Mental health issues are becoming increasingly prominent, and mental disorders are a globally recognized public health challenge (1). Depression and anxiety (D&A) are common psychological disorders in the general population, characterized by persistent sadness, changes in appetite and sleep patterns, diminished concentration, loss of interest in activities, excessive worrying, and restlessness (2). The Global Burden of Disease Study of 2019 reported that D&A disorders were the second and eighth leading causes of disability-adjusted life years, respectively (3). Approximately 3.8% of the global population is affected by depression, including around 5% of adults worldwide (3), and around 4.05% of the population suffers from anxiety disorders (4). D&A pose threats to people’s mental health. Among 12 mental disorders, D&A account for the highest proportions of the global disease burden, at 37.4 and 22.9%, respectively; this burden is increasing annually (3, 5, 6). Moreover, D&A is closely associated with premature death caused by suicide and related illnesses (7, 8). Without preventive measures, D&A will continue to affect individuals, families, and society.

Multiple social pressures and challenges increase women’s susceptibility to D&A. Indeed, women are twice as likely to suffer from D&A, compared to men (9). Similarly, they are more vulnerable to the effects of physiological cycles such as menstruation (10), pregnancy (11), and menopause (12), which are often accompanied by fluctuations in hormone levels that may directly affect women’s emotions and psychological states (13). Moreover, traditional gender roles and societal expectations placed on women (14), such as balancing family and career responsibilities, impose additional psychological burdens on women. At the societal level, women may face discrimination, violence (15), and unfair treatment (16), which can negatively affect their mental health.

During the COVID-19 pandemic, women often bore the dual responsibilities of caregiving and managing household finances. Lockdowns and restrictive measures forced many women to face economic problems, such as unemployment, reduced income, or job instability, further exacerbating their psychological burden (17). Women’s D&A issues not only lead to a decline in their mental health but may also negatively affect family dynamics (18), child development (19), and work performance (20). Thus, understanding and addressing women’s D&A issues are not only a matter of individual healthcare but also a matter of concern for society’s overall mental health. It is necessary to identify the risk factors for women’s mental health and explore effective intervention measures.

A substantial proportion of previous literature examining factors influencing mental health has concentrated on regression modeling, exploring unidirectional linear relationships and causal symmetry under the assumption that independent variables are independent. However, extant research exhibits two critical methodological constraints. First, conventional approaches inadequately capture interaction effects and combinatorial pathways among multiple variables. Second, prior studies have yet to systematically identify divergent conditional configurations that lead to equivalent psychological outcomes — a manifestation of multiple conjunctural causation that epitomizes the complexity of psychosocial phenomena. To address these dual gaps in methodological capability and theoretical conceptualization, this study innovatively employs fuzzy-set qualitative comparative analysis (fsQCA), an analytical approach prevalent in management science. Grounded in Boolean logic, fsQCA enables the identification of causal condition sets associated with outcomes through configurational analysis. This methodology not only elucidates non-linear relationships between multivariate predictors and outcomes but also reveals equifinal pathways whereby distinct antecedent combinations converge on identical psychological manifestations, thereby rectifying inherent limitations of conventional regression paradigms (21, 22).

First, we conducted a binary logistic regression analysis to scrutinize the factors influencing the levels of D&A among adult women in Shanxi Province. Subsequently, we selected and incorporated representative variables from demographics, lifestyle, physical health, and social support into the fsQCA model to identify different configurations conducive to psychological well-being. Our primary objective was to systematically explore how conditional configurations of multiple risk factors jointly shape D&A symptoms in women, particularly focusing on nonlinear synergistic interactions and equifinal pathways. Through systematic comparative analysis with conventional regression results, we aimed to validate the complementary utility of configurational approaches in mental health research. Furthermore, we sought to leverage these differentiated configurations to provide empirical insights for identifying subgroup-specific high-risk populations and to inform the future development of tailored mental health intervention strategies, thereby offering a novel analytical framework to support precision mental health research. This will positively affect women’s overall well-being and quality of life.

