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J. Sleep Res.

(2011) 20, 311317 Sleep and internet addiction


doi: 10.1111/j.1365-2869.2010.00883.x

The eects of insomnia and internet addiction on depression in


Hong Kong Chinese adolescents: an exploratory cross-sectional
analysis
L E E M . C H E U N G 1 and W I N G S . W O N G 2
1
Department of Applied Social Studies, City University of Hong Kong, Kowloon, Hong Kong and 2Department of Psychological Studies,
The Hong Kong Institute of Education, Tai Po, Hong Kong

Accepted in revised form 12 July 2010; received 15 March 2010

SUMMARY The negative association of insomnia and internet addiction with mental health is
widely documented in the literature, yet little is known about their inter-relationships.
The primary aim of this study was to examine the inter-relationships between insomnia,
internet addiction and depression. A total of 719 Chinese adolescents in Hong Kong
participated in this school-based cross-sectional study. Participants completed the
Chinese version of the Pittsburgh Sleep Quality Index (PSQI), the Chinese Internet
Addiction Scale (CIAS), the 12-item version of General Health Questionnaire (GHQ-12)
and questions assessing internet use pattern and sociodemographic characteristics. The
classication of internet addiction and insomnia was based on the CIAS cuto global
score >63 and PSQI cuto global score >5, respectively. Multiple regression analyses
tested the eects of insomnia and internet addiction on depression. Among students
with internet addiction (17.2%), 51.7% were also identied as insomniacs. Internet
addicts scored signicantly poorer on all PSQI components, except sleep duration, than
their non-addicted counterparts. After adjustment for gender and internet use time,
both internet addiction (b = 0.05; Sobel test Z = 6.50, P < 0.001) and insomnia
(b = 0.59; Sobel test Z = 4.49, P < 0.001) demonstrated a signicant association
with depression. Overall, there is high comorbidity between internet addiction and
insomnia. Both insomnia and internet addiction emerged as signicant explanatory
factors, but they exerted dierential eects on depression. Future research should be
directed at determining the causal relationship between internet addiction and
insomnia, and its underlying mechanism with depression.
keywords adolescent, Chinese, depression, insomnia, internet addiction

10.1% had both disturbances (Liu et al., 2007). Epidemiolog-


INTRODUCTION
ical studies suggested older age, heavy smoking, frequent
The negative impact of insomnia on the mental health of alcohol consumption and coee intake, lack of regular
adolescents has been widely documented (Taylor et al., 2003). exercise, poor diet and skipping breakfast were factors
As many as 88% of the children and adolescents with anxiety associated with short sleep duration and insomnia among
disorders experienced at least one sleep dysfunction (Chorney adolescents (Fuligni and Hardway, 2006; Kaneita et al., 2006;
et al., 2008). Among children with major depressive disorders, Liu and Zhou, 2002; Liu et al., 2000; Ohida et al., 2004).
72% had sleep disturbances, 53.5% had insomnia alone and Recently, research has suggested the inuence of problem-
atic internet use or internet addiction on insomnia and other
Correspondence: Wong Wing-sze, Department of Psychological Stud- sleep disturbances. Increased time spent on the internet
ies, The Hong Kong Institute of Education, 10 Lo Ping Road, Tai Po,
Hong Kong. Tel.: +852-2948-8936; fax: +852-2948-7794; e-mail:
disrupted the sleepwake schedule signicantly, and a higher
wingwong@ied.edu.hk rate of insomnia was found among heavy internet users

