You are on page 1of 24

8/25/13

www.medscape.com/viewarticle/778353_print

www.medscape.com

Computer Use and Stress, Sleep Disturbances, and Symptoms of Depression Among Young Adults
A Prospective Cohort Study
Sara Thomée, Annika Härenstam, Mats Hagberg BMC Psychiatry. 2012;12(176)

Abstract
Background: We have previously studied prospective associations between computer use and mental health symptoms in a selected young adult population. The purpose of this study was to investigate if high computer use is a prospective risk factor for developing mental health symptoms in a population-based sample of young adults. Methods: The study group was a cohort of young adults (n = 4163), 20–24 years old, who responded to a questionnaire at baseline and 1-year follow-up. Exposure variables included time spent on computer use (CU) in general, email/chat use, computer gaming, CU without breaks, and CU at night causing lost sleep. Mental health outcomes included perceived stress, sleep disturbances, symptoms of depression, and reduced performance due to stress, depressed mood, or tiredness. Prevalence ratios (PRs) were calculated for prospective associations between exposure variables at baseline and mental health outcomes (new cases) at 1-year follow-up for the men and women separately. Results: Both high and medium computer use compared to low computer use at baseline were associated with sleep disturbances in the men at follow-up. High email/chat use was negatively associated with perceived stress, but positively associated with reported sleep disturbances for the men. For the women, high email/chat use was (positively) associated with several mental health outcomes, while medium computer gaming was associated with symptoms of depression, and CU without breaks with most mental health outcomes. CU causing lost sleep was associated with mental health outcomes for both men and women. Conclusions: Time spent on general computer use was prospectively associated with sleep disturbances and reduced performance for the men. For the women, using the computer without breaks was a risk factor for several mental health outcomes. Some associations were enhanced in interaction with mobile phone use. Using the computer at night and consequently losing sleep was associated with most mental health outcomes for both men and women. Further studies should focus on mechanisms relating information and communication technology (ICT) use to sleep disturbances.

Background
The widespread use of modern information and communication technology (ICT) in work life and private life follows in the wake of rapid advances in technology and popularization of different devices and applications, implying fast changes in exposure profiles in the population over the past few decades. The issue of possible negative effects of exposure to ICT has been raised by various groups. Musculoskeletal symptoms and ergonomics in relation to computer use and different input devices have been examined,[1–3] but also, mental health effects have been considered (e.g. [4]). The term technostress emerged more than two decades ago, to describe stress reactions in relation to computer use.[5] It was suggested that computer use can lead to psychophysiological stress reactions due to occupational strain, and that these reactions can become conditioned to the computer work environment, leading to symptoms associated with computer use.[5,6] The term ICT stress has been used to describe stress induced by interruptions at work, time pressure, and technical problems in connection with ICT use.[7] In 2010, 91% of the Swedish population (16–74 years old) had access to the Internet at home.[8] Young adults, 20–24 years old, were the most frequent users compared to all other age groups.[9] In a previous prospective cohort study, we found associations between high use of ICT, including chatting, emailing, Internet surfing, the sum of hours spent at the computer and mobile phone per week, and the number of mobile phone calls and text messages (SMSs) per day, and reported mental health symptoms among college and university students aged 19–25 years.[10] The study was followed by
www.medscape.com/viewarticle/778353_print 1/24

8/25/13

www.medscape.com/viewarticle/778353_print

a qualitative interview study with 32 high users of ICT who had reported mental health symptoms at 1-year follow-up in the cohort questionnaire.[11] Based on these young adults' own concepts and ideas, a model of possible paths for associations between ICT use and mental symptoms was proposed via consequences of high quantitative computer or mobile phone use, negative qualitative use, and user problems. Consequences of computer use included spending more time than planned at the computer (e.g., working, gaming, or chatting), leading to time pressure, neglect of other activities and personal needs (e.g., breaks, physical activity, social interaction, sleep), exposure to bad ergonomics, and mental overload. Chatting or emailing interrupted other tasks, with difficulties filtering important from unimportant messages, leading to mental overload. Getting stuck in what was perceived as unproductive activities, such as game playing, or "gaming," was another concern, and participants could also relate to having insufficient or dislocated sleep after sitting up late in front of the computer because of getting stuck in tasks, meeting deadlines, chatting, or gaming. In a study among Finnish adolescents,[12] intensive computer use among the boys was a risk for poor perceived health through deteriorated sleeping habits and waking time tiredness. (For the girls, it was intensive mobile phone use that was directly associated with poor perceived health, likewise through deteriorated sleeping habits and waking time tiredness). There has been a growing number of publications concerning ICT addiction.[13] Internet addiction has been proposed as a specific psychiatric illness;[14] however, this form of problematic Internet use could also be considered to share elements with impulse control disorders and be related to the specific activities done on the Internet (such as gambling) rather than the Internet per se.[15,16] Internet addiction has been associated with sleep disorders and depression among adults [17] and adolescents.[18] Most studies we have found concerning problematic Internet use and mental health have a crosssectional design, but one exception is a prospective study among Chinese adolescents 13–18 years old,[19] where Internet addicts, compared to non-pathological users, had a relative risk of about 2.5 for new cases of depression (using the Zung Depression Scale). Another focus has been computer gaming. Playing computer games is more common among men and boys than among women or girls (e.g. [12,20,21]). In a longitudinal study among youths, pathological gaming predicted higher levels of depression, anxiety, social phobia, and poor school performance.[22] It seemed to be a long-term exposure, as most (84%) of the youths who were pathological gamers at baseline were still pathological gamers after 2 years. Furthermore, in our interview study,[11] social isolation was a concern. A negative loop was suggested, where people who are already lonely may have a preference for using computers, which in turn could increase their tendency to lack real-life contacts, and lead to an even higher use. This is in line with the findings of Morahan-Martin and Schumacher.[23] Positive effects of computer use were also listed, such as efficiency, access to information, fun and recreation, the ease of keeping up social contacts, and access to social support.[11] We concluded that there seemed to be many factors in different domains that should be taken into consideration in epidemiological studies concerning associations between ICT use and mental symptoms. While we have previously performed a prospective study on computer use in relation to mental health symptoms in a selected university student cohort,[10] it is important to examine possible prospective associations between computer use and mental health outcomes in a more general and heterogeneous population of young adults. The present study was performed in a population-based sample of young adults. We have recently performed a study on mobile phone use and mental health outcomes in the same cohort population.[24] Frequent mobile phone use was a prospective risk factor for sleep disturbances in the men, and for symptoms of depression in the men and women.
Aims

The purpose of this study was to investigate if high computer use is a risk factor for developing mental health symptoms in a population sample of young adults. Specific aims included examining associations, if any, between time spent on computer use in general, time spent on communication (emailing or chatting) in leisure, time spent on computer gaming, using the computer without breaks, and getting stuck behind the computer screen at night and thus losing sleep, on the one hand, and perceived stress, sleep disturbances, and symptoms of depression, on the other. Furthermore, we wanted to explore perceived social support in relation to computer use. As a final goal, we aimed to examine potential interaction between computer and mobile phone use on mental health symptoms.

www.medscape.com/viewarticle/778353_print

2/24

n = 4163. Also. a questionnaire[26] containing questions about health. Figure 1. 1 Euro) was attached to the cover letter and could be used regardless of participation in the study. In October 2007.medscape. demographic factors. Twelve months later. The study was approved by the Regional Ethics Review Board in Gothenburg. work. and psychosocial factors was sent to the selected young adults by post. those respondents who had indicated that they would consider participating in future studies (n = 5734) were invited to respond to an identical questionnaire. The participation process from study population to study group.8/25/13 www. Response data were categorical. Study population. www. and 50% in the rest of Sweden. as well as how often the computer was used for more than 2 hours without breaks. Sweden (Reg. on emailing or chatting in leisure. Besides returning the postal questionnaire it was also possible to complete the questionnaire online if desired. born between 1983 and 1987. and on computer gaming. 2778 men and 4347 women). information about mobile phone use (average number of calls and SMSs sent and received per day) was collected from the questionnaire. were randomly selected from the general population from a registry held by theSwedish Tax Agency. 1458 men and 2705 women). this time administered via the Web. As an incentive to respond. The response rate at baseline was 36% (n = 7125.and leisure-related exposure factors. and how often sleep was lost because of getting stuck late at night by the computer. 191–05 and 876–11). with the addition of a third reminder offering a paper version of the questionnaire and two cinema tickets for participating. a lottery ticket (value approx. 50% living in the County of Västra Götaland. no. and were further divided into high. 20–24 years old (age span corresponding to the United Nations' definition of young adults [25]).medscape. A cohort of 10000 men and 10000 women. Exposure Variables Information about computer use was collected from the cohort study questionnaire at baseline.com/viewarticle/778353_print Methods Study Population and Data Collection The study population consisted of a cohort of young adults (Figure 1).com/viewarticle/778353_print 3/24 . including average time spent daily on general computer use. The data collection process was similar to that at baseline. The response rate at followup was 73% (Figure 1. Two reminders were sent by post.

