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Effect of stressors on depressive mood among long-term high-altitude workers: a moderated mediation analysis

BMC Psychology volume 13, Article number: 351 (2025) Cite this article

Abstract

Background

Diathesis-stress theory of depression is well known, which stresses that stressor is an inducing factor for depression in general population. High altitude, a combination of variety of stressors, is a special environment that may cultivate more depression. However, how different types of stressors contribute to depression and its underlying mechanisms in high-altitude populations remain unrevealed. The study aimed to reveal the effect of different stressors on depressive mood among long-term high-altitude workers in China and further explore the mediation of emotion regulation and moderation of parent-child alienation.

Methods

2065 Chinese workers at altitude of approximate 4200 m completed a cross-sectional survey with the Baker Depression Inventory-II scale, the Emotional Regulation scale, the Parent-child Alienation scale, and the Stressors scale (i.e., environmental factors, low social support, working challenges, accommodation, personal affairs, and cognitive factors).

Results

Correlation analysis showed positive correlations between stressors and depressive mood (r = 0.05–0.94, p < 0.05). Regression analysis indicated that low social support stressor was the strongest predictor of depressive mood (β = 0.21), while working challenges, personal affairs, and cognitive factors also positively predicted depressive mood. The mediating model showed that expression inhibition played a partial mediating (promoting) role between stressors and depressive mood, accounting for 3.13% of total variance. The moderating model showed that parent-child alienation played a moderating role in the model (β = 0.01, p < 0.001); a lower level of parent-child alienation effectively alleviated the impacts of stressors on depressive mood.

Conclusions

Stressors (working challenges, personal affairs, cognitive factors, and especially low social support) positively predict the depressive mood of long-term high-altitude workers in China. Expression inhibition plays a promoting mediation in the relationship between stressors and depressive mood. A good parent-child relationship alleviates the negative impact of stressors on depressive mood. Findings provide new empirical support for diathesis-stress theory and attract further attention to less expression inhibition and better parent-child relationships in depression prevention.

Peer Review reports

Background

Depressive disorder is a mood disorder that is characterized by persistent feeling down, lack of pleasure, or feelings of worthlessness, often accompanied with vegetative dysfunction [1]. World Health Organization (WHO) reported that approximately 5% of adults suffer from depressive disorder worldwide [2]. Depressive mood, a precursor to clinical depression, is a negative emotional state that, while not meeting the full diagnostic criteria for depressive disorder, significantly impacts an individual’s daily mood and functioning [3]. If left unaddressed, the depressive mood may deteriorate to clinical depression, with far-reaching adverse effects on an individual’s health [4]. Studies have demonstrated that the prevalence of depressive mood varies in different populations, with 25% reported in university students [5], 4-77% in teachers [6], and 17.9% in high-altitude populations [7]. Therefore, instant identification and intervention of depressive mood is crucial to control the exacerbation of symptoms and prevent the occurrence of clinical depression.

The diathesis-stress theory of depression posits that stress and diathesis are two crucial dimensions precipitating depression [8, 9]. Stressors may originate from environmental, interpersonal, or personal aspects. China has the largest high-altitude area worldwide, including Tibet, Qinghai, and others. These regions are characterized by low atmospheric pressure, lack of oxygen, extreme climate, and intense ultraviolet rays, which demand higher physical and mental adaptability for populations located there due to work and may result in higher risk for mental health issues such as depression [10]. Investigation between 2011 and 2021 in China, India, Peru, and Colombia has reported a pooled prevalence of depressive symptoms of 17.9% in high-altitude populations, with a higher prevalence of 28.7% in China [7]. Nevertheless, individuals moving from low to high altitude have increased symptoms of depression, anxiety, and suicidal ideation [11]. Despite these findings, the specific high-altitude stressors correlating with depressive mood remain poorly understood. Previous studies have demonstrated that working stressor was a significant predictor of depressive mood [12,13,14], while social support could alleviate anxiety and depressive mood [15]. Our previous study found that for long-term high-altitude workers, stressors mainly included six aspects: environmental factors, low social support, working challenges, accommodation, personal affairs, and cognitive factors [16]. However, the effects of different kinds of stressors in high-altitude environments on the depressive mood of long-term high-altitude workers have not been revealed yet.

