ORIGINAL RESEARCH

published: 25 January 2022

doi: 10.3389/fpubh.2022.760387

Perceived Academic Stress and

Depression: The Mediation Role of
Mobile Phone Addiction and Sleep
Quality
Xin Zhang 1† , Fei Gao 2† , Zheng Kang 1† , Hongguo Zhou 3 , Jianfeng Zhang 2 , Jingjing Li 2 ,
Jun Yan 2 , Jiahui Wang 1 , Huan Liu 1 , Qunhong Wu 1* and Baohua Liu 4*
1
Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, Harbin,
China, 2 Institute of Food Safety and School Health, Heilongjiang Center for Disease Control and Prevention, Harbin, China,
3
Department of Educational Administration, Ningbo College of Health Sciences, Ningbo, China, 4 Department of Elderly
Healthcare and Management, School of Health Services and Management, Ningbo College of Health Sciences, Ningbo,
China

Edited by: Background: Although academic stress is a well-known risk factor for students’
Samrat Singh Bhandari, depression, little is known about the possible psychological mechanisms underlying
Sikkim Manipal University, India
this association. In this study, we investigated the prevalence of depression and sleep
Reviewed by:
Daniel Kwasi Ahorsu,
disturbance among Chinese students, examined the relationship between perceived
Hong Kong Polytechnic University, academic stress and depression, considered if mobile phone addiction and sleep quality
Hong Kong SAR, China
is a mediator of this relationship, and tested if mobile phone addiction and sleep quality
Preethy Kathiresan,
All India Institute of Medical Sciences together play a serial mediating role in the influence of perceived academic stress
Jodhpur, India on depression.
*Correspondence:
Qunhong Wu
Method: A cross-sectional survey was conducted among students from September
[email protected] to December 2018 in Heilongjiang Province, China. The final analysis included 5,109
Baohua Liu students. Mobile phone addiction, sleep quality, and depressive symptoms were
[email protected]
assessed using the Mobile Phone Addiction Index, Pittsburgh Sleep Quality Index, and
† These authors have contributed Center for Epidemiologic Studies-Depression scales, respectively. The serial mediation
equally to this work
model was used to analyse the relationship between perceived academic stress, mobile
Specialty section: phone addiction, sleep quality, and depression.
This article was submitted to
Public Mental Health,
Results: Among all participants, the prevalence of depressive symptoms and sleep
a section of the journal disturbance was 28.69 and 27.95%, respectively. High school students showed the
Frontiers in Public Health
highest scores of perceived academic stress (2.68 ± 1.06), and the highest prevalence
Received: 18 August 2021 of depressive symptoms (33.14%) and sleep disturbance (36.47%). The serial mediation
Accepted: 07 January 2022
Published: 25 January 2022 model indicated that perceived academic stress was a significant predictor of depression
Citation: (B = 0.10, SE = 0.02, 95% CI = 0.06 – 0.13). Additionally, mobile phone addiction
Zhang X, Gao F, Kang Z, Zhou H, (B = 0.08, 95% boot CI = 0.06–0.11) and sleep quality (B = 0.27, 95% boot CI =
Zhang J, Li J, Yan J, Wang J, Liu H,
Wu Q and Liu B (2022) Perceived
0.22–0.33) played a mediating role between perceived academic stress and depression.
Academic Stress and Depression: The Mobile phone addiction and sleep quality together played a serial mediating role in
Mediation Role of Mobile Phone the influence of perceived academic stress on depression (B = 0.11, 95% boot CI =
Addiction and Sleep Quality.
Front. Public Health 10:760387. 0.08–0.14). Furthermore, the indirect effect (i.e., the mediating effect of mobile phone
doi: 10.3389/fpubh.2022.760387 addiction and sleep quality) was significant and accounted for 64.01% of the total effect.

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Zhang et al. Academic Stress, Depression, Sleep, MPA

Conclusions: Our research results underscore the need for stakeholders—including

family members, educators, and policy makers—to take preventative intervention
measures to address depression among Chinese students, especially high
school students.
Keywords: perceived academic stress, mobile phone addiction (MPA), sleep quality, depression, depressive
symptoms, Chinese students