Table 1.com/viewarticle/778353_print . and low categories. questionnaire items.8/25/13 www. Exposure variables. Exposure variables at baseline Category Variables and response categories Men N = 1458 Women N = 2705 n Computer use (CU) Low Medium High <2 hours per day 2–4 hours per day >4 hours per day Email/chat use Low Not at all <1 hour per day Medium High 1–2 hours per day >2 hours per day Computer gaming Low Not at all <1 hour per day Medium High 1–2 hours per day >2 hours per day CU without breaks Low Never Only occasionally Medium A few times per month A few times per week High Almost every day CU causing lost sleep Low Never Only occasionally Medium High A few times per month A few times per week Almost every day Mobile phone use Low Medium High 0–5 calls + 0–5 SMSs per day 0–5 calls + 6–10 SMSs.medscape. or vice versa >11 calls and/or >11 SMSs.com/viewarticle/778353_print medium. and categories used in the present study are presented in . response categories.medscape. or 804 326 323 55 22 22 1433 616 645 53 23 24 4/24 % n % 382 505 564 26 35 39 993 950 748 37 35 28 120 906 277 151 8 62 19 10 162 1732 558 236 6 64 21 9 655 427 204 168 45 29 14 12 2050 468 114 61 76 17 4 2 202 314 247 324 366 14 22 17 22 25 565 832 526 445 323 21 31 20 17 12 410 490 316 181 57 28 34 22 12 4 1128 920 393 206 46 42 34 15 8 2 www.

computer games or online games. we constructed two separate outcomes: symptoms of depression (one item) and symptoms of depression (two items). approximately 50% of the men and almost 65% of the women confirmed at least one of the two depressive items. Questionnaire items: Computer use (CU): On average. a procedure that has been shown to have high sensitivity for major depression diagnosis (86% [29] and 96% [30]). Mental health outcome variables Variable Cohort questionnaire item Response categories Categories in present study Yes No a = not at all. Therefore.[28] with responses divided into yes and no based on clinical significance (sleep problems several times per week or more). In our cohort study group. Table 2. or anxious or is unable to sleep at night because his/her mind is troubled all the time. how much time per day have you used on a computer (total use)? Email/chat use: On average.8/25/13 www. It has been proposed that if one of the two items is confirmed at screening to go forward with clinical assessment of mood disorder. which indicates that the instrument is probably very sensitive but had low specificity in our study group. how much time per day have you used on a computer for emailing and chatting (leisure/private use)? Computer gaming: On average. the latter presumably with higher specificity. The two depressive items from the Primary Care Evaluation of Mental Disorders (Prime-MD) screening form[29] were included in the questionnaire.medscape. questionnaire items. and How many SMS messages on average have you sent and received per day? The time span for all items was "over the past 30 days". are presented. d = quite a lot. The variable reduced performance was based on reporting that stress. Stress means a situation when a person feels tense. The variable sleep disturbances was constructed for the study by including the most common sleep disturbances (difficulties falling asleep.. depressed mood. Missing values (non-responses to items) are not accounted for.com/viewarticle/778353_print 6–10 calls + 6–10 SMSs per day Frequencies and percentages in exposure variables. private/leisure use)? CU without breaks: How often have you used a computer for more than 2 hours without taking a break longer than 10 minutes? CU causing lost sleep: How often have you lost sleep because of sitting late at night at the computer? Mobile phone use: How many mobile phone calls on average have you made and received per day?.. b = just a little. nervous. The outcome variable current stress was constituted by a validated single-item stress indicator. or tiredness had influenced performance "quite a lot" at work or school over the past 2 weeks. medium. restless. which means that the n varies for the variables. and categories used in the present study are presented in . Mental Health Outcome Variables Information about perceived mental health symptoms was collected from the cohort study questionnaire at baseline and follow-up. In the youngest age group (<35 years old) in Whooley et al.g. how much time per day have you spent on computer gaming (e. and high. Mental health outcome variables. www.medscape. and premature awakening) into a single item.com/viewarticle/778353_print 5/24 Current stress d–e a–c .[30] the sensitivity was 100% and the specificity 59%. but lower specificity (75% [29] and 57% [30]).[27] with the responses divided into yes and no. response categories. loosely adapted from the Karolinska Sleep Questionnaire. fragmented sleep. Are you currently experiencing this k ind of stress? c = to some extent. in primary care populations. including categorizations into low.

repeated awak enings.8/25/13 www. constructed for the study as a single item adaptation of the social support scale in the Karasek-Theorell Job Content Questionnaire. c = Yes. and d = every day One item: (a) Yes or (b) Yes Yes or No Two Two items: items: (a) Yes and (b) Yes a = No. a little. depressed. c = several times per week .com/viewarticle/778353_print e = very much a = never. b = www.. wak ing up too early)? c–d a–b One item: (a) No and (b) No Symptoms of During the past month. Reduced performance Have the following complaints influenced your performance at work or in studies over the past 14 days? (a) stress/depressed mood? (b) tiredness negligibly.g. quite a lot Social Support Sleep disturbances How often have you had problems with your sleep these past 30 days (e. and d = Yes. b = Yes.com/viewarticle/778353_print 6/24 . or item two items hopeless? (a) No and (b) No (a) d or(b) d (a) a– c and(b) a–c The variable social support was based on the item: When I have problems in my private life I have access to support and help. have you often been bothered by: (a) little depression one interest or pleasure in doing things? (b) feeling down.[31] here relating to private life (rather than work life). b = a few times per month.medscape.medscape. Response categories were: a = applies very poorly. difficulties falling asleep.

d = applies very well. subjects with sleep disturbances at baseline were excluded. or college or university studies. was used to calculate prevalence ratios (PRs) with a 95% confidence interval (CI) for multivariate analysis of prospective associations between exposure variables high.. however. Age was not considered a confounder because of the limited age span of the study group. Finally.2 (SAS Institute. There were little if any correlations between computer exposure variables and mobile phone use. ). including only those who reported symptoms at baseline. Sociodemographic Variables In the multivariate analysis. and low (reference level) and mental health outcomes (yes or no). There were moderate positive associations between the exposure variables at baseline (Spearman correlation coefficients. Two sets of extra analyses were performed.33] In all prospective analyses. USA). These potential confounders were chosen based on theoretical hypothesis and were added to all analyses if p ≤ 0. USA). Inc. All analyses were performed using the statistical software package SAS. potentially confounding sociodemographic factors were collected from the baseline questionnaire and adjusted for. NC. by using all nine possible category combinations of the two variables in the analysis. with the strongest associations found between computer use (hours per day) and frequency of CU without break s . Cary. educational level. Inc. The PRs were adjusted for sociodemographic factors including relationship status.00 (before rounding) were considered statistically significant. as described earlier. The Cox proportional hazard model. and Social Support in Study Group at Baseline Almost 40% of the men and 30% of the women were categorized as having high computer use (>4 hours per day) (). and occupation. highest completed educational level: elementary school (basic schooling for 6–16-year-olds). some computer exposure variables were analyzed for possible interaction with mobile phone use. The responses were categorized as low (response categories a–b).. and between the exposure variables and social support.com/viewarticle/778353_print applies rather poorly. when analyzing sleep disturbances. PRs with a 95% CI not including 1. including also those with symptoms at baseline.[32. Mental Health Symptoms. these were not accounted for in the analysis of sleep disturbances. using SAS PROC PHREG (SAS Institute. Results Exposure. Analysis Spearman correlation analysis was used to examine associations between the different computer exposure variables. All analyses were performed separately for the men and women. For analysis of dropout between the initial cohort baseline and 1-year follow-up. one.com/viewarticle/778353_print 7/24 . or being unemployed). which means that the n varied in all analyses. and occupation: working. and the other. The majority spent less than 1 hour per day on leisure time email/chat use. NC. Lost sleep because of late night computer use (CU causing lost sleep) was more common among men than among women (). participants who reported symptoms at baseline were excluded from the analysis of the mental health outcome variable concerned. www. upper secondary school. medium (response category c). while about 20% spent 1–2 hours per day. adding the baseline value of the outcome variable as a confounder. studying. The percentage of men who spent >1 hour on computer gaming (medium or high gaming) was more than four times that of women. medium. Wilcoxon's (two-sided) two-sample test was used.8/25/13 www. and 10% spent more than 2 hours per day on this activity. or other (other included being on long-term sick leave. or on parental or other leave.10 in at least some of the analyses. Missing values (i. The robust variance option (COVS) was used to produce accurate CIs. non-responses to items in the questionnaire) were excluded from the analyses. with time set to 1. including relationship status : single or in a relationship. Multivariate analyses were performed to calculate PRs using the Cox procedure.medscape. It is possible that the included subjects had one or more of the other mental health symptoms at baseline..e. and high (response category d). version 9.medscape. c = applies rather well. using the "low–low" category combination as reference. Cary. For example.

