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A Systematic Review Assessing Bidirectionality between Sleep Disturbances, Anxiety, and Depression

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To investigate whether sleep disturbances are bidirectionally related to anxiety and depression, and thus identify potential risk factors for each problem. A systematic review was conducted on 9 studies (8 longitudinal, 1 retrospective) that assessed bidirectionality between a sleep disturbance, and anxiety or depression. Treatment studies were excluded, along with those solely based on clinical samples or cohorts at high risk of suffering from a sleep disturbance, anxiety and depression. Eligible studies were identified by searching PubMed, PsychINFO, Embase, and Scopus databases, and reference lists of eligible studies. Publication dates ranged from the beginning of each database to December 2011. Syntheses of longitudinal studies suggested insomnia and sleep quality were bidirectionally related to anxiety and depression, and depression/anxiety, respectively. Childhood sleep problems significantly predicted higher levels of depression and a combined depression/anxiety variable, but not vice-versa. A one-way relationship was found where anxiety predicted excessive daytime sleepiness, but excessive daytime sleepiness was not associated with depression. Definitive conclusions regarding bidirectionality cannot be made for most sleep disturbances due to the small number and heterogeneity of cohort samples used across studies. Nevertheless, best available evidence suggests insomnia is bidirectionally related to anxiety and depression. Clinical and theoretical implications are discussed. Alvaro PK; Roberts RM; Harris JK. A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression. SLEEP 2013;36(7):1059-1068.
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SLEEP, Vol. 36, No. 7, 2013
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Review of Sleep Disturbances, Anxiety and Depression—Alvaro et al
INTRODUCTION
Sleep disturbances encompass various potentially overlap-
ping symptoms and disorders including insomnia, hypersomnia,
excessive daytime sleepiness, circadian rhythm disturbance, and
extrinsic sleep disorders (related to insufcient sleep and sleep
hygiene). Sleep disturbances, anxiety and depression are common
problems that lead to neuropsychological impairment,
1-3
alcohol
and drug abuse,
4
and suicidal ideation.
5-7
Recent studies have es-
tablished high comorbidity rates between sleep disturbances (such
as insomnia, narcolepsy, sleep apnea, and circadian rhythm com-
plaints), and depression and anxiety,
8-10
rates which vary across
different anxiety disorders.
11
Longitudinal associations have also
been established between sleep disturbances, anxiety, and depres-
sion.
12,13
Nevertheless, the etiological relationship between these
problems remains unclear. Understanding the etiological relation-
ship could help determine whether the onset of one is a risk-factor
for the onset of the others, and inform public health campaigns
and clinical interventions for each disorder.
11,14,15
Research on bidirectionality can achieve such goals. Bidi-
rectionality is established by accounting for the base rate of
outcome variables,
16
considering whether a sleep disturbance
independently predicts the onset of anxiety or depression, and
whether anxiety or depression independently predicts the onset
of a sleep disturbance.
REVIEW OF SLEEP DISTURBANCES, ANXIETY AND DEPRESSION
http://dx.doi.org/10.5665/sleep.2810
A Systematic Review Assessing Bidirectionality between Sleep Disturbances,
Anxiety, and Depression
Pasquale K. Alvaro, B Psych (Honors)
1
; Rachel M. Roberts, BA (Hons), MPsych (Clinical), PhD
1
; Jodie K. Harris, BPsych (Hons), PhD (Clin Psych)
2,3,4
1
School of Psychology, University of Adelaide, South Australia;
2
Flinders University of South Australia;
3
Centre for Treatment of Anxiety and Depression
(CTAD), Adelaide Health Service;
4
University of Adelaide, South Australia
Submitted for publication June, 2012
Submitted in nal revised form February, 2013
Accepted for publication February, 2013
Address correspondence to: Pasquale Alvaro, School of Psychology, The
University of Adelaide, SA, Australia, 5005; Tel: +61 (08) 8313 3399; Fax:
+61 (08) 8303 3770; E-mail: pasquale.alvaro@adelaide.edu.au
Study Objectives: To investigate whether sleep disturbances are bidirectionally related to anxiety and depression, and thus identify potential risk
factors for each problem.
Design: A systematic review was conducted on 9 studies (8 longitudinal, 1 retrospective) that assessed bidirectionality between a sleep distur-
bance, and anxiety or depression. Treatment studies were excluded, along with those solely based on clinical samples or cohorts at high risk of suf-
fering from a sleep disturbance, anxiety and depression. Eligible studies were identied by searching PubMed, PsychINFO, Embase, and Scopus
databases, and reference lists of eligible studies. Publication dates ranged from the beginning of each database to December 2011.
Measurements and Results: Syntheses of longitudinal studies suggested insomnia and sleep quality were bidirectionally related to anxiety and
depression, and depression/anxiety, respectively. Childhood sleep problems signicantly predicted higher levels of depression and a combined
depression/anxiety variable, but not vice-versa. A one-way relationship was found where anxiety predicted excessive daytime sleepiness, but
excessive daytime sleepiness was not associated with depression.
Conclusions: Denitive conclusions regarding bidirectionality cannot be made for most sleep disturbances due to the small number and hetero-
geneity of cohort samples used across studies. Nevertheless, best available evidence suggests insomnia is bidirectionally related to anxiety and
depression. Clinical and theoretical implications are discussed.
Keywords: Anxiety, depression, insomnia, sleep disturbances, systematic review
Citation: Alvaro PK; Roberts RM; Harris JK. A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression.
SLEEP 2013;36(7):1059-1068.
Various studies have found a bidirectional relationship be-
tween sleep disturbances, anxiety and depression, suggesting
that each contribute to the development and are a consequence
of one another.