HIGHLIGHTS various physical and mental factors influence the prevalence of

depressive symptoms, such as PSQ (29), bodily pain (30), and
- Perceived academic stress significantly predicts depression. poor cognitive and physical functioning (31). Scholars have noted
- Sleep quality mediates perceived academic stress that there is a remarkable association between alterations in
and depression. sleep patterns and depression (32). Furthermore, in the internet
- Mobile phone addiction mediates perceived academic stress age, studies show that individuals who experience depressive
and depression. symptoms often suffer from social media addictions, such as
- Mobile phone addiction and sleep quality together play a Facebook (33, 34), mobile phone (35), and internet addictions
serially mediating role in the influence of PAS on depression. (8). For instance, Ivanova found that MPA was positively related
to both depression and loneliness in Ukrainian students (36).
INTRODUCTION In China, the school environment and parental practices
contribute to the extraordinarily high expectations of students’
Depression (major depressive disorder) is a widespread chronic academic performance (37). Chinese students experience high
medical illness that can influence mood, thoughts, and physical levels of academic stress throughout their academic careers,
health (1), and is a severe problem faced by students worldwide. A including numerous, intense examinations—such as end-of-term
meta-analysis that included 183 studies from 43 countries shows tests and the standardized senior high school and university
that the overall pooled crude prevalence of depression was 27.2% entrance examinations—and a heavy homework burden (37).
among medical students (2). Previous studies demonstrated Scholars have demonstrated that Chinese students experience
that the prevalence of depression was 51.3, 38.3, 28.4, and sleep deprivation owing to this culture of academic achievement.
30.6% among Indian students (3), Japanese adolescents (4), A study of 9,392 Chinese students in primary education through
Chinese university students (5), and Cameroon medical students university levels showed that 35.6% of participants slept <7 h
(6), respectively. It is important to evaluate the prevalence a day (38). In addition to the threat of academic stress and
of depressive symptoms and explore the effect mechanism of sleep deprivation, MPA is a risk factor affecting Chinese students’
depressive symptoms to protect students from the harmful effects physical and mental health. Mobile phones have become an
of depression. Studies related to students’ depressive symptoms integral part of students’ quotidian lives—Meng’s survey from
often focus on a particular group of students, such as medical December 2016 to January 2017 found that 100% of the
(2), college (7), and university students (8), and scant research college students had mobile phones (39)—and the prevalence
exists about depressive symptoms among students at different of problematic mobile phone use has been found to be 28.2%
levels of education. Many risk factors have been associated among Chinese college students (40). Our study explored the
with depression, including being female (9, 10), life stressors correlations between perceived academic stress (PAS), MPA,
(9, 10), physical and mental factors, social media addiction (11), sleep quality, and depression among Chinese students in middle
and parental factors, including parental psychopathology and school through college levels. Based on previous literature, our
parenting attachment (12). Stress has been shown to be one of study proposed research hypotheses, and tested hypothesis by
the most important risk factors of depression, and numerous using survey data on Chinese students. To our knowledge, this
studies have demonstrated that stress plays an important role in was the first study to investigate relations between these variables
the emergence of depression (13–15). For example, Torres-Berrío among Chinese students by using the serial mediation model.
et al. supposed that depression is caused by a combination of
genetic predisposition and life events (16). Stress often leads to
adverse consequences—such as depression and anxiety (17–19), LITERATURE REVIEW AND RESEARCH
mobile phone addiction (MPA) (20, 21), poor sleep quality (PSQ) HYPOTHESES
(22, 23), changes in legal drug consumption (24), cardiovascular
disease (25), and worsens the outcomes of many medical illnesses
Academic Stress
Academic concerns are the most important sources of chronic
(26), potentially even leading to suicide (27, 28). Additionally,
and sporadic stress for young people in both Western and
Asian countries (41). Academic stress is defined as a student’s
Abbreviations: PAS, Perceived Academic Stress; MPA, Mobile Phone Addiction;
MPAI, Mobile Phone Addiction Index; CES-D, Center for Epidemiologic Studies-
psychological state resulting from continuous social and self-
Depression; PSQ, Poor Sleep Quality; PSQI, Pittsburgh Sleep Quality Index; SEM, imposed pressure in a school environment that depletes the
Structural Equation Model. student’s psychological reserves (42, 43). Students experience

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Zhang et al. Academic Stress, Depression, Sleep, MPA