Meanwhile, individual diathesis plays an important role in facilitating or buffering depressive mood. Among these, emotion regulation, a core psychological diathesis, refers to the ability to manage and adapt emotional responses to stressors, may significantly influence vulnerability to depressive outcomes [17, 18]. According to Gross’s emotion regulation theory, individuals employ specific mechanisms to regulate emotional responses toward stressors, thereby offset physical and mental strain [17]. Research indicates that emotion regulation strategies mediate the relationship between stressors and psychological well-being. Specifically, cognitive reappraisal, which re-interprets stressful situations to reduce negative moods and enhance well-being [19, 20], is often preferred under high-stress conditions. In contrast, expressive suppression, which creates emotional inconsistency, exacerbates negative moods and reduces subjective well-being [21]. For high-altitude workers, due to the unique environment and limited education or working opportunities in high-altitude area, high-altitude workers are less likely to bring their families to high-altitude area around them, space distant with their families may result social support deficiency, which mandates intrinsic resources to maintain psychological balance under stress, which underscores emotion regulation as a necessary diathesis. Evidence has indicated that emotion regulation strategy is at the center of the mediating effect of academic stressors on psychological well-being [19]. Thus, the mediation of emotion regulation between stressors and depressive symptoms in high altitude workers is yet to be thoroughly explored and gain further insight into its mechanism among this vulnerable population.

Generally, social support has been viewed as a protective factor in preventing depression [22], with family support, particularly parent-child relationships, playing a significant role in mental health across lifespan [23]. The absence of social support, particularly family support, has been indicated to be a primary causal agent in the development of depressive mood among high-altitude workers [24]. Especially, parent-child alienation (i.e., emotional alienation of children towards parents) is linked with depressive mood strongly [25, 26] and was a specific predictor of depressive mood in children [27]. Individuals who work at high altitude for an extended period may experience greater psychological distance from and less contact with families, which increase the likelihood of fostering parent-child alienation. Under high parent-child alienation, the effect of stressor on depression may be exaggerated, since that poor parent-child relationship may waken the backup of social-support on releasing stress. Moreover, studies have indicated that poor parent-child relationships increased depression in both student [28] and nurse [29] populations. It thus could be assumed that parent-child alienation may act as an underexplored moderating factor in the stress-depression connection in high-altitude workers, which remains unaddressed. This knowledge is important to fully understand the mechanism of depression in this population and further help to form targeted intervention.

Based on diathesis-stress theory, this study aimed to examine the relationship between stressors and depressive mood of long-term high-altitude workers in China, and further explore potential mediation of emotion regulation and moderation of parent-child alienation. The following hypotheses were raised:

  1. 1)

    The prevalence of depressive mood among workers in high-altitude regions is higher than that observed in lowland areas..

  2. 2)

    Stressors would be positive predictors for depressive mood in long-term high-altitude workers..

  3. 3)

    Emotion regulation strategy may mediate the effect of stressors on depressive mood..

  4. 4)

    A low level of parent-child alienation may effectively alleviate the impact of stressors on depressive mood..

Methods

Participants

This study included long-term workers from Tibet, China (average altitude: 4200 m), excluding individuals with physical or mental illnesses. 2104 questionnaires were distributed, and 2065 valid responses were obtained (response rate: 98.15%). All participants were male, aged 19 to 56 years-old (M ± S.D.: 24.55 ± 3.62). In the total sample, 1461 (70.75%) aged ≤ 25 years, while 604 (29.25%) aged > 25 years. Nearly half of the participants (47.89%) had a high school or below education level, while 52.11% had a college or above education level. Regarding to marital status, 86.15% were unmarried, and 13.85% had marital experiences (married, divorced, or widowed).