or vice versa >11 calls and/or >11 SMSs. or 6–10 calls + 6–10 SMSs per day Frequencies and percentages in exposure variables. and high.medscape. Exposure variables at baseline Category Variables and response categories Men N = 1458 Women N = 2705 n Computer use (CU) Low Medium High <2 hours per day 2–4 hours per day >4 hours per day Email/chat use Low Not at all <1 hour per day Medium High 1–2 hours per day >2 hours per day Computer gaming Low Not at all <1 hour per day Medium High 1–2 hours per day >2 hours per day CU without breaks Low Never Only occasionally Medium A few times per month A few times per week High Almost every day CU causing lost sleep Low Never Only occasionally Medium High A few times per month A few times per week Almost every day Mobile phone use Low Medium High 0–5 calls + 0–5 SMSs per day 0–5 calls + 6–10 SMSs.medscape.com/viewarticle/778353_print 8/24 % n % 382 505 564 26 35 39 993 950 748 37 35 28 120 906 277 151 8 62 19 10 162 1732 558 236 6 64 21 9 655 427 204 168 45 29 14 12 2050 468 114 61 76 17 4 2 202 314 247 324 366 14 22 17 22 25 565 832 526 445 323 21 31 20 17 12 410 490 316 181 57 28 34 22 12 4 1128 920 393 206 46 42 34 15 8 2 804 326 323 55 22 22 1433 616 645 53 23 24 . www. including categorizations into low. are presented. medium.com/viewarticle/778353_print Table 1.8/25/13 www.

how much time per day have you spent on computer gaming (e.medscape. Table 1.com/viewarticle/778353_print .8/25/13 www. Exposure variables at baseline Category Variables and response categories Men N = 1458 Women N = 2705 n Computer use (CU) Low Medium High <2 hours per day 2–4 hours per day >4 hours per day Email/chat use Low Not at all <1 hour per day Medium High 1–2 hours per day >2 hours per day Computer gaming Low Not at all <1 hour per day Medium High 1–2 hours per day >2 hours per day CU without breaks Low Never Only occasionally Medium A few times per month A few times per week High Almost every day CU causing lost sleep Low Never Only occasionally Medium A few times per month 410 490 316 28 34 22 1128 920 393 42 34 15 9/24 % n % 382 505 564 26 35 39 993 950 748 37 35 28 120 906 277 151 8 62 19 10 162 1732 558 236 6 64 21 9 655 427 204 168 45 29 14 12 2050 468 114 61 76 17 4 2 202 314 247 324 366 14 22 17 22 25 565 832 526 445 323 21 31 20 17 12 www.medscape. how much time per day have you used on a computer for emailing and chatting (leisure/private use)? Computer gaming: On average.g. private/leisure use)? CU without breaks: How often have you used a computer for more than 2 hours without taking a break longer than 10 minutes? CU causing lost sleep: How often have you lost sleep because of sitting late at night at the computer? Mobile phone use: How many mobile phone calls on average have you made and received per day?. which means that the n varies for the variables. computer games or online games.com/viewarticle/778353_print Missing values (non-responses to items) are not accounted for. how much time per day have you used on a computer (total use)? Email/chat use: On average. Questionnaire items: Computer use (CU): On average. and How many SMS messages on average have you sent and received per day? The time span for all items was "over the past 30 days"..

for men and women respectively: current stress: 10% and 19%.18 0.39/0.34 Mobile phone use Men/Women −0.medscape. computer games or online games. and How many SMS messages on average have you sent and received per day? The time span for all items was "over the past 30 days".09/0.medscape.31/0. The women reported current stress almost twice as often as the men (29% compared to 16%) at baseline.32 0. Associations between exposure variables at baseline Email/chat use Men/Women Computer use Email/chat use Computer gaming CU without breaks CU causing lost sleep 0. symptoms of depression (one item): 24% and 28%. or tiredness.06/0.8/25/13 www.18 −0.08/0. or 6–10 calls + 6–10 SMSs per day 804 326 323 55 22 22 1433 616 645 53 23 24 Frequencies and percentages in exposure variables. Of the men.29/0.02 ns/0.31 0. Table 3. 30% reported one and 34% both symptoms of depression.27/0.04 −0.com/viewarticle/778353_print 10/24 .40/0.56 0. Missing values (non-responses to items) are not accounted for. Ten percent of the men and 20% of the women reported reduced performance due to stress.g. and of the women.19 0.07 Spearman correlation coefficients for the men (n = 1458) and women (n = 2705) included in the study. the prevalence of new cases at 1-year follow-up was as follows.05) except where indicated as non-significant (ns).37/0. are presented.17 CU causing lost sleep Men/Women 0. Twenty-three percent of the men and 34% of the women indicated sleep disturbances. or vice versa >11 calls and/or >11 SMSs.36/0. sleep disturbances: 15% and 20%.02 ns −0. how much time per day have you spent on computer gaming (e. Sixteen percent of the men and 13% of the women perceived low social support in private life. private/leisure use)? CU without breaks: How often have you used a computer for more than 2 hours without taking a break longer than 10 minutes? CU causing lost sleep: How often have you lost sleep because of sitting late at night at the computer? Mobile phone use: How many mobile phone calls on average have you made and received per day?.39/0. www. 27% reported one and 24% both symptoms of depression. All correlations are statistically significant (p < 0.09/0. which means that the n varies for the variables.17/0. how much time per day have you used on a computer for emailing and chatting (leisure/private use)? Computer gaming: On average. Among participants who were symptom-free at baseline (in terms of the outcome variable concerned).04 CU without breaks Men/Women 0. Questionnaire items: Computer use (CU): On average. and reduced performance: 7% and 14%. how much time per day have you used on a computer (total use)? Email/chat use: On average. medium. and 43% of the men and 56% of the women reported high social support.. depressed mood. symptoms of depression (two items): 12% and 18%. including categorizations into low.31 0.40 Computer gaming Men/Women 0.05 0. Forty-one percent of the men and 32% of the women reported medium. and high.com/viewarticle/778353_print High A few times per week Almost every day Mobile phone use 181 57 12 4 206 46 8 2 Low Medium High 0–5 calls + 0–5 SMSs per day 0–5 calls + 6–10 SMSs.59/0.

99 0. high email/chat use was also associated with symptoms of depression (one item) (PR 1.62 477 4 (11) 13 (15) 61 (16) … 0.1 1.4 38 (29) 111 1.29 600 70 (18) 65 (17) 25 (10) 101 (24) 94 (17) 128 (21) 1. or tiredness).78 1.4 0.23– 26 2.68 1167 16 (8) 1.0 1. 95% CI 1.8/25/13 www. Prospective associations between computer exposure at baseline and mental health outcomes (new cases) at 1year follow-up Current stress Cases 95% (%) PR CI Sleep disturbances Cases 95% (%) PR CI Symptoms of depression (two items) n Cases 95% (%) PR CI Reduced performance Cases 95% (%) PR CI n Computer use (CU) Men High 440 n n 43 (10) 42 (10) 28 (10) 92 (20) 117 (19) 122 (19) 1.85– 468 1.50 0.74– 129 2. There were no other statistically significant associations with symptoms of depression (one item).com/viewarticle/778353_print Prospective Associations Between Computer Exposure at Baseline and Mental Health Outcomes (New Cases) at 1-year Follow-up Both high and medium computer use compared to low computer use at baseline were associated with sleep disturbances at 1-year follow-up for the men.18– 0.95 98 27 (28) 31 (16) 102 (14) 35 (30) 73 (22) 212 1.1 1.1 1.95– 152 1.2 12 (4) 1.0 … 100 6 (6) 0.65– 241 1.0 0.0 8 (31) 1. but not for the women ().0 1.0 1.9 1.25 Medium 215 Low Women High 807 136 20 (9) 0.77 0.7 1.2 1.0 0. For the women.31 740 1.79– 1.2 1.0 0.3 1.90– 573 1.51 757 0.79 136 0.8 88 (11) 37 (27) 80 (23) 212 1.63– 400 2.3 45 (6) 1.8 1.94 0.87– 428 1. For the women.2 0.98 0.29– 38 2.0 1.84– 1.9 0.04 0.93 279 0.0 1.23– 118 2.41– 1.61– 2.17– 187 2.0 1.medscape.0 20 (5) 1. depressed mood.66– 373 1.8 1.medscape.2 1.81– 566 1.73– 2.24 1.06 246 31 (18) 30 (16) 17 (12) 39 (26) 64 (27) 56 (23) 1.0 64 (14) 84 (15) 75 (13) 1.76 1149 0.0 1.01– 133 1.com/viewarticle/778353_print 11/24 .50– 210 1.52 0.0 21 (16) 51 (16) 150 1.8 1.77 0.60 Medium 348 Low 1248 www. high computer use was also associated with reduced performance (due to stress.52– 197 1.63 263 0.89– 329 1.0 1.1 1.7 1.0 1.48 0. but positively associated with reported sleep disturbances.46–2.11– 325 1.70 586 35 (9) 2.48 Medium 617 Low Email/chat use Men High 116 655 6 (5) 0.1 1.2 1.88– 1.4 1.01– 3.60– 388 1.0 1. For men.49 Medium 409 Low Women High 289 463 0. not presented in the Table).9 1.82– 1.60– 398 1.9.0 0.77– 86 1.25 1.3 1.14– 173 2. Table 4. High email/chat use was negatively associated with perceived stress for the men.63 373 1.55 0.42 0.1 1.0 1. both high and medium email/chat use were (positively) associated with stress and sleep disturbances.52.

