Published online Feb 19, 2026. doi: 10.5498/wjp.v16.i2.112996
Revised: August 20, 2025
Accepted: October 21, 2025
Published online: February 19, 2026
Processing time: 171 Days and 16.5 Hours
Depressive and anxiety symptoms among adolescents have become significant public health concerns, yet comprehensive studies examining their prevalence and associated factors are limited. Functional constipation (FC), as a common gas
To examine depressive/anxiety symptoms prevalence and their associations with FC and other potential risk factors among adolescents in Lianyungang, Jiangsu Province, China.
We conducted a cross-sectional survey of 22925 adolescents using the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 for depressive and anxiety symptoms, respectively. FC was evaluated using the Rome IV criteria, and social support using the Perceived Social Support Scale.
Depressive symptoms were reported by 16.0%, anxiety symptoms by 24.1%, with 13.1% experiencing both. Among the total group, 27.5% reported mild, 10.0% moderate, 4.0% moderately severe, and 2.0% severe depressive symptoms, while 23.0% reported mild, 7.2% moderate, and 3.8% severe anxiety symptoms. Female sex, smoking, FC, parental conflict, lower household income, lower levels of physical activity, and longer weekly electronic device use time were identified as significant risk factors for depressive and anxiety symptoms (all P < 0.05), while age and body mass index were identified as additional significant risk factors for anxiety symptoms (all P < 0.05). In contrast, received support was identified as a significant protective factor against depressive and anxiety symptoms.
Targeting modifiable risk factors (physical activity, smoking, excessive device use) and improving mental health support access are priorities to address the high prevalence of depression and anxiety symptoms.
Core Tip: This large-scale cross-sectional study of 22925 Chinese adolescents reveals concerning rates of depression (16.0%) and anxiety (24.1%) symptoms, with approximately 10% reporting moderate to severe symptoms. The study uniquely identifies functional constipation as a significant risk factor for both conditions, potentially reflecting brain-gut axis dysfunction. Female sex, smoking, parental conflict, lower household income, reduced physical activity, and excessive electronic device use were also identified as risk factors, while social support emerged as protective. These findings underscore the urgent need for comprehensive screening and targeted interventions addressing modifiable risk factors to improve adolescent mental health outcomes.
- Citation: Yang HD, Zhang J, Yang M, Luan LS, Liu JJ, Zhang XB. Prevalence, severity, and risk factors for depressive and anxiety symptoms among adolescents: A cross-sectional study. World J Psychiatry 2026; 16(2): 112996
- URL: https://www.wjgnet.com/2220-3206/full/v16/i2/112996.htm
- DOI: https://dx.doi.org/10.5498/wjp.v16.i2.112996
Depression and anxiety disorders are among the top 25 leading causes of disability worldwide, and thus are major public health concerns[1,2]. Adolescence is a critical period of psychological development, and both depressive and anxiety symptoms are increasing in prevalence among this age group, hampering academic performance and socialization, and potentially reducing quality of life in adulthood[3-5]. Further, symptoms of depression and anxiety often coexist, and are mutually reinforcing, thereby exacerbating the burden of illness[6,7]. Despite the availability of effective treatments, adolescents are seldom diagnosed and treated unless necessitated by a serious precipitating incident[8-10], highlighting the importance of screening for early identification and intervention.
According to the World Health Organization, the worldwide prevalence of depressive disorders among individuals 10 years to 19 years of age was 4.7% in 2019, and has risen further since due to the coronavirus disease 2019 pandemic and associated countermeasures[11,12]. However, prevalence differs considerably among regions, reflecting the influences of geography, cultural background, socioeconomic status, and potentially also different survey instruments[13-16]. Nonetheless, it is generally agreed that depressive symptoms constitute a major mental health challenge among adolescents due to the increased risks of self-injury, suicidal thoughts, and even suicidal behaviors[17-19].