 2010 European Sleep Research Society 311


312 L. M. Cheung and W. S. Wong

(Jenaro et al., 2007; Rotunda et al., 2003; Thomee et al., Kong. All student subjects and their parents provided written
2007). Intensive mobile telephone and computer usage were informed consent or assent, as appropriate, after receiving a
associated with waking-time tiredness and unhealthy sleep complete description of the study. A total of 730 students
habits (Punamaki et al., 2007). Internet games addicts had completed the questionnaires. Eleven participants were
poor concentration and sleep quality and high ratings on excluded from analysis due to incomplete data, leaving the
hopelessness and worthlessness measures (du Toit et al., 2004). nal sample of 719 secondary students.
The association between internet addiction and poor mental
health among adolescents was also evident (Ha et al., 2007;
Measures
Shaw and Black, 2008; Yen et al., 2008). Adolescent internet
addicts were generally more severely depressed (Yen et al., Insomnia
2007) and reported more suicidal thoughts (Kim et al., 2006).
Since the Pittsburgh Sleep Quality Index (PSQI) (Buysse et al.,
Internet addiction, which is characterized as a psychological
1989) was developed, based upon the International Statistical
dependence on the Internet, regardless of type of activity once
Classication of Disease and Related Health Problems, 10th
logged on (Kandell, 1998), is an emerging mental health
edition (ICD-10) (World Health Organization, 1992) and the
problem among adolescents. The prevalence of internet addic-
Diagnostic and Statistical Manual of Mental Disorders (DSM-
tion among adolescents in Norway and Italy was 1.98%
IV) (American Psychiatric Association, 1994) criteria for
(Johansson and Gotestam, 2004) and 5.4% (Pallanti et al.,
classication of insomnia, it was employed in this study to
2006), respectively. In Asia, up to 7.5% Taiwanese adolescents
assess insomnia and sleep disturbances. The PSQI diers from
were classied as internet addicts (Ko et al., 2007). The
other insomnia scales as it evaluates multiple dimensions of
prevalence of internet addiction among Chinese adolescents in
sleep over a 1-month period (Buysse et al., 1989). Nineteen
Mainland China ranges between 2.4% and 5.5% (Gao and Su,
individual items generate seven component scores (see the
2007; Hu et al., 2007). Despite the increasing prevalence of
seven components in Table 2), which are summed for one
internet addiction and its link with mental health and insomnia,
global score (range 021); higher scores represent poorer
relatively few studies have examined the nature of internet
subjective sleep quality. The Chinese version of the PSQI has
addictions inuence on insomnia and mental health among
good overall reliability and testretest reliability (Tsai et al.,
adolescents. Thomee et al. (2007) reported that internet use
2005). A PSQI global score of 5 6 with a sensitivity of 98%
increased the risk of developing depressive symptoms and sleep
and specicity of 55% was recommended as a cuto for
disturbances among young adults; however, the nature of the
classifying insomnia (Buysse et al., 1989; Tsai et al., 2005).
relationships among the three variables was not examined.
Another study suggested that insomnia mediated the eects of
internet use on perceived health among adolescents (Punamaki Internet addiction
et al., 2007). However, as mental health measures were not
Internet addiction was assessed using the Chinese Internet
included in the study, the question of whether insomnia and
Addiction Scale (CIAS) (Chen et al., 2003). Rating on a four-
internet use exerted dierential eects on mental health,
point Likert scale, the CIAS consists of 26 items divided into
particularly depression, remains unanswered.
seven subscales (see the subscales in Table 1) and the sum of
This cross-sectional study aimed to ll these research gaps
the subscales scores yields a total score (range: 26104). The
by exploring the inter-relationships between internet addiction,
CIAS possesses good internal consistency (Cronbachs as
insomnia and depression. In a sample of Hong Kong Chinese
ranging from 0.79 to 0.93) (Chen et al., 2003). A cuto of
adolescents, we (1) compared the sleep pattern and level of
63 64 with a sensitivity of 67.8%, specicity of 92.6% and
depressive symptoms between internet addicts and non-addicts
diagnostic accuracy of 87.6% was recommended for classifying
and (2) evaluated the possible dierential eects of insomnia
internet addiction (Chen et al., 2003).
and internet addiction on depression. We decided to test these
two explanatory pathways because although individuals with
internet addiction might develop insomnia due to staying up Depression
late for late-night log-on, a reverse explanatory pathway is also
The 12-item version of General Health Questionnaire (GHQ-
possible: internet addiction might reect maladaptive coping
12), which was designed for screening depressive symptoms
by insomniacs. Hence, both insomnia and internet addiction
within 1 month, was employed to evaluate depression (Gold-
may play a role as a causal variable antecedent or exogenous to
berg, 1978). The total score ranges from 0 to 36, with higher
certain criterion eects.
scores indicating higher levels of depression. Acceptable
internet consistency was demonstrated (Cronbach as ranging
METHOD from 0.78 to 0.85) (Ip, 2006; Kilic et al., 1997). The cuto score
of 11 12 yielded a sensitivity of 70% and specicity of 68%
Subjects
(Schmitz et al., 1999). The Chinese version of GHQ-12
After receiving Institutional Review Board approval, study possesses good psychometric properties (Chan and Chan,
subjects were recruited from a secondary school in Hong 1983).