5 1.67 0.98– 3.8 0.53 0.03 Medium 454 Low Women High 404 189 38 (9) 1.6 0.01– 1.77– 230 1.09 863 20 (8) 1.4 1.0 0.17– 221 1.5 28 (4) 1.0 1.05– 202 2.0 1.8 1.5 1.74 1.51 0.com/viewarticle/778353_print (17) Computer gaming Men High 136 13 (10) 17 (10) 83 (10) 0.63 369 16 (16) 29 (14) 32 (16) 21 (34) 62 (30) 76 (21) 0.07– 32 2.06– 208 1.0 0.58– 250 1.70 0.73– 43 1.13 12/24 Medium 214 www.9 0.16 194 1.55 380 0.08 1.63 1.86 659 1.7 1.67– 2.78– 239 2.0 19 (18) 41 (19) 1.9 0.94 340 1.06– 78 1.0 605 1.4 1.8/25/13 www.63 0.92– 2.51– 107 1.78 9 (17) 1.0 1.09 1.55– 156 1.0 280 25 (9) 0.38– 212 2.01– 558 1.com/viewarticle/778353_print .54 846 42 (17) 74 (18) 43 (12) 55 (29) 120 (22) 147 (17) 1.3 1.0 2 (8) … … 0.09 9 (21) 1.4 1.98 0.24– 190 2.50 1.2 0.61 0.39– 1.27– 106 2.92– 100 2.44– 4.0 20 (19) 49 (14) 10 (31) 31 (40) 1.0 0.0 1.46– 253 1.16– 586 2.9 0.3 1.87 0.9 1.50 771 29 59 18) (23) (13) 20 (19) 25 (16) 115 (15) 1.37– 1.42– 53 2.6 1.1 1.70– 73 1.76– 418 1.1 25 (10) 2.85– 108 2.0 35 (28) 55 (26) 1.08 0.6 62 (16) 2 (20) 11 (44) 146 (24) 1.42 0.4 1.54– 155 2.0 0.47 0.78 366 1.0 49 (26) 121 (21) 161 (17) 1.94 38 (26) 39 (17) 83 (13) 29 (27) 55 (25) 2.20 1.32 1.0 7 (24) 1.4 7 (11) 0.0 0.58– 108 1.7 0.2 1.61 Medium 176 Low Women High Medium 826 29 76 53 (7) 1.18 1.5 1.23 1.7 1.3 1.0 0.02 0.80 0.8 0.9 50 (11) 1.medscape.6 16 (4) 1.17– 3.30 377 1.90– 3.20– 180 2.62 14 (9) 2.24 Medium 243 Low Women High 722 123 62 (9) 1.0 1509 1.69 Medium 588 Low CU causing lost sleep Men High 174 958 27 (16) 25 (10) 1.3 15 (20) 309 (19) 1.0 1538 213 (14) 1.2 1.medscape.0 24 (13) 94 (16) 105 (12) 1.03 26 64 5 (5) 9 (6) 0.17– 146 2.76– 1.0 1.6 1.5 1.96– 104 1.0 17 (29) 299 (20) 1.9 30 (7) 1.61 7 (24) 1.2 1.50– 438 1.65– 1.31– 62 2.28– 1.8 Low CU without breaks Men High 1631 1.15– 3.0 … 1.1 7 (10) 0.98 1.8 1.0 1.05 674 0.24 798 … 1.8 1.52– 10 2.14– 2.29– 161 1.92– 25 2.

Furthermore.0 1.60– 398 1. and adjusting for baseline health.60– 388 1. The PRs were approximately in between the PRs in and those that resulted when including only participants with symptoms at baseline (PRs mostly around 1.55 0.87– 428 1. both high and medium CU without break s were associated with perceived stress.06 246 31 (18) 30 (16) 17 (12) 39 (26) 64 (27) 56 (23) 1.2 1.95– 152 1.medscape. gave results in the same direction as the results presented above.61– 2.2 12 (4) 1.2 0. educational level. The study group n was: for Current stress : 1224 men and 1915 women.04 0. sleep disturbances.01– 3.42 0. Table 4.98 0.1 1. for Symptoms of depression (two items): 535 men and 693 women. medium) CU causing lost sleep was associated with stress and sleep disturbances for both the men and the women.0 0.81– 566 1.48 Medium 617 Low Email/chat use 655 0.48 0. PRs with a CI not including 1.79– 1.0 0.0 1.65– 241 1.14– 173 2.66– 373 1.1 1.79 136 0. and for Reduced performance: 1145 men and 1802 women. Furthermore.8 1. The prevalence ratios (PRs) with 95 % confidence intervals (CIs) were adjusted for relationship status. and symptoms of depression (two items) for the women.0 1. The prevalence of mental health symptoms (cases and %) at 1-year follow-up in each exposure category is shown.0 1.medscape.2 1.0 Participants who reported symptoms at baseline were excluded from analysis of the mental health outcome concerned.1 1.0 529 118 (22) 1. The extra analyses including also participants with symptoms at baseline.49 Medium 409 Low Women High 289 463 0. Missing values (non-responses to items) were excluded from the analyses.0). For the men.93 279 0.78 1.18– www.com/viewarticle/778353_print 27 1. High (and.1 1.0 64 (14) 84 (15) 75 (13) 1. for women.85– 468 1.29 600 70 (18) 65 (17) 25 (10) 101 (24) 94 (17) 128 (21) 1. Results of analyses with fewer than five cases are not presented. which means that the n varied further in the analyses.0 1270 239 (19) 1.0 1.77 0.63 263 0.82– 1. while medium (but not high) CU causing lost sleep was associated with symptoms of depression (two items) and reduced performance for the women.8 1. where medium gaming was associated with symptoms of depression (two items).41– 13/24 .90– 573 1.0 1.1 1.0 1.com/viewarticle/778353_print Low 1400 242 (17) 1. for Sleep disturbances : 1109 men and 1764 women.8 1.0 1. and occupation.00 (before rounding) are given in bold. The only clear association concerning computer gaming and mental health outcomes was for women.29– 0.8/25/13 www.52 0. medium CU without break s was associated with sleep disturbances.0 20 (5) 1. for Symptoms of depression (one item): 617 men and 791 women.63– 400 2. high and medium CU causing lost sleep were associated with reduced performance among the men. indicated as "…".17– 187 2.0 1308 163 (12) 1. Prospective associations between computer exposure at baseline and mental health outcomes (new cases) at 1year follow-up Current stress Cases 95% PR (%) CI Sleep disturbances Cases 95% PR (%) CI Symptoms of depression (two items) n Cases 95% PR (%) CI Reduced performance Cases 95% PR (%) CI n Computer use (CU) Men High 440 n n 43 (10) 42 (10) 28 (10) 92 (20) 117 (19) 122 (19) 1.70 586 35 (9) 2.