Anxiety symptoms are also frequent among adolescents. For example, a prevalence rate of 37.89% was reported in Nepal[20], while a survey in Vietnam reported moderate anxiety among 22.8% of respondents and severe anxiety among 7.32%[21]. Similar or higher rates have been reported outside of Asia, including 39.1% in Morocco[22], 61.8% in Peru[23], and 31.9% in the United States[24]. Further, psychosocial stressors experienced during adolescence have been identified as key factors compromising short- and long-term mental health[25,26]. Further, symptoms of anxiety and depression are frequently comorbid, and adolescents with comorbid anxiety and depressive symptoms are more prone to unintentional injuries, premature and unsafe behaviors, smoking, poor diet, and sleep disorders[27].
Depressive and anxiety symptoms in adolescents are influenced by biological traits, social factors, the family environment, and presumably by various interactions among genes and the environment[28]. Indeed, several genetic factors and brain biomarkers have been linked to adolescent mental illness[29,30]. Psychological factors strongly implicated in depressive and anxiety symptom onset among adolescents include low self-esteem, negative thought patterns, and poor coping skills[31-33], while influencing factors related to the family environment include the parent–child relationship, the parental relationship, family economic status, and perception of parental support[22,34,35]. Further, social and environmental factors related to depression and anxiety include peer relationships, academic pressures, childhood trauma, physical activity time, interpersonal conflicts, bullying, and the excessive use of electronic devices[36-39]. Functional constipation (FC), as a common gastrointestinal disorder, is also closely related to mental health through the gut-brain axis[40,41]. Research indicates that gut microbiota influences central nervous system function through the gut-brain axis, including emotion regulation and stress response[42]. Therefore, FC may be an important correlate of depressive and anxiety symptoms in adolescents.
We speculated that FC, gender, smoking, perceived support, parental relationship, family economic status, physical activity level, weekly electronic device usage time (WEDUT), and local civic environment (urban vs suburban) may be significant predictors of depression and anxiety symptoms in adolescents. The aims of the current study were to: (1) Evaluate the prevalence of depressive and anxiety symptoms among adolescents in Lianyungang, Jiangsu Province, China; (2) Assess the severity distribution of depressive and anxiety symptoms; and (3) Explore whether FC influences depressive and anxiety symptoms among adolescents in addition to these other aforementioned potential risk factors. To the best of our knowledge, this is one of the larger-scale investigations of adolescent depressive and anxiety symptom prevalence in Lianyungang area since the coronavirus disease 2019 pandemic, providing important data for under
We conducted a cross-sectional survey of depressive and anxiety symptoms among adolescents in Lianyungang, Jiangsu Province, China, between September and November 2023. Students from eight secondary schools encompassing both junior levels (grades 7 to 9) and senior levels (grades 10 to 12) were invited to complete the survey using the Wenjuanxing online platform (https://www.wjx.cn/app/survey.aspx). These eight secondary schools were selected using a stratified sampling method, considering representativeness of school type and geographic location (urban/suburban). We first stratified the secondary schools in the region by type and location, then randomly selected schools from each stratum. Prior to completing the online survey, students were provided with a detailed guide describing the purpose of the survey and assurances that the data collected was confidential and anonymous (including to parents and teachers). Students also had the opportunity to withdraw from the survey at any point, and that if they decided to do so after the survey was completed, they could still contact the research team and request their data be removed. Figure 1 shows the adolescent recruitment process flowchart.
The project was approved by the Ethics Committee of the Fourth People’s Hospital of Lianyungang City, approval No. 2023 LSYYXLL-P21. Written informed consent was obtained from parents/guardians of all participating students, and verbal assent was obtained from the students themselves before the investigation. The schools and teachers were also informed and provided consent. All signed consent forms were kept by the schools.