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Internet addiction, insomnia and depression 313

Table 1 Sample characteristics Statistical analysis


% Basic descriptive statistics were calculated to determine
Gender sample characteristics, internet use pattern and level of
Male 60.4
Female 39.6
internet addiction (see subscales and descriptions in
Age; M (SD) 14.70 (2.02) Table 1). Components of insomnia and depression were
1014 years 48.8
1520 years 51.2
compared between internet addicts and non-addicts. Inde-
Form level pendent t-tests were used to analyze the mean dierences
Junior (forms 13) 56.2
Senior (forms 45) 43.8 between two groups and chi-square tests were used to
Monthly household income analyze proportional dierences. A series of multiple regres-
Below HK$15 000 27.8
$15 000$24 999 10.5 sion analyses were performed to determine the eects of
$25 000 or above 6.9 insomnia and internet addiction on depression. For insom-
Do not know 54.8
Fathers education level nia to be an explanatory factor (model 1), four criteria
No schooling preprimary 5.7 needed to be met (Baron and Kenny, 1986): (1) internet
Primary 18.0
Secondary 39.3 addiction should predict insomnia signicantly, (2) insomnia
Matriculation postsecondary 4.0
should predict depression signicantly, (3) internet addiction
Tertiary 2.7
Others 0.4 should predict depression signicantly and (4) after control-
Do not know 29.9
Mothers education level
ling for insomnia, the relationship between internet addiction
No schooling preprimary 5.7 and depression should be decreased or become non-signif-
Primary 18.9
Secondary 41.1
icant. A perfect explanatory relationship is established if the
Matriculation postsecondary 3.3 association between internet addiction and depression is
Tertiary 2.8
Others 0.3
reduced to zero. The Sobel test (MacKinnon et al., 2002)
Do not know 28.0 determined whether insomnia carried the inuence of inter-
Fathers employment status
Full-time 60.0 net addiction to depression. These criteria were also applied
Part-time 5.4 to test the eect of internet addiction on the relationship
Retired 3.2
Unemployed 3.6 between insomnia and depression (model 2). Preselection for
Homemaker 1.1 entry of sociodemographic and pattern of internet use
Do not know 26.6
Mothers employment status variables into the multivariate models required a P-value
Full-time 33.8 of <0.05 in univariate regression analyses. The results of
Part-time 16.9
Retired 0.7 multi-collinearity tests suggested low multi-collinearity
Unemployed 1.7
among predictor variables on depression. A 5% signicance
Housewife 27.6
Do not know 19.3 level was accepted for all the tests. All statistical analyses
Number of siblings
0 12.2
were performed using SPSS, 2002 version 15.0. (SPSS Inc.,
1 47.1 Chicago, IL, USA).
2 22.5
3 18.2
Internet addiction pattern, M (SD) RESULTS
CIAS: compulsive symptoms 9.77 (3.39)
CIAS: withdrawal symptoms 10.37 (3.59) Sample characteristics
CIAS: tolerance symptoms 8.62 (2.81)
CIAS: internet addiction core symptoms 28.65 (8.81)
CIAS: interpersonal and health problems 13.48 (4.27) The characteristics of the sample are reported in Table 1. Of
CIAS: time management problems 9.26 (3.29) the 719 participants, 60.4% were male, 48.8% were aged from
CIAS: internet addiction-related problems 22.70 (6.86)
CIAS global score 51.18 (14.56) 10 to 14 years and 56.2% were in junior forms*. Except for
Non-addicts 82.80 one student, all students indicated that they had accessed the
Internet addicts 17.20
internet (>99%) in the past week, with average weekly hours
M, mean; SD, standard deviation; CIAS, Chinese Internet Addiction Scale. of internet use of 10.98 h [standard deviation (SD) = 14.49].
Figures are percentages unless specied otherwise.

