Smartphone Use and Mental Health among Youth: It Is Time to Develop Smartphone-Specific Screen Time Guidelines
Round 1
Reviewer 1 Report
Comments to the Authors
The aim of the paper was to investigate the relationship between high smartphone use and mental health among youth and young adults in two urban centres in Canada. The manuscript is relevant for the field and presented in a well-structured manner.
Title: The manuscript is measuring mental health problems; I suggest adding problems in title. Additionally, I suggest the authors to change the title, so it reflects the aim.
Abstract
In line 9 and 28 the authors use youth and young adults, but later, only youth. Pleas clarify
In line 18, the authors write that the participants are 13-18 years old, but on page 3 line 141, the participants are youth aged 13-21 years. Please clarify.
Introduction
On page 2, line 59-62 the authors write the following:
“There is a lack of research that addresses a broad understanding of smartphone usage (i.e., all of internet, gaming, and texting use) and whether its is related to population health and wellbeing”.
What about mental health problems?
On line 71-73, please add what kind of screen time behaviours that help them succeed.
I suggest that the authors should focus more on smartphone use and mental health problems (symptoms of depression, anxiety, and suicide ideation) in the introduction.
Materials and Methods:
On page 3, please clarify the age.
On page 4, please add why only 437 participants provided relevant data for this study.
On page 7 line 241, I suggest adding “problems” to mental health (dependent variable).
On page 7 line 266, the authors are measuring wellbeing. Under result in table 4 the authors use self-related mental health poor. Please clarify.
On page 8 line291-293, the authors use different concept of the measures in the manuscript, i.e.: health or mental health? Generalized anxiety or anxiety symptoms? Self-reported mental health or subjective well-being? Please clarify.
Results
On page 9, figure 4? Please clarify. I also suggest the authors to add the cut off points.
Discussion:
On page 12 line 373, I suggest the authors to add “problems” as mentioned other places in the manuscript.
Can the authors add more depth to the discussion? They provide a nice overview of existing literature, but it would be helpful to read their thought of implications for future research, practice, and policy.
Page 13 line 409, I suggest the authors to find a more recent ref.
Page 13 line 427, Kleppang et al 2021 is a cross sectional study.
Strengths and limitations
I suggest the authors to add a comment about self-reported measures and the participation rate.
Conclusion
I agree that this is complex, and the results vary, but can the authors summarize the most important in a sentence or two? How can these result help developing guidelines? See also the comment under the discussion.
Author Response
The aim of the paper was to investigate the relationship between high smartphone use and mental health among youth and young adults in two urban centres in Canada. The manuscript is relevant for the field and presented in a well-structured manner.
Title: The manuscript is measuring mental health problems; I suggest adding problems in title. Additionally, I suggest the authors to change the title, so it reflects the aim.
Thank you for this suggestion. We have adapted the title to reflect the aim.
Abstract
Reviewer’s comment 1: In line 9 and 28 the authors use youth and young adults, but later, only youth. Pleas clarify
Authors’ response:
There is a consensus that “youth” can include individuals up to 24 years of age. Our participants are 13 to 21 years of age; as such, we removed the use of young adults and only used youth in-text in the revised manuscript.
Reviewer’s comment 2: In line 18, the authors write that the participants are 13-18 years old, but on page 3 line 141, the participants are youth aged 13-21 years. Please clarify.
Authors’ response:
Thank you, we corrected the text in the abstract (page 1) to the correct age range of 13 to 21.
Introduction
Reviewer’s comment 3: On page 2, line 59-62 the authors write the following:
“There is a lack of research that addresses a broad understanding of smartphone usage (i.e., all of internet, gaming, and texting use) and whether its is related to population health and wellbeing”. What about mental health problems?
