BHSW 3500 - Epidemiologic Project - Final Draft

Running Head: EPIDEMIOLOGIC PROJECT— SCREEN TIME AND DEPRESSION 1
Applied Epidemiology Research Project — Association of Screen Time and Depression in
Adolescence
Pham Bao Ngoc Vuong, N01238584
William Argueta, N01227878
Ishmael Pennino, N01273485
Applied Epidemiology – BHSW 3500
Professor Nora Zwingerman
Friday, April 3, 2020

EPIDEMIOLOGIC PROJECT— SCREEN TIME AND DEPRESSION 2
Applied Epidemiology Research Project — Association of Screen Time and Depression in
Adolescence
Part 1: Development of an Analytical Research Question
Research Question: Is there an association between screen time and depression in adolescence?
This topic was chosen out of interest in the growing exposure to screens (computers,
phones, tablets, etc.) in the general populace specifically during adolescence and whether being
exposed to screens for an extended period of time can increase one’s risk of depression and
anxiety. This particular topic is relevant to workplace health and wellness because adolescents
who are exposed to extensive screen time (i.e. social media and television) may carry these
habits into the workplace which may negatively impact their mental health. Technology is also
increasingly being implemented in the workplace and more people are using products that have
screens which can further affect their mental health. This topic explores if screen time and
depression are linked and might have a significant impact on a person in the workplace and their
health and wellness. (155 words)
Part 2: Literature Search
In our first literature search for our analytical question we consulted PubMed as it is a
reputable database that contains more than 30 million citations for diverse biomedical peer-
reviewed literature from MEDLINE and PubMed Central (PMC), life science journals, and wide-
ranging online books (National Centre for Biotechnology Information [NCBI], n.d.). The key
terms that we used for our PubMed search were: ‘association’[MeSH Terms], ‘screen time’
[MeSH Terms], ‘depression’[MeSH Terms], ‘adolescence’[MeSH Terms]. The search results
from our first query generated 50 entries which we then further refined to align with our research
question. The key words for our refined search were as follows: "association"[MeSH Terms] OR
"association"[All Fields]) AND ("screen time"[MeSH Terms] OR ("screen"[All Fields] AND
"time"[All Fields]) OR "screen time"[All Fields]) AND ("depressive disorder"[MeSH Terms]
OR ("depressive"[All Fields] AND "disorder"[All Fields]) OR "depressive disorder"[All Fields]
OR "depression"[All Fields] OR "depression"[MeSH Terms]) AND ("adolescent"[MeSH Terms]
OR "adolescent"[All Fields] OR "adolescence"[All Fields]). We had specific inclusion and
exclusion measures that were utilized in our literature review. Our inclusion criteria were based
on relatively recent studies carried out within the last five years, in the Western society context,
focusing exclusively on our key terms, and we concentrated particularly on original research
studies. We excluded studies that were older than five years old, outside the Western society
context, and systematic reviews and/or meta-analysis studies to refine our search results to
studies that are current, culturally relevant, and entirely related to our research question. From
the initial 50 entries, we were able to narrow it down to just two results (Boers et al., 2019 &
Khouja et al., 2019). We also used the same criteria for our other searches in Humber Libraries
and Google Scholar and we were able to generate the same two articles with both search engines
and found one additional article (Maras et al., 2015) from Humber Libraries. (310 words)
Part 3: Annotated Bibliography

Boers, E., Afzali, M. H., Newton, N., & Conrod, P. (2019). Association of screen time and
depression in adolescence. JAMA Pediatrics, 173(9), 853-859.
doi:10.1001/jamapediatrics.2019.1759
This study was an observational, analytical, prospective cohort study carried out from
September 2012 to September 2018. It is a longitudinal study and randomized control
trial that collected comprehensive longitudinal data from a large group of adolescents
looking at both self-reported screen time use and depressive symptoms over a four-year
period (Christakis & Rivera, 2019). The study population and sampling were from a large
sample of adolescents (7th to 11th grade students) who were recruited from 31 schools in
the Greater Montreal area, totaling 3826 adolescents (1798 girls [47%], 2028 boys
[53%]). The measurement of exposure was based upon independent variables (social
media, television, video games, and computer use) and the sociodemographic measures
included sex, age, school, and socioeconomic status of the adolescents studied. The
outcomes were the symptoms of depression which were measured by using the Brief
Symptoms Inventory (BSI), an instrument that evaluates psychological distress and
psychiatric disorders in people; the participants were asked to specify, on a scale from 0
to 4, to what degree they experienced symptoms of depression (e.g., loneliness, sadness,
hopelessness, etc.). Screen time was measured by asking participants how much time per
day they spent on various screen devices, social media, watching television and other
computer activities. The time spent on these screen devices and mediums was
functionalized into four categories.
The results were that overall, depressive symptoms had a yearly increment, “year 1 mean
[SD], 4.29 [5.10] points; year 4 mean [SD], 5.45 [5.93] points” (p. 853). Multileveled
models which comprised random intercepts at the school and individual level
approximated between-person and within-person relations between screen time and
depression. Major between-person links showed that for every additional hour consumed
using social media, adolescents exhibited a 0.64-unit rise in depressive symptoms at 95%
CI, 0.32-0.51 estimates. Parallel between-level associations were found for computer use
at 0.69 increase with a 95% CI, 0.47-0.91 estimate range. Important associations between
within-person and social media use revealed that an additional 1-hour increase in a given
year was related with an extra 0.41-unit increase in depressive symptoms in that same
year. A comparable within-person association was observed for television a 0.18 increase
at a 95% CI, 0.09-0.27 in an estimate range. Consequential between-person and within-
person associations amid screen time and exercise and self-esteem reinforced the upward
social comparison yet not the displacement hypothesis. Moreover, a substantial
interaction among the between-person and within-person associations regarding social
media and self-esteem endorsed the reinforcing spirals hypothesis.
We found that this particular research study was directly relevant to our research
question. The major strength of the study was the assessment of the association amongst
various types of screen time and depression, using a sizable prospective adolescent
sample. Even though the study was insightful, there are nevertheless limitations.
Foremost, although the researchers had made a distinction between various types of
screen time, they did not actually differentiate within. For instance, it is uncertain which
types of social media, types/genres of television, and content are associated with
depression. To get a better understanding of the association between screen time and
depression, the authors recommend that future research will not only make a difference
among the types of screen time, but also within. Additionally, while symptoms of
depression and screen time were measured using commonly used and dependable
measurement scales among a large developmental sample of adolescents, the result may
not relate to research carried out within a clinical setting. (Appendix A) (595 words)
Khouja, J. N., Munafò, M. R., Tilling, K., Wiles, N. J., Joinson, C., Etchells, P. J., . . . Cornish,
R. P. (2019). Is screen time associated with anxiety or depression in young people?

Results from a UK birth cohort. BMC Public Health, 19(1), 82-11. doi:10.1186/s12889-
018-6321-9
The type of study used in this research is a prospective cohort study. According to
Khouja et al. (2019), Avon Longitudinal Study of Parents and Children (ALSPAC),
recruited 14,541 pregnant mothers living in Bristol, England who were due to give birth
between April 1st, 1991 and December 31st, 1992. After a year, the study consisted of
14,655 children (single and twins). The study measured for screen time use, depression
and anxiety and potential confounders. Screen time use was assessed using a
questionnaire administered when the children were 16 years old, where six questions
were asked relating to TV use, computer use and texting, categorized based on hours of
use and whether it was during weekdays or weekends. Anxiety and depression were
measured when children reached 18 years of age, using a self-administered, computerized
Clinical Interview Schedule (CIS-R) which was then assigned ICD-10 diagnoses.
Questions asked about symptoms relating to both conditions and were later categorized
as: no anxiety/depression; symptoms but no diagnosis; and diagnosis. Khouja et al.
(2019) later state that previous literature was examined to determine confounders. These
included sex, anxiety and depression examined at age 15, parental covariates including
surveyed maternal anxiety, maternal education, and parental socio-economic status.
Additionally, child covariates included IQ (measured at 8 years), parental conflict
(measured at 8 months), absence of biological father (measured at 4 years), number of
people living at home (measured at 4 years) bullying (measured at 16 years), and early
family TV use (measured at 18 months). The study was also adjusted for covariates
relating to other activities, such as exercising, playing outdoors, playing with others, time
spent alone, etc. Results of the study showed that of the 14,655 participants, 4562
participants completed the CIS-R questionnaire at 18 years, while 3109 completed the
questionnaire at 16 years. Furthermore, 1869 participants completed the covariate
information. Among the participants who completed the CIS-R, 11% (522) met the
criteria for diagnosis of anxiety, 8% (360) met the criteria for diagnosis of depression,
35% (1630) showed symptoms for anxiety but did not meet diagnosis criteria, 32%
(1466) showed symptoms for depression but did not meet diagnosis criteria.
The results of the study indicated that increased computer use at 16 years can increase the
risk of depression and anxiety at 18 years. The causality, however, cannot be confirmed.
Furthermore, there is little evidence to associate time spent watching TV and texting with
increased risk of anxiety and depression; these associations also differ on the day of the
week the devices were used. Strengths of this article include the use of data from a
longitudinal study compared to the more commonly used cross-sectional data. A
longitudinal study is more likely to suggest cause-and-effect relationships than a cross-
sectional study by virtue of its scope which is a period of time, sometimes lasting many
years. Another strength was using and adjusting for a wide range of confounders.
Limitations of the study include confounders not being measured correctly, and the extent
of missing data, which could result in bias. Lastly, limitations occur due to changing
patterns of screen use over time. Khouja et al. (2019) stated that data collected for the
study was conducted between 2007 and 2009, which predates smartphone, watch and
tablet use as well as the use of social media which was not assessed. On a final note,
Khouja et al. (2019) stated that it is difficult to determine if this data is applicable today
as screen use has changed and varies for each person. (Appendix B) (627 words)
Maras, D., Flament, M. F., Murray, M., Buchholz, A., Henderson, K. A., Obeid, N., & Goldfield,
G. S. (2015). Screen time is associated with depression and anxiety in Canadian youth.
Preventive Medicine, 73, 133-138. doi:10.1016/j.ypmed.2015.01.029
This cross-sectional research article is a part of the Research on Eating and Adolescent
Lifestyle study with the focus on identifying the association between sedentary screen
time and symptoms of depression and anxiety in Canadian adolescents. The three main
studied screen-based activities were watching television, playing video games, and using
the computer. The study sample includes 2482 English-speaking grade 7 to 12 students
(1048 males and 1434 females), from a total of 31 schools in Ottawa, Ontario. The study
data were collected between 2006 and 2010 which were originally gathered to test a
psychosocial model expected to predict eating and weight disorders in a community
sample of adolescents.
The adolescents completed self-report questionnaires in class under the supervision of
research staff. The researchers gathered socio-demographic information, assessed
sedentary screen time, depression, anxiety, physical activity, covariates; and used
multiple linear regressions. The students’ height and weight were measured in class,
using an HM200P Portable Stadiometer, and a UC-321 Digital Weighing Scale. Also,
BMI was statistically recorded. The Leisure-Time Sedentary Activities 6-item
questionnaire was used to measure time spent engaging in screen-based activities during
one week day and one weekend day. The participants’ mental state including behavioral
signs of depression and anxiety symptoms were assessed using the Children’s Depression
Inventory (CDI) self-report questionnaire and The Multidimensional Anxiety Scale for
Children self-report scale. The Godin Leisure-Time Exercise Questionnaire (GODIN)