The research team designed a self-reported, semi-structured questionnaire to collect sociodemographic information including age, gender, height, weight, smoking status (yes/no), grade and class, single-parent family status (yes/no), parental relationship (harmony/moderate/conflict), annual household income (better/good/fair), physical activity level (high/medium/Low), and WEDUT (high/moderate/Low). Smoking status was assessed through the question “Do you currently smoke?” with “yes” defined as having smoked (including E-Cigarette) on at least 1 day during the past 30 days, otherwise classified as “no”[43]. Parental relationship was evaluated through the question “How would you describe the relationship between your parents?” with three classification levels: Harmony (referring to parents having an amicable relationship with minimal disputes), moderate (referring to parents having a good relationship but with occasional disagreements), and conflict (referring to parents having a tense relationship with frequent arguments or confrontations). Annual household income was categorized as “fair” if under 100000 yuan, “good” if 100000 yuan to 200000 yuan, and “better” if exceeding 200000 yuan. The categorization was based on the 2022 data from Lianyungang Bureau of Statistics (https://tjj.lyg.gov.cn). Similarly, physical activity level per week was classified as “low” if less than 2 hours, “medium” if 2 hours to 6 hours, and “high” if over 6 hours, while WEDUT was categorized as “high” if over 5 hours per week, “moderate” if 2 hours to 5 hours weekly, and “low” if less than 2 hours weekly.
Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9)[44], which includes nine items based on the diagnostic criteria for major depressive disorder of the Diagnostic and Statistical Manual-IV. The occurrence and frequency of symptoms experienced within the last two weeks are assessed using a quartile grading scale as follows: 0 for “not at all”, 1 for “several days”, 2 for “more than half the days”, and 3 for “nearly every day”. The total score (ranging from 0 to 27) gauges the severity of depression, with scores of 0-4 indicating none or minimal symptoms and scores of 5-9 indicating mild, 10-14 moderate, 15-19 moderately severe, and 20-27 severe depression symptoms. The PHQ-9 demonstrates excellent reliability and validity within the Chinese population and so is widely utilized for the evaluation of depressive symptoms[45]. In this study, a total score of 10 points was used as the cut-off threshold for distinguishing students with and without depressive symptoms[46,47].
We employed the Generalized Anxiety Disorder 7-item (GAD-7) scale to assess anxiety symptoms. This instrument consists of seven items that query respondents about the frequency of anxiety symptoms experienced over the preceding two weeks utilizing a four-point scoring system as follows: 0 for “not at all”, 1 for “several days”, 2 for “more than half the days”, and 3 for “nearly every day”. Again, a total score of 0-4 denotes minimal symptoms while 5-9 indicates mild, 10-14 moderate, and 15-21 severe anxiety symptoms[48]. The GAD-7 has demonstrated good reliability and validity for the assessment of anxiety symptoms in the Chinese adolescent population[49]. A cut-off value of 7 points was set to distinguish students with and without anxiety symptoms[50]. In this study, comorbidity of depressive and anxiety symptoms was defined as simultaneously meeting both the criteria for depressive symptom screening (PHQ-9 ≥ 10) and anxiety symptoms screening (GAD-7 ≥ 7).
The Perceived Social Support Scale (PSSS) was employed to evaluate the social support perceived by students. This instrument consists of 12 items, each scored on a 7-point Likert scale from “strongly disagree” (1 point) to “strongly agree” (7 points) based on their experiences in the preceding month. A higher cumulative score denotes increased perceived social support. The PSSS was stratified into subscales indicating levels of family support, support from friends, and support by others.
FC was diagnosed according to Rome IV criteria[51], which requires the presence of two or more core symptoms, two exclusion criteria within the last three months, and symptom onset at least six months prior. The diagnosis of FC was also excluded if there was a previous diagnosis of constipation attributed to another cause.
All statistical analyses were conducted using SPSS version 23.0. Sample size calculation and effect size estimation were conducted using the locally installed G*Power 3 software (version 3.1.9.7, Heinrich Heine University Düsseldorf), not the online version, with an alpha error probability of 0.05 and statistical power (1-β) of 0.80. Continuous variables such as age, height, weight, and psychometric scale scores (PHQ-9, GAD-7, and PSSS) are presented as mean and SD, while categorical variables such as gender, smoking status, geographical region, income level, and parental relationship are expressed as frequency or percentage. Continuous variables were compared by Student’s t-test or independent samples t-test and categorical variables by the χ2 test. Potential risk factors were first assessed by univariate analysis and those deemed significant were included in a binary logistic regression model to identify independent risk factors for depression or anxiety symptoms among adolescents. A two-tailed P value < 0.05 was considered statistically significant for all tests.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
A total of 23654 questionnaires were collected, of which 729 (3.08%) were excluded for missing information on gender (28, 0.12%), age (88, 0.37%), height (323, 1.37%), weight (141, 0.6%), or multiple items missing in either the PHQ-9 or GAD-7 (149, 0.63%). Ultimately, 22,925 completed questionnaires were collected and included in the analysis. Of the 22925 adolescents included, 52.8% (n = 12115) were male, 47.2% (n = 10810) were female, and age ranged from 11 years to 19 years (mean 14.27 ± 1.52 years). The majority were junior high school students (n = 17780, 77.6% vs n = 5145, 22.4%). Within this total population, 11.0% (n = 2522) reported smoking and 7.8% (n = 1780) had FC.