Authors’ response:
We thank you for this comment. We added literature specific to smartphone use and mental health on pages 2 and 3 as such:
Evidence from a review paper (Thomée, 2018) reports that smartphone use is associated with adverse mental health outcomes. Additionally, a meta-analytic review (Vahedi and Saiphoo, 2018) specifically reported that smartphone use is associated with stress and anxiety. A systematic review also confirms associations between problematic smartphone use and depression severity (Elhai et al., 2017a). Another study confirms associations between problematic smartphone use and negative psychological wellbeing in general (Horwood and Anglim, 2019). Horwood and Anglim assessed for whether there are differences in the association between problematic smartphone usage behaviors and wellbeing. They found that when smartphone use was for entertainment purposes (i.e., used to relax, escape, pass time) it was correlated with lower wellbeing while smartphone use for communication purposes (i.e., texting, calling) was unrelated or slightly positively associated with wellbeing (Horwood and Anglim, 2019). Further research also suggests that specific smartphone activities may have specific associations with health outcomes.
A limitation with previous research is the focus on problematic smartphone use and the predominance of adult related literature, with only one -third of the studies addressing youth populations (Marty-Dugas and Smilek, 2020; Pera, 2020; Thomée, 2018). Problematic smartphone use is complex phenomenon consisting of dysfunctional manifestations (i.e., social isolation, diminished self-confidence, depression, and anxiety) (Pivetta et al., 2019). For public health and policy recommendations, studies are needed that evaluate smartphone use with time cut-off points (e.g., hour-based). This will help in the development of smartphone use guidelines for safe everyday use (i.e., do not pose health consequences).
Currently, there are no public health guidelines for smartphone screen time specifically, and there is scarce research on youth’s smartphone habits and their relationship with their health. The objective of this study is to investigate the association between smartphone use (internet use, gaming, texting, and total use) and mental health (feelings of anxiety, feelings of depression, and suicide ideation) among urban youth aged 13 to 21 years to inform future public health guidelines for youth smartphone use.
Reviewer’s comment 4: On line 71-73, please add what kind of screen time behaviours that help them succeed.
Authors’ response:
We clarified the text as follows on page 2:
In contrast, other evidence suggests that youth who engaged in screen time behaviors (e.g., playing games or internet use) involving academic activities had better mental wellbeing that youth who spent less time on those activities (Javed et al., 2017).
Reviewer’s comment 5: I suggest that the authors should focus more on smartphone use and mental health problems (symptoms of depression, anxiety, and suicide ideation) in the introduction.
Authors’ response:
We thank you for this suggestion. We took this comment into consideration when adding the text in Comment 3 above.
Materials and Methods:
Reviewer’s comment 6: On page 3, please clarify the age.
Authors’ response:
Thank you, the age range is correct in this statement.
Reviewer’s comment 7: On page 4, please add why only 437 participants provided relevant data for this study.
Authors’ response:
We thank you for this comment. We clarified the use of 437 participants at the start of the Results section as such:
Out of 808 youth who were recruited, 437 participants provided relevant data (i.e., more than 25% of the survey was completed by the participant) for this study.
Reviewer’s comment 8: On page 7 line 241, I suggest adding “problems” to mental health (dependent variable).
Authors’ response:
We added “problems” as suggested.
Reviewer’s comment 9: On page 7 line 266, the authors are measuring wellbeing. Under result in table 4 the authors use self-related mental health poor. Please clarify.
Authors’ response:
We changed the heading from “Subjective health” to “Subjective mental health” to more accurately describe the measure “self-rated mental health” which was used in our study.
Reviewer’s comment 10: On page 8 line291-293, the authors use different concept of the measures in the manuscript, i.e.: health or mental health? Generalized anxiety or anxiety symptoms? Self-reported mental health or subjective well-being? Please clarify.
Authors’ response:
Thank you for this comment. In this phrase, we are referring to the measures themselves that fall under the category of mental health. Each measure was described in detail in the corresponding measures section. The section mental health problems (dependent variables) described the questions, cut-off points, and guidelines we used to assess for screening positively for generalized anxiety disorder, suicide ideation, feelings of depression. Similarly, the section subjective mental health described the measure for self-rated mental health. We changed the wording from variable to measures as such in the sentence to clarify:
We used binary regression models to assess for the association between each mental health measure (screening positively for generalized anxiety disorder, suicide ideation, feelings of depression, and self-rated mental health) and smartphone use.