was used to measure the participants’ physical activity levels to better isolate the
association between screen time and symptoms of anxiety and depression.
The results of the study indicate that duration of sedentary screen time may pose a risk
factor for severe symptoms of depression and anxiety in a community of Canadian youth.
Time spent playing video games [F(10,1511) = 21.71, p b 0.001, with R2 at .126
(adjusted R2 = .120)], and time spent using the computer [F(10,1511) = 21.71, p b 0.001,
with R2 at .126 (adjusted R2 = .120)] were significantly associated with more severe
symptoms of depression, while time spent playing video games emerged as a significant
predictor of more severe symptoms of anxiety [F(10,1470) = 12.66, p b 0.001, with R2
at .079 (adjusted R2 = .073)]. However, the findings cannot conclude whether reducing
screen time can also have a significant impact on the prevention and treatment of anxiety
and depression in adolescents.
The study has some limitations. Firstly, the cross-sectional design is a snapshot of time,
therefore, it limits the ability to figure the causal relationships between each screen-based
behavior and depression as well as anxiety. Secondly, the study could not identify
specifically the content or type of media and information the participants accessed which
has a significant impact on the findings. Lastly, with only 45% of the overall student
participation rate among 31 schools, the results of the study cannot be representative for
the entire Canadian youth.
There are several strengths of the study including the research staff objectively measuring
the participants’ height and weight which decrease the possibility of any bias in self-
reported BMI. Next, various methods of measurement, specifically the measurement of

physical activity, were utilized to support the internal validity of the association between
sedentary screen time and symptoms of depression and anxiety. Finally, all of the self-
report questionnaires in the study are all well-validated and used globally which helped
the authors better construct and identify the different associations between screen-based
behaviors and psychological symptoms. (See Appendix C) (599 words)
Part 4: Summary of the Evidence
There are similarities and inconsistency among the results of the three research articles.
Firstly, the longitudinal prospective cohort study “Association of Screen Time and Depression in
Adolescence” by Boers et al. (2019) concludes that among 4 independent variables which are
social media, television, video gaming, and computer use, only time spent on social media,
computer and television were associated with depression (Boers et al., 2019). Secondly, the
prospective cohort study “Is Screen Time Associated with Anxiety or Depression in Young
People? Results from a UK Birth Cohort” by Khouja et al. (2019) shows that increased computer
use at the age of 16 was associated with the risk of depression and anxiety while there was no
clear evidence of an association between time spent watching television and texting at 16 years
and depression (Khouja et al., 2019). Lastly, the cross-sectional study “Screen Time is
Associated with Depression and Anxiety in Canadian Youth” conducted by Maras et al. (2015)
with data collected between 2006 and 2010 indicates that television viewing posed no risk of
depression while video game playing and computer use were associated with depression, and
only video game playing was associated with symptoms of anxiety (Maras et al., 2015).
The three selected research articles have the same conclusion that extensive screen time,
especially computer use, is associated with increased depression in adolescents. However, for the
association with symptoms of depression, some screen-based activities were identified with
different results in each study. The results of the cohort study by Khouja et al. (2019) and the
cross-sectional study by Maras et al. (2015) show that there was little to no clear evidence of an
association between television viewing and depression. On the contrary, the cohort study by
Boers et al. (2019) suggests that while the tendency of television watching was associated with
less depression, the more time spent watching television was actually associated with increased
depression. In terms of video games, the cohort study by Boers et al. (2019) concludes that the
time spent playing video games had no association with depression which goes against the
results of the cross-sectional study by Maras et al. (2015) that video games playing was
significantly associated with depression. Also, among the three studies, only the cohort study by
Boers et al. (2019) measured time spent using social media which was highly associated with an
increased risk of depressive symptoms.
Conflicting results among the longitudinal prospective cohort study by Boers et al. (2019)
and the other two studies, in terms of television watching and video game playing, may arise due
to some of the factors such as inadequate study population/sampling, methods of measurement,
duration of the research, the depth of the research probing, and bias. In the cohort study by Boers
et al. (2019), the data were taken from a randomized clinical trial assessing the 4-year efficacy of
a personality-targeted drug and alcohol prevention program. Therefore, the study population is
unlikely to be representative of adolescents (Teh, Cai, & James, 2019). Furthermore, although
the data were collected from 2012 to 2018, the participants were only given a confidential web-
based survey during class time annually which may affect the accuracy and relevance of the data
(Boers et al., 2019). As for the second cohort study by Khouja et al. (2019), the study has limited
confounders and also misses data due to the low proportion of the participation rate with
complete data. The disadvantage of the study by Maras et al. (2015) is that it is hard to determine
the causal relationships between sedentary screen-based activities and depression because of the
cross-sectional study design. Additionally, all three studies did not address the specific content
and type of technology used. Also, they were not able to identify whether the participants
increased their screen time after or before they had depressive symptoms.
After considering the strengths and limitations of each study, the study by Khouja et al.
(2019) provides the strongest evidence because of the prospective cohort study design, adequate
sample sizes and the research followed up to collect the participants' data over a long-period of
time. Although the research was not able to measure a variety of confounders, the collected data
in the study are relevant and strong.
In conclusion, despite the limited and conflicting evidence of the relationship between
screen-time and depression in young people, these three credible research articles all find an
association between increased screen time of various activities or devices and an increased risk
of depression. (747words)
Word count: 3033 words
References
Christakis, D., & Rivera, F. (2019, September 1). JAMA Pediatrics editors' summary:
Prevalence of anxiety and depression among children and young adults with life-limiting
conditions; Association between screen time and depression in adolescence [Audio
podcast]. Retrieved from https://edhub.ama-assn.org/jn-learning/audio-player/17856054
National Centre for Biotechnology Information. (n.d.). PubMed. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/
Teh, J. J., Cai W., & James N. E. (2019). Association of media screen time use with depression
in adolescents. JAMA Pediatrics, 174(2), 209–210.
doi:10.1001/jamapediatrics.2019.4917
Appendix A
Research | JAMA Pediatrics | Original Investigation