As shown in Table 1, age, gender, region of residence, smoking status, PSSS total score and each subscale score, parental relationship, annual household income, WEDUT, and FC differed significantly between adolescents with and without depressive symptoms and between adolescents with and without anxiety symptoms (all P < 0.05). Education level (P = 0.475) and body mass index (BMI) (P = 0.109) did not differ between adolescents with and without depressive symptoms, but did differ significantly between adolescents with and without anxiety symptoms (all P < 0.05).
| Characteristic | Depressive symptoms | Anxiety symptoms | ||||
| With (n = 3678) | Without (n = 19247) | P value | With (n = 5515) | Without (n = 17410) | P value | |
| Age (year), mean ± SD | 14.36 ± 1.42 | 14.25 ± 1.54 | < 0.001 | 14.45 ± 1.46 | 14.21 ± 1.54 | < 0.001 |
| Sex | < 0.001 | - | < 0.001 | |||
| Male | 1548 (12.8) | 10567 (87.2) | 2395 (19.8) | 9720 (80.2) | ||
| Female | 2130 (19.7) | 8680 (80.3) | 3120 (28.9) | 7690 (71.1) | ||
| Educational levels | 0.475 | - | < 0.001 | |||
| Junior high school | 2836 (16.0) | 14944 (84.0) | 4091 (23.0) | 13689 (77.0) | ||
| Senior high school | 842 (16.4) | 4303 (83.6) | 1424 (27.7) | 3721 (72.3) | ||
| Regions | < 0.001 | - | < 0.001 | |||
| Urban | 3183 (15.4) | 17545 (84.6) | 4856 (23.4) | 15872 (76.6) | ||
| Suburban | 495 (22.5) | 1702 (75.5) | 659 (30.0) | 1538 (70.0) | ||
| BMI (kg/m2), mean ± SD | 21.13 ± 3.89 | 21.02 ± 3.78 | 0.109 | 21.19 ± 3.86 | 20.99 ± 3.78 | 0.001 |
| Smoking | < 0.001 | - | < 0.001 | |||
| Yes | 566 (22.4) | 1956 (77.6) | 772 (30.6) | 1750 (69.4) | ||
| No | 3112 (15.3) | 17291 (84.7) | 4743 (23.2) | 15660 (76.8) | ||
| PSSS total scores, mean ± SD | 49.50 ± 14.92 | 66.14 ± 14.49 | < 0.001 | 52.21 ± 14.71 | 67.04 ± 14.39 | < 0.001 |
| Family support | 15.70 (5.94) | 22.23 (5.37) | < 0.001 | 16.85 (5.87) | 22.56 (5.31) | < 0.001 |
| Friend support | 17.46 (5.97) | 21.86 (5.18) | < 0.001 | 18.03 (5.66) | 22.15 (5.15) | < 0.001 |
| Significant others | 16.34 (5.59) | 22.04 (5.10) | < 0.001 | 17.33 (5.42) | 22.33 (5.08) | < 0.001 |
| Parental relationship | < 0.001 | - | < 0.001 | |||
| Harmony | 1604 (10.0) | 14412 (90.0) | 2742 (17.1) | 13274 (82.9) | ||
| Moderate | 1647 (27.7) | 4303 (72.3) | 2277 (38.3) | 3673 (61.7) | ||
| Conflict | 427 (44.5) | 532 (55.5) | 496 (51.7) | 463 (48.3) | ||
| Annual household income | < 0.001 | - | < 0.001 | |||
| Better | 1169 (11.7) | 8851 (88.3) | 1882 (18.8) | 8138 (81.2) | ||
| Good | 1954 (17.7) | 9068 (82.3) | 2927 (26.6) | 8095 (73.4) | ||
| Fair | 555 (29.5) | 1328 (70.5) | 706 (37.5) | 1177 (62.5) | ||
| Physical activity level | < 0.001 | - | < 0.001 | |||
| High | 502 (11.5) | 3866 (88.5) | 804 (18.4) | 3564 (81.6) | ||
| Medium | 1274 (14.3) | 7666 (85.7) | 1936 (21.7) | 7004 (78.3) | ||
| Low | 1902 (19.8) | 7715 (80.2) | 2775 (28.9) | 6842 (71.1) | ||