academic stress throughout their secondary school (41), high to depression symptoms in postpartum women (29). Hence, we
school (44), and university (45, 46), educational careers. Studies propose the following hypothesis:
have shown that academic stress has been positively associated H7: PSQ is positively associated with depression.
with depression (41), PSQ (24, 47), and MPA (48) among Scholars have also demonstrated that there are relationships
students. Jayanthi observed that, compared to adolescents between stress, PSQ, and depression. A prospective birth cohort
who do not experience academic stress, adolescents who study showed that PSQ is associated with stress and depression
experienced academic stress were 2.4 times more likely to symptoms among Chinese pregnant women (58). Zhang et al.
have depressive symptoms (41). Other studies have found that found that perceived stress is associated with sleep quality and
there is a relationship between high academic stress and PSQ depressive symptoms among Chinese nursing students (59).
(47, 49). However, scholars have not adequately addressed However, it has not been documented if sleep quality mediates
the adverse consequences (e.g., depression, PSQ, and MPA) the relationship between PAS and depression among Chinese
of Chinese students’ academic stress. Hence, we propose the students. Hence, we propose the following hypothesis:
following hypotheses: H8: Sleep quality mediates the relationship between PAS
H1: PAS is positively associated with depression. and depression.
H2: PAS is positively associated with MPA.
H3: PAS is positively associated with PSQ. Mobile Phone Addiction and Sleep Quality
MPA and the Relationship Between Perceived
MPA is one of the most common behavioral (i.e., non-drug) Academic Stress and Depression
addictions (48), and is accompanied by negative effects, such as Scholars have posited that there are significant associations
PSQ (50), depression (35), and impaired academic performance between MPA, depression levels, and sleep quality. Demirci
(51). The positive relationship between MPA and PSQ has found that there were positive correlations between MPA,
been proved in previous studies, including a longitudinal study depression levels, and sleep quality (60). The results of Kaya’s
conducted among Korean adolescents (52) and a one-year multivariate regression analysis showed a relationship between
prospective study among Chinese college students (50). Zhang smartphone usage, PSQ, and depression in university students
found that among Chinese university students, there is a (57). A recent meta-analysis also found that there are positive
significant positive relationship between smartphone addiction correlations between MPA, depression, and sleep quality (61).
and bedtime procrastination, which is one of the indicators of Another literature review and case study found that depressive
PSQ (53). Hence, we propose the following hypothesis: symptoms are associated with screen time-induced poor sleep,
H4: MPA is positively associated with PSQ. digital device night use, and mobile phone dependency (62).
Similarly, the positive relationship between MPA and Although these studies explored the correlations between MPA,
depression has been proved in previous studies, including a sleep quality, and depression among students, several scholars
cross-sectional study conducted among Saudi university students have added academic stress into the relationship—for example,
(35), a cross-sectional study among Ukrainian college students a review found that sleep disturbance, anxiety, stress, and
(36), and a systematic review of relations between problematic depression have been associated with problematic mobile phone
smartphone use, anxiety and depression psychopathology (54). use (63). There still exist gaps in the literature on how PAS
Furthermore, another study based on three cohorts of Korean influences depression. First, few scholars have focused on PAS,
children and adolescents confirmed the bidirectional relationship MPA, sleep quality, and depression among Chinese students.
between MPA and depression (55). Hence, we propose the Second, the underlying mediating mechanisms that account for
following hypothesis: this association have been disregarded partly. Based on H6 and
H5: MPA is positively associated with depression. H8, it remains unclear if MPA and sleep quality serially mediate
Researchers have documented that stress is associated with the relationship between PAS and depression. Therefore, we
MPA, and that MPA is associated with depression. For example, propose the following hypothesis:
according to Wan et al., smartphone addictions are significantly H9: MPA and sleep quality serially mediate the relationship
positively associated with both depression and stress among between PAS and depression.
Malaysian public university students (56). However, it is unclear
if MPA mediates the relationship between PAS and depression. Study Objectives
Hence, we propose the following hypothesis: In this study, our primary aim was to investigate the prevalence
H6: MPA mediates the relationship between PAS of depression and sleep disturbance among Chinese students.
and depression. Our secondary aim was to test if there were relationships
between PAS, MPA, sleep quality, and depression. First, we
Sleep Quality tested if there was a relationship between PAS and depression
Sleep disturbance has complex associations with depression among Chinese students (H1: PAS is positively associated with
(major depressive disorder) (31), and is a common physical depression). Second, we tested if MPA was a mediator of the
symptom of depression. Numerous studies have confirmed the relationship between PAS and depression (H2: PAS is positively
remarkable association between PSQ and depression (29, 57, 58). associated with MPA, H5: MPA is positively associated with
For example, Okun et al. found that PSQ is positively related depression, and H6: MPA mediates the relationship between

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Zhang et al. Academic Stress, Depression, Sleep, MPA