14,15,17
Other studies have suggested the existence
of two distinct cause-effect associations, where anxiety predicts
a sleep disturbance and a sleep disturbance predicts depression,
but not vice-versa.
11,18
The inconsistent nature of the research
may relate to variations of sleep disturbances that have been
assessed across studies. The statistical signicance and mag-
nitude of the relationship between sleep disturbances, anxiety
and depression differs across sleep and mental health variables
(anxiety and depression),
18-21
which in turn may affect the re-
sults of bidirectionality studies. The current study, therefore,
presents a systematic review that aims to determine whether
a variety of sleep disturbances are risk factors for the develop-
ment of anxiety or depression, and whether anxiety or depres-
sion are risk factors for the development of sleep disturbances.
METHODS
Data Sources and Study Selection
An extensive search of PubMed, PsychINFO, Embase, and
Scopus was conducted using the following search terms in com-
binations specied for each database: (anxiety OR anxious*
OR phobic OR phobia* OR psychological stress OR stress
OR stresses OR internalization OR internalization OR obses-
sive compulsive OR asthenia OR depression OR depress* OR
depressive disorder OR dysthym* OR seasonal affective dis-
order OR rumination) AND (sleep initiation and maintenance
disorders OR sleep* OR insomnia OR early awakening OR
early waking OR non-restorative OR non-restorative OR night
waking). The Embase and Scopus searches also included the
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Review of Sleep Disturbances, Anxiety and Depression—Alvaro et al
following terms to account for the large number of search hits:
NOT (neoplasm OR cancer OR tumor OR tumour OR carcino-
ma* OR oncolog* OR ‘cardiovascular disease’ OR dementia*
OR Alzheimer* OR parksinson* OR therapy’ OR ‘psychiatric
treatment’ OR medicat* OR treatment). Publication dates for
the searches ranged from the beginning of each database to De-
cember 2011, and all searches were limited to English and hu-
man studies. The Reference lists of retrieved studies were also
assessed for other citations.
Studies were eligible if the following criteria was met: (1)
Study assessed any sleep disturbance; (2) Study assessed an
anxiety or depression variable; (3) Study reported a signi-
cance test when assessing bidirectionality; (4) Study accounted
for baseline/previous sleep, anxiety or depression variable.
Based on the recommendations of Jansson-Frojmark and Lind-
blom,
15
treatment studies, along with those who solely included
clinical samples or cohorts at high risk of suffering from a sleep
disturbance, anxiety, and depression were excluded due to the
potential bias towards a stronger association between sleep
disturbances, anxiety, and depression. The inclusion/exclusion
criteria were developed by the primary author and reviewed by
the secondary author.
Quality Assessment
The methodological quality of the eligible studies was as-
sessed by the rst author who used a modied version of a 15-
item checklist from a recent meta-analysis (Table 1).
22
Items
10 and 11 were included because the nature and magnitude of
associations between sleep disturbances, anxiety, and depres-
sion often differs across sleep and mental health variables.
18-21
Sleep disturbances, anxiety and depression have been found
to be associated with demographic information (e.g., age and
gender),
23,24
circadian rhythm disorders,
25-27
alcohol and drug
use,
4,28
exercise,
29,30
and caffeine,
31-33
thus providing the ratio-
nale behind items 12 and 13. Each item was labelled with a
(+) or (-), depending on whether the study satised the cri-
terion or not. A cutoff score was not used as a reference for
quality because such methods assign equal importance to all
criteria. However, items were not weighted: the Cochrane Col-
laboration recommend against this method due to difculties
in justifying the weights assigned to each item.
34
Instead, qual-
ity was assessed along a continuum that ranged from 0-15,
where lower scores indicated lower quality and higher scores
indicated higher quality.
Data Extraction and Synthesis
A coding form was developed to extract the following data
from each study: geographical location of the study, sample
size at baseline and follow-up, response rate, method of partici-
pant recruitment, method of data collection, use of medication,
study methodology, possible biases, prediction and outcome
variables, demographic statistics at baseline and (when avail-
able) follow-up, descriptive statistics for the variables of sleep
disturbance, anxiety and depression, statistical analyses, vari-
ables controlled for, results, interpretation of results, author(s)’
conclusions, and cited articles that were potentially relevant.
Data extraction was conducted by the rst author.
A meta-analysis could not be conducted due to the heteroge-
neous characteristics of the studies that met the inclusion cri-
teria. Therefore, the research questions were analyzed by two
narrative syntheses. The rst presented an overall representa-
tion of the ndings from each study, whereas the second com-
pared results across different sleep variables.
RESULTS
Included and Excluded Studies
The PubMed, PsychInfo, Embase, and Scopus database
searches identied 2,273, 2,352, 1,252, and 2,664 studies, re-
spectively, and one study was identied from the reference
searches. Ninety-three studies were selected as potentially rel-
evant following the application of the inclusion criteria to the
titles and abstracts. Most articles were excluded because they
did not assess bidirectionality. Five studies
13,35-38
assessed bi-
directionality but not between a sleep disturbance and anxiety
or depression; one study assessed bidirectionality but used a
cohort that was at risk for sleep disturbances, anxiety, and de-
pression
39
; and one study did not report a signicance test when
assessing bidirectionality.
18
Therefore, 10 studies were eligible
for analysis in the systematic review (12% of the original ar-
ticles). Two eligible studies contained identical samples
40,41
and
hence were collapsed into 1, leaving 9 independent studies that
were included in the systematic review (refer to Figure 1 for
a representation of the database searches and summary of the
reasons for exclusion). Eligibility of each study was assessed
by the rst author.
Table 2 displays the general characteristics of each study.