3 1.68 1167 16 (8) 1.0 49 (26) 121 (21) 161 (17) 1.0 0.65– 1.0 0.77 1.24– 190 2.31– 62 2.60 Medium 348 Low Computer gaming Men High 136 1248 13 (10) 17 (10) 83 (10) 0.4 0.01– 558 1.05– 202 2.46– 253 1.76– 418 1.24 1.98 0.39– 1.29– 161 1.0 0.51 757 0.63 1.30 377 1.6 16 (4) 1.0 7 (11) 0.0 25 (9) 0.54 846 42 (17) 74 (18) 43 (12) 55 (29) 120 (22) 147 (17) 1.47 0.8 0.42 0.76 1149 0.98– 3.0 8 (31) 1.17– 3.89– 329 1.medscape.61 0.67– 2.9 1.4 1.92– 25 2.51– 107 1.17– 38 1.2 1.com/viewarticle/778353_print Men High 116 6 (5) 0.0 1.76– 1.92– 100 2.0 24 (13) 94 (16) 105 (12) 1.7 1.01– 1.51 0.80 0.67 0.0 0.08 0.9 1.77– 86 1.16– 586 2.74– 129 2.0 0.03 26 64 1538 5 (5) 9 (6) 0.3 1.0 7 (24) 1.0 0.8 0.94 0.0 0.23 1.6 62 (16) 2 (20) 11 (44) 146 (24) 1.7 1.09 605 9 (21) 1.0 … 100 6 (6) 0.90– 3.58– 108 1.4 38 (29) 111 (23) 1.4 1.16 194 1.61 Medium 176 Low Women High Medium Low CU without breaks Men High 280 826 29 76 1631 53 (7) 1.0 1.50– 438 1.54– 1.0 21 (16) 51 (16) 150 (13) 1.73– 43 1.1 7 (10) 0.73– 2.55 380 0.0 38 4 (11) 13 (15) 61 (16) … 0.09 1.15– 14/24 .2 0.25 1.8 213 (14) 1.8 1.78 366 1.50– 210 1.3 1.53 0.63 29 59 1509 20 (19) 25 (16) 115 (15) 1.31 740 1.37– 1.55– 156 1.18 1.2 1.95 98 (28) 31 (16) 102 (14) 35 (30) 73 (22) 212 18) 1.99 0.1 1.62 477 0.25 Medium 215 Low Women High 807 136 20 (9) 0.0 … 1.23– 26 2.63 373 1.50 0.0 2 (8) … … 0.9 1.69 Medium 588 Low CU causing lost sleep 958 27 www.8/25/13 www.84– 1.6 1.20– 180 2.61 7 (24) 1.3 1.8 88 (11) 37 (27) 80 (23) 212 (17) 1.0 1.50 771 0.74 1.03 Medium 454 Low Women High 404 189 38 (9) 1.8 1.24 798 … 1.9 2.0 0.01– 133 1.52– 10 2.63 369 16 (16) 29 (14) 32 (16) 21 (34) 62 (30) 76 (21) 0.6 1.11– 325 1.5 1.2 1.0 1.com/viewarticle/778353_print 1.42– 0.58– 250 1.28– 1.7 0.1 1.3 45 (6) 1.medscape.06– 208 1.9 1.88– 1.70– 73 1.52– 197 1.9 30 (7) 1.2 1.9 50 (11) 1.23– 118 2.09 863 20 (8) 1.4 1.7 1.0 17 (29) 299 (20) 1.0 1.0 1.3 15 (20) 309 (19) 1.9 0.0 0.

medscape.17– 1.0 529 1.07– 32 2.5 155 14 (9) 2. only the "high–high" category was a risk exposure (). Interaction Effects: Computer and Mobile Phone Use Because computer use and email/chat use were risk factors for sleep disturbances among the men.24).medscape. with sleep disturbances as the outcome.com/viewarticle/778353_print WOMEN Mobile phone use High Low Medium PR (95% CI) High Cases (%) PR (95% CI) Medium Cases PR Cases PR Cases PR Cases PR Cases (%) (95% CI) (%) (95% CI) (%) (95% CI) (%) (95% CI) (%) 15/24 .62 212 1. for Symptoms of depression (one item): 617 men and 791 women.4 0. the CIs overlapped.44– 4.4 1. Men with high email/chat use in combination with medium or high mobile phone use had an almost tripled risk for sleep disturbances at follow-up.6 2. PRs with a CI not including 1.86 659 1.20 Medium 214 1.85– 108 2. as mobile phone use had been in a previous study (PR 1. using "low–low" users as reference ().50 62 (9) 1. while for the women.27– 106 2. with symptoms of depression (two items) as the outcome.0 1270 1. In the same analysis.0 1.8 2. Missing values (non-responses to items) were excluded from the analyses.96– 104 1. for Sleep disturbances : 1109 men and 1764 women. Caution in interpretation is necessary since in all the combined analyses.5.70 1.13 Low 1400 1.0 Participants who reported symptoms at baseline were excluded from analysis of the mental health outcome concerned.8.5 53 9 (17) 1.8/25/13 www. as mobile phone use had been in the previous study (PR 1. only effects of the email/chat use variable could be seen.0 2.98 25 (10) 2. The study group n was: for Current stress : 1224 men and 1915 women.00 (before rounding) are given in bold.1 3. for women.14– 1. CI 1. indicated as "…".[24] we tested these two exposure variables in combination with mobile phone use.08 0.02–2.0 2.0 35 (28) 55 (26) 242 (17) 1.4 1. The prevalence of mental health symptoms (cases and %) at 1-year follow-up in each exposure category is shown.02 20 (19) 49 (14) 10 (31) 31 (40) 118 (22) 1. and for Reduced performance: 1145 men and 1802 women.24 Medium 243 Low Women High 722 123 0.5 1.7 28 (4) 1. The prevalence ratios (PRs) with 95 % confidence intervals (CIs) were adjusted for relationship status.3 1.94 221 1.77– 230 1.87 1.0 19 (18) 41 (19) 163 (12) 1.94 340 1. educational level.9 2.5 1.38– 1.2 146 (26) 39 (17) 83 (13) 29 (27) 55 (25) 239 (19) 2.78 78 1. these were tested in combination. Furthermore.92– 2.78– 239 2. There seemed to be an interaction between computer use and mobile phone use in relation to sleep disturbances in a near additive fashion for the men.32 0. Interaction between computer exposure variables and mobile phone use at baseline. for Symptoms of depression (two items): 535 men and 693 women.com/viewarticle/778353_print Men High 174 (16) 25 (10) 1.21–2. since CU without break s was a risk factor for symptoms of depression among the women. CI 1. Table 5.69). there was a tendency towards interaction between CU without break s and mobile phone use with symptoms of depression (two items) as outcome for the women (). Results of analyses with fewer than five cases are not presented.0 1.06– 1. Finally. which means that the n varied further in the analyses.0 1308 1. and occupation.05 674 0. and sleep disturbances (new cases) at 1-year follow-up MEN Mobile phone use Low Computer exposure Computer www.

55) 2.82– 2. Prevalence of mental health symptoms (cases and %) at 1-year follow-up in each exposure category is shown.03– 4.2 (1.66) 1.29) 1.1 (1.1 (0.96– 3.2 (1.34) 1.47– 7.47– 5.92– 2.50– 1.16) 1.76) 0.8 (0.32– 6.44) 2. and occupation.78– 1.32) 1. The prevalence ratios (PRs) with 95 % confidence intervals (CIs) were adjusted for relationship status.34) 3.84– 1.8 (1.7 (0.81– 8.08) 7 (32) 2.2 (1.9 (1.55– 7.33) 1.8 (0.63) 3.8 (1.06– 2.50– 1.08) 1.7 (0.2 (1.69– 4.75– 1.2 (1.66– 5.68) 1.66) 1.25) 1.9 (1.08– 2.37) 31 (31) 23 (26) 39 (21) 1.33) 1.68) 1.82– 2.38) 14 (22) 17 (24) 3.24) 1.12) 1.34) 14 (29) 30 (19) 126 (18) 1.32) 17 (19) 16 (21) 2.47– 7.00– 4.88– 3.8 (0.4 (0.1 (0.8/25/13 www.76) 0.47) Medium 9 (20) 4 (10) 19 (24) 47 (18) Low 23 (14) 29 (22) Participants who reported symptoms at baseline were excluded from analysis of the mental health outcome concerned.2 (0.94– 1.32– 6.13) 1.0 (ref) 7 (28) 1.7 (1.0 (0.4 47 (21) 57 (17) 1. Results of analyses with fewer than five cases are not presented.61) 1.0 (ref) 9 (32) 2.29) 1.46) 1.03– 4.75– 1.com/viewarticle/778353_print WOMEN Mobile phone use High Low Medium PR (95% CI) High Cases (%) PR (95% CI) Medium Cases PR Cases PR Cases PR Cases PR Cases (%) (95% CI) (%) (95% CI) (%) (95% CI) (%) (95% CI) (%) 14 (22) 17 (24) 3.1 (1.69– 1.59) … 2.medscape.2 (0.44) 2.52– 1.0 (0.0 (ref) 17 (19) 16 (21) 2.9 (1.92) 36 (34) 17 (15) 24 (23) 1.4 (1.1 (0.3 (0.51) 0.96– 3.55– 7.00– 4.00 (before rounding) are given in bold.8 (0.7 (1.4 (1. Interaction between computer exposure variables and mobile phone use at baseline.55) 2.51) 0.78– 1.9 (1.70– 1.3 36 (34) 17 (15) 1.52– 1.34) 18 (19) 19 (15) 1.34) 3.99– 2.0 (0.90) 47 (21) 57 (17) 68 (19) 1.7 www.0 (ref) 18 (19) 19 (15) 36 (25) 1.3 (0.8 (0.69– 1.com/viewarticle/778353_print use High 38 (16) 32 (14) 2.4 (0.84– 1.4 (1.1 (0. PRs with a CI not including 1.1 16/24 Medium .00– 5.medscape.5 (0.72) Medium Low Email/chat use High 8 (6) 8 (10) 9 (15) 11 (23) 18 (16) 49 (11) 1.8 (0.81– 8.9 (1.70– 1. indicated as "…".63) 3.9 (1.28– 2.28– 2. educational level.16) 1. Table 5.31) 1.41– 3. and sleep disturbances (new cases) at 1-year follow-up MEN Mobile phone use Low Computer exposure Computer use High 38 (16) 32 (14) 2.1 (0.

