From adversity to depression: a structural equation modelling study of the public health burden and mediating pathways among female college students in China

Background Mental health challenges such as anxiety, insomnia, burnout, and depression are increasingly recognised as major public health concerns among university students. Female undergraduates may be particularly vulnerable due to gendered social expectations, academic pressures, and socioeconomic inequalities. However, the interplay of these conditions and their determinants remains underexplored in Chinese populations. Methods A cross-sectional survey was conducted among 354 female undergraduates at Hainan Medical University in 2024. Validated self-report scales assessed anxiety, sleep quality, burnout, and depression. Structural equation modelling (SEM) was used to compare direct and indirect pathways, with demographic and academic factors (birthplace, major, monthly living expenses, and GPA) included as predictors. Results The indirect effect model fit the data better than the direct model (χ²/df = 2.15, CFI = 0.95, RMSEA = 0.05). Sleep disturbances significantly predicted anxiety (β = 0.45, p < 0.001) and burnout (β = 0.38, p < 0.001), while anxiety mediated the association between sleep disturbances and depression (indirect effect = 0.64, 95% CI [0.38, 1.10], p = 0.001). Burnout did not significantly mediate this pathway (p = 0.149). Students in clinical medicine and those with lower monthly expenditure reported greater sleep disturbances, urban students experienced more somatic depressive symptoms, and low GPA was associated with higher burnout-related behaviours. Conclusions Female undergraduates face interconnected mental health risks that constitute a pressing public health issue. Sleep disturbances and anxiety emerged as key prevention targets, while socioeconomic and academic disparities further increased vulnerability. Public health strategies should prioritise gender-sensitive, population-level interventions, including sleep health promotion, financial support, and campus-based mental health services to reduce risks of depression and academic burnout.