All studies were conducted between 2002 and 2010; 8 were
longitudinal and prospective, and the other study was retro-
spective and cross-sectional. Studies were set in various coun-
tries; 2 in the USA, 2 in the UK, and 1 each in Switzerland,
Sweden, Japan, South Korea, and the Netherlands. Sample
populations also differed across studies; adolescents were as-
sessed by 3 studies, adults by 2, and young adults, the elderly,
child twin pairs, and adopted children were assessed by 1
study each. Participants were recruited by random selection in
Table 1—Items for quality assessment
1. Sampling procedure of cohort described?
2. Population characteristics described?
3. Inclusion and exclusion criteria described?
4. Studied population ≥ 75% of originally selected population?
5. Information about responders vs nonresponders
6. Lost to follow-up < 20%?
7. Information about completers vs noncompleters?
8. Are insomnia, anxiety and depression assessments for clinical
diagnosis?
9. Same measures at both baseline and follow-up?
10. Are depression and anxiety assessed separately?
11. Does the sleep variable assess a specic sleep related problem?
12. Correction for potential demographic confounders?
13. Correction for circadian rhythm disorders, alcohol & drug use,
exercise or caffeine intake?
14. Correction for other potential non-demographic confounders such
as physical disorders or medication?
15. Are given data usable/transformable for meta-analysis?
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Review of Sleep Disturbances, Anxiety and Depression—Alvaro et al
3 studies, high schools in 2, and a 2-stage sampling procedure,
the Colorado adoption agency, birth records, and a national
registrations list of all community residents were used in 1
study each. Participants were recruited by self-report ques-
tionnaires in 4 studies (2 were postal surveys), interviews in 3
(2 were structured and 1 was semi-structured), parent report-
ed questionnaires in 1, and parent reported and self-reported
questionnaires in 1 study.
Quality Assessment
Study quality ratings ranged from 7 to 13 (M = 9.9, SD = 1.9).
All studies described the sampling procedure and population
characteristics, used the same measures at baseline and follow-
up, and gave data useable for a meta-analysis. Seven stud-
ies compared responders to non-responders and completers
to non-completers, assessed a specic sleep disturbance, and
corrected for potential demographic confounders; 6 studies re-
tained 75% of the originally selected population and assessed
depression and anxiety separately; 4 studies lost more than 20%
of participants at follow-up; 3 studies described the inclusion
and exclusion criteria, and corrected for other potential non-
demographic confounders such as physical disorders; 2 studies
assessed insomnia, anxiety, and depression according to a clini-
cal diagnosis; 1 study corrected for alcohol and exercise; and
no study corrected for circadian rhythm disorders, drug use, or
caffeine intake (Table 3).
Overall Synthesis
Table 4 presents the data for the overall synthesis. Four of the
9 independent studies supported the bidirectional theory,
14,15,17,42
2 of which assessed insomnia, anxiety, and depression,
15,17
1 as-
sessed insomnia and depression,
42
and 1 assessed insomnia and
mental health status.
14
The unidirectional theory discussed above
was supported by 3 studies.
11,43,44
One study found 2 one-way
relationships where anxiety predicted insomnia and insomnia
predicted depression but not vice-versa
11
; the other reported that
childhood sleep problems predicted depression but not vice-ver-
sa
43
; and the last suggested that childhood sleep problems pre-
dicted higher levels of depression/anxiety, but not vice-versa.
44
However, this does not necessarily support the unidirectional
theory discussed above, as the mental health variable that was
used (depression/anxiety) assessed anxiety and depression as a
single construct rather than separate variables.
Two independent studies reported mixed results.
40,41,45
One
study found no relationship between excessive daytime sleepi-
ness and major depressive episodes or “pure insomnia” (in-
somnia without concurrent depression) and “pure depression”
(depression without concurrent insomnia), a bidirectional rela-
tionship between insomnia and major depressive episodes, and
a one-way relationship where anxiety predicted excessive day-
time sleepiness.
40,41
The other found a bidirectional relationship
between sleep quality and depression/anxiety and a one-way
relationship between time in bed and depression/anxiety, where
less time in bed at baseline predicted higher levels of depres-
sion/anxiety, but not vice-versa.
45
Therefore, 6 independent
studies supported the bidirectional theory,
14,15,17,40-42,45
5 sup-
ported a unidirectional relationship,
11,40,41,43-45
and 1 study did
not nd a signicant relationship between excessive daytime
sleepiness and major depressive episodes or “pure insomnia”
and “pure depression.
40,41
Figure 2 depicts the number of stud-
ies and analyses that supported each type of relationship.
Synthesis of Sleep Variables
Insomnia was the most commonly assessed sleep vari-
able,
11,15,17,40,42
followed by childhood sleep problems,
43,44
sleep
quality,
14,45
excessive daytime sleepiness,
41
and time in bed
(Table 5).
45
Studies that assessed bidirectionality between anxi-
ety, depression, and other common sleep disturbances such as
sleep apnea were not found.
For insomnia, 3 of the 5 studies supported the bidirectional
theory.
15,17,42
One study supported the unidirectional theory,
where anxiety disorders predicted insomnia, which predicted
major depressive disorder.
11
The remaining independent study
reported several analyses across 6 time points over 20 years. No
relationship was found in either direction between “pure insom-
nia” and “pure depression,” along with a bidirectional relation-
ship between insomnia and insomnia comorbid with depression
across 5 separate bidirectional analyses over 20 years.
40
The
same study also found conicting results across these 5 analy-
ses when assessing bidirectionality between “pure depression”
and insomnia comorbid with depression (2 bidirectional rela-
tionships, a one-way relationship where insomnia comorbid
with depression predicted pure depression but not vice-versa,
and 2 relationships where no association was found in either
direction). Finally, insomnia without concurrent depression
predicted the development of depression at the interview di-
rectly following baseline and interviews at any given follow-
up, whereas depression without concurrent insomnia predicted
insomnia at the interview at any given time-point only.