| WEDUT | < 0.001 | - | < 0.001 | |||
| High | 1014 (26.0) | 2882 (74.0) | 1365 (35.0) | 2531 (65.0) | ||
| Moderate | 1330 (17.0) | 6477 (83.0) | 2048 (26.2) | 5759 (73.8) | ||
| Low | 1334 (11.9) | 9888 (88.1) | 2102 (18.7) | 9120 (81.3) | ||
| FC | < 0.001 | - | < 0.001 | |||
| Yes | 384 (21.6) | 1396 (78.4) | 540 (30.3) | 1240 (69.7) | ||
| No | 3294 (15.6) | 17851 (84.4) | 4975 (23.5) | 16170 (76.5) | ||
Depressive symptoms were reported by 16.0% and anxiety symptoms by 24.1% of the total cohort, with females reporting significantly higher rates of both depressive symptoms (19.7% vs 12.8% of males, χ2 = 203.471, P < 0.001) and anxiety symptoms (28.9% vs 19.8% of males, χ2 = 258.557, P < 0.001). Additionally, among participants, 21.6% of those with self-reported depressive symptoms have FC, compared to 15.6% without FC (χ2 = 43.805, P < 0.001). Similarly, 30.3% of participants with self-reported anxiety symptoms have FC compared to 23.5% without FC (χ2 = 41.665, P < 0.001).
According to PHQ-9 scores, 27.5% of the total cohort reported mild, 10.0% moderate, 4.0% moderately severe, and 2.0% severe depressive symptoms, while according to GAD-7 scores, 23.0% of the total cohort reported mild, 7.2% moderate, and 3.8% severe anxiety symptoms (Table 2). Among the adolescents in this study, 13.1% presented with comorbid depressive and anxiety symptoms. Mean scores for subgroups are also presented in Table 2.
| Characteristic | Depressive symptoms | Anxiety symptoms | Comorbid depressive and anxiety symptoms | ||
| n (%) | mean ± SD | n (%) | mean ± SD | n (%) | |
| Minimal | 12941 (56.4) | 1.32 ± 1.46 | 15136 (66.0) | 1.0 ± 1.33 | 19916 (86.9) |
| Mild | 6306 (27.5) | 6.93 ± 1.45 | 5283 (23.0) | 6.63 ± 1.18 | - |
| Moderate | 2288 (10.0) | 11.59 ± 1.39 | 1646 (7.2) | 11.84 ± 1.44 | - |
| Moderately severe | 923 (4.0) | 16.67 ± 1.41 | - | - | - |
| Severe | 467 (2.0) | 22.94 ± 2.39 | 860 (3.8) | 17.89 ± 2.22 | - |
| Overall prevalence | 3678 (16.0) | - | 5515 (24.1) | - | 3009 (13.1) |
Binary logistic regression analyses (Table 3) identified female sex [B = 0.413, P < 0.001, odds ratio (OR) = 1.511, 95% confidence interval (CI): 1.391-1.641], smoking (B = 0.533, P < 0.001, OR = 1.704, 95%CI: 1.440-2.017), and FC (B = 0.232, P = 0.001, OR = 1.261, 95%CI: 1.101-1.444) as significant risk factors for depressive symptoms in adolescents. A parental relationship characterized as “moderate” (B = 0.482, P < 0.001, OR = 1.619, 95%CI: 1.482-1.770) or by “conflict” (B = 0.825, P < 0.001, OR = 2.282, 95%CI: 1.940-2.684) was also a significant risk factor for depressive symptoms compared to a relationship characterized by “harmony”. In addition, a physical activity level rated as “moderate” (B = 0.173, P = 0.008, OR = 1.188, 95%CI: 1.047-1.349) or “low” (B = 0.441, P < 0.001, OR = 1.555, 95%CI: 1.373-1.760), a WEDUT level rated “moderate” (B = 0.217, P < 0.001, OR = 1.243, 95%CI: 