This study collected data from November 2021 to March 2022 using a multi-stage sampling method. To calculate the sample size, we utilized the following parameters per the standard formula for cross-sectional studies:

Z = 1.96 (95% confidence level),

p = 0.313 (estimated prevalence of anxiety) (23),

E = 0.025 (margin of error),

Since we used multi-stage sampling with a design effect (DEFF) of 2 (24), the final required sample size was:

The base sample size was calculated to be 2,643 (21, 22). To account for potential data loss or outliers, we increased the sample size by 10%, resulting in a final target of 2,908.

The province of Shanxi was divided into four regions based on geographical distribution and economic conditions. Two cities/counties were randomly selected from each region, and the sample size was allocated according to the population proportion in each region. Within each selected city or county, streets and townships were randomly chosen for the survey based on population size. The study included female residents of Shanxi Province who had lived there for at least one year, were proficient in Chinese, and were willing to provide informed consent for voluntary participation. Those who had resided in Shanxi Province for less than one year, were under the age of 18 years, had cognitive or language barriers preventing them from understanding or completing the survey, or were unwilling to cooperate or provide informed consent were excluded. The survey (see Supplementary file 1) comprised a total of 135 questions and covered multiple aspects, including sociodemographic traits, lifestyle, social support, mental health status and knowledge, attitudes, and behaviors related to gynecological diseases (25). We did not collect personal identity information to protect the participants’ privacy; we distributed 3,298 surveys, of which 3,063 valid responses were collected, yielding a response rate of 92.87%.

Women often face challenges and confusion in their lives due to mental health issues, such as D&A. According to three nationally representative sampling datasets, the overall prevalence rate of positive depression screenings in the Chinese population is 25.7%, with a positive depression screening rate of 29.5% among women (35). In this study, the positive depression screening rate for women was 16.7%, which is lower than the national level, but close to the 17.8% screening prevalence rate of depression among women in the National Health and Nutrition Examination Survey (NHANES) in the US (45). Additionally, the screening prevalence of generalized anxiety among women was 26.0%, which was slightly lower than the prevalence of anxiety symptoms (31.3%) reported in a survey of the general population’s mental health in China during the COVID-19 pandemic (23). Furthermore, we found a significant positive correlation between the scores on the CESD-10 and GAD-7 scales (not the disorders themselves), consistent with the findings of previous studies (46). Additionally, 67.3% of individuals who screened positive for depression also screened positive for generalized anxiety, indicating a high degree of overlap. This comorbidity is consistent with findings in Western populations, where studies have suggested that shared underlying mechanisms, such as dysregulated stress response (47) and cognitive vulnerability, contribute to the high co-occurrence of D&A (48). These results indicate that mental health issues, especially D&A, are more prevalent among women, highlighting the urgency of addressing women’s mental health problems. We explored the factors influencing D&A among women, including sociodemographic traits (age, place of residence, education level, marital status, and income), lifestyle factors (smoking, alcohol consumption, frequency of physical exercise, sleep duration, and occupational stress), physical health (self-rated health, chronic diseases, and illness within the past two weeks), and social support. In addition, we compared the regression and fsQCA methods.

The regression outcomes showed that D&A symptoms share common influencing factors. Higher age, good self-rated health, no illness in the past two weeks, longer sleep duration, and good social support were common protective factors against D&A symptoms among women, whereas occupational stress had a negative impact, in line with the findings of existing research (36, 38, 49, 50). Additionally, smoking is positively correlated with depression symptoms because it can compromise physical health and may exacerbate the development of depression (51). However, we conducted a cross-sectional study, and the proportion of female smokers was only 3.2%. Therefore, the possibility of some depressed women smoking to alleviate psychological stress cannot be ruled out (52), and the directionality of the relationship between smoking and depression symptoms remains uncertain. Similarly, we found a correlation between alcohol consumption and anxiety symptoms, which may align with the Self-Medication Hypothesis, suggesting that individuals use alcohol as a means of alleviating anxiety (53). Moreover, women with chronic diseases are at greater risk of developing anxiety, further demonstrating the interplay between physical and mental health. Univariate analysis showed that a higher frequency of physical exercise was associated with a lower risk of D&A. In addition, multivariate analysis indicated that physical exercise could be a predictive factor of anxiety, confirming the well-established benefits of physical exercise on both physical and mental health (54).