40
Regarding sleep quality, both studies found a bidirectional
relationship, one with depression/anxiety
45
and the other with
mental health status (a variable that contains a depression/anxiety
scale).
14
Childhood sleep problems predicted depression and de-
pression/anxiety but not vice-versa.
43,44
One study found that less
time in bed at baseline is associated with more severe symptoms
of depression/anxiety at follow-up, but not vice-versa.
45
Finally,
Figure 1—Summary of the reasons for exclusion.
93 potentially relevant articles from initial searches
10 articles eligible for the systematic review
Reasons for exclusion
• 76 studies did not assess directionality
• 5 studies did not assess directionality
of sleep related problems, anxiety or
depression
• 1 study assessed an “at risk”
population
• 1 study did not control for relevant
baseline variables
2 articles assessed the same population
9 articles included in the systematic review
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Review of Sleep Disturbances, Anxiety and Depression—Alvaro et al
one study found a one-way relationship where anxiety predicted
excessive daytime sleepiness, but no relationship between exces-
sive daytime sleepiness and depression (i.e., excessive daytime
sleepiness did not predict depression and vice-versa).
41
DISCUSSION
Each study included in the systematic review reported at
least one signicant relationship between a sleep disturbance,
anxiety and/or depression, which further consolidates the no-
tion of an association between these problems.
8,23,44
Interest-
ingly, one study
41
found that anxiety predicted later excessive
daytime sleepiness but no relationship between excessive day-
time sleepiness and major depressive disorder symptoms, sug-
gesting that a bidirectional relationship is not consistent across
mental health problems. This is surprising given the overlap
of abnormalities in neurotransmitters and brain structures in-
volved in problems with the sleep wake cycle, anxiety, and
depression,
46-53
but Hasler and colleagues
41
suggested that the
association between excessive daytime sleepiness and depres-
sion may be mediated by sleep disorder symptoms and co-
morbid anxiety. More studies are needed to draw a denitive
conclusion on whether excessive daytime sleepiness, anxiety,
and depression are bidirectionally related.
Best available evidence suggests that insomnia is bidirec-
tionally related to anxiety and depression. One retrospective
study reported a one-way relationship where anxiety predicted
Table 2—General Characteristics of Each Study Included in the Systematic Review
Study
Sample
size
Study
design
City/
Country Population
Age
range at
baseline
Method of participant
recruitment
Method of
participant
assessment
N time
points
(N years
between
follow
up)
40/41 457 Longitudinal,
Prospective
Switzerland Young adults,
representative,
stratied
sample
20-21 Two stage sampling procedure:
(1) Participants were screened
for health problems, (2) Those
at risk for psychiatric syndromes
were identied using a stratied
sampling procedure and selected
for interviews. Males recruited
through conscription, females
recruited through electoral
register. Males were investigated
in groups of 10, and females
received postal surveys
Semi-structured
interview
6 (2, 5, 2,
5, 6)
44 360 Longitudinal,
Prospective
USA Adopted
children
4 Participants recruited from the
Colorado Adoption Project
Parent reported
questionnaires
2 (11)
43 500 Longitudinal,
Prospective
Wales &
England
Child twin pairs 8 Twin pairs identied through birth
records. Parents were contacted
by the UK Ofce for National
Statistics after screening for
infant mortality.
Questionnaires.
Parent reported
at baseline, and
Self-report at
follow up
2 (2)
15 1,498 Longitudinal,
Prospective
Sweden Adult 20-60 Random selection, identied via
public register
Self-report
questionnaires,
postal
2 (1)
11 1,014 Cross-
sectional,
Retrospective
USA Adolescents,
metropolitan
13-15 Random selection, Youth-parents
pairs identied from a 400,000
member Health Maintenance
Organisation
Structured
interviews
1 (n/a)
14 516 Longitudinal,
Prospective
Japan Adolescents 13-15 High schools from metropolitan
Tokyo
Self-report
questionnaires
2 (2)
42 909 Longitudinal,
Prospective
South Korea Elderly, general
population
65+ All community residents within
2 geographic catchment areas
(one urban, one rural) were
identied and approached
through national registration list.
Structured
interview, home
based
2 (2)
45 493 Longitudinal,
Prospective
Netherlands Adolescents 12-15 High schools Self-report
questionnaires
3 (1)
17 1,589 Longitudinal,
Prospective
UK Adults 18+ Random selection, adults
registered to 1 of 5 general
practices from urban and rural
areas
Self-report
questionnaires,
postal
2 (1)
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Review of Sleep Disturbances, Anxiety and Depression—Alvaro et al
depression, but not vice-versa.
11
Conversely, four longitudinal
studies found a bidirectional relationship between insomnia,
anxiety and/or depression.
15,17,40,54
Due to the retrospective na-
ture of, and hence the memory bias apparent in retrospective
methodology,
55
longitudinal study designs allow for more ac-
curate causal inferences and reliable assessment of bidirec-
tionality, and are therefore the preferred methodology for
bidirectional studies.
