk factors and mental health symptoms. Moreover, the study has a small percentage of Chinese ethnic minorities adolescent girls (0.7%), which limits its generalizability of the results to more ethnically diverse populations. Furthermore, variables such as academic pressure and physical/mental violence were measured as either present or absent when in reality, individuals likely experienced academic pressure and physical/mental violence to a varying degree of severity and further categorization could elicit different and more accurate study results. What’s more, the academic pressure was measured through a self-report based on a yes and no response, which might cause a tendency that low-performing students to report higher pressure compared to their high-performing counterparts. In the end, the risk factor smoking is linked to tobacco/nicotine. However, we did not include the question of different types of smoking in our questionnaire. Therefore, we are unable to distinguish the effect of smoking among tobacco, electronic cigarettes, or vaping. These limitations call for further profound, high-quality, prospective studies with larger sample sizes to extend the generalizability, assess the causality between factors and mental health status, and improve the accuracy of results using a scaled response system to account for varying severities of certain factors.

Conclusions

The findings of this study may inform educators and policy makers and highlight the need for mental health recourses provided to adolescent girls in school, especially for junior high school and above students. Illustratively, parents should provide more emotional support. Schools can develop strategies to encourage adolescent to keep a healthy lifestyle. Teachers could encourage adolescents to develop a wealth of interests and ensure sufficient sleep duration, as well as avoid overburdening students with schoolwork. Finally, the government should optimize the layout of education, safeguard education resources and promote fairness in education in order to prevent the onset and exacerbation of psychological issues in adolescents.

Author contributions

Conceptualization: X.Z., B.S. and J.J.; Analysis and interpretation of data: X.Z., B.S. and J.J.; Investigation: X.Z., B.S., J.J., J.L., X.W., and D.G.; Writing—original draft preparation, X.Z., J.J., J.L., and B.S. review and editing. All authors had agreed to the published version of the manuscript.

Funding

This work was supported by the Beijing Nova Program (2024010).

Data availability

The data that support the findings of this study are available from the corresponding author, X.Z., upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethical Approval

The study had been approved by the Ethical Review Committee of the Chinese Center for Disease Control and Prevention (ethic code: 201810), and all participants provided a written informed consent.