Logistic regression can be used to identify the degree of influence of individual variables on D&A, whereas fsQCA complements logistic regression’s shortcomings by revealing the complex interactions among multiple factors and exploring causal pathways through a combination of different conditions (55). According to the fsQCA results, we did not observe any conditions necessary for promoting mental health (without D&A symptoms). In the sufficiency analysis, we obtained eight and two configurations to explain mental health.

The results of the depression configuration revealed that self-rated health appeared in all configurations as an existing state, indicating its important role in buffering against depression. Research suggests that various factors influence self-rated health, including sleep quality and chronic pain. Poor self-rated health may increase life-related burdens (56), whereas individuals with good self-rated health are more likely to face life with a positive attitude (57). Therefore, it is recommended that community health services strengthen their focus on individuals with poor self-rated health, regularly monitor their health status, and provide them with psychological counseling and health education. Another crucial variable was social support, which appeared in seven configurations as a core condition. Social support refers to the support individuals receive from others (e.g., spouses, family members, friends, or healthcare professionals). Previous studies have shown a significant positive correlation between low levels of social support and D&A (58). Women with low levels of social support may not receive help from others to reduce their negative emotions, leading to the development of D&A (59). Consistently, studies have demonstrated that increasing social support can significantly reduce depressive symptoms, particularly in women, reinforcing the protective role of strong social networks (60). Through community activities and online and offline support groups, enhancing neighborly interactions and strengthening family support education is important to improve family members’ understanding of women’s emotional needs, and help women balance life stress. Additionally, public awareness campaigns should be utilized to raise societal recognition of women’s mental health needs, encouraging women to actively seek support when facing difficulties.

A significant variable is marriage, which is negatively related to depression and has a significant impact on mental health. Numerous studies have shown that marriage positively affects individual mental health. Compared to married individuals, unmarried, divorced, and widowed individuals are more prone to D&A (61). In configurations 5 and 8, being married appears as “irrelevant” and “absent,” respectively, which suggests that modern young women are open-minded and independent, and that marriage is not the only thing that matters to them. However, they can gain satisfaction and a strong sense of self through their efforts and independent living (62). Among the five configurations where age appeared, individuals of different ages had different paths to resist depression, which explains that age and mental health have different outcomes in different studies and that there may be a non-linear relationship between age and depression (63).

Simultaneously, we found that highly educated women tended to have a lower likelihood of developing depression, which can enhance an individual’s ability to cope with adverse emotions by acquiring more knowledge, skills, and thought patterns, improving cognitive and problem-solving abilities, and thereby better coping with challenges in work and life (64). Comparable findings’ studies suggest that higher education is associated with lower depression risk due to increased psychological resilience and economic stability (65). According to previous literature, longer sleep duration is closely related to mental health. Daily sleep duration influences mental health (66), while D&A can affect sleep quality, creating a vicious cycle (67). Therefore, improving sleep quality among women is essential. Women can be encouraged to establish regular sleep patterns and reminded to avoid caffeine and alcohol intake before bedtime, opting for sleep-inducing herbal teas instead.

Additionally, communities can provide sleep education and training in psychological relaxation techniques to enhance overall sleep quality. Occupational stress appears as “non-existent” in the configurations and is negatively correlated with mental health, which is consistent with the findings of previous studies (68). To alleviate occupational stress and promote employee mental health, enterprises can implement flexible work arrangements and leave policies, provide mental health education and stress management training, establish a supportive work environment, foster teamwork and open communication, and regularly conduct employee satisfaction surveys to identify and address stress-related issues timely. This reinforces previous studies on workplace mental health interventions and highlights the need for targeted policies to mitigate stress among working women (69). In our study, physical exercise did not have the expected effect, with most configurations appearing in a state of “irrelevance.” Although many studies have reported the effects of physical exercise on mental health (70), our study suggests that other factors may attenuate these effects. This finding suggests that the relationship between physical activity and mental health may be more context-dependent than previously assumed, warranting further exploration in future research (71).