14
Interestingly, insomnia could predict depression more con-
sistently than depression predicts insomnia. Buysse and col-
Table 3—Amount of studies (n) that met each criterion of quality assessment
Criterion Number (n) +, n/a Studies
Sampling procedure of cohort described? 9 11, 14, 15, 17, 40, 42-45
Population characteristics described? 9 11, 14, 15, 17, 40, 42-45
Inclusion and exclusion criteria described? 3 11, 15, 42
Studied population ≥ 75% of originally selected population? 6 14, 40, 42-45
Information about responders vs nonresponders 7 11, 15, 17, 40, 42, 44, 45
Lost to follow-up < 20%? 4 11, 15, 43, 45
Information about completers vs noncompleters? 7 11, 17, 40, 42-45
Are insomnia, anxiety and depression assessments for clinical diagnosis? 2 11, 42
Same measures at both baseline and follow-up? 9 11, 14, 15, 17, 40, 42-45
Are depression and anxiety assessed separately? 6 11, 15, 17, 40, 42, 44
Does the sleep variable assess a specic sleep related problem? 7 11, 14, 15, 17, 40, 42, 45
Correction for potential demographic confounders? 7 11, 14, 15, 17, 42, 44, 45
Correction for circadian rhythm disorders, alcohol & drug use, exercise, or caffeine intake? 1 42
Correction for other potential non-demographic confounders, such as physical disorders or medication? 3 14, 17, 42
Are given data usable/transformable for meta-analysis? 9 11, 14, 15, 17, 40, 42-45
Figure 2—Summary of the total number of studies (analyses) that supported each type of relationship between sleep disturbances, anxiety and depression.
1(2)
Unidirectional relationships
No relationships
Bidirectional relationships
Sleep disturbance
Sleep disturbance
Sleep disturbance
Depression/Anxiety
Depression
Insomnia/Depression
3(3)
Sleep disturbance/
Depression
2(2)
4(4)
2(2)
1(2)
3(3)
Anxiety
Sleep disturbance
Sleep disturbance/
Depression
Sleep disturbance
Sleep disturbance
Anxiety
Depression
Depression
Depression/Anxiety
1(6)
Sleep disturbance
Depression Depression
2(2)
1(5)
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Review of Sleep Disturbances, Anxiety and Depression—Alvaro et al
leagues
40
assessed bidirectionality over a 20-year period across
six time-points. They found consistent bidirectional relation-
ships between “pure insomnia” and insomnia comorbid with
depression, yet conicting relationships between “pure depres-
sion” and insomnia comorbid with depression. Such results
suggest that insomnia at baseline is a stronger and more persis-
tent predictor of follow-up depression than baseline depression
is of follow-up insomnia.
Various types of mechanisms may explain the bidirectional
association between insomnia, anxiety and depression. Com-
Table 4—Main ndings from each study
Study
Sleep variable
(instrument name)
Mental health
variables (instrument
name) Baseline/past variables accounted for Results
40, 41 Insomnia – immediate
follow up only (SPIKE
63
)
MDE – immediate follow
up only (SPIKE
63
)
Concurrent MDE when predicting insomnia, and vice-versa.
Insomnia immediate follow up
depression.
Insomnia – any follow
up (SPIKE
63
)
MDE – any follow up
(SPIKE
63
)
Concurrent MDE when predicting insomnia, and vice-versa. Bidirectional: baseline variable and
follow up at any time
“Pure insomnia”
(SPIKE
63
)
“Pure depression”
(SPIKE
63
)
Only participants who reported no baseline symptoms of the outcome
variable were included in the analysis.
5 analyses, all no relationship
“Pure insomnia”
(SPIKE
63
)
Insomnia comorbid with
depression (SPIKE
63
)
“Pure insomnia” refers to those without concurrent depression 5 analyses, all bidirectional
Insomnia comorbid with
depression (SPIKE
63
)
“Pure depression”
(SPIKE
63
)
“Pure depression” refers to those without concurrent insomnia 5 analyses: 2 bidirectional, 2 no
relationship, 1insomnia + depression
depression
EDS (SPIKE
63
) Cumulative MDE
(SPIKE
63
), Cumulative
Anxiety (SPIKE
63
)
Baseline EDS when assessing anxiety and depression as predictors, and
vice-versa. Gender and stratied sampling for both analyses.
Anxiety EDS. No relationship
between EDS and MDE
44 Childhood sleep
problems (CBC
64
)
Depression/Anxiety
(CBC
64
)
Baseline depression/anxiety, when assessing childhood sleep problems
as a predictor, and vice-versa. Adoptive status and child sex for both
analyses.
Childhood sleep problems
Depression/Anxiety
43 Childhood sleep
problems (CSHQ
65
)
Depression (CDI
66
) When predicting depression: the effects of depression at age 8 on
depression at age 10 and the association between sleep and depression
at age 8. When predicting childhood sleep problems: the effects of
childhood sleep problems at age 8 on childhood sleep problems at age 10
and the association between sleep and depression at age 8.
Childhood sleep problems
Depression
15 Insomnia (BNSQ
67
&
USI
68
)
Depression (HADS
69
),
Anxiety (HADS
69
)
Only participants who reported low or no symptoms of the outcome
variable at baseline were included in analyses, e.g., if assessing anxiety
as an outcome variable, only participants with low scores of anxiety were
used. Age and gender were used as predictor variables for all analyses.
Bidirectional
11 Insomnia (DSM-IV)
70
* Depression (DSM-
IV)
70
*, Any Anxiety
Disorder(DSM-IV)
70
*
Prior depression was controlled for in the insomnia – anxiety disorders
models and prior anxiety disorders in the insomnia – depression models.
Gender and race/ethnicity were also controlled for in each analysis.
Anxiety Insomnia Depression
14 Sleep quality (PSQI
71
) Mental Health Status
(GHQ-12)
72
Only participants who did not report symptoms of the outcome variable at
baseline were included in the analyses, e.g. only those without poor sleep
quality were used when assessing sleep quality as an outcome variable.
Predictor variables, gender, and lifestyle and contentment with daily life at
baseline were used as covariates.
Bidirectional
42 Insomnia
(10/66DDCRG)
73
*
Depression (GMS B3)
74
* Only participants who did not report symptoms of the outcome variable
at baseline were included in the analyses, e.g. those without insomnia at
baseline were used when assessing insomnia as an outcome variable.
