*Article* **Problematic Smartphone Use and Mental Health in Chinese Adults: A Population-Based Study**

**Ningyuan Guo 1, Tzu Tsun Luk 1, Sai Yin Ho 2, Jung Jae Lee 1, Chen Shen 3, John Oli**ff**e 4, Sophia Siu-Chee Chan 1, Tai Hing Lam <sup>2</sup> and Man Ping Wang 1,\***


Received: 2 December 2019; Accepted: 24 January 2020; Published: 29 January 2020

**Abstract:** Problematic smartphone use (PSU) has been associated with anxiety and depression, but few explored its mental well-being correlates that could co-occur with or be independent of mental symptoms. We studied the associations of PSU with anxiety, depression, and mental well-being in Hong Kong Chinese adults in a probability-based survey (*N* = 4054; 55.0% females; mean age ± SD 48.3 ± 18.3 years). PSU was measured using Smartphone Addiction Scale-Short Version. Anxiety and depression symptoms were evaluated using General Anxiety Disorder screener-2 (GAD-2) and Patient Health Questionnaire-2 (PHQ-2). Mental well-being was measured using Subjective Happiness Scale (SHS) and Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS). Multivariable regression analyzed associations adjusting for sociodemographic and lifestyle-related variables. Associations of PSU with mental well-being were stratified by symptom severity of anxiety (GAD-2 cutoff of 3) and depression (PHQ-2 cutoff of 3). We found that PSU was associated with higher odds of anxiety and depression symptom severity and lower scores of SHS and SWEMWBS. Associations of PSU with lower SHS and SWEMWBS scores remained in respondents who screened negative for anxiety or depression symptoms. To conclude, PSU was associated with anxiety, depression, and impaired mental well-being. Associations of PSU with impaired mental well-being could be independent of anxiety or depression symptoms.

**Keywords:** problematic smartphone use; smartphone addiction; anxiety; depression; mental well-being; population-based study

### **1. Introduction**

The evolving mobile information and communication technologies (ICTs) have raised debates about the potential effects on mental health. Instant messaging (IM) and social networking sites (SNS) can be used for unpleasant moods avoidance, social contacts, and relationship maintenance especially in females [1], whereas a practical and instrumental use such as for social position advancement was found in males [2]. In contrast, many studies have shown the associations between poor mental health outcomes and excessive or intensive use of phone calls, texts, IM, emails, and SNS [3]. These are privileged applications of problematic smartphone use (PSU), an impaired ability to control smartphone use with core symptoms such as loss of control, tolerance, and withdrawal shared with gaming disorder and substance use disorders [4]. PSU has been associated with an array of health outcomes, including self-reported dependence [5], cyberbullying [5], traffic accidence [5], physical symptoms (e.g., eye

strain and fatigue) [6], and sleep disturbances [7,8]. Our previous study also showed the lower levels of family communication and well-being associated with PSU [9].

Research in adolescents and young adults have identified psychopathological correlates with PSU, with affective disorders including anxiety and depression were most studied [1]. Small to medium effect size associations were observed between PSU and the severity of anxiety and depression symptoms [10]. Longitudinal studies further supported the predicting effects of PSU on anxiety and depression in college students [7,8]. Although these age groups were deemed to be at higher risk for PSU because of developing self-control and more access to the ICTs, increasing prevalence of both smartphone ownership and PSU in adults of a wider age range warranted general population studies [11–14].

The definition of mental health has been established as not the mere absence of psychopathological symptoms, which leads researchers to broaden the investigation field to positive psychology [15]. Mental well-being investigates hedonic well-being that includes affective emotions and cognitive assessments of life satisfaction and eudemonic well-being that includes psychological functioning and self-realization [16]. Our previous study showed that people with greater mental well-being tended to have lower risks for anxiety and depression [16]. Despite the correlations, the dual continuum model of mental health proposes that mental illness and well-being are on two distinct dimensions [17]. This notion was supported by studies in adults reporting greater well-being despite concurrent affective disorders or impaired mental well-being but without mental illness [18,19]. One study using data from a sample of college students showed that PSU was negatively correlated with mental well-being outcomes [20]. Little is known about whether such associations could co-occur with or operate independently from affective disorders.

The present study took advantage of a representative population-based survey in Chinese adults in Hong Kong, where the smartphone penetration rate (88.6% in people aged 10 years or above in 2017) has been among the highest worldwide due to advanced cyber-infrastructure and low-cost Internet access [21]. We aimed: (a) to confirm the associations of PSU with anxiety and depression symptom severity in the general population; (b) to examine the associations of PSU with mental health outcomes including hedonic and eudemonic well-being; (c) to examine the associations of PSU with mental well-being outcomes with stratification of symptom severity of anxiety and depression.

### **2. Materials and Methods**