Association of Screen Time and Depression in Adolescence
Elroy Boers, PhD; Mohammad H. Afzali, PhD; Nicola Newton, PhD; Patricia Conrod, PhD
IMPORTANCE Increases in screen time have been found to be associated with increases in depressive
symptoms. However, longitudinal studies are lacking.
OBJECTIVE To repeatedly measure the association between screen time and depression to test 3
explanatory hypotheses: displacement, upward social comparison, and reinforcing spirals.
DESIGN, SETTING, AND PARTICIPANTS This secondary analysis used data from a randomized
clinical trial assessing the 4-year efficacy of a personality-targeted drug and alcohol prevention
intervention. This study assessed screen time and depression throughout 4 years, using an annual survey
in a sample of adolescents who entered the seventh grade in 31 schools in the Greater Montreal area. Data
were collected from September 2012 to September 2018. Analysis began and ended in December 2018.
MAIN OUTCOMES AND MEASURES Independent variables were social media, television, video
gaming, and computer use. Symptoms of depression was the outcome, measured using the Brief
Symptoms Inventory. Exercise and self-esteem were assessed to test displacement and upward social
comparison hypothesis.
RESULTS A total of 3826 adolescents (1798 girls [47%]; mean [SD] age, 12.7 [0.5] years) were
included. In general, depression symptoms increased yearly (year 1 mean [SD], 4.29 [5.10] points; year 4
mean [SD], 5.45 [5.93] points). Multilevel models, which included random intercepts at the school and
individual level estimated between-person and within-person associations between screen time and
depression. Significant between-person associations showed that for every increased hour spent using
social media, adolescents showed a 0.64-unit increase in depressive symptoms (95% CI, 0.32-0.51).
Similar between-level associations were reported for computer use (0.69; 95% CI, 0.47-0.91). Significant
within-person associations revealed that a further 1-hour increase in social media use in a given year was
associated with a further 0.41-unit increase in depressive symptoms in that same year. A similar within-
person association was found for television (0.18; 95% CI, 0.09-0.27). Significant between-person and
within-person associations between screen time and exercise and self-esteem supported upward social
comparison and not displacement hypothesis. Furthermore, a significant interaction between the between-
person and within-person associations concerning social media and self-esteem supported reinforcing
spirals hypothesis.
CONCLUSIONS AND RELEVANCE Time-varying associations between social media, television,
and depression were found, which appeared to be more explained by upward social comparison and
reinforcing spirals hypotheses than by the displacement hypothesis. Both screen time modes should be
taken into account when developing preventive measures and when advising parents.
Key Points
Question What is the association of various types of screen time and depression in adolescence?
Findings In this cohort study of 3826 adolescents, a within-person association, based on repeated
measures, was found between social media and television use with symptoms of depression in
adolescence.
Meaning Use of social media and television in adolescents may enhance symptoms of depression and
should therefore be taken into account when developing preventive methods.
Depression is a common mental health disorder at all ages. 1 However, depression during the
developmental phase of adolescence is associated with significant academic, 2 psychosocial,3 and cognitive
impairment.4 Depression during adolescence has also been linked to substance use, poor interpersonal
relationships, lower self- esteem, and suicide. 5,6 Concerning findings suggest increased rates of depression
among adolescents.7 By 2020, mental health issues, including depression, are predicted to be among the
leading causes of morbidity and mortality among adolescents. 8 Researchers have attributed this rise in
rates of internalizing problems to the amount of time children spend in front of digital screens (i.e., screen
time).9,10
Several studies have found a positive association between screen time and depression in
adolescents.11,12 Other research has found no association,13,14 whereas several studies found a positive
association between screen time and correlates of depression, including self-esteem and loneliness. 15,16
Although we value these previous studies, we value that they have been methodologically limited to
assess how changes in screen time within a given year were associated with further changes in depression
from 1 year to the next.
Because of differences in the nature of the content and the way in which content is provided, it is
important to evaluate the association of different types of screen time, as each could have differing
associations. Therefore, our second aim concerns examining the association between 4 types of screen
time and depression in adolescents: social media, television, video gaming, and computer use, all of
which are popular modes of screen time among adolescents. 17 We draw on 3 media effect theories (i.e.,
displacement hypothesis, upward social comparison, and reinforcing spirals) that have been widely used
to assess associations between screen time and mental well-being. 18-20 Although our study does not take
place in the context of screen time content but in the context of screen time frequency, we posit that our
statistical modeling approach allows us to test whether similar processes occur as described within these 3
theories. Furthermore, to clarify the association between depression and screen time, we analyzed the
association between depression and 2 common factors: self-esteem and exercise. 21,22
As to the first aim, previous studies have not investigated the association between screen time and
depression repeatedly over time, to our knowledge. Instead, they simply tested a cross-sectional
association or tested pre-post differences in depression at a given follow-up period. Such methods do not
allow within-person inferences to be drawn because they do not account for developmental changes or
common underlying vulnerability. To establish a within-person association between screen time and
depression, it is important to use designs that model the association of year-to-year changes in screen
time and depression while also accounting for common vulnerability and within-person developmental
trends.
As to the second aim, we draw on 3 media effect theories. The displacement hypothesis posits
that all screen time negatively affects mental well-being because it displaces time participating in
healthier activities, such as physical exercise. 23,24 Upward social comparison suggests that the effects of
screen time on mental health depends on the nature of content. Upward social comparison occurs when
people compare themselves with others who they believe are in a more favorable position, 25,26 such as
others with perfect bodies and lives.27 It has been found that exposure to television depicting idealized
bodies leads to decreased body satisfaction, in turn resulting in more severe symptoms of depression.28
Social upward comparison has also been found to occur while using social media. For example, when
exposed to Facebook profiles containing upward comparison information (e.g., high-activity social
network), adolescents reported lower levels of self-esteem, which has been found to be correlated with
depression.29,30 Accordingly, a stronger association between screen time and depression should be
observed for social media and television compared with video gaming and computer use, which do not
contain depictions of actual individuals in real life to which youth socially compare themselves.
Reinforcing spirals31 also holds that screen time effects are mediated through content. However,
reinforcing spirals adds that people seek out and select information consistent with their cognitions.
Reinforcing spirals have been reported on exposure to violent content and aggression (e.g., violent
movies)32 and on exposure to political information and political stance. 33 For instance, it was found that
conservative media use (e.g., newspapers) was negatively associated with global warming belief
certainty, while nonconservative media (e.g., digital media) was positively associated with global
warming belief certainty and that beliefs toward global warming certainty made people more likely to
consume media congruent with these beliefs.33
Based on reinforcing spirals, one may argue that adolescents with depression seek out
information consistent with their depressive mindset, e.g., social media posts with depressive content. We
posit that reinforcing spirals might be particularly relevant for screen time that features algorithm-based
content feeding that is repeated inside a closed system (i.e., a filter bubble). 34 Within a filter bubble,
algorithms automatically recommend content an individual is likely to be interested in based on previous
search and selection behavior.
Multilevel models applied to each type of screen time that distinguish between time-varying
factors, between- person associations, and within-person associations, provide an opportunity to test the
abovementioned theories in association with screen time and depression. With respect to the displacement
hypothesis, all 4 types of screen time would be expected to be equally associated with depression.
Upward social comparison would be confirmed by demonstrating that for every unit increase in time
spent engaged in the type of media that promotes exposure to idealized images, similar increases in
depression should be found. Finally, reinforcing spirals may be displayed by showing convergent
associations across between-person associations and within-person associations as well as a positive
interaction between these associations. That is, the between- person association should be consistent with
and strengthened by the within-person association. Video gaming and computer use lack algorithmic
profiling, while television includes some of these features, particularly in recent years with the greater
availability of television streaming products. However, less sophisticated algorithms relative to social
media would yield stronger reinforcing spirals for social media and depression than television, video
gaming, and computer use.
Methods
Participants and Procedure
This study used data from a randomized clinical trial assessing the 4-year efficacy of a
personality-targeted drug and alcohol prevention program. A detailed description of the measures and
procedure has been published elsewhere (ClinicalTrials.gov identifier: NCT01655615). 35 A large sample
of adolescents were recruited from 31 schools in the Greater Montreal area starting September 2012 and
studied from grade 7 to 11. Students completed a confidential annual web-based survey during class time
to assess screen time and symptoms of depression. Data were collected from September 2012 to
September 2018. Analysis began and ended in December 2018.
All participants were included in the analysis if at least 75% of their data across all items and
assessment point was found to be complete. While the intervention in this study is expected to be
associated with substance use among adolescents, there is no reason to expect that the intervention would
be associated with how substance use will be associated with screen time and symptoms of depression.
Ethical approval was obtained from the CHU Sainte-Justine Research Center, and written informed con-
sent was obtained from parents and students.
Measures
Sociodemographic measures included sex, age, school, and socioeconomic status. Symptoms of
depression were measured using the depression subscale of the Brief Symptoms Inventory. 36 Participants
were requested to indicate, on a scale from 0 (not all) to 4 (very much), to what extent they experienced 7
symptoms of depression (e.g., feeling lonely, sad, hopeless). 37
Screen time was measured by asking participants how much time per day they spend on playing video
games (on a computer, cell phone, game console), Facebook, Twitter, or other social networking sites;
watching shows or movies on television or the computer; and on other activities on the computer. The
time spent was operationalized into 4 categories: 0 to 30 minutes, 30 minutes to 1 hour and 30 minutes, 1
hour and 30 minutes to 2 hours and 30 minutes, and 3 hours and 30 minutes or more.
Self-esteem was measured using the Rosenberg Self- Esteem Scale, 38 a self-report instrument containing
10 items on a 4-point Likert-type scale ranging from 0 (strongly dis- agree) to 3 (strongly agree). Exercise
was measured by asking how many times the participant exercises per week for more than 30 minutes
other than gym class at school.
Each multilevel model controlled for baseline socioeconomic status (coded on a range of 0
[lower] to 10 [higher]) and sex (coded as 0 [female] and 1 [male]). Socioeconomic status was assessed
using the Family Affluence Scale for Adolescents. 39
Analyses
One multilevel model was applied to assess the association of the 4 types of screen time with
depression. The model included random intercepts and slopes at individual and school levels. The time
parameter was coded as wave. Independent variables were person-mean centered. The model estimated
intercept and time parameters and evaluated the contribution of the mean use of 4 types of screen time
throughout 4 years (between-person associations) and change in use in a given year compared with the
participant’s mean use (within-person associations). Missing data were handled through full information
maximum likelihood. R, version 3.5.0 (R Foundation for Statistical Computing) was used.
Results
Overall, 3826 adolescents (1798 girls [47%]; mean [SD] age, 12.7 [0.5] years) were included.
Among the 3826 participating adolescents, 3659 (95.6%) passed the data quality requirements while also
providing the required demographic information. Regardless of intervention exposure, all participants
were included in the analysis. For sex and socioeconomic status (mean [SD] score, 5.30 [1.70]), girls and
those who reported lower socioeconomic status showed more severe symptoms of depression. Concerning
the main variables, depression symptoms (year 1 mean [SD], 4.29 [5.10] points; year 4 mean [SD], 5.45
[5.93] points) and the usage of social media (year 1 mean [SD], 0.94 [1.25] points; year 4 mean [SD],
1.44 [1.26] points) and television (year 1 mean [SD], 1.52 [1.16] points; year 4 mean [SD], 1.61 [1.24]
points) increased yearly. Video gaming use (year 1 mean [SD], 1.34 [1.30] points; year 4 mean [SD], 1.36
[1.44] points) decreased slightly, whereas computer use (year 1 mean [SD], 0.60 [1.03] points; year 4
mean [SD], 0.62 [1.05] points) remained stable over the course of 4 years (eTable in the Supplement).
A significant between-person association indicated that a 1-hour increase in social media use was
associated with a 0.64- unit (on a scale from 0 to 28) increase in the severity of depression symptoms
over 4 years (95% CI, 0.48-0.81) (Table 1).
Analyzing within-person associations, we found that increasing the mean amount of time spent using
social media by 1 hour within a given year was associated with a 0.41-unit increase in the severity of
depression symptoms (95% CI, 0.32-0.51) within that same year. A between-person association was
found for computer use, indicating that increasing the mean amount of computer use by 1 hour was
associated with a 0.69-unit increase in the severity of depression symptoms (95% CI, 0.47- 0.91). Also
at a between-person level, increasing the mean amount of time spent watching television by 1 hour was
associated with a −0.22-unit decrease in the severity of depression symptoms (95% CI, −0.40 to −0.05).
Analyzing within- person associations, increasing the mean amount of time spent watching television by
1 hour within a given year was associated with a 0.18-unit increase in the severity of depression
symptoms (95% CI, 0.09-0.27) within that same year. No significant associations were found between
video gaming and depression. Because social media between-person and within- person associations were
convergent, another model examined their interaction (Table 2). The results revealed a significant
interaction (95% CI, 0.01-0.22), potentially indicating a reinforcing spiral.
In providing more clarity on the association between screen time and depression, we performed
explanatory post hoc analyses with 2 common factors associated with depression: self-esteem and
exercise.12,21 Self-esteem has been used in work on upward social comparison and exercise in work on
the displacement hypothesis. No significant between-person and within-person associations were found
for screen time and exercise, indicating that exercise was not associated with depression (Table 3).
Lower levels of self-esteem were associated with more severe symptoms of depression, at both a
between-person (95% CI, −6.96 to −6.46) and within-person (95% CI, −5.62 to −5.16) level. Given these
findings, we analyzed the association between screen time and self-esteem.
Analyzing between-person associations, increasing the mean amount of time spent using social media by
1 hour was associated with a −8.47-unit (on a scale from 0 to 40) decrease in self-esteem (95% CI, −10.02
to −6.74); for television use, a 2.39- unit increase in self-esteem (95% CI, 0.48-4.27); for video gaming, a
−3.15-unit decrease in self-esteem; and 1 hour of increased computer use, a −4.88-unit decrease in self-
esteem (95% CI, −7.20 to −2.50) (Table 4). At the within-person level, the associations between social
media use, television use, and self-esteem were found to be significant. Increasing the mean amount of
time spent using social media by 1 hour within a given year was associated with a −3.32-unit decrease in
self- esteem (95% CI, −4.30 to −2.30) within that same year. In- creasing the mean amount of time spent
watching television by 1 hour was associated with a −9.80-unit decrease in self- esteem (95% CI, −19.50
to −0.01). Because there was convergence between social media use and self-esteem at the between-
person and the within-person levels, we analyzed their interaction, which was nonsignificant (Table 5).
Discussion
To our knowledge, this study is the first to use developmental data from a large sample of
adolescents to examine the association between 4 types of screen time and depression. We found that high
mean levels of social media over 4 years and any further increase in social media use in the same year
were associated with increased depression. We also demonstrated that the tendency to engage in high
mean levels of television over 4 years was associated with less depression. However, any further increase
in television use in the same year was associated with increased depression. Furthermore, we showed that
high mean levels of computer use over 4 years are associated with increased depression; however, any
further increase in computer use in the same year is not associated with increased depression.
Furthermore, video gaming is not associated with depression. Finally, post hoc analyses reveal that self-
esteem, but not exercise, is associated with depression in adolescence and that only social media and
television have a time-varying negative association with self-esteem (within-person association).
The results of our study do not support the displacement hypothesis, stating that all screen time has
negative consequences for mental well-being. Time spent playing video games shows no association with
depression. This nonsignificant association may be explained by a 2007 study,31 arguing that playing
video games is not detrimental for adolescents’ mental well-being because it has social and emotional
benefits. Compared with their forerunners 15 to 20 years ago, the average video gamer is not socially
isolated. It has been shown that more than 70% of gamers play their games with a friend, either physically
together or online.40 Furthermore, it is argued that playing video games is among the most effective means
by which adolescents generate positive feelings. 41
The finding that high mean levels of television use over 4 years was associated with less
depression among adolescents is also neither in line with the displacement hypothesis nor with upward
social comparison. However, the within- person association of television use and depression is in line
with both hypotheses. Furthermore, the divergence between television use between-person and within-
person associations with depression indicated that reinforcing spirals do not characterize this association.
Youth who are less prone to depression appear to be more likely to spend time in front of the television,
but the more time they spend watching television is associated with increasing depressive symptoms.
Based on the social comparison hypothesis, we argue that watching more television over time increases
the likelihood of upward social comparison to occur, in turn potentially triggering and enhancing
depression.
High mean levels of computer use are associated with higher levels of depression among
adolescents; however, there was no evidence of a within-person association. An explanation might be that
increased computer use was found to be positively associated with computer self-efficacy (beliefs of
one’s capability of performing tasks on the computer). 42 In turn, increased computer self-efficacy has been
shown to be associated with improved mental well-being. 43 Thus, it seems that over time, adolescents gain
more computer experience, which may positively affect their self-efficacy, in turn resulting in less severe
symptoms of depression.
We found an association between social media and depression in adolescence. Based on the
upward social comparison, it may be that repeated exposure to idealized images lowers adolescents’ self-
esteem, triggers depression, and enhances depression over time. Furthermore, heavier users of social
media with depression appear to be more negatively affected by their time spent on social media,
potentially by the nature of information that they select (e.g., blog posts about self- esteem issues),
consequently potentially maintaining and enhancing depression over time. The latter is in line with a
study showing that the lower adolescents’ mood level, the less positive media content they select. 44
However, whether the algorithmic function of social media enhances this process is not yet known and
should therefore be tested.
The most important finding of the post hoc analyses was that increased social media and
television use were associated with lower self-esteem over time. Taking into account the upward social
comparison, it might be that repeated exposure to idealized images on social media and television
decreases self-esteem. However, according to our results, the reinforcing spirals only applies to
depressive symptoms and not self-esteem, suggesting cognitive and mood exacerbating effects of social
media.
Strengths and Limitations