Number of physical disorder, age, gender, education, housing, past
occupation, current employment, living area, life events, social decit,
physical activity, organicity, anxiety, and daily drinking were controlled for
in all analyses.
Bidirectional
45 Sleep quality (SQS)
75
Depression/Anxiety
(YSR)
76
Time is included as a covariate, along with time 1, sleep quality, and mean
time in bed.
Bidirectional
Time in Bed (TBS)
45
Depression/Anxiety
(YSR)
76
Time is included as a covariate, along with time 1, sleep quality, and mean
time in bed.
Less time in bed Depression/
Anxiety
17 Insomnia (ISRS)
77
Depression (HADS
69
),
Anxiety (HADS
69
)
Only participants who did not report symptoms of the outcome variable
at baseline were included in analyses, e.g., if assessing insomnia as an
outcome variable, only participants who were not categorised as having
insomnia were used. Age and gender were used as predictor variables for
all analyses. Baseline covariates such as age, sex, social class and pain
areas were also controlled for.
Bidirectional
*Diagnosis. EDS, excessive daytime sleepiness; MDE, major depressive episode; SPIKE, The Structured Psychopathological Interview and Rating of Social Consequences of Psychic
Disturbances for Epidemiology; CBC, Child Behavior Checklist; CSHQ, Child Sleep Habits Questionnaire; CDI, Child Depression Inventory; BNSQ, Basic Nordic Sleep Questionnaire; USI,
Uppsala Sleep Inventory; HADS, Hamilton Anxiety Depression Scale; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders-IV; PSQI, Pittsburgh Sleep Quality Index; General Health
GHQ, Questionnaire; 10/66DDCRG, 10/66 Dementia in Developing Countries Research Group; GMS B3, Geriatric Mental State diagnostic schedule; SQS, Sleep Quality Scale; YSR, Youth
Self-report; TBS, Time in Bed Scale; ISRS, Insomnia Self-report Scale.
SLEEP, Vol. 36, No. 7, 2013
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Review of Sleep Disturbances, Anxiety and Depression—Alvaro et al
mon neurobiological underpinnings (i.e., neurotransmitters
and brain structures, discussed above) have been associated
with insomnia, anxiety, and depression.
46-53
Batterham and col-
leagues
56
hypothesize there may also be biological factors such
as increased inammatory dysregulation in response to sleep
disturbances
57
that are associated with anxiety
58
and depres-
sion.
59
Three other potential mechanisms discussed by Kaneita
and colleagues,
14
which may coexist, include common factors
(e.g., genetic, familial, social, or environmental) that indepen-
dently contribute to the development of insomnia, anxiety and
depression; insomnia, anxiety, and depression may be related,
in which only the order of appearance of symptoms may alter;
and insomnia, anxiety, and depression may be independent, but
mutually inuencing disorders.
A denitive conclusion is difcult to make regarding whether
sleep disturbances, anxiety, and depression are bidirectionally
related. Firstly, the small number of studies that assessed each
sleep disturbance variable prevents an accurate representation
of the true relationship between sleep disturbances, anxiety,
and depression. Further longitudinal studies are needed to un-
derstand whether there is a bidirectional relationship between
sleep disturbances, anxiety, and depression.
Secondly, sleep disturbance variables that were assessed by
the studies in this systematic review were limited and some-
times problematic. Prevalent sleep disorders such as obstruc-
tive sleep apnea and circadian rhythm sleep disorders were not
investigated, while insomnia symptoms such as problems with
sleep latency, nighttime awakenings, and daytime functioning
decits as a result of sleep were incorporated in the denition of
sleep quality
14,45
and childhood sleep problems.
43,44
The deni-
tion of childhood sleep problems also incorporated other sleep
disturbances such as nightmares, sleep duration, overtiredness,
bedtime resistance, sleep anxiety, parasomnias, sleep disor-
dered breathing, and daytime sleepiness. Therefore, implying
differences in ndings across sleep variables is problematic be-
cause distinctions between sleep variables are obscured and the
denition of childhood sleep problems was overly inclusive.
Future bidirectionality studies should focus on a broader range
of clearly dened sleep disturbances that contain reasonable
conceptual overlap.
Variables of anxiety and depression were also sometimes de-
ned using conceptually overlapping and overly inclusive vari-
ables, along with non-diagnostic self-report questionnaires, and
may variably reect current diagnostic criteria. Such cases in-
clude a combined depression/anxiety variable, which assessed
depression and anxiety as one construct. These inventories
could mask potential differences in bidirectionality across vari-
ables, and are problematic because bidirectional inferences can-
not be made about the relationship between sleep disturbances.
Indeed, only two studies assessed diagnosed insomnia, anxiety,
and depressive disorders.
11,42
Future studies should refrain from
using overly inclusive variables, and use denitions based on
established diagnostic criteria.