Interestingly, configurations 7 and 8 for resisting depression symptoms overlapped with configurations for resisting anxiety symptoms, indicating the presence of common factors or conditions. This overlap implies that a certain degree of correlation exists between D&A rather than a completely independent phenomenon. Some configurations that resist depression also achieve the effect of resisting anxiety when specific factors increase. Specifically, adding low occupational stress in configuration 7 and long sleep duration in configuration 8 can produce the effect of resisting anxiety. This indicates that low occupational stress and adequate sleep duration may play important bridging roles between depression and anxiety and that by regulating these factors, dual positive effects on D&A can be obtained.

These findings provide valuable information for developing more effective psychological health interventions and treatment strategies, as well as clues for a deeper understanding of the relationship between D&A. We call on governments around the world to prioritize women’s mental health issues and take effective measures to protect and promote mental health. Mental health is a vital component of overall societal well-being, affecting the stability and harmony of families and communities. It is essential for governments and all sectors of society to work together to create a supportive environment for women, ensuring they have access to the necessary mental health resources and services to enhance their quality of life and overall happiness.

This study has several limitations. First, the sample’s representativeness is limited, as the data were collected exclusively from Shanxi Province. While this region may represent certain areas in northern China, it could restrict the generalizability of the findings. To enhance the generalizability of our results, future studies could collect data from multiple provinces, such as Guangdong, to represent southern urbanization and Zhejiang to reflect private economic development and conduct in-depth regional comparisons to validate the universality of the configuration model. Second, although we employed two methods to explore the multiple causality and asymmetry among variables, limitations may remain in interpreting the complex dynamic relationships between them. Moreover, to improve the interpretability of QCA results, future studies could utilize machine learning techniques like LASSO regression to identify the most predictive variables before conducting QCA and simplify the model by reducing the number of independent variables.

Additionally, combining QCA with panel data methods in a longitudinal design could help capture the temporal evolution of variable configurations over a 3-5-year period, particularly regarding policy cycles. Third, fsQCA can complicate the interpretation of results when an excessive number of independent variables are included, making it challenging to adequately account for all relevant factors. To address this, future research could prioritize variable selection based on theoretical relevance and use additional robustness checks to ensure the reliability of the findings. Finally, the study’s cross-sectional design prevents us from inferring the direction of causal relationships, which may lead to potential misinterpretations of the findings. To address this limitation, future research could adopt mixed-methods approaches, integrating qualitative interviews with case studies of typical configurations to uncover the micro-mechanisms behind statistical relationships.

Our study reveals that the prevalence of D&A symptoms among adult women in Shanxi Province aligns with national trends in China, with individuals who screened positive for depression also often screening positive for generalized anxiety, highlighting the pressing nature of mental health challenges in this population. Both regression analysis and fsQCA demonstrated a strong interconnection between D&A, with shared influencing factors such as age, self-rated health, and social support. Moreover, fsQCA results indicated that D&A follow similar configurational pathways, emphasizing the necessity of integrated mental health interventions rather than treating these conditions in isolation.

Notably, fsQCA did not identify any necessary condition for the absence of D&A symptoms, suggesting that mental well-being results from the synergistic effects of multiple protective factors rather than isolated variables. This underscores the importance of a comprehensive, multidimensional approach to mental health promotion, where interventions should consider the combined influence of various factors rather than focusing on singular determinants. Furthermore, the identification of multiple distinct pathways to the absence of D&A symptoms indicates that there is no universal solution. Instead, tailored interventions that account for individual and group differences are crucial for effectively mitigating mental health risks.

From a methodological perspective, our findings highlight the complementary strengths of regression analysis and fsQCA. While regression analysis identifies the significance and directionality of individual factors, fsQCA captures complex causal configurations contributing to mental health outcomes. Integrating both approaches provides a more nuanced understanding of mental health determinants and should be considered in future research to develop more targeted and effective intervention strategies.