Results of analyses with fewer than five cases are not presented.87) 1.52– 2.8/25/13 www.92) 24 (23) (0.9 (1.62) Medium 7 (16) 3 (9) … 1.4 (0.68) 14 (28) 19 (22) 14 (39) 20 (29) Low 9 (21) 8 (18) Participants who reported symptoms at baseline were excluded from analysis of the mental health outcome concerned.82– 2.46– 1.08– 2.7 (1. Results of analyses with fewer than five cases are not presented.3 (1. indicated as "…".08) 6 (40) 2.92– 2.6 (1.13) 1.4 (1.96– 3.0 (ref) 36 (25) (0.7 (0. and occupation.31) 1.66– 5. PRs with a CI not including 1. Prevalence of mental health symptoms (cases and %) at 1-year follow-up in each exposure category is shown.69– 4.88– 3.34) 14 (29) 30 (19) 126 (18) 1.5 (0. educational level. at 1-year follow-up MEN Mobile phone use Low Computer exposure CU without breaks High 12 (17) 18 (14) 15 (14) 0.com/viewarticle/778353_print Low 8 (6) 1. and occupation.04– 3.96– 3.06– 2.75– 1.37) 31 (31) 23 (26) 39 (21) 1.72) Email/chat use High 11 (23) 18 (16) 49 (11) 1.1 (0.58) 2.com/viewarticle/778353_print 17/24 .09– 2.0 (0.8 (0.76– 3. and symptoms of depression: two items (new cases).59) … 2.99– 2.75) 0 (0) … 10 (29) 33 (27) 37 (17) 1. PRs with a CI not including 1.09) 1.78– 1. Table 6.1 (0.8 (0.9 (1.08) 7 (32) 2.41– 3.40) 1.78– 2.38) 9 (15) (1.08) 1. www.0 (ref) 4 (22) … 1. educational level.06) 1.00 (before rounding) are given in bold.0 (0.0 (ref) 8 (10) (0.02– 2. Prevalence of mental health symptoms (cases and %) at 1-year follow-up in each exposure category is shown.38– 3.85– 3. The prevalence ratios (PRs) with 95 % confidence intervals (CIs) were adjusted for relationship status.62) 1.0 (ref) 7 (28) 1.18– 4.25) 1. indicated as "…".3 (0.61) 1.12) 1.7 (1.78– 1.7 (1.90) 68 (19) 1.51– 1.47– 5.medscape.9 (1.52) 1.2 (0.46) 1.8 (0.06– 3.68) 1. Interaction between computer exposure variables and mobile phone use at baseline. The prevalence ratios (PRs) with 95 % confidence intervals (CIs) were adjusted for relationship status.4 (0.0 (ref) 9 (32) 2.2 (1.medscape.13– 5.75– 1.81) 1.3 (1.3 (0.7 (0.82– 2.00 (before rounding) are given in bold.8 (1.94) 1.9 (0.94– 1.0 (ref) Medium High Low WOMEN Mobile phone use Medium PR (95% CI) High Cases (%) PR (95% CI) Cases PR Cases PR Cases PR Cases PR Cases (%) (95% CI) (%) (95% CI) (%) (95% CI) (%) (95% CI) (%) 5 (38) 2.24) 1.68) 1.00– 5.47) Medium 9 (20) 4 (10) 19 (24) 47 (18) Low 23 (14) 29 (22) Participants who reported symptoms at baseline were excluded from analysis of the mental health outcome concerned.

hours spent on general computer use was a risk factor.8/25/13 www. With the exception of a lower prevalence of sleep disturbances among the men in the study group (23% compared to 27%) the prevalence of mental health symptoms at baseline was about the same among the dropouts and those who remained in the study. say. For example. The women in the study group were less often single (34% compared to 37%) and reported a slightly higher level of social support (differences of up to 3 percentage units). for men.4 percentage points). except for a very low negative association with CU causing lost sleep (−0. implying that men who communicated via the computer more than 2 hours per day had less than half the risk to perceive stress a year later. resulting in almost twice as many women as men (65% vs. A major strength of the study is its longitudinal design. we do not know if other mental health symptoms were present among those participants who were symptom-free in the outcome concerned in the specific analysis. With regard to inconsistency of results. 35%) in the final study group (n = 4163).[34] sleep disorders was a predictor of major depression onset with an odds ratio of nearly 4.medscape. For the women. On the other hand. by contrast. For example. p < 0.06 and −0. i.10. and more often foreign-born (8 percentage points difference). There is of course a www. compared to low users. p < 0. Hence. although with lower PRs).medscape. it was the intensity of use. For example. at the same time. Some of the associations were enhanced in interaction with mobile phone use. The results were not consistent for all outcomes or for both men and women. while for women. a more general pattern occurred. This could be expected since the current stress item actually encompasses sleep problems. there were very low negative associations with all computer variables (between −0. The mental health outcome that seemed most affected for men was sleep disturbances. the dropout group (n = 2962) from the initial cohort baseline (n = 7125) to 1-year follow-up also had a higher proportion of men. according to the Diagnostic and Statistical Manual of Mental Disorders. or that a shortterm exposure/short latency period is relevant for perceived stress.[26] Furthermore.12.com/viewarticle/778353_print Social Support There were no associations between social support and computer exposure variables at baseline for the men. depression.. including also participants with symptoms at baseline and adjusting for baseline health. in one study of young adults. It is possible that those who developed symptoms of depression in our study already had sleep disturbances at baseline. The participants in the study group had a slightly higher educational level and differed in occupation in that they were less often working and more often studying at baseline compared to the dropout group (differences of up to 10 percentage units). (Extra analyses. they had an almost double risk for developing sleep disturbances.001). The level of computer use and CU without break s was slightly higher in the study group. For example.1 years). Sleep disturbances can be a first step towards depression (and is a diagnostic criterion for depression. with exposure assessed among symptom-free participants prior to outcome assessment. the latency period in our study is fairly long (1 year) and we have no information about the exposure and mental health outcomes in the latency period. there was even a negative association between high email/chat use and stress among the men (while the association was positive for the women). for women. 4th edition (DSM IV)). more often married (a difference of 1. We have not assessed the relationship between the different mental health outcomes or pursued possible comorbidity within the study. Effects of computer exposure on perceived current stress at follow-up were mostly seen in parallel with sleep disturbances.e.com/viewarticle/778353_print 18/24 . gave results in the same direction as the presented results. while mobile phone use was lower (differences of up to 10 percentage units). compared to the study population invited to participate. using the computer without breaks.05). the time span between measurements may not be optimal for assessing possible effects of the exposure on mental health. Dropout Analysis The non-respondents at the initial cohort baseline were more often male (a difference of 17 percentage points) and were somewhat younger (an age difference of <0. Discussion We found prospective associations between aspects of computer use and several mental health outcomes in this population-based sample of young adults. The mental health symptoms are common in the population and may come and go in the latency period. it is possible that long-term exposure is needed to develop. However.

