Preplanned Studies: A Large-Scale Cross-Sectional Study on Mental Health Status Among Children and Adolescents — Jiangsu Province, China, 2022

Mental health disorders in childhood and adolescence often indicate a long-term and recurring disease course that extends into adulthood, causing significant psychological distress and financial strain for families and society. An increasing trend in the prevalence of these disorders has been noted in recent years, making them a significant public health concern in China (1). Li et al. reported that the general prevalence of mental disorders among children and adolescents in China was 17.5%, and 18.8% in Jiangsu Province. Notably, Jiangsu Province, one of the nation’s most developed regions located in eastern China, is renowned for its high-quality education. This research intends to examine the mental health status of children and adolescents in Jiangsu Province in order to inform and guide prevention and intervention strategies. This cross-sectional study was carried out from September to November 2022, encompassing 123,005 students, aged 6–18 years, from all 13 cities (84 counties), and 499 schools across Jiangsu Province. Diligent public health surveillance of children’s and adolescents’ mental health can offer essential data on prevalence trends and health behavior variances in different populations. This information is crucial for proposing early identification and targeted interventions for high-risk groups (2).

This cross-sectional study, conducted in 2022, was aligned with the “Surveillance for Common Disease and Health Risk Factors Among Students” program. Participants were students aged 6–18 years, drawn from all 13 cities (encompassing 84 counties) and 499 schools in Jiangsu Province. The sampling approach utilized a cluster randomized method, selecting two primary schools, two middle schools, and two high schools from each county. Within these institutions, two classes per grade level were targeted, and all members of the chosen classes were invited to participate, yielding at least 80 survey participants per grade.

Survey participants completed an online questionnaire in multimedia computer classrooms resulting in the accumulation of 123,005 valid responses, representing a 97.7% effective rate. Inclusion criteria required participants to be residents of Jiangsu Province, studying there, and willing to take part in the research. The exclusion criteria were: acute or severe illnesses impacting the ability to cooperate with the investigation, or an incomplete electronic questionnaire submission.

The questionnaire was segmented into two sections. The first solicited sociodemographic information which included variables such as age, gender, grade, family type, parental education level, accommodation status, and residential area. Resident students were defined as those who lived in a school dormitory more than three days per week. Single-parent family was denoted as living exclusively with one parent. Current smoking and drinking behaviors were described as the consumption of alcohol or smoking of cigarettes within the past 30 days.

The second part of the questionnaire appraised the participants’ mental health status over the preceding week. Evaluation tools used included the Center for Epidemiology Studies Depression (CES-D) scale and the Depression Anxiety Stress Scale (DASS-21). It also scrutinized health behaviors related to smoking and drinking.

This study utilized the CES-D to evaluate the prevalence of depressive symptoms. Responses were graded on a four-point Likert scale, with higher accumulated scores indicating severe depressive symptoms. The Chinese version of the CES-D scale has been employed and verified for its reliability in previous studies involving Chinese cohorts (3). A CES-D score of 20 or higher was utilized to determine the presence of depressive symptoms.

The DASS-21 was used to gauge three negative emotional states: depression, anxiety, and stress. As the depressive symptoms were already appraised using CES-D, the study employed only two subscales or 14 items of the DASS-21 to evaluate the participants’ symptoms of anxiety and stress. Responses were calculated on a four-point Likert scale. Each subscale’s total score was determined by doubling the sum of its seven items. High scores indicated severe negative emotions. The presence of anxiety symptoms was determined with scores above 7, while indications of stress symptoms were ascertained with scores exceeding 14 (4).

The Cronbach’s alpha for both the CES-D and DASS-21 were 0.866 and 0.914, respectively, pointing to substantial internal validity.

Categorical variables are presented in percentages, while continuous variables are furnished as Mean ± SD. The statistical evaluations were executed using IBM SPSS Statistics (version 25, IBM SPSS Inc., Chicago, USA), and the Chi-square test served to juxtapose the prevalence of symptoms linked to depression, anxiety, and stress across different variables. Factors associated with depressive symptoms were evaluated a priori, drawing on clinical significance, established scientific knowledge, as well as predictors spotlighted in previously published articles. With univariate logistic regression, variables of statistical significance were incorporated into a multivariate logistic regression in a subsequent step to assess the correlations between depressive symptoms and the explanatory variables, utilizing R software (version 4.2.2; The R Foundation for Statistical Computing, Vienna, Austria). In this study, a P-value of less than 0.05 was accepted to signal statistical significance.

This study incorporates 123,005 eligible questionnaires. Among the respondents, 64,785 (52.7%) identified as males and 58,220 (47.3%) as females; 34.9% were primary school attendees, 32.9% were middle school students, and 32.2% were high school pupils. It was found that 14.6% exhibited depression symptoms, 8.0% exhibited evidence of anxiety, and 27.4% demonstrated signs of stress (Table 1). The Chi-square test disclosed a statistically significant discrepancy in the prevalence of depression, anxiety, and stress-related symptoms (P<0.001) across distinct academic phases. A higher incidence of these symptoms was observed among female students, upper-grade students, current smokers or alcohol users, and individuals from single-parent households. Multivariable logistic regression results indicated that the potential risk factors for depressive symptoms include being female [odds ratio (OR)=1.39, 95% confidence interval (CI): 1.35–1.44], a high school student (OR=1.98, 95% CI: 1.88–2.07), residing in a single-parent household (OR=1.12, 95% CI: 1.08–1.17), current smoking (OR=2.40, 95% CI: 2.14–2.68), and current alcohol consumption (OR=3.18, 95% CI: 3.06–3.30) (Table 2).