1.131-1.366) or “high” (B = 0.756, P < 0.001, OR = 2.129, 95%CI: 1.912-2.370), and a “fair” annual household income (B = 0.360, P < 0.001, OR = 1.434, 95%CI: 1.211-1.698) were risk factors for depressive symptoms. As expected, family support (B = -0.101, P < 0.001, OR = 0.904, 95%CI: 0.894-0.914) and the support of significant others (B = -0.075, P < 0.001, OR = 0.928, 95%CI: 0.915-0.941) were associated with reduced risk of depressive symptoms. Conversely, age, educational level, region of residence, BMI, and friend support were not significantly associated with depressive symptoms (all P > 0.05).
| Characteristic | Depressive symptoms | Anxiety symptoms | ||||
| OR | 95%CI | P value | OR | 95%CI | P value | |
| Age | 1.034 | 0.992-1.079 | 0.116 | 1.078 | 1.040-1.117 | < 0.001 |
| Sex | ||||||
| Male | 1 | - | - | 1 | - | - |
| Female | 1.511 | 1.391-1.641 | < 0.001 | 1.525 | 1.421-1.636 | < 0.001 |
| Educational level | ||||||
| Junior high school | 1 | - | - | 1 | - | - |
| Senior high school | 1.154 | 0.993-1.342 | 0.062 | 0.965 | 0.848-1.097 | 0.586 |
| Regions | ||||||
| Urban | 1 | - | - | 1 | - | - |
| Suburban | 1.102 | 0.963-1.261 | 0.159 | 0.981 | 0.869-1.106 | 0.751 |
| BMI (kg/m2) | 1.010 | 0.999-1.021 | 0.062 | 1.016 | 1.007-1.026 | < 0.001 |
| Smoking | ||||||
| No | 1 | - | - | 1 | - | - |
| Yes | 1.704 | 1.440-2.017 | < 0.001 | 1.843 | 1.589-2.138 | < 0.001 |
| PSSS | ||||||
| Family support | 0.904 | 0.894-0.914 | < 0.001 | 0.908 | 0.899-0.917 | < 0.001 |
| Friend support | 0.999 | 0.988-1.010 | 0.864 | 0.978 | 0.968-0.987 | < 0.001 |
| Significant others | 0.928 | 0.915-0.941 | < 0.001 | 0.949 | 0.937-0.962 | < 0.001 |
| Parental relationship | ||||||
| Harmony | 1 | - | - | 1 | - | - |
| Moderate | 1.619 | 1.482-1.770 | < 0.001 | 1.521 | 1.407-1.643 | < 0.001 |
| Conflict | 2.282 | 1.940-2.682 | < 0.001 | 1.818 | 1.556-2.124 | < 0.001 |
| Annual household income | ||||||
| Better | 1 | - | - | 1 | - | - |
| Good | 1.048 | 0.959-1.146 | 0.303 | 1.035 | 0.961-1.115 | 0.366 |
| Fair | 1.434 | 1.211-1.698 | < 0.001 | 1.177 | 1.010-1.372 | 0.037 |
| Physical activity level | ||||||
| High | 1 | - | - | 1 | - | - |
| Medium | 1.188 | 1.047-1.349 | 0.008 | 1.106 | 0.996-1.229 | 0.060 |
| Low | 1.555 | 1.373-1.760 | < 0.001 | 1.437 | 1.296-1.594 | < 0.001 |
| WEDUT | ||||||
| Low | 1 | - | - | 1 | - | - |
| Moderate | 1.243 | 1.131-1.366 | < 0.001 | 1.303 | 1.204-1.411 | < 0.001 |
| High | 2.129 | 1.912-2.370 | < 0.001 | 1.891 | 1.720-2.078 | < 0.001 |
| FC | ||||||
| No | 1 | - | - | 1 | - | - |
| Yes | 1.261 | 1.101-1.444 | 0.001 | 1.195 | 1.060-1.348 | 0.004 |