Instruments

Demographic details

Demographic details were collected, including gender, age, education level, marital status, general physical and mental health status.

The high-altitude worker stressor scale

The High-Altitude Worker Stressor Scale, which was developed in our previous work [16], was used to assess participants’ stressors. This 26-item scale measures six factors: environmental factors, low social support, working challenges, accommodation, personal affairs, and cognitive factors. Among these, “Cognitive factors” refer to psychological stressors such as cognitive load, decision-making difficulties, and reduced concentration. For example, hypoxia at high altitude may impair cognitive function, resulting in blunted thinking, memory loss, and poor judgment during complex tasks. A 0–3 scale was utilized (0 = none, 1 = mild, 2 = moderate, 3 = severe), and higher scores suggested more stressors. The Cronbach’s alpha coefficient was 0.94 in this study.

Beck depression inventory-II (BDI-II)

The Chinese Beck Depression Inventory-II was used to measure the severity of depression [30]. The instrument has 21 items with a 0–3 scale, and the total score ranges from 0 to 63, where higher score represents severe depression. Scores of 13 or lower represent no depression, 14–19 mild depression, 20–28 moderate depression, and 29 or higher severe depression. The Cronbach’s alpha coefficient was 0.91 in this study.

Emotion regulation scale

The Chinese version of the Emotion Regulation Questionnaire (ERQ), which was translated and validated by Wang et al. [31], was utilized to measure emotion regulation strategies. It contains 10 items, six on cognitive reappraisal and four on expressive inhibition, using a 7-point scale (1 ‘strongly disagree’ to 7 ‘strongly agree’). The higher the scores, the higher the application of this emotion regulation. In this study, the Cronbach’s alpha coefficients of cognitive reappraisal and expressive inhibition scales were 0.93 and 0.86, respectively.

Parent-child alienation scale

Parent-Child Alienation Scale was used to assess the alienation towards parents in high-altitude workers, which was developed in our previous work [26]. The Parent-Child Alienation Scale contains 18 items with two sub-questionnaires: mother-child alienation and father-child alienation, with a scale of 1 (‘not at all compatible’) to 5 (‘completely compatible’). The higher the score, the greater the feelings of alienation toward parents. The Cronbach’s alpha coefficient was 0.88 in this study.

Procedures

The study was approved by the Medical Ethics Committee of Army Medical University (2022 No. 04 − 02). The investigators received standardized training for scale administration and data collection. A cross-sectional survey (in March 2023) was carried out among high-altitude workers in Tibet’s Ali region (mean altitude: 4200 m). Potential participants were invited through advertisements within factories. Workplace-based data collection ensured participant’s convenience. All participants signed on informed consent before the survey was conducted. Participation was voluntary, and withdrawal was permitted without any negative consequence. After survey, participants received incentives for time compensation and accessed to free psychological counseling.

Statistical analysis

Statistical analyses were carried out using SPSS 26.0. Due-to non-normal distribution of data, non-parametric tests were conducted to assess the differences in scores of stressor and depression, while Spearman correlation analysis was carried out to observe the correlations between variables. A five-level hierarchical regression model (demographics, stressor dimensions, parent-child alienation, emotional regulation scores, and the interaction of stressors × alienation) was used to identify the predictors of depressive mood and emotional regulation. The mediation of emotional regulation and the moderation of parent-child alienation were tested using the PROCESS 3.3 macro program (Model 4 and Model 5, respectively). The 95% confidence interval (CI) was calculated based on 5,000 bootstrap samples to estimate the mediating and moderating effects. Results were considered statistically significant if the confidence interval did not include 0 [32]. Furthermore, simple slope analyses were performed to resolve any potentially significant interactions, with a significant level of alpha as 0.05 [32].