PAS and depression). Third, we tested if sleep quality was a 686 college students from grades 1, 2 and 3, respectively. Of
mediator of the relationship between PAS and MPA (H3: PAS is these participants, there were 2,422 (47.41%) boys and 2,687
positively associated with PSQ, H7: PSQ is positively associated (52.59%) girls; on average, the mean age of participants was 15.53
with depression, and H8: Sleep quality mediates the relationship years, with a standard deviation of 2.22, ranging from 11 to 25
between PAS and depression). Finally, we also tested if MPA years. Approval was obtained from the Medical Research Ethics
and sleep quality together played a serial mediating role in the Committee of Harbin Medical University and the principals of
influence of PAS on depression (H4: MPA is positively associated the participating schools.
with PSQ and H9: MPA and sleep quality serially mediate the
relationship between PAS and depression). Measures
Perceived Academic Stress
METHODS Consistent with previous studies (69–71), PAS was measured
using one self-report item “How much academic stress did you
Survey feel in the study during the past month?” using a 5-point Likert
Data were collected from a cross-sectional questionnaire survey scale where 1 = “No,” 2 = “relatively low,” 3 = “average/general,”
that was conducted from September to December 2018 in 4 =“relatively high” and 5 = “extremely heavy,” with a higher
Heilongjiang Province, China, by the Heilongjiang Center for score indicating more PAS.
Disease Control and Prevention. A multistage cluster sampling
method was used. In the first stage, three cities of Heilongjiang Depression
province were randomly selected by economic characteristics. Center for Epidemiologic Studies-Depression Scale. The 20-
In the second stage, one urban district and one rural township item CES-D developed by Radloff (72) is a self-report measure
were chosen at random. In the third stage, two middle schools that has been widely used to assess depressive symptoms in
were randomly selected in each urban district and rural township; different populations (73). The reliability and validity of the
Since nine-year compulsory education was implemented in CES-D have been tested among Chinese populations (74).
China, high school education is not included in the nine-year The CES-D, when used in Chinese adolescents and university
compulsory education, high schools are more in urban districts students, has shown good reliability (75–78), as well as good
than in rural townships, two high schools and one high school validity (77, 78). There are four components of CES-D, namely
were randomly selected in urban district and rural township, somatic and retarded activity, depressed affect, positive affect,
respectively; Since vocational high schools and universities are and interpersonal relationships. Among the 20 items, four (items
scarce in rural townships, one vocational high school and one 4, 8, 12, and 16) are reversed scores. All items are evaluated on
college were randomly selected from the urban district. In the a 4-point Likert scale in relation to their incidence during the
fourth stage, two classes were randomly selected from each grade previous week, and are scored from 0 to 3 (0 = not at all, 1 =
of middle school, high school, vocational high school, and from a little, 2 = some, 3 = a lot); total possible scores thus range
grades 1, 2, and 3 in college. Since senior students may have been from 0 to 60, with higher scores indicating greater number of
looking for a job or working as an intern, some of them were not symptoms (79).
on campus, they were not been investigated. Finally, four middle For the original CES-D scale, a total score of 16 or greater is
schools, three high schools, one vocational high school, and one considered as indicative of subthreshold depression (72). Many
college were randomly selected within each city (Harbin, Jiamusi, studies have evaluated the diagnostic accuracy of the CES-D to
and Jixi) of Heilongjiang Province. Data were collected through detect depression among the general population and proposed a
a self-administered questionnaire distributed in class. Students variety of cut-off scores, such as a cut-off score of 21 for Chinese
completed the survey within 1 h, while a well-trained member of patients with type 2 diabetes (80), and a cut-off score of 22 for
the research group supervised. All the students were informed of the older Chinese population (81). However, the cut-off score of
the purpose of the study and assured that their identities would 16 has been widely used for Chinese adolescents and university
remain confidential. Students and their parents provided written students (7, 76, 82–84). Therefore, the same cut-off score has been
informed assent to participate in the study. used in our study too. Students with CES-D scores between 16
and 21 were defined as “mildly depressed,” between 21 and 24 as
Participants “moderately depressed,” and ≥ 25 as “severely depressed” (83).
Finally, we recruited 6,480 students in our investigation; 6,430 The CFA on the four-factor model showed a good model fit, with
(99.23%) valid questionnaires were analyzed after excluding χ2 = 16.54, df = 1, P < 0.000, RMSEA = 0.06, SRMR = 0.01, CFI
those with incomplete information. Participants were included = 0.99, TLI = 0.98. Additionally, the Cronbach’s alpha coefficient
in the sample if they had one constant internet-accessible was 0.84 for the total scale, all four dimensions had acceptable
mobile phone, which is similar with previous studies (64– reliability with Cronbach’s alpha coefficient of 0.70, 0.83, 0.78,
68). A total of 5,109 (79.46%) participants reported having and 0.62.
one constant internet-accessible mobile phone at the time of
the survey. The final sample comprised 1,904 middle school Mobile Phone Use Situation and Mobile Phone
students from grades 1, 2, and 3, respectively; 1,859 high school Addiction
students from grades 1, 2, and 3, respectively; 660 vocational Mobile phone use situation was assessed by three items. First,
high school students from grades 1, 2, and 3, respectively; and “How many hours do you use your mobile phone every day?”

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Zhang et al. Academic Stress, Depression, Sleep, MPA

to which participants answered with one of four options: “less TABLE 1 | Participants’ mobile phone use.
than a half hour,” “a half hour to one hour,” “one to two hours,”
N %
or “more than two hours.” Second, “How long have you had a
mobile phone?” to which participants answered “<1 year,” “1–2 Daily usage time of mobile phone
years,” “2–3 years,” or “more than 3 years.” Third, “How much <a half hour 195 3.82
do you spend on mobile phone charges every month?” to which A half hour to 1 h 1,108 21.69
participants answered “less 30 yuan,” “30–50 yuan,” “50–100 1–2 h 1,479 28.95
yuan,” or “more than 100 yuan.” More than 2 h 2,327 45.55
The Mobile Phone Addiction Index (MPAI) was used in our Duration of owing a mobile phone
study (85). Participants rated the 17 items on a 5-point Likert <1 year 842 16.48
scale ranging from 1 (not at all) to 5 (always). Higher scores
1–2 years 1,320 25.84
indicated greater addiction to mobile phones (86). There are four
2–3 years 929 18.18
components of MPAI, namely inability to control craving, feeling
More than 3 years 2,018 39.5
of anxiety and being lost, withdrawal or escape, and productivity
Mobile phone charges every month
loss. The Confirmatory Factor Analysis (CFA) on the four-factor
<30 yuan 2,389 46.76
model showed a good model fit, with χ2 = 6.44, df = 1, p <
30–50 yuan 1,942 38.01
0.05, RMSEA = 0.03, SRMR = 0.004, CFI = 0.99, TLI = 0.99.
50–100 yuan 574 11.24
Additionally, the Cronbach’s alpha coefficient was 0.90 for the
More than 100 yuan 204 3.99
total scale. All four dimensions had satisfactory reliability with
Cronbach’s alpha coefficient of 0.76, 0.81, 0.85, and 0.75.

