Academic stress and anxiety among Chinese medical students: Chain mediation of loneliness and insomnia moderated by resilience

BACKGROUNDMedical students experience substantial academic stress, which may contribute to anxiety symptoms; however, the underlying psychological mechanisms remain incompletely understood. AIMTo investigate whether loneliness and insomnia sequentially mediate the association between academic stress and anxiety, and whether psychological resilience moderates the association between insomnia and anxiety. METHODSA cross-sectional observational study was conducted among 4219 medical students from two medical colleges in Heilongjiang Province, China.Anxiety symptoms were assessed with the 21-item Depression Anxiety Stress Scales, insomnia using the Insomnia Severity Index, loneliness using the 3-item UCLA Loneliness Scale, and psychological resilience with the 10-item Connor-Davidson Resilience Scale. RESULTSAcademic stress, loneliness, insomnia, and anxiety symptoms were positively correlated with one another (ρ = 0.236-0.647,all P < 0.001), whereas resilience was negatively correlated with all four variables (ρ = -0.257 to -0.445, all P < 0.001).Academic stress had a significant total effect on anxiety symptoms (effect = 2.681, 95%CI: 2.381-2.981).The direct effect accounted for 29.6% of this total (effect = 0.792, 95%CI: 0.559-1.026),whereas the indirect effect through loneliness and insomnia accounted for 70.4% (effect = 1.888, 95%CI: 1.640-2.140)across three significant mediation pathways, with insomnia emerging as the strongest individual mediator.Resilience significantly moderated the 4 / 34 association between insomnia and anxiety (B = -0.014,SE = 0.002, P < 0.001), with the strength of this association decreasing as resilience increased (B = 0.810, 0.670, 0.530 at low, mean, and high resilience).The index of moderated mediation was significant (index = -0.018,95%CI: -0.029 to -0.008). CONCLUSIONAcademic stress was associated with anxiety symptoms both directly and indirectly through loneliness and insomnia, with insomnia emerging as the strongest mediating pathway.Higher resilience was associated with a weaker insomnia-anxiety association, suggesting that resilience-related factors may be relevant to efforts to address anxiety among medical students experiencing high academic stress.