Moreover, bidirectionality between anxiety, depression,
and different types of insomnia symptoms (i.e., sleep onset in-
somnia, early morning awakening) was not assessed. Recent
Table 5—Comparison of study ndings between sleep variables
Sleep variables Study
Mental health
variable(s) Study design Results
Insomnia 40, 41 MDE Longitudinal
(immediate only)
Insomnia immediate follow up depression
40, 41 MDE Longitudinal (any
follow up)
Bidirectional
40, 41 “Pure depression” Longitudinal All no relationship
40, 41 Insomnia comorbid with
depression
Longitudinal All bidirectional
15 Depression, Anxiety Longitudinal Bidirectional
42 Depression* Longitudinal Bidirectional
17 Depression, Anxiety Longitudinal Bidirectional
11 Depression*, Anxiety* Retrospective
Anxiety Insomnia Depression
Insomnia comorbid
with depression
40, 41 “Pure depression” Longitudinal
2 bidirectional, 2 no relationship, 1 insomnia + depression
depression
EDS 40/41 MDE, Anxiety Longitudinal
Anxiety EDS, No relationship between EDS & major depression
Childhood sleep
problems
44 Depression/Anxiety Longitudinal
Childhood sleep problems Depression/Anxiety
43 Depression Longitudinal
Childhood sleep problems Depression
Sleep quality 14 Mental Health Status Longitudinal Bidirectional
45 Depression/Anxiety Longitudinal Bidirectional
Time in bed 45 Depression/Anxiety Longitudinal
Less time in bed Depression/Anxiety
*Diagnosis. EDS, Excessive Daytime Sleepiness; MDE, Major Depressive Episode.
SLEEP, Vol. 36, No. 7, 2013
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Review of Sleep Disturbances, Anxiety and Depression—Alvaro et al
studies have suggested that the association between insomnia,
anxiety and depression may differ across specic insomnia
symptoms.
19,20
Therefore, it remains unclear whether anxiety
and depression are bidirectionally related across insomnia
symptoms. Further contributions to the eld may consider
different insomnia proles.
Also, studies did not consider bidirectionality across different
types of anxiety disorders. Johnson et al.,
11
found that comor-
bidity rates of insomnia vary across different subtypes. Future
research can assess whether sleep disturbances are consistently
bidirectionally associated with different anxiety proles.
Furthermore, the samples used by the included studies were
heterogeneous, assessing children, adolescents, young adults,
adults, and the elderly. Recent evidence has suggested age
may be related to types and prevalence rates of sleep distur-
bances,
60-62
rendering a comparison between studies potentially
awed at this time. The heterogeneous samples across studies
also prevented the use of meta-analytic techniques to perform
quantitative analyses.
Finally, important potential covariates were not controlled
for. One study corrected for alcohol and exercise, but no study
accounted for variables that have been associated with sleep dis-
turbances, anxiety, and depression such as lifestyle factors, med-
ical conditions, and other sleep disorders.
4,25-33
Bidirectionality
is difcult to infer without controlling for such variables. Future
research should account for variables such as circadian rhythm
disorders, drug and alcohol use, caffeine intake, and exercise.
Although few conclusions can be made, this study contrib-
utes to the burgeoning understanding of the etiological relation-
ship between, and prevention of anxiety, depression and various
sleep disturbances. At the very least, patients who present with
a sleep disturbance should also be assessed for anxiety and de-
pression, and vice-versa.
Bidirectionality was found between insomnia, anxiety, and de-
pression, suggesting that insomnia predicts and is predicted by
anxiety and depression. Therefore, successful treatment of in-
somnia may prevent the onset of subsequent or exacerbation of
comorbid anxiety or depression, and vice-versa.
14
Future research
should consider the most appropriate and cost-effective targets of
prevention and intervention for insomnia, anxiety and depression.
The unidirectional relationship between childhood sleep
problems and depression suggests that some sleep disturbances
may signicantly contribute to depression, at least in children,
but not vice-versa. Such conclusions should be treated with
caution due to the limited research in this area, the overly inclu-
sive nature of the childhood sleep problems variable, and the
conceptual overlap with insomnia. Further research is needed
to identify the specic sleep disturbance proles that indepen-
dently predict anxiety and depression.
In conclusion, due to the small number of studies in this area
and the heterogeneity of cohort samples used across studies,
few denitive conclusions about the bidirectionality of most
sleep disturbances can be made. Best available evidence to
date suggests depression bidirectional relationship between in-
somnia, anxiety, and depression, and further consolidates the
association found between sleep disturbances, anxiety, and de-
pression. Therefore, treatment of insomnia may prevent the de-
velopment of anxiety and depressive disorders, and vice-versa.
Future research should consider whether insomnia, anxiety,
or depression should be targeted to ensure the most efcient
and cost-effective method for prevention and intervention
of these disorders.
ACKNOWLEDGMENTS
Authors did not have conict of interests, including specic
nancial interests and relationships and afliations relevant to
the subject of this manuscript. The principal author “had full
access to all of the data in the study and takes responsibility for
the integrity of the data and the accuracy of the data analysis.”
DISCLOSURE STATEMENT
This was not an industry supported study. The authors have
indicated no nancial conicts of interest.
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... During global health crises including COVID-19, sleep disturbance is common [9,10]. For example, it is quite difficult for anxious individuals to fall asleep and they may wake up several times during the night [11]. ...
... The total scores are categorized into five levels of anxiety: minimal (0-4), mild (5-9), moderate (10)(11)(12)(13)(14), and severe (15)(16)(17)(18)(19)(20)(21). Scores of 10 or higher are indictive of GAD. ...
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Objective. To assess the impact of the COVID-19 pandemic on the mental health of female doctors and nurses in Oman. Methods. A cross-sectional, web-based survey of 402 female doctors and nurses recruited from several health facilities in Oman. The prevalence rates of anxiety, stress, well-being, and sleep quality were assessed using the Generalized Anxiety Disorder scale (GAD-7), the Perceived Stress Scale (PSS-10), the WHO-5 Well-Being Index (WHO-5) and Sleep Quality Scale. Results. A total of 231(57.5%) Omanis and 171 (42.5%) non-Omanis participated in this study. Of the total 402 participants, 28.4% were physicians and 71.6% were nurses. One in four (27.9%) participants reported caring for COVID-19 patients. Also, one in four (27.9%) had moderate to severe anxiety. A higher proportion of Omanis (32%) had moderate to severe anxiety compared to non-Omanis (22.2%). Six in ten (60.7%) scored at or above the mean on the perceived stress scale. Doctors and nurses who cared for COVID-19 patients reported higher 2 levels of stress than those who did not. Almost half of the participants (45.3%) scored 50% or less on the well-being scale. A higher proportion of Omanis and those who cared for COVID-19 scored ≤ 50. Four in ten (39.3 %) had poor sleep quality; this was particularly prevalent among Omanis. A multiple regression analysis revealed that anxiety, stress, and well-being were significant predictors of poor sleep quality. Conclusion. The COVID-19 pandemic is having a significant effect on the mental health of health care workers in Oman. In this study, nurses, Omanis, and frontline health care workers were the most impacted by the global health crisis. Urgent psychological, social, and administrative interventions and support should be implemented to mitigate mental health risks in these groups.