Sleep Quality
sample size and a fixed degree of freedom, the χ2 value increases.
The Pittsburgh Sleep Quality Index (PSQI) was used in our study
It is difficult to get a nonsignificant chi-square (indicative of
(87). PSQI scale contains 19 items covering seven components:
good fit) when sample sizes are over 200 (89). This can lead to a
subjective sleep quality, sleep latency, sleep duration, habitual
problem where plausible models might be rejected. Because this
sleep efficiency, sleep disturbances, use of sleep medication, and
statistic is sensitive to the sample size, inspection of the other fit
daytime dysfunction. Each component was scored from 0 (no
indices is recommended (90). (2) The root mean square error
difficulty) to 3 (severe difficulty). The total score was calculated
of approximation (RMSEA) in which values ranging from 0.05
from the seven component scores, ranging from 0 to 21. A score
to 0.08 represent adequate fit, and values <0.05 indicate good
of more than 5 implied poor sleep (87). The CFA on the seven-
fit. (3) The standardized root mean square residual (SRMR) in
factor model showed a good model fit, with χ2 = 79.49, df = 11,
which values are ≤0.08 indicate good fit. (4) The comparative
P < 0.000, RMSEA = 0.04, SRMR = 0.02, CFI = 0.99, TLI = 0.98.
fit index (CFI), in which values range from 0.90 to 0.95 indicate
Additionally, Cronbach’s alpha coefficient was 0.624 for the PSQI
an adequate fit and values ≥0.95 indicate a good fit, and (5)
scale in our study.
the Tacker-Lewis index (TLI) in which values >0.90 indicate a
good fit.
Data Analyses
SPSS version 19.0. and Mplus 7.0 were used to analyse data
in our study. Descriptive analyses were first conducted of RESULTS
participants’ characteristics, participants’ mobile phone use and
the prevalence of sleep disturbance, MPA, and depression. Descriptive Statistics
We tested the reliability and validity of the MPAI scale, The mean scores of PAS were 2.61 ± 1.03, 2.68 ± 1.06, 2.13
PSQI scale and CES-D scale by examining their Cronbach’s ± 0.98, and 2.29 ±0.96 for middle school students, high school
alpha coefficient and performing a CFA. Spearman’s correlation students, vocational high school students, and college school
analysis was performed to examine the general relationships students, respectively.
among the four variables—PAS, MPA, sleep quality, and Among the participants, 45.55% used their mobile phone
depression. A structural equation model (SEM) was built to more than 2 h daily; 39.5% of the participants had a mobile phone
examine hypotheses. We tested the mediating role of MPA and for more than 3 years; 53.24% of the participants spent more
sleep quality; the constructed serial mediation model included than or equal to 30 yuan on mobile phone charges every month
three latent variables (MPA, sleep quality and depression) and (Table 1). The mean MPAI score of all the participants was 30.62
one manifest variable (PAS), PAS was the independent variable, ± 11.92.
depression was the dependent variable, and MPA and sleep The prevalence of depressive symptoms was 28.69% (n =
quality were the mediating variables (88). The bootstrapping 1,466) with a mean CES-D score of 12.52 ± 8.86. Prevalence
analyses used 5,000 samples at the 95% confidence interval (CI) of depression at a mild level (CES-D ≥ 16 and CES-D < 21),
to indicate significance. moderate level (CES-D ≥ 21 and CES-D < 25), and severe level
To determine whether the model fits the data well, multiple (CES-D ≥ 25) was 12.62, 6.95, and 9.12%, respectively. The
indices were tested, including (1) the model χ2 and its p value, in prevalence of depressive symptoms among high school students
which non-significance is desirable for good fit. With increasing (33.14%) was the highest, while the prevalence of depressive

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Zhang et al. Academic Stress, Depression, Sleep, MPA

TABLE 2 | Depression classifications of participants. Test for Serial Mediation Model