Test of common method bias

All questionnaire entries were analyzed using Harman’s one-way test. The results indicated three common factors with an eigen value greater than 1. The first factor explained 26.24% of the variance, which was less than the critical value of 40%, indicating no serious common method bias in this study.

Results

Demographic characteristics of stressor level and depressive mood in long-term high-altitude workers

Non-parametric tests indicated that the participants aged > 25 years reported higher depression compared to their younger peers. Participants with college or higher educational levels reported higher depression than those with lower education. In addition, those with a marital experience (married, divorced, or widowed) showed more depressive mood than unmarried individuals. No significant differences were observed in other variables. The mean score of depression was 1.32 ± 3.95. Based on the scale criteria [30], the depression was categorized into four levels: 2018 participants (97.72%) were classified as having no depression (13 or lower), 21 (1.02%) as mild depression (14–19), 16 (0.78%) as moderate depression (20–28), and 10 (0.48%) as severe depression (29 or higher). Individuals with any (mild, moderate, or severe) depression were categorized as having a depressive mood, yielding a total prevalence rate of 2.28% (Table S1).

For stressors, high-altitude workers aged > 25 reported higher stressor levels than those younger workers. Similarly, those with college or higher educational levels, and individuals with marital experience (married, divorced, or widowed) reported higher stressor levels than those with lower education and who were unmarried (Table 1).

Table 1 Demographic characteristics of stressor level and depressive mood in long-term high-altitude workers (n = 2065)
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Bivariate correlations between stressors, emotional regulation, parent-child alienation, and depressive mood

Spearman correlation analysis showed significant positive correlations between stressors, emotional regulation, parent-child alienation, and depressive mood (r = 0.05–0.87, p < 0.05). However, the correlation between cognitive reappraisal and low social support was non-significant (Table 2).

Table 2 Correlations between stressors, emotion regulation, parent-child alienation and depressive mood (n = 2065)
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Prediction of stressors on emotional regulation and depressive mood in stratified regression analyses

To explore potential predictors of emotional regulation, a stratified regression was carried out, with demographic variables (age, educational level, and marital status) were placed at level one, and independent variable (stressors) was placed at level two. Regression analysis indicated that low social support stressor was a negative predictor of cognitive reappraisal (β = -0.06, p < 0.05), while environmental stressor was a positive predictor of expression inhibition (β = 0.08, p < 0.01), see details in Table 3.

Table 3 Hierarchical regression analyses of emotional regulation and depressive mood
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To further explore potential predictors of depressive mood, another stratified regression was carried out, with the same first two levels same with emotional regulation, the third level was the moderating variable (parent-child alienation), the fourth level was the mediating variable (cognitive reappraisal and expressive inhibition), and the fifth layer was the interaction between the stressor and alienation. The results showed that four stressors (low social support, working challenges, personal affairs, and cognitive factors), parent-child alienation, expression inhibition, and stressors × alienation were positively predicting depressive mood (β = 0.06-0.21, p < 0.05). In contrast, cognitive reappraisal negatively predicted depressive mood (β = -0.05, p < 0.05). In all predictors, low social support had the most significant effect (β = 0.21), which suggested that social support was most strongly associated with depressive mood, see Table 3.

The mediation of cognitive reappraisal and expressive inhibition in the relationship between stressors and depressive mood

Based on our hypothesis and regression result, Model 4 (in the PROCESS) was used to test the masking and mediating effects of cognitive reappraisal and expressive inhibition in the relationship between stressors and depressive mood. Results showed that expressive inhibition was a positive mediator [0.004, 0.013], while cognitive reappraisal was not a significant mediator [-0.001, 0.002] (Fig. S1). The net effect of stressors on depressive mood was 0.32 (direct effect 0.31, and indirect effect 0.01) (Fig. 1, Table S1).