Results
Reviewer’s comment 11: On page 9, figure 4? Please clarify. I also suggest the authors to add the cut off points.
Authors’ response:
We thank you for this suggestion. We changed the figure numbering to Figure 4. The cut-off points are mentioned in the measures section, and we included them in the figure as well as such:
A cut-off point of “Two hours or more” was established for weekday and weekend day, which indicated “high smartphone use” while a “fourteen hours or more” cut off point was established for "high weekly smartphone use”.
Discussion:
Reviewer’s comment 12: On page 12 line 373, I suggest the authors to add “problems” as mentioned other places in the manuscript.
Authors’ response:
Thank you, we added “problems” after “mental health” as suggested.
Reviewer’s comment 13: Can the authors add more depth to the discussion? They provide a nice overview of existing literature, but it would be helpful to read their thought of implications for future research, practice, and policy.
Authors’ response:
Thank you for encouraging us to be more assertive in this area. We find it is always tricky to balance recommendations with not overstating the implications of the findings. We added the following text pertaining to policies and recommendations to page 15 and 16 in the revised manuscript.
In line with the cognitive-behavioural model of pathological internet use (Davis, 2001), our findings suggest that smartphone gaming may be a specific behaviour with health outcomes that are different from other smartphone use behaviours.
To develop appropriate policies and interventions, future research should further investigate behaviour-specific (gaming, texting etc.) associations between high smartphone use and mental health outcomes. Such investigations may also include space-specific investigations (e.g., school versus home use) and the incorporation of other variables associated with poor mental health such as victimization and overall screen time use.
Finally, complex movement behaviours such as physical activity and sedentary behaviour should be captured across different seasons, as weather variation can have significant impact on them (Katapally et al 2015; Katapally et al., 2016). Since smartphone use (i.e., screen time) is often used as a proxy for sedentary behaviour, future studies should focus on capturing smartphone use across seasons.
Reviewer’s comment 14: Page 13 line 409, I suggest the authors to find a more recent ref.
Authors’ response:
We replaced the Rosenberg reference with (Marty-Dugas and Smilek, 2020).
Marty-Dugas, J., Smilek, D., 2020. The relations between smartphone use, mood, and flow experience. Pers. Individ. Dif. https://doi.org/10.1016/j.paid.2020.109966.
Reviewer’s comment 15: Page 13 line 427, Kleppang et al 2021 is a cross sectional study.
Authors’ response:
Thank you, we removed the word “longitudinal” from the revised manuscript.
Strengths and limitations
Reviewer’s comment 16: I suggest the authors to add a comment about self-reported measures and the participation rate.
Authors’ response:
We added to the limitations section to address this important limitation:
Although innovative and efficient, another potential limitation of this research is that the surveys for this study were deployed entirely through youth owned smartphones, an approach which may have increased the amount of time youth spend on their smartphones. Since the surveys were conducted on their personal smartphones, smartphone use time was self-reported by youth themselves. Future studies should move towards objective measurements to minimize over or under-reporting of usage (Katapally and Chu, 2019).
Conclusion
Reviewer’s comment 17: I agree that this is complex, and the results vary, but can the authors summarize the most important in a sentence or two? How can these result help developing guidelines? See also the comment under the discussion.
Authors’ response:
We added the following content to the beginning of the Conclusion section to summarize the main findings.
This study reports that among youth, high smartphone use was associated with almost a 2 times higher risk of screening positive for anxiety (specifically, high weekday and high weekly total smartphone use) and almost a 3 times higher risk of poor self-rated mental health (specifically, high weekend total smartphone use). High smartphone use was also associated with almost a 3 times higher risk of suicide ideation (specifically, high weekend gaming and high total smartphone use).
Thereafter, we reiterate the importance of considering both positive and negative implications of this ubiquitous device usage, and conclude that it is important to involve youth in guideline development.
Reviewer 2 Report
Overall, this is an interesting study investigating young people’s smartphone use time and mental health using an online platform. This study has some implications for the fields of cyberpsychology and problematic smartphone use. This paper needs some revisions before publishing. I have several concerns and comments as below.