Age (B = 0.075, P < 0.001, OR = 1.078, 95%CI: 1.040-1.117), female sex (B = 0.422, P < 0.001, OR = 1.525, 95%CI: 1.421-1.636), high BMI (B = 0.016, P < 0.001, OR = 1.016, 95%CI: 1.007-1.026), smoking (B = 0.611, P < 0.001, OR = 1.843, 95%CI: 1.589-2.138), and FC (B = 0.178, P = 0.004, OR = 1.195, 95%CI: 1.060-1.348) were significant independent factors for anxiety symptoms. In addition, a parental relationship characterized as “moderate” (B = 0.419, P < 0.001, OR = 1.521, 95%CI: 1.407-1.643) or by “conflict” (B = 0.598, P < 0.001, OR = 1.818, 95%CI: 1.556-2.124) was a risk factor compared to a parental relationship characterized by “harmony”. A “fair” annual household income (B = 0.163, P = 0.037, OR = 1.177, 95%CI: 1.010-1.372), low physical activity level (B = 0.363, P < 0.001, OR = 1.437, 95%CI: 1.296-1.594), and low WEDUT (B = 0.637, P < 0.001, OR = 1.891, 95%CI: 1.720-2.078) were also risk factors for adolescent anxiety symptoms. Conversely, family support (B = -0.096, P < 0.001, OR = 0.908, 95%CI: 0.899-0.917), friend support (B = -0.023, P < 0.001, OR = 0.978, 95%CI: 0.968-0.987), and support from significant others (B = -0.052, P < 0.001, OR = 0.949, 95%CI: 0.937-0.962) were associated lower risk of adolescent anxiety symptoms. Level of education and region of residence were not significantly associated with adolescent anxiety (all P > 0.05). As shown in Figure 2.
This study yielded several key findings. First, substantial minorities of the sampled adolescent cohort reported depressive (16.0%) and anxiety (24.1%) symptoms, with 13.1% experiencing both. Second, over 10% of the total cohort rated these psychiatric symptoms as moderate to severe. Third, FC, lower levels of physical activity, and longer durations of WEDUT were identified as risk factors for both depression and anxiety, while perceived support emerged as an important protective factor.
Whilst numerous studies have investigated the prevalence of depressive and anxiety symptoms among adolescents in the general population, results have varied across samples, suggesting influences by multiple uncontrolled or unknown risk and protective factors as well as differences in research methodologies (e.g., sample selection, symptom criteria, population ethnicity, etc.)[23,52]. Nonetheless, the prevalence of both symptom types is high. For instance, a network perspective reported depressive symptoms in 44.6% and anxiety symptoms in 31.12% of adolescents aged 12-20 years in Chinese[53]. Further, symptom expression is strongly predictive of future clinical depression, as an overview of 113 studies reported that the subgroup with subthreshold symptoms (14.17% of the adolescents sampled) was at 2.95-fold greater risk of developing depression than the non-depressed subgroup[54]. Another summary and overview reported a lifetime anxiety disorder prevalence of 15%-20% up to age 18 years[55]. Thus, despite considerable heterogeneity across populations, preclinical depressive and anxiety symptoms are ubiquitous among adolescents and contribute not only to reduced quality of life, lower achievement, and potential harm in the short term but also to poor mental health in adulthood.