The main strength of our study is the assessment of the association between various types of
screen time and depression, using a large prospective sample of adolescents. Although our study provides
important insights, there are limitations. First, although we distinguish between various types of screen
time, we do not distinguish within. For example, it remains unclear which types of social media,
types/genres of television, and content are associated with depression. To obtain a better understanding of
the association between screen time and depression, we suggest that future research not only makes a
distinction between the types of screen time, but also within.
Second, although symptoms of depression and screen time were assessed using commonly used and
reliable measurement scales among a large developmental sample of adolescents, the result may not
match those from research conducted within a clinical setting.
Conclusions
To our knowledge, the present study is the first to present a developmental analysis of variations
in depression and various types of screen time. This study indicated that adolescents’ social media and
television use should be regulated to prevent the development of depression and to reduce exacerbation of
existing symptoms over time.
Article Information
Accepted for Publication: March 23, 2019.
Published Online: July 15, 2019. doi:10.1001/jamapediatrics.2019.1759
Author Contributions: Dr Boers had full access to all of the data in the study and takes responsibility for
the integrity of the data and the accuracy of the data analysis.
Concept and design: Boers, Conrod. Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Boers, Conrod. Critical revision of the manuscript for important intellectual
content: All authors.
Statistical analysis: All authors.
Obtained funding: Conrod.
Administrative, technical, or material support: Conrod.
Supervision: Conrod.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by the Canadian Institutes of Health Research (grant
FRN114887, Dr Conrod). This work was partially supported by a grant from the Fonds de la recherche en
santé under the framework of ERANET-Neuron ELSA (JTC 2018). Dr Afzali was supported by a
postdoctoral fellowship from the Canadian Institutes of Health Research. Dr Newton was supported by a
fellowship from the National Health and Medical Research Council in Australia. Dr Conrod was
supported by a senior investigator award from the Fonds de la recherche en santé
du Québec.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript;
and decision to submit the manuscript for publication.
Tables
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Appendix B
Research article
Is screen time associated with anxiety or depression in young people? Results from a UK birth
cohort
Jasmine N. Khouja1,2,3*, Marcus R. Munafò1,2, Kate Tilling3, Nicola J. Wiles3, Carol Joinson3, Peter J.
Etchells4, Ann John5, Fiona M. Hayes7, Suzanne H. Gage1,2,6† and Rosie P. Cornish3†
Abstract
Background: There is limited and conflicting evidence for associations between use of screen-based
technology and anxiety and depression in young people. We examined associations between screen time
measured at 16 years and anxiety and depression at 18.
Methods: Participants (n = 14,665; complete cases n= 1869) were from the Avon Longitudinal Study of
Parents and Children, a UK-based prospective cohort study. We assessed associations between various
types of screen time (watching television, using a computer, and texting, all measured via questionnaire at
16y), both on weekdays and at weekends, and anxiety and depression (measured via the Revised Clinical
Interview Schedule at 18y). Using ordinal logistic regression, we adjusted for multiple confounders,
particularly focussing on activities that might have been replaced by screen time (for example exercising
or playing outdoors).
Results: More time spent using a computer on weekdays was associated with a small increased risk of
anxiety (OR for 1–2 h = 1.17, 95% CI: 1.01 to 1.35; OR for 3+ hours = 1.30, 95% CI: 1.10 to 1.55, both
compared to < 1 h, p for linear trend = 0.003). We found a similar association between computer use at
weekends and anxiety (OR for 1–2h = 1.17, 95% CI: 0.94 to 1.46; OR for 3+ hours = 1.28, 95% CI: 1.03
to 1.48, p for linear trend = 0.03). Greater time spent using a computer on weekend days only was
associated with a small increased risk in depression (OR for 1–2h = 1. 12, 95% CI: 0.93 to 1.35; OR for
3+ hours = 1.35, 95% CI: 1.10 to 1.65, p for linear trend = 0.003). Adjusting for time spent alone
attenuated effects for anxiety but not depression. There was little evidence for associations with texting or
watching television.
Conclusions: We found associations between increased screen time, particularly computer use, and a
small increased risk of anxiety and depression. Time spent alone was found to attenuate some
associations, and further research should explore this.
Keywords: Screen time, Anxiety, Depression, Mental health, ALSPAC, Is screen time associated with
anxiety or depression in young people? Results from a UK birth cohort
Background
The amount and nature of time spent using screen-based devices such as televisions, computers,
and mobile phones has changed over recent years. A report in 2017 suggested that British children aged
5–15 years spent 1.5 more hours per week online than watching TV which is in contrast to their findings
in 2007 when they spent roughly 5 h more per week watching TV than online [1]. Patterns of screen use
also differ depending on time of the week, with more time spent using screens on weekends than
weekdays [2]. The report found that screen-based products were commonly used by children and
adolescents, with 79% of 12–15-year olds owning their own smart phone, and 48% of 5–15-year olds
having a TV in their bedroom in 2016 [1]. Alongside increases in screen time there has been an increase
in the recorded incidence of common mental health disorders in children and adolescents [3], leading us
to question whether they are related.
Teychenne and colleagues [4] recently systematically reviewed the literature on the association
between sedentary behaviour and anxiety; they included studies that specifically examined screen time.
Of the four studies in the review that explored the association between increased screen time and anxiety,
two found positive associations [5, 6]. However, like many in this field, these studies were cross-sectional
and could not assess the temporal direction of association. The two remaining studies either found no
association [7] or an inverse association [8] (in a cross-sectional study and prospective cohort,
respectively). Of the four studies, only one [5] was assessed as having strong methodological quality.
Other reviews of the literature concluded that there was insufficient or inconclusive evidence for an
association between screen time and anxiety [9, 10].
There is more consistent evidence for an association between screen time and depression [11–13].
However, the evidence base is still limited, with research conclusions restricted by methodological
limitations such as cross-sectional designs and broad age ranges (including both children and adults) [4].
What evidence there is indicates that associations between screen time and depression may operate in
both directions [12, 14].
We therefore examined the association between screen time and both anxiety and depression
during adolescence using prospectively collected longitudinal data from the Avon Longitudinal Study of
Parents and Children (ALSPAC) [15, 16]. Building on previous research, ours is the first study to assess
the association between screen time (and different types of screen time) in a prospective UK cohort.
Importantly, we also attempted to adjust for a range of other activities in order to identify what other
activities are sacrificed for screen time. Such measures include time spent outside, time spent socialising,
and time spent alone. We also separately investigated the associations with weekday and weekend screen
use.
Methods
Participants and recruitment
ALSPAC is a large prospective cohort which initially recruited 14,541 pregnant mothers living in
and around Bristol, England, and due to give birth between 1st April 1991 and 31st December 1992. Of
the 14,062 live births, 13,988 children were alive at 1 year. A further 706 pregnant women – individuals
who were eligible but failed to enrol in the original recruitment phase – were recruited in subsequent
years. This cohort has been described in detail previously [15, 16]. The study website contains details of
all available data through a fully searchable data dictionary [17]. The sample in this study consists of the
14,665 single- tons and twins alive at one year who had not subsequently withdrawn from the study (Fig.
1).
Ethics statement
Ethics approval for the study was obtained from the ALSPAC Ethics and Law Committee and the
Local Research Ethics Committee (NHS North Somerset & South Bristol Research Ethics Committee).
Full details of ethics committee approval references for ALSPAC can be found online
(http://www.bristol.ac.uk/alspac/researchers/researc h-ethics/). This study was approved by the ALSPAC
Executive Committee. Study participants who complete questionnaires consent to the use of their data by
approved researchers. Up until age 18 an overarching parental consent was used to indicate parents were
happy for their child (the study participant) to take part in ALSPAC. Consent for data collection and use
was implied via the written completion and return of questionnaires. Study participants have the right to
withdraw their consent for specific elements of the study, or from the study as a whole, at any time.
Measures
Screen time use
Screen time was assessed in a study questionnaire administered when the children were aged 16
years. Respondents were asked six questions relating to watching television, computer use, and texting
(Additional file 1, section 1). Answers were categorised as less than one hour, one to two hours, and three
or more hours per average day and separate responses were collected for weekend and weekday use.
Anxiety and depression

Anxiety and depression were measured at approximately 18 years, using a self-administered,