- Please review some more empirical studies on “smartphone use time or frequency and mental health” and clearly address what your research gap is. What is the difference between the present study and existing evidence? Why is this study important?
- A theory on internet use or smartphone use is necessary to undergird and justify the research framework. The rationale of this study needs to be further clarified.
- This study collected self-reported smartphone use time, which could be a limitation. Participants might provide biased usage time based on their own perceptions. Problematic or addictive internet users might provide shorter time of internet use or gaming than the actual use time.
- On page 6, “The survey collected smartphone screen time by weekday and weekend day during the school year by providing the following options: ” It is not clear to me how long (a school year?) this study lasted and how many times you collected smartphone use time during the year. Please explain the “8-day circles”. When was the mental health and well-being data collected (at the beginning of the study)? The procedure of data collect needs to be described clearly and straightforward.
- It is recommended to discuss the Cognitive-Behavioral Model of Pathological Internet Use (Davis, 2001) and specify your implications to the “generalized and specific model”. Gaming in the present study appears to be specific internet use.
Author Response
Overall, this is an interesting study investigating young people’s smartphone use time and mental health using an online platform. This study has some implications for the fields of cyberpsychology and problematic smartphone use. This paper needs some revisions before publishing. I have several concerns and comments as below.
Thank you for taking the time to review our paper. Below we have addressed your comments/suggestions.
Reviewer’s comment: Please review some more empirical studies on “smartphone use time or frequency and mental health” and clearly address what your research gap is. What is the difference between the present study and existing evidence? Why is this study important?
Authors’ response:
Thank you for your comment. As suggested, we added more empirical studies in the revised manuscript. We also clarified that rather than use ‘problematic smartphone use’ as the previous literature has done, we use screen time guidelines as cut-off points to inform future public health and policy guidelines as to what may constitute ‘safe’ consumption among youth. Our additions to the revised manuscript’s Introduction section (on pages 2, 3, and 4) are as follows:
Evidence from a review paper (Thomée, 2018) reports that smartphone use is associated with adverse mental health outcomes. Additionally, a meta-analytic review (Vahedi and Saiphoo, 2018) specifically reported that smartphone use is associated with stress and anxiety. A systematic review also confirms associations between problematic smartphone use and depression severity (Elhai et al., 2017a). Another study confirms associations between problematic smartphone use and negative psychological wellbeing in general (Horwood and Anglim, 2019). Horwood and Anglim assessed for whether there are differences in the association between problematic smartphone usage behaviors and wellbeing. They found that when smartphone use was for entertainment purposes (i.e., used to relax, escape, pass time) it was correlated with lower wellbeing while smartphone use for communication purposes (i.e., texting, calling) was unrelated or slightly positively associated with wellbeing (Horwood and Anglim, 2019). Further research also suggests that specific smartphone activities may have specific associations with health outcomes.
A limitation with previous research is the focus on problematic smartphone use and the predominance of adult related literature, with only one -third of the studies addressing youth populations (Marty-Dugas and Smilek, 2020; Pera, 2020; Thomée, 2018). Problematic smartphone use is complex phenomenon consisting of dysfunctional manifestations (i.e., social isolation, diminished self-confidence, depression, and anxiety) (Pivetta et al., 2019). For public health and policy recommendations, studies are needed that evaluate smartphone use with time cut-off points (e.g., hour-based). This will help in the development of smartphone use guidelines for safe everyday use (i.e., do not pose health consequences).
Currently, there are no public health guidelines for smartphone screen time specifically, and there is scarce research on youth’s smartphone habits and their relationship with their health. The objective of this study is to investigate the association between smartphone use (internet use, gaming, texting, and total use) and mental health (feelings of anxiety, feelings of depression, and suicide ideation) among urban youth aged 13 to 21 years to inform future public health guidelines for youth smartphone use.
Reviewer’s comment: A theory on internet use or smartphone use is necessary to undergird and justify the research framework. The rationale of this study needs to be further clarified.