SEM was used to provide the fit indexes of the serial mediation
Classifications N %
model. A model was constructed with MPA (M1) as a mediator
Depression No (CES-D < 16) 3,643 71.31 and sleep quality (M2) as another mediator. In this model, PAS
Mild (CES-D ≥ 16 and CES-D < 21) 645 12.62 was set as the predictor (X) and depression as the outcome
Moderate (CES-D ≥ 21 and CES-D < 25) 355 6.95 (Y). Results of the serial mediation model indicated that the
Severe (CES-D ≥ 25) 466 9.12
constructed model exhibited a satisfactory fit with the data: χ2
Learning stage Middle school 508 26.68
= 1,196.50, df = 95, P < 0.000, SRMR = 0.04, RMSEA = 0.05,
High school 616 33.14
CFI = 0.95, and TLI = 0.94.
Vocational high school 195 29.55
First, PAS was positively associated with depression (B = 0.10,
College 147 21.43
SE = 0.02, 95% CI = 0.06–0.13). Higher levels of PAS were
related to higher levels of depression, and thus H1 was supported.
All participants 1,466 28.69
Second, PAS positively predicted MPA (B = 0.18, SE = 0.02, 95%
CI = 0.15–0.21). Higher levels of PAS were related to higher levels
of MPA, and thus H2 was supported. Third, PAS was positively
TABLE 3 | Prevalence of sleep disturbance for participants at different education
levels. associated with PSQ (B = 0.23, SE = 0.02, 95% CI = 0.19–0.26).
Higher levels of PAS were related to poorer sleep quality, and thus
Learning stage N % H3 was supported. Fourth, MPA was positively associated with
PSQ (B = 0.51, SE = 0.02, 95% CI = 0.47–0.54). Higher levels
Middle school 395 20.75
of MPA were related to poorer sleep quality, and thus H4 was
High school 678 36.47
supported. Fifth, MPA was positively associated with depression
Vocational high school 177 26.82
(B = 0.17, SE = 0.02, 95% CI = 0.13–0.22). Higher levels of
College 178 25.95
MPA were related to higher levels of depression, and thus H5 was
All participants 1,428 27.95
supported. Last, PSQ was positively associated with depression
(B = 0.44, SE = 0.03, 95% CI = 0.39–0.49). PSQ was related to
higher levels of depression, and thus H7 was supported.
TABLE 4 | Means, SD, Pearson’s correlation coefficient of variables.

M SD 1 2 3 4
Total, Direct, and Indirect Effects
Table 5 shows all possible indirect effects of the mediation model.
1. PAS 2.53 1.04 1 First, the indirect effect of PAS on depression through MPA was
2. MPAI global score 30.62 11.92 0.164* 1 significant (B = 0.08, 95% boot CI = 0.06–0.11), and thus H6
3. PSQI global score 4.29 2.59 0.253* 0.401* 1 was supported. Second, the indirect effect of PAS on depression
4. CES-D global score 12.52 8.85 0.236* 0.327* 0.410* 1 through sleep quality was significant (B = 0.27, 95% boot CI =
0.22–0.33), and thus H8 was supported. Third, the indirect effect
*p ≤ 0.01.
of PAS on depression through MPA and sleep quality was also
significant (B = 0.11, 95% boot CI = 0.08–0.14), and thus H9
was also supported. The total indirect effect was B = 0.46, 95%
symptoms among college students (21.43%) was the lowest boot CI = 0.40–0.53, and the mediating effect of MPA and sleep
(Table 2). quality were significant (P < 0.001), accounting for 64.01% (total
The prevalence of sleep disturbance was 27.95% (n = 1,428) indirect effect/total effect) of the total effect. The indirect effect
with a mean global PSQI score of 4.29 ± 2.59. The prevalence of related to sleep quality accounted for 82.61% of the total indirect
sleep disturbance among high school students (36.47%) was the effect, that is, (indirect effect 2 + indirect effect 3)/total indirect
highest, while the prevalence of sleep disturbance among middle effect (Table 5).
school students (20.75%) was the lowest. The average sleep time
and sleep latency were 7.40 ± 1.28 h and 15.81 ± 12.48 min, DISCUSSION
respectively. Among the participants, 14.50% reported that they
had bad or very bad sleep quality; 36.29% reported that their sleep Although academic stress is a well-known risk factor for
latency was more than 15 min; 50.89% reported that they slept depression in students, little is known about the possible
≤7 h a day; 12.62% reported that their sleep efficiency was ≤85%; psychological mechanisms underlying this association, or how
67.59% reported that they experienced sleep disturbances; 2.90% MPA and PSQ—which also are risk factors of depression—
of them reported that they used sleep medication; and 78.80% operate to have an impact on it. The main aim of our study
reported that they had daytime dysfunction (Table 3). was to test if there is a relationship between PAS and depression
Means, Standard Deviation (SD) and correlations of the and if MPA and sleep quality together play a serial mediating
main variables in the mediation model are shown in Table 4. role in the influence of PAS on depression among Chinese
The results, indicating that the variables were significantly and students. To the best of our knowledge, this was the first study
positively correlated, provide initial support for the hypotheses of to investigate the relationship between the variables using SEM.
this study, and act as a foundation of the serial mediation model. As expected, the serial mediation model showed that PAS was a

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Zhang et al. Academic Stress, Depression, Sleep, MPA

TABLE 5 | Total, direct, and indirect effects.