computerised version of the revised Clinical Interview Schedule (CIS-R) [18] completed during a study
clinic. The CIS-R asks questions about a range of symptoms and can be used to assign ICD-10 diagnoses
of depression and anxiety disorders [19,20]. Anxiety and depression were coded as three-level variables
categorised as: no anxiety/depression; symptoms but no diagnosis; and diagnosis. For anxiety, symptoms
related to general anxiety, phobias, panic and worry; for depression, symptoms related to depression or
depressive thoughts. Sleep, concentration and fatigue scores were not used to indicate symptoms of
depression due to their lack of specificity [21–23]. Earlier depression and anxiety at 7, 10, 13 and 15
years were assessed using the Development and Well-Being Assessment (DAWBA) [24]. At 7, 10 and 13
years, computerised DAWBA questions were completed by the parent of the child, at 15 years the
computerised DAWBA questionnaire was self-administered. A computerised algorithm was used to
derive ordered categorical variables (with 6 categories) for anxiety and depression, with higher categories
indicating increasing levels of symptoms [24]. Due to small numbers in some of the categories, anxiety
and depression at 7, 10 and 13 were dichotomised into low (categories 1 and 2) and medium/high
(categories 3 to 6); anxiety and depression at 15 were regrouped into low (categories 1 and 2), medium
(category 3) and high (categories 4–6).
Potential confounders
Previous literature was examined to select potential confounders. These included sex and
anxiety/depression measured at age 15 years. Parental covariates were: maternal age at delivery;
maternal anxiety measured via questionnaire at seven time points on and after the child was 8 months
(these were used to create a single binary variable – maternal anxiety – which was positive if the
mother reported anxiety at any time point, no if she reported no anxiety on all occasions, and missing
otherwise); maternal depression measured when the child was 8 months using the Edinburgh Post-
natal Depression Scale (EPDS) [25]; maternal education measured during pregnancy and determined
by the mother’s highest educational qualification (a 4-level categorical variable, Additional file 1, section
1); and parental socio-economic status (SES). SES was measured when the mothers were 32 weeks
pregnant and was based on the higher of the mother or partner’s occupational social class, dichotomised
into non-manual (professional, managerial or skilled professions) and manual (partly or unskilled
occupations).
Childhood covariates included for further adjustment were: IQ, measured at 8 years using the
Wechsler Intelligence Scale for children (WISC-IIIUK) [26]; parental conflict measured at 8 months;
presence of the child’s father in the child’s home measured at 4 years; number of people living in the
child’s home measured at 4 years; bullying measured at 16 years; and early family TV use measured at 18
months.
We also adjusted for covariates relating to time spent doing other activities: exercising; on
transport; playing outdoors in summer and winter; playing with others; making, drawing and constructing
things; being alone; completing home or college work; reading; playing musical instruments; talking on a
mobile; and talking on a landline phone.
Further details about these measures including the measurement methods and definitions are
available in the supplementary material (Additional file 1, section 1).
Data analysis
Only 1869 participants (12.7% of the overall study sample) had complete data on the outcomes,
exposure and covariates, so we used multiple imputation (MI) using chained equations (fully conditional
specification) [27] to address missing data. Logistic regression was used to assess whether earlier
depression and anxiety (at 7 years) was associated with missing outcome information after adjustment for
covariates to assess whether the outcome data were likely to be missing not at random (MNAR)
conditional on the baseline covariates.
The MI models, in which 100 datasets were imputed, included the exposures, outcomes and all
covariates listed above as well as auxiliary variables – included to make the missing at random
assumption more plausible. These variables included all the earlier measures of depression and anxiety
as well as earlier measures of screen use and other activities and additional measures predictive of
childhood and parental factors. Further details of the imputation models, including the auxiliary
variables, are given in the supplementary material (Additional file 1, section 2 and Table S1).
We assessed the association between screen time, separately for types of device (watching
television, computer use, and texting) and timing (weekday or weekend), and anxiety and depression
using ordinal logistic regression models. This gave an odds ratio for being in a higher anxiety/depression
category for a one unit change in a covariate. The ordinal logistic regression model assumes that the
relationship between the lowest category of the outcome and all the higher categories are equal to the
relationship between the second lowest category and all the higher categories; a Brant test was conducted
to confirm the data did not violate this assumption [28]. Covariates were grouped and added to the
unadjusted model (model 1) to examine their effect on the association. Model 2 adjusted for sex, maternal
age, anxiety/depression at 15 years, maternal anxiety and depression, maternal education, and parental
SES. Model 3 also included IQ, parental conflict, presence of the child’s father, number of people living
in the child’s home, bullying, and family TV use in early life. Each of the sub-models of model 4
additionally adjusted for time spent engaging in one other activity on weekdays or weekends (time alone
[model 4a], on transport [model 4b], playing outdoors in summer [model 4c], playing outdoors in winter
[model 4d], playing with others [model 4e], drawing, making or constructing things [model 4f],
exercising [model 4 g], completing school or college work [model 4 h], reading [model 4i], playing
musical instruments [model 4j], talking on a mobile phone [model 4 k] and talking on a landline phone
[model 4 l]). P-values for the association between types of screen time and anxiety and depression were
obtained using a test for linear trend.
We carried out the following sensitivity analyses. Firstly we repeated the above analyses for the
complete case sample (n = 1869). Second, because there was evidence that individuals with missing data
were more likely to have higher levels of anxiety/depression we carried out a sensitivity analysis in
which all individuals with imputed anxiety/depression were recategorised as one level higher than
predicted in each imputed dataset (except when they were already predicted as being in the highest
category).
All analyses were carried out in Stata (versions 14 and 15) (Stata Corp LP, College Station, TX
USA); MI used the mi impute command.
Results
Study sample
Of the 14,665 participants in the study, 4562 (31.1%) had completed the CIS-R questions relating
to anxiety and depression at age 18, of whom 3109 (68.1%) had also completed the questionnaire at 16
regarding screen time. There were 1869 individuals with complete covariate information. This
information is summarised in Fig. 1. Characteristics of the complete cases and the 14,665 individuals
included in this study are given in Table 1. Characteristics were similar among the complete cases and the
individuals included, however those with complete data were more likely to be female, have an older
mother with a higher level of education and have a mother with maternal anxiety (Table 1). Similar
patterns of screen use, anxiety and depression were seen in both the complete cases and the included
individuals (Table 1).
Both anxiety and depression measured at age 7 years were associated with non-response at age 18
(results not shown): individuals with evidence of anxiety and depression at age 7 were more likely to have
missing outcome data at age 18, suggesting that the outcomes could be MNAR, or MAR conditional on
anxiety and depression at age 7 (we acknowledge that this cannot be determined from the observed data).
Among the 4562 adolescents who completed the CIS-R, 522 (11%) met the criteria for a
diagnosis of anxiety and 360 (8%) met the criteria for a diagnosis of depression. 1630 (35%) displayed
anxiety symptoms but did not meet the criteria for a diagnosis and 1466 (32%) displayed symptoms of
depression but did not meet the criteria for a diagnosis (Table 1). These figures were slightly lower
among those with complete covariate information (10 and 7% for diagnosis of anxiety and depression,
respectively, and 37 and 32% for symptoms of anxiety and depression, respectively). In contrast, in the
multiply imputed datasets, which took account of the fact that individuals with anxiety and depression
were less likely to complete the CIS-R, the proportions with a diagnosis were higher, though this was not
the case for symptoms (12 and 9% for diagnosis of anxiety and depression, respectively; 33 and 32% for
symptoms of anxiety and depression, respectively). Screen time was slightly higher at weekends than on
weekdays. This finding was consistent across all the types of device: 52% reported watching television
for 1–2 h and 22% for 3 or more hours on weekdays compared to 46 and 33% (respectively) at weekends.
The corresponding figures for computer use were 48 and 29% on weekdays and 40 and 38% at weekends;
and for texting 23 and 18% on weekdays and 24 and 21% at weekends (Table 1).
Anxiety
Table 2 shows that, after adjusting for confounders, there was no clear evidence of an association
between time spent watching television or texting at age 16 and anxiety. There was moderate evidence for
a small positive association between time spent using a computer on a weekday at age 16 and anxiety
(OR for 1–2 h = 1.17, 95% CI: 1.01 to 1.35; OR for 3+ hours = 1.30, 95% CI
1.10 to 1.55, p for linear trend = 0.003, model 3; Table 2). However, this association attenuated to the null
after adjusting for time spent alone (OR for 1–2 h = 1.12, 95% CI: 0.97 to 1.30; OR for 3+ hours = 1.14,
95% CI: 0.97 to 1.35, p for linear trend = 0.13; Table 2). Similarly, for weekend computer use, there was
evidence of an association with anxiety at 18 years (OR for 1–2 h = 1.17, 95% CI: 0.94 to 1.46; OR for
3+ hours = 1.28, 95% CI: 1.03 to 1.58, p for linear trend = 0.03, model 3). Again, this association
attenuated to the null after adjusting for time spent alone (OR for 1–2 h = 1.13, 95% CI: 0.91 to 1.41; OR
for 3+ hours = 1.15, 95% CI: 0.92 to 1.44, p for linear trend = 0.25, Table 2). Adjustment for other
activities (apart from time spent alone) had very little effect on the odds ratios (Additional file 1, Tables
S2-S4).
Depression
Odds ratios for the association between watching television, computer use and texting and
depression are shown in Table 3. After adjustment for potential confounders, there was no evidence for
an association between time spent watching television or time spent texting and depression, on
weekdays or weekends. Similarly, there was no clear evidence of an association between time spent
using a computer on a weekday and depression (OR for 1–2 h = 1.04, 95% CI: 0.85 to 1.29;
OR for 3+ hours = 1.13, 95% CI: 0.89 to 1.44, p for linear
trend = 0.29, model 3; Table 3). Evidence of a small positive association was found between time spent
using a computer on weekend days and depression (OR for 1–2 h = 1.12, 95% CI: 0.93 to 1.35; OR for 3+
hours = 1.35, 95% CI: 1.10 to 1.65 p for linear trend = 0.003, model 3). This association was only slightly
attenuated by adjusting for time spent alone (OR for 1–2 h = 1.11, 95% CI: 0.92 to 1.35; OR for 3+ hours
= 1.30, 95% CI: 1.06 to 1.58, p for linear trend = 0.007; Table 3). As was the case for anxiety, adjusting
for other activities (apart from time spent alone) had very little impact on the odds ratios (Additional file
1, Tables S5-S7).
Sensitivity analyses
The results from the complete case analyses were generally consistent with those obtained using
multiple imputation (although less precisely estimated), although the odds ratios for watching television
on weekend days for both anxiety and depression were somewhat larger than those obtained using
multiple imputation (Additional file 1, Tables S8 and S9). Nevertheless, the conclusions from these
analyses were essentially the same. When all individuals with imputed anxiety/depression were re-
categorised as one level higher than predicted in each imputed dataset (except when they were already
predicted as being in the highest category), the association between computer use and both anxiety and
depression were weaker (Additional file 1, Table S10). However, again the overall conclusion of no
evidence for an association between watching television and texting and anxiety/depression but some
evidence for a small association between computer use and both anxiety and depression remained the
same.
Discussion
Our results indicate that there is a small positive association between computer use at age 16 and
both anxiety and depression two years later. Although the increase in the risk of developing anxiety and
depression is small, given the high prevalence of screen use in young people, effects of small magnitude
may still result in a substantial population burden and could therefore be clinically significant. Increased
time spent alone attenuated the associations, particularly for anxiety.
The existing evidence regarding the association between screen use and anxiety is limited,
whereas the evidence for an association between depression and screen time is more consistent [4, 10,
13]. However, these studies cannot tell us whether any associations are likely to be causal. Several studies
have found evidence for an association between anxiety and screen time [5, 6], but none adjusted for time
spent alone, which attenuated the association in our study. In addition, none of these studies were
longitudinal, so it was not possible to establish the temporality of the association. Our findings for
depression are in line with previous research suggesting there is an association with screen time when
time spent alone is not adjusted for [12].
There are different possible explanations for the results relating to time spent alone. It is possible
that the measure of time alone used in this study may be measuring variance in anxiety or depression
rather than confounding the relationship. Alternatively, time alone and screen time could be common
markers of underlying causes of depression such as family circumstances or peer relationships. Our
research highlights that time spent alone is an important factor (potentially as a confounder or as a marker
of depression or anxiety) in this association that until now has been overlooked.
Besides time spent alone, various other mechanisms could explain the associations found between
screen time and both anxiety and depression. Screen time allows for social comparisons with both
fictional characters and real people who are perceivably higher up the social ladder than the viewer. In
support of this theory, negative social comparisons on social networking sites are related to higher levels
of depression and anxiety [29]. Cyber bullying (whereby individuals are bullied via social media and
texting) could also partly explain this association; victims report feeling depressed and worried as a
consequence of cyber bullying [30]. Alternatively, the sedentary nature of the screen time measured in
this study may be the mechanism by which screen time and anxiety and depression are associated, as
sedentary behaviour has been shown to be associated with both [4, 31].
A common criticism in the reviews of the literature is the widespread use of cross-sectional rather
than longitudinal data [10]. An important strength of our study was the use of data from a longitudinal
study and, in particular, our ability to adjust for previously identified anxiety and depression. Another
strength of our study was the ability to adjust for a wide range of potential confounders. Nonetheless,
there may be important confounders that were not measured in ALSPAC, or that were measured
imperfectly. As a result, there is potential for residual confounding.
Another limitation is the extent of missing data; the proportion of individuals with complete
data was low, which could have resulted in bias. We found evidence that individuals with anxiety and
depression at age 7 years were more likely to have missing anxiety and depression data at age 18. This
suggests (but cannot establish for certain) that the outcome data – depression and anxiety – were MNAR
conditional on the covariates included in the analysis model – that is, the probability that depression and
anxiety data were missing depended on their (unknown) missing values, even after taking account of the
observed variables. If an outcome measure is MNAR then both a complete case analysis and MI will
generally produce biased estimates of exposure-outcome associations, although there are exceptions to
this if the outcome is binary [32]. However, since we had four earlier measures of anxiety and depression
(that were more complete than the measures at 18 years), we were able to include these as auxiliary
variables in the MI models, thus giving a better approximation to MAR and hence reducing the likelihood
of bias [33]. The results for depression were generally weaker in the MI models, indicating some bias
may have been present in the complete case analysis, although we cannot determine whether we have
eliminated bias by using MI. We carried out sensitivity analyses making the assumption that imputed
values of anxiety and depression were underestimates; although this weakened the results, the general
conclusions remained the same.
A final limitation of our study is that screen use patterns have changed over time [34], and the
data for the current study were gathered between 2007 and 2009. This pre-date the wide availability of
smart phones, smart watches and tablets that allow for use of screens (and particularly social media which
was not assessed in this study) at times and in situations where screen use may have previously been
limited. It is difficult to ascertain whether the findings of this study would apply to young people and
screen use today, and evidence actually suggests that increased screen time using more recent technology
may have positive effects on social capital [35]. Additionally, screen time no longer necessarily means
sedentary behaviour - some screen-based games, such as Pokemon Go, even encourage physical activity
[36]. There is clearly a need to capture different aspects of screen time including the context and amount
of time spent using screen-based devices and types of devices as well as types and range of different
activities being undertaken in order to fully investigate how screen time affects mental health in young
people. Recent research by Przybylski and Weinstein [37] suggested that moderate screen use may be
beneficial. In their study, between one and four hours (depending on the type of activity) was found to
be beneficial but was negatively associated with wellbeing above this threshold. They also found that any
beneficial effects depended on whether use was on weekdays or weekends with negative effects on
wellbeing seen at lower thresholds of use on weekdays. We found some differences between the effects of
weekday and weekend exposure. However, the highest category of screen time measured in our study
was three or more hours; as such, we could not differentiate between moderately high and very high use –
and, as a consequence, could not assess whether there was a stronger association with very high levels of
screen time. Furthermore, the categorisation of the screen time measure used in this analysis may not
have been sensitive enough to detect moderate use between 2 and 3 h. As is the nature of secondary data,
we were unable to create a category for 2 to 3 h due to the wording of the answer options provided in the
questionnaire. Different types of screen time may have different effects, both in terms of wellbeing and in
terms of poor mental health. In their study, Przybylski and Weinstein found that different types of screen
use had different effects on wellbeing [37]. For example, there was a negative linear trend for smart
phone use on weekends in relation to wellbeing whereas there were positive trends for TV, computer or
video game use below the pivot point for beneficial vs non-beneficial use. We also found differences
between type of screen use, where only time spent on the computer was clearly associated with an in-
crease in anxiety and depression whereas there was little evidence of associations with time spent texting
or watching television. Evidently, the association between screen use and mental health is complex and
there is not a linear association between simply any type of screen use and mental health. This difference
could be due to the use of social networking sites, which were primarily accessed through computers at
the time of the study, whereby negative social comparisons may be the mechanism of the association
found. Alternatively, texting could be associated with social behaviour whereas computer use could be
associated with exam and work-related stress. Another theory to explain the difference is that some screen
types may induce effects at lower levels of exposure than others, perhaps due to perceived level of
immersion; young people may be more likely to multi-task when watching TV, and texting is intermittent
whereas computer use may be more focussed and continuous. The pattern of association between
computer use and anxiety also differs from the association between computer use and depression. Where
the effects for anxiety seem to be consistent across the time of the week, the association for depression is
much stronger with computer use on weekends than weekdays suggesting the mechanisms underlying
these effects may be different for anxiety and depression. This highlights the need for on-going research
in the area to assess the effect of specific types of activity on mental health in young adults in order to
provide up-to-date, accurate advice for screen use.
Conclusions
In summary, our results suggest that increased computer use at age 16 is associated with an
increased risk of depression and anxiety at age 18, although causality cannot be ascertained. After
adjustment for potential confounders, there was little evidence of an effect of time spent texting or
watching TV on risk of anxiety and depression indicating there may be a more complex relationship
between screen time and mental health outcomes than simply more screen time increasing risk.
Additionally, the size and strength of the associations differ depending on the time of the week the
devices are used, suggesting further complexities in the relationship. Further research is needed to capture
a wider range of use to distinguish between moderate through to very high screen time, and with more up-
to-date screen time.
Tables
Additional files
Abbreviations
ALSPAC: Avon Longitudinal Study of Parents and Children; CI: Confidence interval; CIS-R: Revised
Computerised Interview Schedule; CSE: Certificate of Secondary Education; DAWBA: Development and
Well-Being Assessment; EPDS: Edinburgh Post-Natal Depression Scale; ICD-10: International Statistical
Classification of Diseases and Related Health Problems 10th Revision;
MAR: Missing at random; MI: Multiple imputation; MNAR: Missing not at random; OR: Odds ratio;
SES: Socioeconomic Status; WISC-IIIUK: Wechsler Intelligence Scale for children
Acknowledgements
We are extremely grateful to all the families who took part in this study, the midwives for their help in
recruiting them, and the whole ALSPAC team, which includes interviewers, computer and laboratory
technicians, clerical workers, research scientists, volunteers, managers, receptionists and nurses.
Consent for publications