Fig. 1
figure 1

Mediation of expression inhibition in the effect of stressors on depressive mood. Note: ***p < 0 0.001

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The moderation of parent-child alienation in the relationship between stressors and depressive mood

As per our hypothesis and regression result, Model 5 (in the PROCESS) based on the constructed mediation model (Table S2) was then used to test the moderating effect of parent-child alienation in the mediation model.

The results showed (Table S3) that parent-child alienation played a significant moderating role in the effect of the stressors on depressive mood (β = 0.01, p < 0.001, Fig. 2). Further simple slope analyses indicated that both high (M + 1 S.D.; βsimple = 0.28, t = 3.52, p < 0.001) and low level of parent-child alienation (M-1 S.D.; βsimple = 0.23, t = 2.86, p < 0. 01) showed higher depressive mood under high-stress levels, and the slope was steeper in individuals with high levels of parent-child alienation, which meant that stressors led to higher depressive mood as parent-child alienation increased (Fig. 3). The results suggested that reduced parent-child alienation counteracted the influence of stressors on depressive mood.

Fig. 2
figure 2

Moderation of parent-child alienation between stressor and depressive mood. Note: ***p < 0 0.001

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Fig. 3
figure 3

Simple effects analysis: moderation of parent-child alienation in the effect of stressors on depressive mood

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Discussion

Based on the diathesis-stress theory, this study observed the predictors of depressive mood in long-term high-altitude workers in China and found that social support stressor was the most relevant predictor of depressive mood. Furthermore, expression inhibition diathesis mediated the effect of stressors on depressive mood, with parent-child alienation serving as a moderator.

The prevalence of depressive mood and stressor levels in long-term high-altitude workers in China

Surprisingly, the mean score of depressive mood was 1.32 ± 3.95 in high-altitude workers, with a prevalence rate of 2.28% for any (mild, moderate, or severe) depression. This rate was significantly lower than those reported in lowland populations using the same scale (Chinese version BDI-II), 17.2% in nurses [33], 12.1% in pregnant woman [34], 13.1% in medical students [35], and 34.98% in middle school students [36], which was different with Hypothesis 1. The reason might be that people in high-altitude areas have received more government support (e.g., financial subsidies that increasing with altitude, the distribution of free health medicines, and more extended vacations to promote family reunification) [37, 38]. This may result in more social and financial support and improved overall well-being of high-altitude workers. In addition, regular adaptive training in high-altitude and mental health service have been implemented to help these workers maintain optimal mental health status.

Furthermore, this study found that long-term high-altitude workers reported lower levels of stressor than short-term high-altitude personnel [16]. The reason might be that long-term high-altitude workers might experience a phenomenon known as altitude acclimatization (regular oxygen inhalation and limited activities) [39], which usually lasted for half a month to one month, and helps them adapt to high-altitude environment and reduce stress level. The result emphasizes the importance of sustained, tailored environmental and psychological support, offering practical guidance for policymakers and organizations to enhance the well-being of high-altitude workers.

Stressor positively predicts depressive mood

Based on diathesis-stress theory, it is widely acknowledged that stressor is a significant risk factor for the development of depression [40]. This study targeted at a cohort of high-altitude workers, which is different from the general population [41, 42]. The findings confirmed that low social support, working challenges, personal affairs, and cognitive factors positively predicted depressive mood (Hypothesis 2, stressor would be a positive predictor of depression), which was consistent with previous findings [43,44,45,46]. Previous studies have confirmed that lack of social support increases the risk for depressive mood [47, 48]. In the face of adverse events such as severe trauma or significant setbacks, the lack of support from social relationships, such as family, friends, and co-workers, would correspondingly increase the risk of developing depression [49, 50]. Due to the unique environment and limited education or working opportunities in high-altitude area, high-altitude workers are less likely to bring their families to high-altitude area around them, which may result in increased social isolation and limited access to social support. Therefore, families and organizations should create a more supportive and understanding environment for long-term high-altitude workers. Improving family communication, addressing their needs, and providing emotional support may collectively strengthen their social support and mitigate or prevent depression in this population.