Authors’ response:
We thank you for this suggestion. We added the cognitive-behavioural model of pathological internet use and the Uses and Gratifications Theory as such in the following text to the Introduction section of our revised manuscript (page 3):
The cognitive-behavioural model of pathological internet use can further contextualize the literature’s findings (Davis, 2001). It suggests that generalized pathological internet use is to be distinguished from specific pathological internet use; where the latter refers to specific internet use such as online gambling. Additionally, the Uses and Gratifications Theory (UGT) also highlights that people consume media depending on their own personal needs that this can differ due to psychological and/or demographic characteristics (Elhai et al., 2017b; Katz et al., 1973). Findings from the literature, the cognitive-behavioural model of pathological internet use, and the UGT support that smartphone use behaviors differ at an individual level.
Reviewer’s comment: This study collected self-reported smartphone use time, which could be a limitation. Participants might provide biased usage time based on their own perceptions. Problematic or addictive internet users might provide shorter time of internet use or gaming than the actual use time.
Authors’ response:
We thank you for this important suggestion. We added following text to the Limitations section of our revised manuscript (pages 15-16):
Since the surveys were conducted on their personal smartphones, smartphone use time was self-reported by youth themselves. Future studies should move towards objective measurements to minimize over or under-reporting of usage.
Reviewer’s comment: On page 6, “The survey collected smartphone screen time by weekday and weekend day during the school year by providing the following options: ” It is not clear to me how long (a school year?) this study lasted and how many times you collected smartphone use time during the year. Please explain the “8-day circles”. When was the mental health and well-being data collected (at the beginning of the study)? The procedure of data collect needs to be described clearly and straightforward.
Authors’ response:
We agree that this needs clarification and thank you for pointing it out. All data (including smartphone use, mental health, and wellbeing) were collected once during the school year in a single 8-day period. We included a clear statement at the beginning of the “Measures” sub-section to clarify this.
All data were collected during the school year in a single 8-day period.
Moreover, replaced the existing statement about smartphone use data collection with the following statement:
The survey asked youth to report how much time on average they spent on smartphones on a typical weekday and weekend day by categorizing the behaviours into the following options
Reviewer’s comment: It is recommended to discuss the Cognitive-Behavioral Model of Pathological Internet Use (Davis, 2001) and specify your implications to the “generalized and specific model”. Gaming in the present study appears to be specific internet use.
Authors’ response:
Thank you for this suggestion. We discussed the Cognitive-Behavioral Model of Pathological Internet Use theory in the Introduction (page 3) as such:
The cognitive-behavioural model of pathological internet use can further contextualize the literature’s findings (Davis, 2001). It suggests that generalized pathological internet use is to be distinguished from specific pathological internet use; where the latter refers to specific internet use such as online gambling. Additionally, the Uses and Gratifications Theory (UGT) also highlights that people consume media depending on their own personal needs that this can differ due to psychological and/or demographic characteristics (Elhai et al., 2017b; Katz et al., 1973). Findings from the literature, the cognitive-behavioural model of pathological internet use, and the UGT support that smartphone use behaviors differ at an individual level.
And in the discussion (page 15) as follows:
In line with the cognitive-behavioural model of pathological internet use (Davis, 2001), our findings suggest that smartphone gaming may be a specific behaviour with health outcomes that are different from other smartphone use behaviours.
Reviewer 3 Report
Dear Authors! Thank you for possibility of reviewing your work. Research subject is remarkably interesting, I suggest for future extend questionnaire (with more questions precising about using devices in particular activities or even places like school etc.). Try add few more references. For next research I suggest add also more sociological questions due to mental problems like depression may cause from other things than media devices.
Author Response
Dear Authors! Thank you for possibility of reviewing your work. Research subject is remarkably interesting, I suggest for future extend questionnaire (with more questions precising about using devices in particular activities or even places like school etc.). Try add few more references. For next research I suggest add also more sociological questions due to mental problems like depression may cause from other things than media devices.
Authors' response: Thank you for your constructive comments. We are working to further improve data collection measures in the future by developing ecological momentary assessments that captures social and physical context. As suggested we have added more references.
