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Anxiety and depression are severe public health problems worldwide. The effects of ozone exposure on anxious and depressive symptoms remain largely unknown, especially in China. We evaluated the associations between ozone exposure and depression and anxiety among middle-aged and older adults across China. A multi-center community-based repeated measurement study among middle-aged and older adults was conducted from 2017 to 2018 in 11 provinces in China. The status of depression and anxiety was measured using Patient Health Questionnaire-9 (PHQ-9) and the generalized anxiety disorder seven-item (GAD-7) scale at the cut-off point of five, respectively. Concentrations of multiple ozone metrics were collected from real-time monitoring stations. The multilevel logistic regression model with random intercept was used to evaluate the effects of ambient ozone on anxiety and depression over different exposure windows. After adjusting for potential confounders, a 10  μ g /m 3  increase in the three months moving average of ozone was associated with the risk of anxiety [odds ratio (OR) = 1.25; 95% confidence interval (CI): 1.15; 1.37] and depression (OR = 1.17; 95% CI: 1.08; 1.27). A significantly positive modification effect of temperature on associations between ozone and anxiety was also found, while there is no interaction for depression. Exposure-response curves showed that there may be a threshold for the effect of ozone exposure on anxiety and depression over the three months moving average concentrations, with similar patterns observed at different temperature levels. People over 65 years old were at significantly higher risks of ozone-associated depression, while anxiety was more strongly associated with ozone in hypertensive patients. Our study supports the theory that anxiety and depression is associated with mid-term ozone exposure in China, and temperatures significantly enhanced their associations. These findings may have significant implications for promoting prevention activities regarding mental disorders and approaches in reducing the disease burden by simultaneously controlling air pollution and mitigating climate change.

environmental research letters

Association of ambient ozone exposure with anxiety and depression among middle-aged and older adults in China: exploring modification by high temperature