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SUMMARY The negative association of insomnia and internet addiction with mental health is
widely documented in the literature, yet little is known about their inter-relationships.
The primary aim of this study was to examine the inter-relationships between insomnia,
internet addiction and depression. A total of 719 Chinese adolescents in Hong Kong
participated in this school-based cross-sectional study. Participants completed the
Chinese version of the Pittsburgh Sleep Quality Index (PSQI), the Chinese Internet
Addiction Scale (CIAS), the 12-item version of General Health Questionnaire (GHQ-12)
and questions assessing internet use pattern and sociodemographic characteristics. The
classication of internet addiction and insomnia was based on the CIAS cuto global
score >63 and PSQI cuto global score >5, respectively. Multiple regression analyses
tested the eects of insomnia and internet addiction on depression. Among students
with internet addiction (17.2%), 51.7% were also identied as insomniacs. Internet
addicts scored signicantly poorer on all PSQI components, except sleep duration, than
their non-addicted counterparts. After adjustment for gender and internet use time,
both internet addiction (b = 0.05; Sobel test Z = 6.50, P < 0.001) and insomnia
(b = 0.59; Sobel test Z = 4.49, P < 0.001) demonstrated a signicant association
with depression. Overall, there is high comorbidity between internet addiction and
insomnia. Both insomnia and internet addiction emerged as signicant explanatory
factors, but they exerted dierential eects on depression. Future research should be
directed at determining the causal relationship between internet addiction and
insomnia, and its underlying mechanism with depression.
keywords adolescent, Chinese, depression, insomnia, internet addiction
(Jenaro et al., 2007; Rotunda et al., 2003; Thomee et al., Kong. All student subjects and their parents provided written
2007). Intensive mobile telephone and computer usage were informed consent or assent, as appropriate, after receiving a
associated with waking-time tiredness and unhealthy sleep complete description of the study. A total of 730 students
habits (Punamaki et al., 2007). Internet games addicts had completed the questionnaires. Eleven participants were
poor concentration and sleep quality and high ratings on excluded from analysis due to incomplete data, leaving the
hopelessness and worthlessness measures (du Toit et al., 2004). nal sample of 719 secondary students.
The association between internet addiction and poor mental
health among adolescents was also evident (Ha et al., 2007;
Measures
Shaw and Black, 2008; Yen et al., 2008). Adolescent internet
addicts were generally more severely depressed (Yen et al., Insomnia
2007) and reported more suicidal thoughts (Kim et al., 2006).
Since the Pittsburgh Sleep Quality Index (PSQI) (Buysse et al.,
Internet addiction, which is characterized as a psychological
1989) was developed, based upon the International Statistical
dependence on the Internet, regardless of type of activity once
Classication of Disease and Related Health Problems, 10th
logged on (Kandell, 1998), is an emerging mental health
edition (ICD-10) (World Health Organization, 1992) and the
problem among adolescents. The prevalence of internet addic-
Diagnostic and Statistical Manual of Mental Disorders (DSM-
tion among adolescents in Norway and Italy was 1.98%
IV) (American Psychiatric Association, 1994) criteria for
(Johansson and Gotestam, 2004) and 5.4% (Pallanti et al.,
classication of insomnia, it was employed in this study to
2006), respectively. In Asia, up to 7.5% Taiwanese adolescents
assess insomnia and sleep disturbances. The PSQI diers from
were classied as internet addicts (Ko et al., 2007). The
other insomnia scales as it evaluates multiple dimensions of
prevalence of internet addiction among Chinese adolescents in
sleep over a 1-month period (Buysse et al., 1989). Nineteen
Mainland China ranges between 2.4% and 5.5% (Gao and Su,
individual items generate seven component scores (see the
2007; Hu et al., 2007). Despite the increasing prevalence of
seven components in Table 2), which are summed for one
internet addiction and its link with mental health and insomnia,
global score (range 021); higher scores represent poorer
relatively few studies have examined the nature of internet
subjective sleep quality. The Chinese version of the PSQI has
addictions inuence on insomnia and mental health among
good overall reliability and testretest reliability (Tsai et al.,
adolescents. Thomee et al. (2007) reported that internet use
2005). A PSQI global score of 5 6 with a sensitivity of 98%
increased the risk of developing depressive symptoms and sleep
and specicity of 55% was recommended as a cuto for
disturbances among young adults; however, the nature of the
classifying insomnia (Buysse et al., 1989; Tsai et al., 2005).
relationships among the three variables was not examined.