Not applicable.
Availability of data and material

The datasets generated and/or analysed during the current study are available from the corresponding
author on reasonable request, subject to the ALSPAC study executive data access procedures, as specified
on the ALSPAC website (http://www.bristol.ac.uk/alspac/researchers/access/) for researchers who meet
the criteria for access to confidential data.
Funding
The UK Medical Research Council and Wellcome (Grant ref.: 102215/2/13/2) and the University of
Bristol provide core support for ALSPAC. This publication is the work of the authors and JK, SG and
RC will serve as guarantors for the contents of this paper. This work was supported by the Elizabeth
Blackwell Institute for Health Research, University of Bristol and the Wellcome Trust Institutional
Strategic Support Fund (Grant ref.: 105612/Z/14/ Z), and the Medical Research Centre Integrative
Epidemiology Unit at the University of Bristol [grant number MC_UU_12013/6]. These funding bodies
were not involved in the design of the study or the collection, analysis, or interpretation of data and were
not involved in writing the manuscript.
Authors’ contributions
All authors (JK, SG, RC, MM, PE, AJ, FH, NW, CJ and KT) contributed to the design of this study. RC,
SG and JK were responsible for the analysis of data and all authors (JK, SG, RC, MM, PE, AJ, FH, NW,
CJ and KT) contributed to the interpretation of the findings. All authors (JK, SG, RC, MM, PE, AJ, FH,
NW, CJ and KT) contributed to the revising of the manuscript and approved the final version.
Ethics approval and consent to participate

Ethics approval for the study was obtained from the ALSPAC Ethics and Law Committee and the Local
Research Ethics Committee (NHS North Somerset & South Bristol Research Ethics Committee). Full
details of ethics committee approval references for ALSPAC can be found online (http://
www.bristol.ac.uk/alspac/researchers/research-ethics/). This study was approved by the ALSPAC
Executive Committee. Study participants who complete questionnaires consent to the use of their data by
approved researchers. Up until age 18 an overarching parental consent was used to indicate parents were
happy for their child (the study participant) to take part in ALSPAC. Consent for data collection and use
was implied via the written completion and return of questionnaires. Study participants have the right to
withdraw their consent for specific elements of the study, or from the study as a whole, at any time.
Competing interests
JK reports personal fees from Actelion Pharmaceuticals, outside the submitted work; CJ reports grants
from Elizabeth Blackwell Institute, during the conduct of the study. SG, RC, MM, PE, AJ, FH, NW and
KT have nothing to disclose.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional
affiliations.
Author details
1
MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK. 2UK
Centre for Tobacco and Alcohol Studies and School of Psychological Science, University of Bristol,
Bristol, UK. 3Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK.
4
College of Liberal Arts, Bath Spa University, Bath, UK. 5Swansea University Medical School, Swansea,
UK.6 Department of Psychological Sciences, University of Liverpool, Liverpool, UK.
7University of Bristol Students’ Health Service, Bristol, UK.
Received: 27 April 2018 Accepted: 13 December 2018
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Appendix C
Preventive Medicine
Screen time is associated with depression and anxiety in Canadian youth
Danijela Maras a, Martine F. Flament b, Marisa Murray c, Annick Buchholz d, Katherine A. Henderson a,
Nicole Obeid e, Gary S. Goldfield f,⁎
a
Carleton University Department of Psychology, 1125 Colonel By Drive, Ottawa, Canada, K1S 5B6
b
University of Ottawa Institute of Mental Health Research, Royal Ottawa Mental Health Centre, 1145
Carling Avenue, Ottawa, Canada, K1Z 7 K4
c
University of Ottawa Department of Psychology, 550 Cumberland Street, Ottawa, Canada, K1N 6 N5
d
Centre for Healthy Active Living, Children's Hospital of Eastern Ontario, 1355 Bank Street, Suite 111,
Ottawa, Canada, K1H 8 K7
e
Eating Disorder Program, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Canada,
K1H 8 L1
f
Healthy Active Living & Obesity Research Group, Children's Hospital of Eastern Ontario Research
Institute, 401 Smyth Road, Ottawa, Canada, K1H 8 L1
Article Info.
Available online 2 February 2015
Keywords: Sedentary lifestyle, Depression, Anxiety, Adolescent, Mental health, Television, Video
games, and Computers
Abstract
Objective. This study examined the relationships between screen time and symptoms of depression and
anxiety in a large community sample of Canadian youth.
Method. Participants were 2482 English-speaking grade 7 to 12 students. Cross-sectional data collected
between 2006 and 2010 as part of the Research on Eating and Adolescent Lifestyles (REAL) study were
used. Mental health status was assessed using the Children's Depression Inventory and the
Multidimensional Anxiety Scale for Children—10. Screen time (hours/day of TV, video games, and
computer) was assessed using the Leisure-Time Sedentary Activities questionnaire.
Results. Linear multiple regressions indicated that after controlling for age, sex, ethnicity, parental
education, geographic area, physical activity, and BMI, duration of screen time was associated with
severity of depression (β = 0.23, p b 0.001) and anxiety (β = 0.07, p b 0.01). Video game playing (β =
0.13, p b .001) and computer use (β = 0.17, p b 0.001) but not TV viewing were associated with more
severe depressive symptoms. Video game playing (β = 0.11, p b 0.001) was associated with severity of
anxiety.
Conclusion. Screen time may represent a risk factor or marker of anxiety and depression in adolescents.
Future research is needed to determine if reducing screen time aids the prevention and treatment of these
psychiatric disorders in youth.
Crown Copyright © 2015 Published by Elsevier Inc. All rights reserved.
◆ Corresponding author. Fax: +1 613 738 4800.