$1 US = $7.8 HK. Based on the CIAS cuto score of 63 64, 17.2% of the sample

Score ranges from 5 to 20, with higher scores indicating more serious compulsive
were classied as internet addicts.
symptoms.

Score ranges from 5 to 20, with higher scores indicating more serious withdrawal
symptoms.

Score ranges from 4 to 16, with higher scores indicating more serious tolerance symptoms.

Derived from the compulsive symptoms component, withdrawal symptoms component
and tolerance symptoms component. Score ranges from 14 to 56, with higher scores
indicating more serious internet addiction score symptoms.
*In the Hong Kong education system, teenagers enter

Score ranges from 7 to 28, with higher scores indicating more serious interpersonal and secondary school at the age of around 12 years and leave after
health problems.

Score ranges from 5 to 20, with higher scores indicating more serious time management 5 years of study (i.e. forms 15). They then enter a 2-year
problems.

matriculation education (i.e. forms 6 and 7) before entering
Derived from the interpersonal and health problems component and time management
problems component. Score ranges from 12 to 48, with higher scores indicating more university. Secondary education is compulsory. Junior form
serious internet addiction-related problems.

refers to forms 13 classes, which are equivalent to grades 79
Score ranges from 26 to 104. Internet addiction was dened as CIAS global score >63.
in the International Baccalaureate system.

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314 L. M. Cheung and W. S. Wong

Table 2 Components of insomnia

Entire sample Non-addicts Internet addicts Group


(n = 719) (n = 555) (n = 116) dierences P-value

Sleep latency; M (SD) 21.56 (60.99) 18.43 (26.61) 36.39 (141.44) )2.69 0.01
5 min 24.40 24.50 21.60
10 min 20.60 21.30 17.20
20 min 25.60 25.40 26.70
30 min 14.50 14.80 12.90
45 min 3.40 3.40 3.40
60 min 3.70 3.20 6.00
>60 min 8.20 7.40 12.10
Sleep duration; M (SD) 7.68 (1.66) 7.69 (1.51) 7.55 (1.85) 0.90 0.37
<7 h 27.50 25.70 35.70
78 h 34.50 35.40 30.40
>8 h 38.00 38.90 33.90
Habitual sleep eciency; M (SD) 85.17 (21.24) 87.32 (18.91) 78.33 (26.29) 3.32 <0.001
85% 69.70 72.90 56.00
7584% 16.60 16.10 19.00
6574% 4.50 3.90 7.10
<65% 9.20 7.20 17.90
Use of sleep medication
Not during the past month 92.80 95.30 80.90 43.13 <0.001
Less than once a week 3.70 3.30 6.10
Once or twice a week 2.50 1.30 8.70
Three or more times a week 0.90 0.20 4.30
Subjective sleep quality; M (SD) 1.04 (0.89) 0.95 (0.86) 1.48 (0.92) )5.93 <0.001
Sleep disturbances; M (SD) 1.07 (0.58) 1.02 (0.53) 1.36 (0.66) )5.93 <0.001
Daytime dysfunction; M (SD) 0.51 (0.83) 0.45 (0.77) 0.79 (1.04) )4.02 <0.001
PSQI global score; M (SD) 4.70 (3.19) 4.26 (2.75) 6.66 (3.92) )7.84 <0.001
Non-insomniacs 69.30 73.70 48.30
Insomniacs 30.70 26.30 51.70
GHQ-12 total score; M (SD) 11.04 (5.73) 10.57 (5.44) 13.34 (6.77) )4.69 <0.001
Non-depressed 54.80 57.90 41.10
Depressed 45.20 42.10 58.90

Figures are percentages unless otherwise specied.


Mean differences were analyzed by t-tests; proportional dierences were analyzed by v2 tests.
M, mean; SD, standard deviation; PSQI, Pittsburg Sleep Quality Index; GHQ, General Health Questionnaire.

Internet addiction was dened as CIAS global score >63.

Habitual sleep efciency = total hours of sleep (get-up time)bedtime) 100%.

Score ranges from 0 to 3, with higher scores indicating poorer functioning.

Insomnia was dened as PSQI global score >5.