Our findings regarding depressive and anxiety symptoms in adolescents may reflect the complex nature of adolescent psychological development and the potentially transient nature of developmental and emotional distress[56,57]. Nonetheless, adequate attention and intervention are required to minimize progression. This trend also suggests that severe psychological problems require more complex triggering mechanisms and longer developmental processes[58]. Of greater concern is the small group (about 10%) reporting moderate to severe symptoms, as these are often associated with higher levels of functional impairment and decreased future quality of life[59-61]. Thus, without timely intervention, these symptoms may have a profound impact on life outcomes[62,63].
We also identified multiple risk factors for these depressive and anxiety symptoms, although most are likely not independent but rather mutually influence symptom development and expression within a complex causal network[64-66]. The risk conferred by female sex may be attributed to hormonal changes during puberty or to stress-related cytokines[67,68]. We also detected a significant association between time spent using electronic devices (such as internet surfing) and symptoms of depression and anxiety, in accord with previous studies[69-71]. It is possible that prolonged WEDUT interferes with academics and limits physical activity, leading to deleterious effects on health and self-image. Alternatively, excessive WEDUT may be a coping mechanism. Adolescents in families with lower incomes were also at greater risk for depressive and anxiety symptoms, potentially due to higher levels of financial stress[72], while lower levels of physical activity enhanced risk due to declines in physical health, self-esteem, and other sequelae[73]. Academic and social pressures as well as self-expectations increase with age and may cause anxiety symptoms[38], while excess weight may trigger concerns about body image[74]. Support received by adolescents was an important protective factor against symptoms of depression and anxiety, consistent with the findings of previous studies[75,76]. A longitudinal study also reported that poor family functioning promoted depression, anxiety, and aggression in adolescents[77].
The current study further supports the associations of depressive and anxiety symptoms with FC, particularly in Chinese adolescents. A previous systematic review and meta-analysis reported a pooled global FC prevalence of 15.3%[51]. However, prevalence varies markedly by region, with lower estimates of 8.5% in China[78], 8.1% in Thailand[79], and 6.8% in Germany[80], but 27% in Nigeria[81] and 12.6% in Mexico[82]. Further, FC is more common among adolescents, and may impact daily life and learning. Notably, the risk of FC was 1.261 times higher in adolescents with depressive symptoms compared to those without, and 1.195 times higher in adolescents with anxiety symptoms compared to those without. The potential mechanisms underlying these associations remain unclear. As a cross-sectional study, we cannot determine the direction of causality, and a bidirectional relationship may exist between depressive and anxiety symptoms and persistent bowel dysfunction. The literature suggests that associations of psychological symptoms such as depression and anxiety with FC may be mediated by brain-gut axis dysfunction[83], the stress response[84], abnormalities in gut microbiome composition (dysbiosis)[85], deleterious lifestyle factors (poor diet)[86,87], and altered neurotransmitters[88]. These interactions warrant further research.
These results have significant implications for clinical practice and policy making. First, the relatively high prevalence of depressive and anxiety symptoms among adolescents and the documented associations of these symptoms with adult mental illness indicate the need for general screening to facilitate timely and effective intervention as well as enhanced provision of mental health and medical resources. Second, individually tailored and staged intervention strategies should be implemented according to symptom severity. For instance, early detection and intervention at the level of the school could prevent further aggravation of mild symptoms, while severe symptoms should ideally be addressed by professional counseling and pharmacological therapies. Increased attention, understanding, and support from parents, schools, and communities could facilitate the development and implementation of systematic mental health education and intervention schemes within schools, homes, and communities.
This study has several limitations. First, the cross-sectional design does not allow for demonstration of causal rela
In conclusion, depressive and anxiety symptoms, including moderate to severe symptoms, are prevalent among adolescents, and are influenced by numerous factors such gender, smoking, home environment, physical activity, age, and BMI. In addition, we demonstrate significant associations with FC. These findings emphasize the importance of providing adolescents with comprehensive mental health support, including guidance on coping strategies, positive lifestyle choices, and maintaining a favorable environment in order to prevent and mitigate depressive and anxiety symptoms. A deeper comprehension of adolescent mental health issues, coupled with reinforced multidimensional and multilevel comprehensive interventions, is key to effectively improving mental health standards among adolescents.
We would like to thank the participants in the study.
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