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. 2025 Oct 10;25(1):970.
doi: 10.1186/s12888-025-07437-4.

Associations of depression, anxiety, and insomnia symptoms in subthreshold depression: a network analysis

Xiumin Jiang #  1   2 , Xiaotong Wang #  3 , Bodong Liu  1 , Lin Yu  4   5 , Jun He  6 , Shengwei Wu  4 , Yuanyuan Zhou  1 , Bingyan Zhang  1 , Qinghua Gao  1 , Lin Yao  1 , Yuanjia Zheng  1   7 , Jinglan Yan  1 , Yongjun Chen  8   9   10
Affiliations

Associations of depression, anxiety, and insomnia symptoms in subthreshold depression: a network analysis

Xiumin Jiang et al. BMC Psychiatry. .

Abstract

Background: Subthreshold depression (SD) represents a critical public health concern, marked by clinically significant depressive symptoms below the diagnostic threshold for major depressive disorder. Despite frequent comorbidity with anxiety and insomnia, the symptom-level interactions remain poorly understood. Network analysis offers a novel framework to examine these dynamic relationships and identify central symptoms that may drive SD’s psychopathology. We hypothesize that the symptom network of SD may exhibit specific patterns of interconnectivity, with certain central and bridge symptoms potentially playing a key role in the development and maintenance of the disorder.

Methods: This study included a sample of 1,049 patients with SD. Zung Self-Rating Depression Scale (SDS), Zung Self-Rating Anxiety Scale (SAS), and Pittsburgh Sleep Quality Index (PSQI) were used to assess depression, anxiety and insomnia symptoms, respectively. Network analysis was used to estimate the symptom network, with centrality (expected influence, EI) and bridge symptoms (bridge EI) calculated to identify core and bridge symptoms. Additionally, the Network Comparison Test (NCT) was performed to examine potential gender-based differences.

Results: The results showed that SAS.1 “Anxiousness” emerged as the most central node (EI = 2.39), followed by SAS.2 “Fear” (EI = 2.30), SAS.3 “Panic” (EI = 2.15), and SDS.20 “Interest loss” (EI = 1.21). Bridge analysis identified PSQI.7 “Daily dysfunction” (bridge EI = 1.56) and PSQI.4 “Sleep efficiency” (bridge EI = 1.47) as key transdiagnostic links. Gender did not significantly affect the overall network structure.

Conclusion: This network analysis of SD represents the first comprehensive examination of depressive, anxiety, and sleep symptoms simultaneously within this population. The findings identify “Anxiousness”, “Fear”, “Panic”, and “Interest loss” as central symptoms and sleep-related dysfunction as a potential bridge between symptom domains. These symptoms may represent candidate targets for future longitudinal and intervention studies aimed at alleviating the symptom burden of SD.

Supplementary Information: The online version contains supplementary material available at 10.1186/s12888-025-07437-4.

Keywords: Anxiety; Depressive symptom; Insomnia; Network analysis; Subthreshold depression.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study was executed in compliance with the Declaration of Helsinki and granted ethical approval by the Ethics Committee of the Affiliated Brain Hospital of Guangzhou Medical University (Approval No. AF/SC-07/02.2). Furthermore, the study protocol was registered and approved by the Chinese Clinical Trial Registry (i.e., ChiCTR1900028530 on 26 December, 2019, with URL: https://www.chictr.org.cn ). Written informed consent was obtained from all enrolled participants after comprehensive explanation of the study objectives and procedures. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Network structure of depressive, anxiety, and insomnia symptoms in patients with SD. A Network of depressive, anxiety, and insomnia symptoms; (B) Centrality plot depicted the expected influence. Abbreviation: SD, subthreshold depression; SDS, Zung self-rating depression scale; SAS, Zung self-rating anxiety scale; PSQI, pittsburgh sleep quality index
Fig. 2
Fig. 2
Network structure of depressive, anxiety, and insomnia symptoms showing bridge symptoms in patients with SD. A Network of depressive, anxiety, and insomnia symptoms showing bridge symptoms; (B) Centrality plot depicted the bridge expected influence
Fig. 3
Fig. 3
The stability of centrality and bridge centrality indices using case-dropping bootstrap method
Fig. 4
Fig. 4
Estimated network model for depressive, anxiety, and insomnia symptoms in males and females. Left panel: network structure in male participants; Right panel: network structure in female participants
See this image and copyright information in PMC

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