Score ranges from 0 to 36, with higher scores indicating more severe depressive symptoms. Depressed cases were classied based on GHQ-12
total score >11.

PSQI components (all P < 0.05). Specically, internet addicts


Comparison on components of insomnia between internet
had longer sleep latency (mean = 36.39; t = )2.69,
addicts and non-addicts
P < 0.05), lower sleep eciency (mean = 78.33; t = 3.32,
As shown in Table 2, the average sleep latency of the present P < 0.001), more frequent use of sleep medication (13% for
sample was 21.56 min (SD = 60.99), with 15.3% being unable at least once a week; v2 = 43.13, P < 0.001), poorer
to fall asleep within 30 min. The average sleep duration was subjective quality (mean = 1.48; t = )5.93, P < 0.001),
7.68 h (SD = 1.66) and 27.5% slept fewer than 7 h. The more sleep disturbances (mean = 1.36; t = )5.93,
average habitual sleep eciency was 85.17% (SD = 21.24%). P < 0.001) and more daytime dysfunction (mean = 0.79;
Most of the participants did not use sleep medication (92.8%). t = )4.02, P < 0.01). Signicantly more internet addicts
The mean scores for subjective sleep quality, sleep disturbances (51.7%) were being classied as insomniacs than their non-
and daytime dysfunction were 1.04 (SD = 0.89), 1.07 addicted counterparts (26.3%) (v2 = )7.84, P < 0.001). Also,
(SD = 0.58) and 0.51 (SD = 0.83), respectively. Based on 45.2% of the sample were classied as depressed based on the
the PSQI cuto, 30.7% of the sample were classied as GHQ-12 cuto. The mean score of GHQ-12 was signicantly
insomniacs. higher among internet addicts (mean = 13.34; t = )4.69,
Except for sleep duration (P > 0.05), signicant dierences P < 0.001) than their non-addicted counterparts, with
were found between internet addicts and non-addicts on all 58.90% of internet addicts being classied as depressed.

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Internet addiction, insomnia and depression 315

Table 3 Multiple regression models for the relationships between insomnia, internet addiction and depression

Std b b SE 95% CI P-value

Model 1: Insomnia accounts for the link between internet addiction and depression
Internet addiction (IV) depression (DV) 0.25 0.10 0.02 0.07, 0.13 <0.001
Internet addiction (IV) insomnia (EV) 0.39 0.08 0.01 0.07, 0.09 <0.001
Insomnia (EV) depression (DV) 0.37 0.67 0.06 0.54, 0.79 <0.001
Internet addiction (IV) depression (DV) | insomnia (EV) 0.13 0.05 0.02 0.01, 0.74 <0.001
Sobel test Z = 6.50 P < 0.001
Model 2: Internet addiction accounts for the link between insomnia and depression
Insomnia (IV) internet addiction (EV) 0.37 1.73 0.17 1.40, 2.06 <0.001
Insomnia (IV) depression (DV) | internet addiction (EV) 0.32 0.59 0.07 0.45, 0.74 <0.001
Sobel test Z = 4.49 P < 0.001

All regression equations were controlled for gender and internet use time. Of the sociodemographic variables assessed, only gender and internet
use time were signicantly associated with depression in univariate analyses; hence, only these two variables were included in the multivariate
regression models to adjust for potential confounding effects.
IV, independent variable; DV, dependent variable; EV, explanatory variable; Std b, standardized beta coefcient; b, unstandardized beta
coefcient; SE, standard error; CI, condence interval.