Depression outcomes as criterion

B SE t LLCI ULCI

Total effect of PAS on depression 0.71 0.05 15.11 0.63 0.81

Total direct effect of PAS on depression 0.26 0.05 5.75 0.17 0.35
Total indirect effect of PAS on depression 0.46 0.03 13.47 0.40 0.53
Indirect effect 1: PAS→ MPA→ depression 0.08 0.01 5.92 0.06 0.11
Indirect effect 2: PAS→ sleep quality→ depression 0.27 0.03 9.50 0.22 0.33
Indirect effect 3: PAS→ MPA→ sleep quality→ depression 0.11 0.01 8.16 0.08 0.14

Number of bootstrap samples for bias-corrected bootstrap CIs: 5,000. Level of confidence for all CIs: 95.
CI, confidence interval; LLCI, low limit confidence interval; ULCI, upper limit confidence interval.

significant predictor of depression. MPA and sleep quality played illustrated the mediating role of MPA in line with our hypothesis.
a mediating role between PAS and depression. Furthermore, As H6 predicted, MPA played a role in the path from PAS to
MPA and sleep quality together played a serial mediating role depression. MPA could partially explain the association between
in the influence of PAS on depression. In our study, the indirect PAS and depression among Chinese students—hence, MPA was
effect (i.e., the mediating effect of MPA and sleep quality) was not only an outcome of PAS, but also a catalyst of depression.
significant and accounted for 64.01% of the total effect. Thus, First, we found that high levels of PAS were associated with
apart from the direct effect of PAS on depression, the indirect high levels of MPA. This finding is consistent with previous
effect of PAS on depression should be emphasized. Our findings research results (48) and suggests that PAS may be a significant
provide significant insights into the risk factors for depressive trigger for students’ negative behaviors—such as MPA. Scholars
symptoms in students. have posited that young people’s digital distraction activities—
including playing computer games and online surfing—may
Depression Among Students be interpreted as a way to avoid problems, reality, and stress
According to studies that have focused on depression among (99, 100). High levels of PAS were associated with high levels of
Chinese students, the prevalence of depression varies from 22.0 MPA, which may be due to students’ use of mobile phones to
to 68.5% (5, 91–95). In our study, the prevalence of depressive escape from academic stress. Second, we found that high levels
symptoms was 28.69%. The differences across these studies may of MPA were associated with high levels of depression, which is
have resulted from temporal or regional disparities or variations in line with existing research results (35, 36, 101). Students who
in depression definitions and assessment methods. Depressive experience MPA may neglect real-world social engagement (102)
symptoms are related to many negative consequences, such resulting in academic underperformance (103), clinical health
as increased suicide risk among students (96) and increased symptoms (68), which are related to negative emotions—such
college withdrawal rates (97). Controlling depressive symptoms as depression. Our findings add to the existing research that
among students can both protect human capital value from suggests that when students are facing academic stress, they may
the societal perspective and maintain students’ physical and be addicted to their mobile phones to escape from academic
mental health from the individual perspective. In our study, the stress, and thus the negative consequences of MPA may lead to
most stressed, depressed, and sleep-deprived students were high depression in students.
school students. Thus, Chinese high school students’ physical
and mental health requires attention. In China, high school Mediating Role of Sleep Quality
students are admitted to colleges and universities based on As H8 predicted, sleep quality is not only an outcome of
gaokao, the standardized National College Entrance Examination academic pressure—it is also a catalyst of depression. Moreover,
(98). These admission decisions are extremely important, as they the indirect effect related to sleep quality accounted for 82.61%
impact high school students’ future educational opportunities, of the total indirect effect. Thus, compared to MPA, sleep
career paths, and life experiences. Our research results prove that quality played a more important role in the path from PAS to
Chinese students experience the most stressful and competitive depression. We found that higher levels of PAS were associated
academic environment of their academic careers when they are with poorer sleep quality. This finding is consistent with
in high school. previous research findings (24, 47). For example, Waqas et al.
demonstrated that perceived stress is a significant predictor of
Mediating Role of Mobile Phone Addiction PSQ (47). In China, students exist in a prolonged competitive
Chinese students spend considerable time on mobile learning environment and experience unrelenting academic
phones−45.55% of the participants spent more than 2 h stress. To achieve better academic performance and meet the
daily on their mobile devices. 39.5% of participants had had extraordinarily high expectations of parents and educators,
a mobile phone for more than 3 years, while the mean age of Chinese students have heavy homework burdens and learning
participants was 15.53 years. Using the mediation model, we burdens, resulting in sleep deprivation. Furthermore, academic

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Zhang et al. Academic Stress, Depression, Sleep, MPA