Expression Inhibition mediates the relationship between stressor and depressive mood

This study found that expressive inhibition mediated the relationship between stressors and depressive mood, with frequent use of this strategy exacerbating stressor-induced depressive mood, supporting Hypothesis 3. This aligns with traditional psychological perspectives that emotional suppression harms well-being, as suppressed emotions may persist subconsciously and cause more distress upon resurfacing [51, 52]. Long-term high-altitude workers, facing emotional isolation and limited social support, may adopt expressive inhibition to adapt their environment shortly. However, this strategy only masks external emotional expressions without alleviating internal emotional perception, potentially increasing negative emotions and depression over time [53], suggesting that reducing expressive inhibition could improve well-being in this population. Interestingly, cognitive reappraisal was positively associated with stressors, expressive inhibition, and parent-child alienation, but did not mediate the relationship between stressors and depressive mood. The result may stem from the unique stressor context of long-term high-altitude workers, who face less social support and a lack of extrinsic resources (e.g., social support and family companionship). Meanwhile, parent-child alienation due to long-term separation with families further underscores the “inward-looking” emotion regulation mode in this group. This forces them to rely excessively on intrinsic resources like cognitive reappraisal, shifting its function from a protective factor to a necessary stress-coping approaching. As a result, cognitive reappraisal was excessively used and less useful in mediating the effect of stressors on depression. The positive correlation between cognitive reappraisal and expressive inhibition further suggests that they may form a composite approach to maximize emotion regulation effectiveness. This finding challenges the view of cognitive reappraisal as a purely protective factor, supports the context-dependent nature of emotion regulation strategies [17, 18], validates the diathesis-stress model in high-altitude workers, and highlights the importance of intrinsic diathesis in alleviating depressive symptoms.

Parent-child alienation moderates the role of stressor on depressive mood

Analyses revealed that low levels of parent-child alienation were effective in mitigating the impacts of stressors on depressive mood (Hypothesis 4). The family, as the primary source of social support for individuals, not only fulfills the fundamental needs of love and care, but plays a pivotal role in mental health status under stress. Our finding was consistent with previous findings [25,26,27], thereby confirming the link between family dysfunction and depressive symptoms. For high-altitude workers, modern communication technologies facilitate parent-child communication, but such online communication cannot entirely replace face-to-face interactions, and may result in an increase in parent-child alienation and reduction in individual’s strength to cope with stressors, thereby exacerbating depressive mood [54]. The quality of parent-child relationships has a significant effect on depressive mood [55], i.e., good parent-child relationships have been demonstrated to have a protective effect [25,26,27, 54, 55]. Thus, it is meaningful to encourage high-altitude workers to obtain more social support to compensate the limited support from families. Furthermore, it is essential to develop an appropriate rotation system and organize moderate reunion activities, with the aim of strengthening ties with families, enhancing the emotional connection with family, reducing the risk for depression, and improving working efficacy. The finding broadens the diathesis-stress theory: social support, especially family support, may mute the effect of stressors on depression.

Theoretical and practical significance of this study

Theoretically, this study confirms and broadens the diathesis-stress model by revealing expression inhibition as a mediator and parent-child alienation as a moderator in the relationship between stressors and depressive mood among high-altitude workers. It highlights the context-specific effect of emotion regulation, challenging the general assumption that cognitive reappraisal is an universally protector, and underscores the critical role of intrinsic emotion regulation and family relationship in individual’s mental health status.

Practically, the findings underscore the necessity of government support and adaptive training in reducing depression. The strong link between low social support and depressive mood calls for expanded policies in environmental acclimatization and psychological resilience: such as improving communication, providing emotional support, and facilitating family reunions. Furthermore, reducing reliance on maladaptive strategies like expressive inhibition while promoting adaptive emotion regulation, can further enhance mental well-being. These insights provide actionable guidance for policymakers to improve the mental health status of high-altitude workers.