[17] the prevalence of Internet addiction was 1% and that of at risk users was approximately 5%. on the other hand.37] Interestingly. for both men and women. It can mirror a lifestyle with lack of recovery. e. and the results are in part supported by a previous study in a university sample of young adults. and a negative loop has been suggested. and other social aspects of ICT.[36. as it seemed to be experienced as stressful regardless of the amount of work it generated. SMS. and therefore feeling safer and more confidence than during interactions "in real life." Addiction to the Internet has been suggested as a possible mental health risk factor. Problematic Internet use (addicted and at risk users) was more common among men and younger age groups. and developments seem to be towards an ever-increasing accessibility.[38] time spent emailing was associated with feeling overloaded.[40] playing computer games in the workplace was associated with recovery experience. and the overload was independent of the hours worked. the only risk category in the analysis of computer gaming. Moreover. which also turned out to be a risk factor for several mental health outcomes including reduced performance.[35] In our study. since it encompasses lost sleep as part of the exposure. In a study of online game players. web forums. Getting stuck behind the screen and thus losing sleep was reported as a problem in our interview study [11] and was the basis for constructing the variable CU causing lost sleep. However. The positive effects of the social aspects of ICT use are often emphasized (e. Facebook. use the computer for communication purposes. more than men.[38] Social isolation is another possible consequence of high computer use. Only a few percent of the women played games more than 2 hours per day. It should be noted that the study was carried out before Facebook (and other networking services) became a widespread and popularly used application. In future studies. Such benefits. It has been claimed that women. because of benefits in comparison to face-to-face communication. include having control of self-presentation. and was also associated with self-reported sleeping disorders and depression. be a way of coping with stress. however.[42] computer gaming before going to bed increased sleep latency and heart rate. but was not assessed in the present study.23] Morahan-Martin and Schumacher[23] found support for the position that loneliness leads to increased Internet use. there seemed to be little or no association between hours spent emailing or chatting and perceived social support in our study. men and women reported almost the exact same levels of email/chat use It is possible to develop and maintain large social networks via email. and even made the participants overlook other aspects of work that contributed to overload. as in this study. A sedentary lifestyle can have negative effects on mental health.medscape. among the subjects participants in [11]). habitual gaming at night was related to an increase in depression scores in adolescents (13–17 years) and emerging adults (18–22 years).8/25/13 www. [12]). Computer gaming may. while Caplan[39] concludes that social anxiety (rather than loneliness) explains the preference for online social interaction. While participants spent time on other activities their emails accumulated.. and decreased subjective sleepiness and rapid eye movement (REM) sleep. it is possible that ICT use contributes to a sedentary lifestyle. though not in the group defined as young adults (23–30 years). high chat use and high email use (as separate variables) were associated with symptoms of depression in women. Social support is a well-known factor that both promotes health and buffers negative effects of psychosocial strain..com/viewarticle/778353_print 19/24 . In a Norwegian cross-sectional adult population sample.g. phrasing. In a population of Internet game players. while physical activity has positive effects on www. and the speed of interaction. and have potential effects on sleep.g. Computer gaming was more common among the men than the women in our study (as in other studies (e. This was. Email use in work life can also induce stress. The email/chat use variable in our study concerned leisure use.medscape. It may be argued that the variable involves circular reasoning. It was concluded that emailing became a symbol of stress. which limits interpretation of causality. However. compared to controlled conditions.. playing long hours and at night may have detrimental effects. the study was cross-sectional. and gaming at night was not related to sleep problems. according to the author.g. High ICT use can mirror a hectic lifestyle with high demands (extrinsic as well as intrinsic). it should be taken into consideration that social media as well as emails are increasingly accessed via the mobile phone and other portable devices. By contrast. In a laboratory study. and email use also implied interference between work and private life. which at the same time may be considered an outcome.[10] where. In a study among employees in an engineering company. besides including social media use. and playing 1–2 hours per day almost doubled the risk of symptoms of depression among the women.[11.com/viewarticle/778353_print risk of chance findings when performing multiple tests.[41] The association with depression was independent of total time spent playing. the variables we tested were not chosen at random.

[45] However. though difficult. it is important. Perhaps in a future study. and to create items that sufficiently capture relevant exposure.medscape. For comparison. Moreover. which was the time that almost 40% of the men and 30% of the women spent on the computer. including the social support variable. with almost all respondents overestimating their use.com/viewarticle/778353_print mental health and is acknowledged as a possible complementary treatment for depression and stress-related disorders. at school.. approximately 50% of the men and almost 65% of the women confirmed at least one of the two depressive items. which is a limitation of the study. Gender bias was eliminated by separately analyzing men and women. However. expecting that the two-item outcome would have higher specificity than if following the suggested procedure. The prevalence of reported depressive symptoms was alarmingly high in our study group. as is common in questionnaire studies administered in the general population (and probably more so among young adults). which need to be considered. which may be further enhanced when excluding participants with symptoms at baseline before analysis. this was done only at baseline and situations may have changed during the latency period. rather than self-report. The study suffered from a high dropout rate. including TV viewing and computer/Internet use. However.[47] Suspecting that the instrument would be too sensitive for our population. the prevalence of depression in a population such as the one included in this study is most likely lower than in primary care populations. e. [43. Consequently. It is possible that ICT exposure in the study group differs from that of the source population. Since sleep and recovery are essential for maintained health. Some of the mental health outcomes used in the study were not validated (sleep disturbances and reduced performance due to stress. especially in longitudinal studies. possibly. There are several limitations in using a questionnaire to collect information on exposure and health aspects. The study was performed in a population-based sample of young adults. caution must be taken when generalizing the results. destructive use. and may be markers for (other) mechanisms associated with mental health risks. CU without break s . as the remaining participants might differ from the source population in several aspects including health and resilience.30] a predictive power of 33% [30] would imply that about 20% of the study group was clinically depressed.8/25/13 www. educational level. we adjusted for potential confounding in all analyses. It is important to point out that the study concerns subjective symptom reports and not actual mental disorders or diagnoses. even though all confounders were not relevant in all analyses. Methodological Considerations There are several limitations in the study. and relationship status.medscape. women and native-born Swedes being overrepresented in the study group. Following the suggested PRIME-MD procedure. Recall bias and recall difficulties are most likely present.44] A review suggests that sedentary behavior. Implications Aspects of ICT use can contain risk factors for mental wellbeing among young adults. for example the inconsistencies in the results. depressed mood or tiredness). which will not have been accounted for. further studies could focus www. is associated with an increased risk of depression. resulting in. it seems desirable to support healthy use of modern technologies in order to prevent possible destructive uses or effects.g.. and CU causing lost sleep) can reflect a more extreme and.e. than those concerning mere hours of use. Also. It is possible that more extreme exposure is more hazardous to health than the tested exposures and having more categories with higher cutoffs may have enabled a more detailed dose–response analysis. and at leisure. There is probably a healthy participation selection bias in the cohort. Perhaps the variables concerning intensity of use (i. Agreement between self-reported and registered exposure clearly was low in one validity study concerning computer use[46] where more than 80% of respondents misclassified their computer use. since the cutoff for the highest category of general computer use was 4 hours per day. We did adjust for potential confounding by occupation. since ICT is an ever-increasing part of daily life. The cutoff for the high category in email/chat use and computer gaming was 2 hours per day. However. the 1-month prevalence of depression among Finnish young adults (20–24 years of age) was 9.com/viewarticle/778353_print 20/24 . Furthermore. to keep up to date with advances in technology and applications. The computer use variables based on time spent at the computer in our study did not permit us to evaluate extreme use.6%. we chose to adapt the analysis accordingly. we would want to use objective exposure assessment via technical registration. as discussed above. at work. which is one of its strengths. the possible role of physical activity was not assessed in the present study. geographical confounding may be present because half of the source population was from one region of Sweden and the other half was from the rest of the country.[29.