stress decreases sleep quality. According to Almojali et al., disturbances. Third, given that higher levels of MPA are
students who are not suffering from academic stress are less associated with poorer sleep quality and higher levels of
likely to experience PSQ (104). Previous studies have proved that depression, stakeholders should develop mitigating strategies
sleep deficiency and sleep health problems are common among to manage mobile phone use to ensure students’ sleep
Chinese students (105). Our research results may explain why quality and to relieve their depressive symptoms. Rational
higher levels of PAS were related to poorer sleep quality. and normative mobile phone use should be advocated and
We also found that high levels of PSQ were associated with classroom management strategies enforced to ensure that
high levels of depression, which is consistent with prior research students use their mobile phones at restricted times and
findings (31, 50, 57). Scholars have proved that PSQ is related places for positive purposes, such as online learning. Fourth,
to multiple negative consequences that may lead to depression— regular psychological assessment of depression, MPA, and PSQ
including daytime dysfunction, poor academic performance, and will help stakeholders detect and manage students’ health
fatigue (106, 107). Our findings add to the existing research problems. Last, parents and family members, educators, and
that suggests that sleep quality is a mediator between PAS and policy makers should encourage students to exercise more to
depression among students, which means that higher levels of alleviate MPA (114), improve sleep quality (115), and reduce
PAS were related to poorer sleep quality—such as sleep deficiency depression (116).
and daytime dysfunction—which was related to higher levels
of depression. Limitations
This study has several limitations. First, although we conducted
Serial Mediating Effect of Mobile Phone our research based on previous studies, due to the cross-
sectional design of our study, we could not confirm causal
Addiction and Sleep Quality relationships among the study variables. Second, the study
As per H9, MPA and sleep quality together play a serial period was September to December 2018, which was more
mediating role in the influence of PAS on depression. The than 2 years ago. However, we believe that the results of
results of our study showed that higher levels of PAS were our study are valuable for understanding the mechanisms of
related to higher levels of MPA, which was associated with how PAS influences students’ depression through MPA and
poorer sleep quality, which was associated with higher levels sleep quality, and our study can provide a basis for future
of depression. Numerous studies have documented that there research. Third, the study measured the participants’ perceived
is a positive relationship between MPA and PSQ (50, 52). academic stress using a single item, which may not have
For example, Kang et al. found that there were bidirectional captured various other relevant stressors, such as parental
longitudinal relationships between MPA and PSQ (50). Scholars learning expectations. Future studies should use a multiple-
have posited that the more screen time young people use, item scale to assess the participants’ perceived academic stress.
the less sleep time they have (108). Moreover, young people Forth, this study was limited to middle school, high school,
often use their mobile phone in the bedroom—bedtime mobile vocational high school, and college students. Future research on
phone use is related to higher insomnia scores and increased Chinese students at all education levels from primary school
fatigue (109), and both insomnia and fatigue are related to postgraduate levels is necessary. Fifth, perceived academic
to depression (110, 111). This may explain why MPA and stress can increase during stressful conditions (117), such as
PSQ together play a serial mediating role in the influence during exams or major change in life (e.g., from high-school
of PAS on depression. Our findings suggests that Chinese student to freshman). While our study was conducted in 27
students are likely to distract themselves from PAS by using schools in three cities, it is impossible that we conducted the
their mobile phones, and thus shortening their sleep duration, survey when the participants had no examinations or changes.
decreasing their sleep quality, leading to PSQ, and resulting in Future studies can control for stressful academic conditions
depressive symptoms. in the analyses to enhance their accuracy. Last, gender, age,
and other factors are important influencing factors of PAS,
Measures to Reduce Depressive MPA, sleep quality, and depression. Since the main aim of
Symptoms Among Chinese Students this study was to test if there was a relationship between PAS
To reduce depressive symptoms among students, their PAS and depression and if MPA and sleep quality together play a
should be managed. Given the multiple, negative consequences serial mediating role in the influence of PAS on depression,
(MPA, PSQ, and depression) of PAS, stakeholders—family the aforementioned factors were not considered in this study.
members, educators (including teachers, school administrators, Future studies should consider these factors and test the
and school health professionals), and policy makers—should relationships between PAS, MPA, sleep quality, depression, and
take preventative measures to help students manage and other health indicators.
relieve academic stress, such as provide counseling services
(112), foster their psychological resilience (113), and increase CONCLUSIONS
social support (19) to improve their overall well-being.
Second, students’ sleep quality should be ensured to reduce Our study’s results showed that Chinese students face the risk
depressive symptoms. Stakeholders should actively promote of depression and sleep disturbance, and the most stressed,
counseling and intervention for students experiencing sleep depressed, and sleep-disturbed students are those in high

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Zhang et al. Academic Stress, Depression, Sleep, MPA

school. Second, the results of the serial mediation model AUTHOR CONTRIBUTIONS
indicated that PAS predicted depression, and MPA and sleep
quality played a mediating role between PAS and depression. XZ, FG, ZK, and QW: conceptualization. XZ, HZ, JW, and HL:
Furthermore, MPA and sleep quality together play a serial formal analysis. FG, JZ, JL, JY, HZ, and BL: investigation. XZ, FG,
mediating role in the influence of PAS on depression. Our ZK, and BL: data curation. XZ, FG, and ZK: writing—original
study extends the understanding of how PAS is associated draft preparation. QW and BL: writing—review and editing.
with depression among Chinese students. Considering the All authors have read and agreed to the published version of
harmful effects of depression, stakeholders—including parents the manuscript.
and family members, educators, and policy makers—should take
preventative measures to alleviate Chinese students’ depression FUNDING
and depressive symptoms.
This research was funded by QW of The National Key Social
Science Fund of China (Grant No.19AZD013).
DATA AVAILABILITY STATEMENT
ACKNOWLEDGMENTS
The raw data supporting the conclusions of this article
will be made available by the authors, without undue The authors would like to express our appreciation to all of the
reservation. Requests to access these datasets should be individuals for their involvement in the study, including each of
directed to [email protected]. students and teachers for their support during the data collection.

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