Another study suggested that insomnia mediated the eects of
internet use on perceived health among adolescents (Punamaki Internet addiction
et al., 2007). However, as mental health measures were not
Internet addiction was assessed using the Chinese Internet
included in the study, the question of whether insomnia and
Addiction Scale (CIAS) (Chen et al., 2003). Rating on a four-
internet use exerted dierential eects on mental health,
point Likert scale, the CIAS consists of 26 items divided into
particularly depression, remains unanswered.
seven subscales (see the subscales in Table 1) and the sum of
This cross-sectional study aimed to ll these research gaps
the subscales scores yields a total score (range: 26104). The
by exploring the inter-relationships between internet addiction,
CIAS possesses good internal consistency (Cronbachs as
insomnia and depression. In a sample of Hong Kong Chinese
ranging from 0.79 to 0.93) (Chen et al., 2003). A cuto of
adolescents, we (1) compared the sleep pattern and level of
63 64 with a sensitivity of 67.8%, specicity of 92.6% and
depressive symptoms between internet addicts and non-addicts
diagnostic accuracy of 87.6% was recommended for classifying
and (2) evaluated the possible dierential eects of insomnia
internet addiction (Chen et al., 2003).
and internet addiction on depression. We decided to test these
two explanatory pathways because although individuals with
internet addiction might develop insomnia due to staying up Depression
late for late-night log-on, a reverse explanatory pathway is also
The 12-item version of General Health Questionnaire (GHQ-
possible: internet addiction might reect maladaptive coping
12), which was designed for screening depressive symptoms
by insomniacs. Hence, both insomnia and internet addiction
within 1 month, was employed to evaluate depression (Gold-
may play a role as a causal variable antecedent or exogenous to
berg, 1978). The total score ranges from 0 to 36, with higher
certain criterion eects.
scores indicating higher levels of depression. Acceptable
internet consistency was demonstrated (Cronbach as ranging
METHOD from 0.78 to 0.85) (Ip, 2006; Kilic et al., 1997). The cuto score
of 11 12 yielded a sensitivity of 70% and specicity of 68%
Subjects
(Schmitz et al., 1999). The Chinese version of GHQ-12
After receiving Institutional Review Board approval, study possesses good psychometric properties (Chan and Chan,
subjects were recruited from a secondary school in Hong 1983).
Sleep latency; M (SD) 21.56 (60.99) 18.43 (26.61) 36.39 (141.44) )2.69 0.01
5 min 24.40 24.50 21.60
10 min 20.60 21.30 17.20
20 min 25.60 25.40 26.70
30 min 14.50 14.80 12.90
45 min 3.40 3.40 3.40
60 min 3.70 3.20 6.00
>60 min 8.20 7.40 12.10
Sleep duration; M (SD) 7.68 (1.66) 7.69 (1.51) 7.55 (1.85) 0.90 0.37
<7 h 27.50 25.70 35.70
78 h 34.50 35.40 30.40
>8 h 38.00 38.90 33.90
Habitual sleep eciency; M (SD) 85.17 (21.24) 87.32 (18.91) 78.33 (26.29) 3.32 <0.001
85% 69.70 72.90 56.00
7584% 16.60 16.10 19.00
6574% 4.50 3.90 7.10
<65% 9.20 7.20 17.90
Use of sleep medication
Not during the past month 92.80 95.30 80.90 43.13 <0.001
Less than once a week 3.70 3.30 6.10
Once or twice a week 2.50 1.30 8.70
Three or more times a week 0.90 0.20 4.30
Subjective sleep quality; M (SD) 1.04 (0.89) 0.95 (0.86) 1.48 (0.92) )5.93 <0.001
Sleep disturbances; M (SD) 1.07 (0.58) 1.02 (0.53) 1.36 (0.66) )5.93 <0.001
Daytime dysfunction; M (SD) 0.51 (0.83) 0.45 (0.77) 0.79 (1.04) )4.02 <0.001
PSQI global score; M (SD) 4.70 (3.19) 4.26 (2.75) 6.66 (3.92) )7.84 <0.001
Non-insomniacs 69.30 73.70 48.30
Insomniacs 30.70 26.30 51.70
GHQ-12 total score; M (SD) 11.04 (5.73) 10.57 (5.44) 13.34 (6.77) )4.69 <0.001
Non-depressed 54.80 57.90 41.10
Depressed 45.20 42.10 58.90
Table 3 Multiple regression models for the relationships between insomnia, internet addiction and depression
Model 1: Insomnia accounts for the link between internet addiction and depression
Internet addiction (IV) depression (DV) 0.25 0.10 0.02 0.07, 0.13 <0.001
Internet addiction (IV) insomnia (EV) 0.39 0.08 0.01 0.07, 0.09 <0.001
Insomnia (EV) depression (DV) 0.37 0.67 0.06 0.54, 0.79 <0.001
Internet addiction (IV) depression (DV) | insomnia (EV) 0.13 0.05 0.02 0.01, 0.74 <0.001
Sobel test Z = 6.50 P < 0.001
Model 2: Internet addiction accounts for the link between insomnia and depression
Insomnia (IV) internet addiction (EV) 0.37 1.73 0.17 1.40, 2.06 <0.001
Insomnia (IV) depression (DV) | internet addiction (EV) 0.32 0.59 0.07 0.45, 0.74 <0.001
Sobel test Z = 4.49 P < 0.001
All regression equations were controlled for gender and internet use time. Of the sociodemographic variables assessed, only gender and internet
use time were signicantly associated with depression in univariate analyses; hence, only these two variables were included in the multivariate
regression models to adjust for potential confounding effects.
IV, independent variable; DV, dependent variable; EV, explanatory variable; Std b, standardized beta coefcient; b, unstandardized beta
coefcient; SE, standard error; CI, condence interval.
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