E-mail addresses: danijelamaras@gmail.com (D. Maras), martine.flament@theroyal.ca (M.F. Flament),
mmurr087@uottawa.ca (M. Murray), abuchholz@cheo.on.ca
(A. Buchholz), drkhenderson@icloud.com (K.A. Henderson), nobeid@cheo.on.ca (N. Obeid),
ggoldfield@cheo.on.ca (G.S. Goldfield).
Introduction
Depression and anxiety are among the leading causes of burden of disease in youth (Patel, 2013).
Epidemiological data show that 5 to 9% of adolescents are clinically depressed (U.S. Department of
Health and Human Services, 1999), while 21% to 50% report depressed mood (Merikangas and
Avenevoli, 2002). The prevalence of anxiety disorders in youth ranges from 12% to 20% (Costello et al.,
2005), with subclinical rates paralleling those of depressed mood (Merikangas and Avenevoli, 2002).
These figures are alarming given that depression and anxiety are strong predictors of a multitude of
negative health and psychosocial outcomes, such as interruption in development, academic difficulties,
poor interpersonal relationships, behavioral problems, low self- esteem, substance abuse, and suicide
(Hawgood and De Leo, 2008; Lemstra et al., 2008). Moreover, youth experiencing anxiety and depression
are at significantly increased risk of these psychiatric conditions in adulthood (Pine et al., 1999). The
World Health Organization predicts that by the year 2020, childhood and adolescent mental health
problems will become one of the leading causes of morbidity, mortality, and disability among children
worldwide (World Health Organization, 2001).
The use of electronic devices is a popular sedentary activity in West- ern society, particularly
among youth. In Canada and the U.S., youth spend an average of 7 to 8 h per day engaging in sedentary
screen- based activities (Active Healthy Kids Canada, 2013; Rideout et al., 2010), drastically exceeding
the 2-hour recommended daily maximum (American Academy of Pediatrics, 2013; Tremblay et al.,
2011). The pervasiveness of screen time among adolescents is of concern given its demonstrated
association with obesity (Andersen et al., 1998; Gortmaker et al., 1996), cardiometabolic risk (Andersen
et al., 2006; Carson and Janssen, 2011; Goldfield et al., 2011a; Hardy et al., 2010), and diabetes
(Bowman, 2006; Jakes et al., 2003). However, previous research examining the relationship between
sedentary screen-based activities and mental health in adolescents is sparse and has yielded mixed results:
some studies have shown a positive association with anxiety or depression (Cao et al., 2011; Kremer et
al., 2013; Mathers et al., 2009; Primack et al., 2009; Sund et al., 2011), and others have not (Casiano et
al., 2012; Hume et al., 2011). While all studies statistically controlled for the confounding effects of
socio-demographic factors, only two (Mathers et al., 2009; Rosen et al., 2014) accounted for BMI and
physical activity. These are important methodological limitations since screen time has been previously
associated with increased adiposity and reduced physical activity levels in youth (Marshall et al., 2004),
and obesity and physical activity are well documented risk and protective factors, respectively, for
anxiety and depression in youth (De Moor et al., 2006; Goldfield et al., 2011b; Roberts et al., 2003).
Given that the use of electronic media devices (typically sedentary) is rampant among youth in
Western (Active Healthy Kids Canada, 2013; Rideout et al., 2010) and other industrialized societies (Rey-
López et al., 2010; Martin, 2011), and that symptoms of depression and anxiety are prevalent in this age
group (Costello et al., 2005; Patel, 2013), further examination of the relationship between sedentary
screen time and mental health in youth is warranted. Moreover, given that youth spend more time on the
computer and playing video games, compared to watching TV (Active Healthy Kids Canada, 2013;
Rideout et al., 2010), and that little is known on how specific screen time activities relate to mental health
(Casiano et al., 2012; Mathers et al., 2009), further inquiry is needed. Elucidating a better understanding
of any association between duration and types of screen time behaviors and mental health may be
critical to developing more effective strategies to prevent or treat anxiety and depression in youth.
The present study aimed to examine the relationships between sedentary screen time and
symptoms of depression and anxiety in a large community sample of Canadian youth. It was
hypothesized that longer duration of screen time would be associated with more severe symptoms of
depression and anxiety, after controlling for a wide set of possible confounders. The effects of the type of
screen behavior (TV, video games, computer use) on depression and anxiety symptomatology were also
examined as secondary objectives.
Methods
Participants
Participants were 2482 English-speaking grade 7 to 12 students (1048 males and 1434 females), ranging
in age from 11.08 to 20.75 years (M = 14.10 years, SD = 1.57). Data were collected between 2006 and
2010 as part of a larger study, i.e. the Research on Eating and Adolescent Lifestyles (REAL) study, which
was originally conceived to test a psychosocial model expected to predict eating and weight disorders in a
community sample of adolescents. This study was approved by the relevant institutional research ethics
boards.
Procedure
All schools within three school boards and several private schools in the capital region of Canada
(Ottawa, Ontario) were invited to participate. Based on schools' interest and feasibility, a total of 31
schools permitted study recruitment in one or several of their classrooms, representing a school
participation rate of approximately 34%. Signed informed consent was obtained from students and their
parents, and small incentives were provided to participants (pizza party or lottery for gift certificates). The
overall student participation rate was 45%. The survey was conducted during regularly scheduled class
time under the supervision of research staff, who upon survey completion, took objective measures of
participants' height and weight in a private area. A more detailed description of the study procedure has
been published elsewhere (Goldfield et al., 2011b).
Measures
Demographics
Socio-demographic information included sex, age, school, grade, mother's
and father's education level, ethnic background of the family, and language spoken at home.
Sedentary screen time

The Leisure-Time Sedentary Activities 6-item questionnaire was designed by the investigators to measure
how many hours per day respondents typically engage in: TV viewing, video game playing, and computer
use. Scores range from 0 to 5, where 0 = not at all; 1 = less than 1 h; 2 = 1 to 3 h; 3 = 3 to 5 h; 4 = 5 to 8
h; and 5 = more than 8 h. The first three items address time spent engaging in screen-based activities
during a typical week day, and the last three items assess screen time accrued on a typical weekend day.
Total screen time and time spent on each specific screen activity were weighted as follows: [(week day ×
5) + (weekend × 2)] / 7. Higher scores are representative of more time engaged in sedentary screen-based
activities; note that the raw score does not represent the number of hours of screen-time.
Depression
The Children's Depression Inventory (CDI) is a self-report questionnaire consisting of 27 items reflecting
cognitive, affective, and behavioral signs of depression (Kovacs, 1992). Each item is assigned a score
from 0 to 2, with the higher number being attributed to the most depressive statement (Kovacs, 1992).
The total score ranges from 0 to 54. This widely used inventory has ample evidence supporting its
psychometric properties, with high internal consistency (r = .71 to r = .89), and test–retest reliability (r = .
50 to r = .83), and good concurrent validity (Kovacs, 1992). In the present study, Cronbach's alpha for the
total score was .89.
Anxiety
The Multidimensional Anxiety Scale for Children—10 (MASC-10) is a 10- item, 4-point Likert-style,
self-report scale that is a short and efficient global measure of anxiety symptoms (March and Sullivan,
1999). The MASC-10 is a unifactorial scale that evaluates anxiety symptoms across the four basic anxiety
dimensions assessed by the original (39-item) MASC (physical symptoms, harm avoidance, social
anxiety and separation anxiety/panic) (March et al., 1997). The MASC-10 has demonstrated satisfactory
internal reliability and excellent stability in adults and youth (March and Sullivan, 1999; Osman et al.,
2008). Cronbach's alpha in the present sample was .76.
Physical activity
The Godin Leisure-Time Exercise Questionnaire (GODIN) measures how often participants engage in
strenuous, moderate, and mild exercise for more than 15 min at a time, and has been shown to be reliable
and valid with test– retest reliability coefficients as high as r = 0.94 (Godin and Shephard, 1985). In this
study, the total volume of physical activity was calculated as follows: (frequency of mild exercise × 3
METS (metabolic equivalent of task) + (frequency of moderate exercise × 5 METS) + (frequency of
strenuous exercise × 9 METS). Higher total scores are indicative of more volume of exercise. Sedentary
behavior is conceptually and empirically distinct from a lack of physical activity (Hamilton et al., 2004;
Healy et al., 2008), and physical activity has been associated with decreased anxiety and depression (De
Moor et al., 2006). Thus, physical activity was controlled for in the present study to better isolate the
association between screen time and symptoms of anxiety and depression.
Covariates
Age, sex, ethnicity, parental education, and school geographic area were included as covariates. Height
and weight were measured using an HM200P Portable Stadiometre (Quick Medical Equipment and
Supplies, U.S.A.), and a UC-321 Digital Weighing Scale, respectively (Quick Medical Equipment and
Supplies, U.S.A.). BMI was calculated by dividing weight in kilograms (kg) by height in squared meters
(m2), and was also statistically controlled for because increased BMI has been associated with increased
symptoms of depression (Goldfield et al., 2010) and anxiety (Van Reedt Dortland et al., 2013)
Statistical analysis
All variables were examined for outliers and normality, and all assumptions for multiple regression were
met. To test whether total sedentary screen time (hours per day spent watching TV + recreational
computer use + video games) was associated with more severe symptoms of depression and anxiety, two
separate multiple linear regressions were conducted, controlling for: age (years), sex (0 = female, 1 =
male), ethnicity (0 = Caucasian, 1 = other), parental education (0 = neither parent completed college, 1 =
at least one parent completed college or higher), geographic area of school (0 = urban, 1 = suburban, 2 =
rural), BMI, and physical activity (total score). Additional multiple linear regressions were conducted to
examine the relative contribution of each type of sedentary screen-based activity (i.e., TV viewing, video
game playing, and computer use) on anxiety and depression symptoms, controlling for the same
covariates. Analyses were conducted using the statistical package for the social sciences (SPSS Inc., New
York) version 21.0, with an alpha level of 0.05.
Results
Sample characteristics are presented in Tables 1 and 2. Bivariate correlations between variables
of interest are shown in Table 3. The sample was approximately evenly comprised of males (42.2%) and
females (57.8%). The majority had at least one parent who completed college (87.2%), and about two
thirds were Caucasian (72.1%). Mean depression and anxiety raw scores were below the clinical cut-off
values generally used for depression (22 to 28) and anxiety (16 to 21). Screen time rates were slightly
below average compared to Canadian youth in other epidemiological studies (Active Healthy Kids
Canada, 2013), but still greatly exceeded the recommended 2 h per day maximum of total screen time
(Tremblay et al., 2011).
Results of the regression predicting symptoms of depression are presented in Table 4. The overall
model was significant after controlling for covariates, F(8,1513) = 25.81, p b 0.001, with R2 at .120
(adjusted R2 = .115). Duration of total screen time was significantly associated with depressive
symptoms, controlling for age, sex, ethnicity, parental education, BMI, and physical activity.
Results of the regression predicting symptoms of anxiety are presented in Table 5. The overall
model was significant after controlling for covariates, F(8,1472) = 14.55, p b 0.001, with R2 at .073
(adjusted R2 = .068), and duration of total screen time was significantly associated with severity of
anxiety symptoms, after controlling for covariates.
The contribution of each of the three sedentary screen-based activities on depression and anxiety
was explored using linear regression, while controlling for the aforementioned covariates and the other
two screen-based activities (see Table 6). Time spent playing video games [F(10,1511) = 21.71, p b
0.001, with R2 at .126 (adjusted R2 = .120)],
and time spent using the computer [F(10,1511) = 21.71, p b 0.001, with R2 at .126 (adjusted R2 = .120)]
were significantly associated with more severe symptoms of depression, while time spent playing video
games emerged as a significant predictor of more severe symptoms of anxiety [F(10,1470) = 12.66, p b
0.001, with R2 at .079 (adjusted R2 = .073)].
Discussion
To our knowledge, the present study is the first to examine the relationship between sedentary
screen-based activity and symptoms of depression and anxiety in a large community sample of Canadian
adolescents. Results indicate that time spent engaging in sedentary screen-based activities was
significantly associated with severity of depression and anxiety, after controlling for relevant covariates.
Regarding the type of screen time behavior, video game playing and computer use were significantly
associated with depressive symptoms, while only video gaming was significantly associated with anxiety.
Our finding of an association between screen time and depressive symptoms among Canadian
youth is consistent with results from several studies using large cohorts of adolescents from the U.S.
(Primack et al., 2009), China (Cao et al., 2011), Norway (Sund et al., 2011), and Australia (Kremer et al.,
2013; Mathers et al., 2009). However, two other studies showed no association between screen time and
depression (Casiano et al., 2012; Hume et al., 2011): one had a relatively small sample size, therefore lack
of power may have contributed to the null findings (Hume et al., 2011), while the other utilized a clinical
interview to diagnose major depressive disorder, thus not including subclinical levels of depressive
symptoms (Casiano et al., 2012). Few studies have examined the association between screen time and
anxiety in youth. Our finding that screen time was associated with more severe symptoms of anxiety is
consistent with results from a study in a large sample of adolescents from China (Cao et al., 2011), but
not with youth from Australia (Mathers et al., 2009).
There is little research evidence yet on the relationships between specific types of screen behavior
and depression or anxiety in adolescents. Such relationships are important to investigate given that time
spent in recreational computer use and video gaming may be more prevalent than time watching TV
among North American youth (Active Healthy Kids Canada, 2013; Rideout et al., 2010). Our finding that
time watching TV was not significantly associated with symptoms of depression is consistent with
findings by Mathers et al. (2009) and Casiano et al. (2012), while Primack et al. (2009) found TV viewing
was related to depression. These discrepant findings could be due to methodological differences across
studies, including covariates and measurement of outcome variables. Research on anxiety and TV
viewing in youth is sparse. In a sample of 925 adolescents in Australia, no association was found
(Mathers et al., 2009), consistent with our findings.
We found that time spent playing video games was significantly associated with symptoms of
depression and anxiety. This is in line with an Australian study that included symptoms of depression and
anxiety together in a global measure (Kessler-10 (Kessler et al., 2002)), but did not differentiate between
these symptoms (Mathers et al., 2009).
Our findings are also in accordance with research examining multiplayer online gaming behavior,
which has been associated with anxiety and negative mood (Cole and Hooley, 2013; Lo et al., 2005), and
with research demonstrating that excessive video game playing and internet use were significantly
associated with sadness and suicidality (Messias et al., 2011). Conversely, a study among 9137
adolescents found that video game playing was cross-sectionally associated with lower rates of depression
(anxiety was not examined) (Casiano et al., 2012). Discrepancy with other findings might relate to the
outcome variable being ‘probability of major depression’ or a combined measure of depression and
anxiety, and not controlling for physical activity.
In the current study, computer time was associated with symptoms of depression but not anxiety,
while Casiano et al. (2012) did not find an association between computer use and depression (anxiety was
not examined). Similarly, a study from the U.S. found that computer use and time spent surfing the web
were not associated with depression, and predicted increased anxiety only for adolescents with an
alcoholic parent (McCauley, 2009). Mathers et al. (2009) found a protective relationship between
computer use and psychological distress in youth. Thus, results are mixed regarding the effects of
computer time on mental health in youth, perhaps due to methodological differences across studies.
There are many possible explanations for the relationship between increased screen time and
poorer psychological health in youth. Screen-based activities could displace time otherwise spent
fostering healthy interpersonal relationships. Researchers have acknowledged that youth who spend large
amounts of time engaging in screen-based activities may be socially isolating themselves (Bohnert and
Garber, 2007; McHale et al., 2001). Moreover, it is well known that a healthy attachment orientation is
crucial to healthy development (Scharfe and Eldredge, 2001), and increased screen time can have a
negative effect on attachment relationships, which can negatively impact mood (Richards et al., 2010).
Another mechanism could relate to the nature of the content, situation, or messaging of the screen
exposure. For example, computer/internet use may expose youth to cyber-bullying, and it has been shown
that depression and anxiety are correlates of cyberbullying among youth (Kowalski and Limber, 2013).
Also, as posited by social comparison theory and objectification theory (Fredrickson and Roberts, 1997),
exposure to unattainable images that objectify the human body may contribute to feelings of depression
and anxiety (Dakanalis et al., 2013; Tiggemann and Kuring, 2004). Also, adolescents who spend more
time in front of electronic screens have more sleeping problems (Nelson and Gordon-Larsen, 2006; Van
den Bulck, 2004), which could compromise their ability to cope with stress, resulting in increased
feelings of depression or anxiety. Finally, screen time can also displace time spent engaging in physical
activity, which is concerning given previous findings that physical activity is associated with decreased
anxiety and depression symptoms (De Moor et al., 2006; Dunn et al., 2001; Ströhle, 2009).
Study limitations and strengths