Limitations

This study has several limitations. First, the cross-sectional design precludes causal inferences. Second, the potential influence of altitude on stressor and depressive mood was not examined despite its known physiological and psychological effects. Third, the large sample size (n = 2065) may have inflated statistical significance for small regression coefficients (e.g., β = 0.06), potentially reflecting false positives rather than meaningful associations. Despite these limitations, this study provides valuable insights into how stressors influence depressive mood in long-term high-altitude workers through mechanisms such as expression inhibition mediator and parent-child alienation moderator, offering a foundation for targeted interventions.

Conclusions

Based on the diathesis-stress model, the study confirms that working challenges, personal affairs, cognitive factors, especially low social support positively predict depressive mood in long-term high-altitude workers in China. Expression inhibition plays a mediating role between stressors and depression. A good parent-child relationship alleviates the influence of stressors on depression. These findings validate and expand the diathesis-stress theory, and underscore the importance of improving emotion regulation (e.g., reducing expression inhibition) and strengthening family bonds in mental health improvement and depression prevention. This work highlights the need for integrated strategies that address psychological, environmental, and social factors to prevent and treat depression, such as bolstering social networks, fostering adaptive emotion regulation, and enhancing family connections.

Data availability

The datasets supporting this study’s findings are available from the corresponding author upon reasonable request.

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Acknowledgements

We are grateful for the generosity of time and effort by all the participants, and all researchers who make this project possible.

Funding

This work was supported by the Social Science Foundation of Chongqing (2023NDYB94) and the education project of Army Medical University (2023yjsB02).

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Author notes

  1. Qiaoning Zhou and Zongpei Dai contributed equally to this work.

Authors and Affiliations

  1. Psychological Training Centre, Department of Medical Psychology, Army Medical University, Chongqing, China

    Qiaoning Zhou, Zongpei Dai, Chenxuan Jin, Wenjun Xiang, Weihong Hao & Qin Dai

  2. Department of Clinical Nursing, First Affiliated Hospital, Army Medical University, Chongqing, China

    Qiaoning Zhou

  3. Department of Preventive Medicine, First Affiliated Hospital, Army Medical University, Chongqing, China

    Li Hou

  4. School of Public Policy and Administration, Chongqing University, Chongqing, China

    Jieying Tan

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Contributions

This article was authored and the data analyzed by Q.Z., with Z.D. overseeing all research designs and manuscript drafts, while Q.D. provided objective proofreading of the document. All authors contributed to subsequent revisions of the article. Given the heterogeneity of knowledge inherent in challenging clinical research, C.J., W.X., J.T., and W.H. were involved in study design, critical decision-making throughout the research process, data collection, and initial reporting. Regarding data analysis, both Z.D. and L.H. have extensive experience in research; she was responsible for statistical analyses and figure preparation while concentrating on processing statistical data to ensure accuracy and quality. The integrity of the data was also verified by Q.D. Additionally, Z.D. offered significant guidance in addressing complex issues within the manuscript. Furthermore, both Q.D. and Z.D. participated fully in the review process to affirm the scientific rigor of this article. Ultimately, all authors played a role in writing and revising this work by providing constructive feedback aimed at ensuring that complex research findings are accurately represented.

Corresponding author

Correspondence to Qin Dai.

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Ethics approval and consent to participate

This study has been performed in accordance with the Declaration of Helsinki and received ethical approval from the Ethics Committee of the Army Medical University (No. 04 − 02, 2022), and a written informed consent was obtained from the participants.

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Not applicable.

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The authors declare no competing interests.

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Zhou, Q., Dai, Z., Hou, L. et al. Effect of stressors on depressive mood among long-term high-altitude workers: a moderated mediation analysis. BMC Psychol 13, 351 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40359-025-02666-4

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BMC Psychology

ISSN: 2050-7283

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