J Occup Rehabil 2006. 8. Comput Human Behav 2007. 1(3):237–244. 97(2):102–107. J Psychosom Res 1997. Hagberg M: Perceived connections between information and communication technology use and mental symptoms among young adults . Wästlund E. Hagberg M: Computer mouse use in two different hand positions: Exposure. 9. 16(3):265–277.scb. http://www. Arnetz BB. References 1. Eklöf M. 4. and cell phone addiction. Gustafsson E. J Occup Med 1992. Carbonell X. http://www. 7. Andersson A. Wiholm C: Technological stress: Psychophysiological symptoms in modern offices. 10.com/viewarticle/778353_print 21/24 . 34(2):107–113. www.se. to deepen our understanding and develop meaningful and evidence-based intervention programs. Eneroth P. Okubo Y. J Adolesc 2007. Ekman A. Guardiola E. In HumanIT. Appl Ergon 2003. Cyberpsychol Behav 1998. Dellve L. Further studies should focus on mechanisms relating ICT use to sleep disturbances. Gerr F. Berg M. Kallner A: Techno-stress.a qualitative study. J Med Libr Assoc 2009. 42(5):421–426. Karlstad: Karlstad University Studies. Using the computer at night and thus losing sleep was associated with most mental health outcomes for both men and women. Wallin S: Reflecting on ICT and stress: conceptional connections and a suggested application. Kobayashi E.an explorative prospective study. 11. Arnetz BB. Nogawa K: Association between duration of daily VDT use and subjective symptoms.gu.medscape. Nakazawa T. Conclusions Time spent on general computer use was prospectively associated with sleep disturbances and reduced performance for the men included in this study. Rimpela A: Use of information and communication technology (ICT) and perceived health in adolescence: the role of sleeping habits and waking-time tiredness. Hagberg M: Prevalence of perceived stress. Saarni L. 6. video games. using the computer without breaks was a risk factor for several mental health outcomes. exertion and productivity. 13. Nilsson R. Wallenius M. 12. Hjelm EW: Gender differences in musculoskeletal health of computer and mouse users in the Swedish workforce. 3. Thomée S. Occup Med 2000. Suwazono Y.8/25/13 www. Marcus M: Keyboard use and musculoskeletal outcomes among computer users. Kato N. For the women. 34(7):698–701. Nordicom: Internetbarometer 2010 [In Swedish]. 10(1):66. 23(3):1300–1321. 14. Sweden: University of Gothenburg. comfort. Johansson-Hidén B. 50(8):608–613. Bellés A: A bibliometric analysis of the scientific literature on Internet. BMC Publ Health 2010.se. 2011. Young KS: Internet addiction: the emergence of a new clinical disorder. 43(1):35–42. Nygard CH. Punamäki RL. Härenstam A. symptoms of depression and sleep disturbances in relation to information and communication technology (ICT) use among young adults . A psychophysiological study of employees with VDU-associated skin complaints. 2011.medscape. Some associations were enhanced in interaction with mobile phone use. Komine S. 5. Statistics Sweden: Use of computers and the Internet by private persons in 2010 [In Swedish and parts in English]. Gustafsson E. Am J Ind Med 2002. 2003. 2. Liden S.nordicom.com/viewarticle/778353_print on mechanisms relating ICT use to sleep disturbances. 30(4):569–585. Monteilh CP. Beranuy M. Hagberg M. Thomée S.

27. Molde H. 25. Johnson JG: Utility of a new procedure for diagnosing mental disorders in primary care. Cheung LM.com/viewarticle/778353_print 15. Linzer M. Ahlstrand C.org/esa/socdev/unyin/qanda. 32.medscape. 24. Gentile DA. 23(3):1447– 1453. 1(Suppl 1):113. Liau A. Peng ZW: Effect of pathological use of the internet on adolescent mental health: a prospective study. Marks S: Problematic Internet use or Internet addiction? Comput Hum Behav 2007. Two questions are as good as many. Scazufca M. Hetland J. Johansson A. 1990. 19. 19(6):659–671. 12(7):439–445. 29(6):441–451.baseline questionnaire) [In Swedish]. Skouverøe KJM. Williams JB. Choo H. Brody D. 11(1):66.un. BMC Publ Health 2011. Boström M. Goldsmith TD. 14(10):591–596. Myrseth H.a prospective cohort study. Gustafsson E. Härenstam A. Browner WS: Case-finding instruments for depression.8/25/13 www. Comput Hum Behav 2003. Bakken IJ. Brunborg GS. Eriksson J. Occupational and Environmental Medicine. Khoo A: Pathological video game use among youths: a two-year longitudinal study. Andrén M. Coutinho LMS. 18. Hagberg J. Rev Saude Publica 2008. Hagberg M: Mobile phone use and stress. et al. 127(2):e319-e329. 31. Yellowlees PM. Li D. 17. Spitzer RL. www. J Affect Disord 2000. 50(2):121–127. 28. Scand J Work Environ Health 2003. J Gen Intern Med 1997. In: Rapport från Arbets. Tsai MJ: Gender differences in Taiwan high school students' computer game playing. Pediatrics 2011. 23(1):812–824. Shapira NA. 42(6):992–998. 20(2):311–317. J Sleep Res 2011.Basenk ät (Young adults . Åkerstedt T: The psychometric properties of the Karolinska Sleep Questionnaire. http://www. 16. 23. Kecklund G. Sim T. New York: Basic Books. 30. 22. Chou C. 21. Miranda J. Ekman A. Avins AL. J Am Med Assoc 1994. Scand J Psychol 2009. Jahkola A: Validity of a single-item measure of stress symptoms. Khosla UM. Theorell T: Healthy Work . sleep disturbances. Thomée S. Dellve L.och miljömedicin [Occupational and Environmental Report] No 118. Arch Pediatr Adolesc Med 2010. 29.medscape. Mentzoni RA. and symptoms of depression among young adults .com/viewarticle/778353_print 22/24 . McElroy SL: Psychiatric features of individuals with problematic internet use. Comput Hum Behav 2007. The PRIME-MD 1000 study. 2008. Sweden: University of Gothenburg. Pallesen S: Problematic video game use: estimated prevalence and associations with mental and physical health. Gothenburg. J Sleep Res 1992.: Ung Vuxen . 20. Kroenke K.htm. de Gruy FV III. Whooley MA. 272(22):1749–1756. The United Nations: Youth and the United Nations . 164(10):901–906. Karasek R. Fung D. Gotestam KG. Hahn SR. Morahan-Martin J. Schumacher P: Loneliness and social uses of the Internet. 26. Menezes PR: Methods for estimating prevalence ratios in cross-sectional studies. Elo A. Keck PE Jr. 57(1–3):267–272. Thomée S. Wong WS: The effects of insomnia and internet addiction on depression in Hong Kong Chinese adolescents: an exploratory cross-sectional analysis. Lindegård A. Lam LT. Cyberpsychol Behav Soc Netw 2011. Leppänen A. Wenzel HG. Oren A: Internet addiction among Norwegian adults: a stratified probability sample study.

Grodal S: E-mail as a source and symbol of stress. 14(3):267–273. Bes-Rastrollo M. Liu Y. 31(5):791–801. 32(6):443–462. J Sleep Res 2005. Health Psychol 1988. Bongers PM: Test-retest reliability and validity of self-reported duration of computer use at work. Motohashi Y. Deddens JA. exercise and consequences for memory function and affective disorders. Cyberpsychol Behav 2009. 22(4):887–906. Reinecke L: Games at work: the recreational use of computer games during working hours. 10(2):234–242. 40. 481. Med Sci Sports Exerc 2008. 6(1):2–6. 38. Salmon J: Sedentary behavior and depression among adults: a review.8/25/13 www. Rosenthal L. Perkinson-Gloor N. 12(4):461–465. Varo-Cenarruzabeitia JJ. 17(4):246–254. Andreski P: Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry 1996. Maeda A: Effects of playing a computer game using a bright display on presleep physiological variables. Meyerson DE. 34(2):113–119. Stansfeld S. 45. Martínez-Gonzílez MA: Physical activity. 40(5):827–834. van der Beek AJ. Gant LM: Users divided? Exploring the gender gap in Internet use. and MH designed the study. Teychenne M. ST performed the data analysis and wrote the manuscript.com/viewarticle/778353_print 23/24 . Ball K. Allemand M. 35. sleep latency. Scand J Work Environ Health 2008. Lonnqvist J: One-month prevalence of depression and other DSM-IV disorders among young adults. 65(7):501–486.medscape. 39(6):411–418. Petersen MR: Approaches for estimating prevalence ratios. Acknowledgements www. 7(3):269–297. AH. Leijssen JNM. 34. slow wave sleep and REM sleep. Sanchez-Villegas A. Authors' contributions ST. 5(6):517– 527. Cyberpsychol Behav 2007. Guilleén-Grima F. Scand J Work Environ Health 2006. Higuchi S. Aalto-Setala T. Marttunen M. Caplan SE: Relations among loneliness. Psychol Med 2001. Roth T. 39. Cyberpsychol Behav 2002.com/viewarticle/778353_print 33. Brand S. Jonsdottir IH: Stress. AH and MH supervised the data analysis. Occup Environ Med 2008. 44. and problematic internet use.medscape. Barley SR. Personal Individ Differ 2011. sedentary index. 51(2):117–122. and mental disorders in the SUN cohort study. Ara I. 37. social anxiety. Grob A: Habitual computer game playing at night is related to depressive symptoms. Candy B: Psychosocial work environment and mental health–a meta-analytic review. 46. 43. Lemola S. Vogler N. Cohen S: Psychosocial models of the role of social support in the etiology of physical disease. Tuulio-Henriksson A. All authors have read and approved the final manuscript. Breslau N. 42. Neurol Cogn Neurosci 2006. Ijmker S. 36. Blatter BM. 47. Shaw LH. 41. Organ Sci 2011. and discussed and contributed to the manuscript. Poikolainen K. Int J Behav Med 2010. van Mechelen W.

medscape.com/viewarticle/778353_print 24/24 .8/25/13 www.12(176) © 2012 BioMed Central.medscape.com/viewarticle/778353_print The study was funded by the Swedish Council for Working Life and Social Research. Ltd. 2012. BMC Psychiatry. © 1999-2006 BioMed Central Ltd www.