Several limitations of the current study should be recognized. First, the cross-sectional design
limits the ability to make causal inferences about the observed relationships. Theoretically, because
children and youth engage in sedentary screen-based behaviors from a very young age, sedentary screen
time behaviors could precede the development of depression and anxiety symptoms. The reverse may also
be true since youth with symptoms of depression and/or anxiety may spend disproportionately more time
engaging in screen-based activities, perhaps as a maladaptive coping strategy. Indeed, prospective data
high- light the potential for bidirectional influences, with two studies showing that screen time predicted
depression in adolescents (Primack et al., 2009; Sund et al., 2011), while another found that depression
predicted screen time usage (Hume et al., 2011). Future research should probe the times of the day youth
engage in these activities, and examine what specific types of media and information they access. Future
studies should also include objective measures of physical activity, and objective and continuous
measures of screen time. Lastly, not all schools and participants approached for the current study
consented to participate, but the fact that the socio-demographic characteristics of the large community-
based sample closely resemble those for the entire Ottawa area (see recent Canada Census data (Statistics
Canada, 2007)) supports the generalizability of the study findings.
Limitations are balanced with several strengths of the current study. Height and weight were
objectively measured, which decreases the possibility of any bias in self-reported BMI, an important
covariate. Compared to previous research, the present study utilized the largest number of covariates,
strengthening the internal validity of the findings. Specifically, very few studies on sedentary screen time
and mental health have controlled for physical activity. Finally, depression and anxiety were assessed
using well-validated questionnaires, and as separate constructs, allowing for differential associations
between screen-based activities and psychological symptoms to emerge.
Conclusion
The present study makes a unique contribution to the limited existing research examining how
sedentary screen-based activities may relate to symptoms of depression and anxiety in youth. Our data
indicate that duration of sedentary screen time was associated with more severe symptoms of depression
and anxiety in a large sample of Canadian adolescents. This suggests that screen time may represent a risk
factor for, or a marker of these psychiatric disorders among youth. Thus, physicians and other medical
and mental health practitioners should in- quire about screen time in their assessment of children and
adolescents seeking treatment for anxiety or depression, as this may inform treatment planning. In
addition, our findings could help better inform sedentary behavior guidelines for children and adolescents,
by including information on the potential psychiatric risks of excessive sedentary screen-based activities.
Longitudinal studies examining the relationship between screen time and mental health are warranted.
Moreover, while research has shown that reducing screen time can reduce adiposity in obese children
(Goldfield et al., 2002), our findings support the conduct of randomized controlled trials to determine if
reducing screen time can also have a significant impact on the prevention and treatment of anxiety and
depression in adolescents.
Conflict of interest statement

Danijela Maras, Martine F. Flament, Nicole Obeid, Marisa Murray, Annick Buchholz, Katherine A.
Henderson, and Gary Goldfield declare that there are no conflicts of interest.
Acknowledgments
This study has been funded by the Ontario Centre of Excellence for Child and Youth Mental Health at
CHEO (# RG627), the University of Ot- tawa Medical Research Fund (# 03-2009), and the Children's
Hospital of Eastern Ontario Research Institute (RI 11-19). We wish to thank the Ottawa-Carleton District
School Board, the Ottawa-Carleton Catholic School Board, the Upper Canada District School Board, and
the many schools who generously contributed to the study. A special thanks to all students who
completed the survey. Many thanks to research assistants who worked on the REAL database, and to
students and volunteers who contributed to data collection and entry.
Tables
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Running Head: EPIDEMIOLOGIC PROJECT— SCREEN TIME AND DEPRESSION 1

Applied Epidemiology Research Project — Association of Screen Time and Depression in

Pham Bao Ngoc Vuong, N01238584

William Argueta, N01227878

Ishmael Pennino, N01273485

Applied Epidemiology – BHSW 3500

Professor Nora Zwingerman

Friday, April 3, 2020

Applied Epidemiology Research Project — Association of Screen Time and Depression in

Part 1: Development of an Analytical Research Question

health and wellness. (155 words)

Part 2: Literature Search

[MeSH Terms], ‘depression’[MeSH Terms], ‘adolescence’[MeSH Terms]. The search results

"association"[All Fields]) AND ("screen time"[MeSH Terms] OR ("screen"[All Fields] AND

"time"[All Fields]) OR "screen time"[All Fields]) AND ("depressive disorder"[MeSH Terms]

OR ("depressive"[All Fields] AND "disorder"[All Fields]) OR "depressive disorder"[All Fields]

OR "depression"[All Fields] OR "depression"[MeSH Terms]) AND ("adolescent"[MeSH Terms]

OR "adolescent"[All Fields] OR "adolescence"[All Fields]). We had specific inclusion and

Part 3: Annotated Bibliography

depression in adolescence. JAMA Pediatrics, 173(9), 853-859.

September 2012 to September 2018. It is a longitudinal study and randomized control

Symptoms Inventory (BSI), an instrument that evaluates psychological distress and

to 4, to what degree they experienced symptoms of depression (e.g., loneliness, sadness,

functionalized into four categories.

approximated between-person and within-person relations between screen time and

at a 95% CI, 0.09-0.27 in an estimate range. Consequential between-person and within-

social comparison yet not the displacement hypothesis. Moreover, a substantial

interaction among the between-person and within-person associations regarding social

media and self-esteem endorsed the reinforcing spirals hypothesis.

R. P. (2019). Is screen time associated with anxiety or depression in young people?

measured when children reached 18 years of age, using a self-administered, computerized

as: no anxiety/depression; symptoms but no diagnosis; and diagnosis. Khouja et al.

surveyed maternal anxiety, maternal education, and parental socio-economic status.

Additionally, child covariates included IQ (measured at 8 years), parental conflict

(measured at 8 months), absence of biological father (measured at 4 years), number of

questionnaire at 16 years. Furthermore, 1869 participants completed the covariate

longitudinal study compared to the more commonly used cross-sectional data. A

longitudinal study is more likely to suggest cause-and-effect relationships than a cross-

Preventive Medicine, 73, 133-138. doi:10.1016/j.ypmed.2015.01.029

psychosocial model expected to predict eating and weight disorders in a community

The adolescents completed self-report questionnaires in class under the supervision of

research staff. The researchers gathered socio-demographic information, assessed

BMI was statistically recorded. The Leisure-Time Sedentary Activities 6-item

Children self-report scale. The Godin Leisure-Time Exercise Questionnaire (GODIN)

association between screen time and symptoms of anxiety and depression.

predictor of more severe symptoms of anxiety [F(10,1470) = 12.66, p b 0.001, with R2

and depression in adolescents.

the entire Canadian youth.

reported BMI. Next, various methods of measurement, specifically the measurement of

behaviors and psychological symptoms. (See Appendix C) (599 words)

Part 4: Summary of the Evidence

increased risk of depressive symptoms.

to some of the factors such as inadequate study population/sampling, methods of measurement,

in the study are relevant and strong.

Word count: 3033 words

conditions; Association between screen time and depression in adolescence [Audio

podcast]. Retrieved from https://edhub.ama-assn.org/jn-learning/audio-player/17856054

National Centre for Biotechnology Information. (n.d.). PubMed. Retrieved from

in adolescents. JAMA Pediatrics, 174(2), 209–210.

Research | JAMA Pediatrics | Original Investigation

Strengths and Limitations

Anxiety and depression

Anxiety and depression were measured at approximately 18 years, using a self-administered,