symptoms than non-addicts. More importantly, our study


Insomnia as a mediator between internet addiction
extended previous data regarding the relationships between
and depression
insomnia, internet addiction and insomnia (Punamaki et al.,
The results of model 1 (Table 3) show that internet addiction 2007; Thomee et al., 2007) showing that insomnia and
was associated signicantly with insomnia (b = 0.08, internet addiction carried dierential eects on depression.
P < 0.001) and depression (b = 0.10, P < 0.001). Insomnia Our ndings showed that when insomnia was the explana-
was associated signicantly with depression (b = 0.67, tory factor, it accentuated the negative eects of internet
P < 0.001). When internet addiction was controlled, internet addiction on depression. The indirect eect of insomnia on
addiction was associated signicantly with depression the relationship between internet addiction and depression
(b = 0.05, P < 0.001), demonstrating a partial explanatory was 0.05 (without mediation minus with mediation),
eect of insomnia between internet addiction and depression indicating that approximately 5% of the eect of internet
(Sobel Z = 6.50, P < 0.001) (Fig. 1a). addiction on depression went through the explanatory factor
(i.e. insomnia), and 95% of the eect was direct. When
internet addiction was the explanatory factor, internet
Internet addiction as a mediator between insomnia
addiction accentuated the negative eects of insomnia on
and depression
depression. The indirect eect of internet addiction on the
In model 2, insomnia was associated signicantly with internet insomniadepression pathway was 0.12, suggesting that
addiction (b = 1.73, P < 0.001). When internet addiction was about 12% of the eect of insomnia on depression went
controlled, insomnia remained associated signicantly with through the mediator (i.e. internet addiction), and 88% of
depression (b = 0.59, P < 0.001) (Sobel Z = 4.49, P < 0.001) the eect was direct. If considering the explanatory eect
(Fig. 1b). alone, internet addiction (model 2: 12%) exerted a stronger
eect than insomnia (model 1: 5%). This suggests that
internet addiction had a higher practical value when consid-
DISCUSSION
ered as a mediator given the higher indirect eect it carried.
We know of no previous study that has examined the eects of However, with a higher Z-score (=6.50) model 1, in which
insomnia and internet addiction on depression among adoles- insomnia was the explanatory factor, contributed higher
cents. Our results show that of the 17.2% of internet addicts precision as a whole than model 2 (Z = 4.49), where internet
identied in this Chinese adolescent sample, more than half of addiction was the explanatory factor, in explaining the
them were also identied as insomniacs (51.7%) and depressed variance of the link between the three variables. One
(58.9%). After controlling for potential confounding factors explanation for these interesting ndings is that the nature
(including gender and internet use time), both insomnia and of the relationship among the three variables is, at least
internet addiction were associated signicantly with depres- partially, dynamic and inuenced by the causal relationship
sion. These data imply that possible complex mechanisms exist between insomnia and internet addiction. While our data
between insomnia, internet addiction and depression. showed a high comorbidity of insomnia and internet addic-
In line with previous studies (Ha et al., 2007; Shaw and tion (51.7%), the cross-sectional design of this study did not
Black, 2008; Yen et al., 2008), internet addicts in the present allow us to determine, among those with comorbid condi-
adolescent sample displayed signicantly more depressive tions, the proportion of adolescents who had insomnia as a

 2010 European Sleep Research Society, J. Sleep Res., 20, 311317


316 L. M. Cheung and W. S. Wong

(a) unlikely to be the only two explanatory factors of depression.


Insomnia Other covariates may include low self-esteem, social support
0.08* 0.06* and loneliness (Leung, 2004; Morahan and Schumacher,
2003). This suggestion is plausible, considering the multi-
faceted nature of internet addiction and insomnia. The
With mediation: 0.05*
Internet addiction Depression possible range of interaction between variables that can derive
Without mediation: 0.10*
from the link between internet addiction and insomnia with
(b)
depression is therefore wide. This should also be addressed in
Internet addiction future studies.
Despite these shortcomings, our ndings point to the high
1.73* 0.10* co-occurrence of internet addiction and insomnia and their
signicant association with depression among adolescents.
With mediation: 0.59* School-based health programmes may consider incorporating
Insomnia Depression internet use as part of the routine assessment. Programmes
Without mediation: 0.67*
that promote sleep hygiene may also address the adverse
Figure 1. (a) Regression coecients in the insomnia explanatory impact of problematic internet use on sleep quality and mental
pathway from internet addiction to depression; *P < 0.001. (b) health. We hope that this study will generate more research on
Regression coecients in the internet addiction explanatory pathway
this important issue, given the rising trend of internet addiction
from insomnia to depression; *P < 0.001.
and sleep problems among adolescents worldwide.

primary condition and internet addiction as a secondary DECLARATIONS OF INTEREST


condition, and vice versa. Longitudinal and prospective
research is therefore needed to provide a nal determination No competing nancial interests exist.
regarding the causal associations between insomnia, internet
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