... A substantial body of literature has shown that stressful life events and outbreaks of infectious diseases, including COVID-19, can affect sleep quality [34,[38][39][40][41], and 84.69% of the participants in the present study had poor sleep quality. Syntheses of longitudinal studies suggested that sleep quality was bidirectionally related to anxiety [42]. There is a large amount of data on the effects of sleep quality on anxiety symptoms in other populations, such as shift workers, firefighters, paramedics, pregnant females, and older adults. ...
... There is a large amount of data on the effects of sleep quality on anxiety symptoms in other populations, such as shift workers, firefighters, paramedics, pregnant females, and older adults. Poor sleep quality was found to be associated with higher risk for anxiety symptoms, and greater anxiety was found to be associated with poorer sleep quality [43][44][45][46][47]. Similarly, anxiety affects sleep quality because anxious people find it hard to fall asleep and wake up frequently [42]. In addition, the present study demonstrated that patients with more physical symptoms of COVID-19 were more vulnerable to anxiety symptoms. ...
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Fangcang shelter hospitals were established in China during the coronavirus disease 2019 (COVID-19) pandemic as a countermeasure to stop the spread of the disease. To our knowledge, no research has been conducted on mental health problems among patients in Fangcang shelter hospitals. This study aimed to determine the prevalence and major influencing factors of anxiety and depressive symptoms among COVID-19 patients admitted to Fangcang shelter hospitals. From February 23, 2020, to February 26, 2020, we obtained sociodemographic and clinical characteristics information of COVID-19 patients in Jianghan Fangcang Shelter Hospital (Wuhan, China) and assessed their mental health status and sleep quality. Data were obtained with an online questionnaire. The questionnaire consisted of a set of items on demographic characteristics, a set of items on clinical characteristics, the Self-Rating Anxiety Scale, Self-Rating Depression Scale, and Pittsburgh Sleep Quality Index. Three hundred seven COVID-19 patients who were admitted to Jianghan Fangcang Shelter Hospital participated in this study. The prevalence of anxiety and depressive symptoms were 18.6% and 13.4%, respectively. Poor sleep quality and having ≥ two current physical symptoms were independent risk factors for anxiety symptoms. Female sex, having a family member with confirmed COVID-19, and having ≥ two current physical symptoms were independent risk factors for depressive symptoms. Anxiety and depressive symptoms were found to be common among COVID-19 patients in Fangcang Shelter Hospital, with some patients being at high risk.
... A systematic review of longitudinal studies of both children and adults on the association between sleep and depression, suggested that there was some evidence for a significant bidirectional association. However, the review also concluded that definitive conclusions regarding bidirectionality could not be made due to the small number and heterogeneity of cohort samples, and that more research was needed to further explore the nature of the link, and across age cohorts (Alvaro, Roberts, & Harris, 2013). ...
... Together, these findings demonstrate a bidirectional association between sleep and internalizing/depressive symptoms from toddlerhood to later in childhood. This is consistent with the emerging evidence of a close relationship between depression and sleep throughout the lifespan (Baglioni et al., 2011;Hysing et al., 2016;Sivertsen et al., 2014), and thus supports the conclusion from a recent review that highlighted the reciprocal nature of the relationship (Alvaro et al., 2013). However, to the best of our knowledge, this is the first study to examine this association spanning over so many years from early toddlerhood and well into childhood. ...
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Sleep and depression are interlinked throughout the lifespan, but very few studies have examined the directionality of the sleep–depression link in children. The aim of the current study was to prospectively examine the bidirectional association between sleep problems and internalizing problems and depressive symptoms in toddlers and children aged 1.5 and 8 years. Data stem from the large ongoing population‐based longitudinal study, the Norwegian Mother, Father and Child Cohort Study, recruited from October 1999 to July 2009. A total of 35,075 children were included. Information on sleep duration, nocturnal awakenings and internalizing problems (Child Behaviour Checklist) was provided by the mothers at 1.5 years, whereas data on sleep duration and depressive symptoms (Short Mood and Feelings Questionnaire) were provided by the mothers when the children were 8 years old. Odds ratios (ORs) were calculated using logistic regression analyses. After accounting for previous internalizing problems, short sleep duration (≤10 hr) and frequent (≥3) nightly awakenings at 1.5 years predicted the development of depressive symptoms at 8 years of age (adjusted OR = 1.28; 95% confidence interval [CI] 1.08–1.51, and adjusted OR = 1.27, 95% CI 1.08–1.50, respectively). Also, internalizing problems at 1.5 years predicted onset of later short sleep duration (adjusted OR = 1.83, 95% CI 1.32–2.54) after accounting for early sleep problems. This prospective study demonstrated a bidirectional association between sleep and internalizing/depressive symptoms from toddlerhood to middle childhood. Intervention studies are needed to examine whether targeting either of these problems at this early age may prevent onset of the other.
... The sleep disturbances of cruise ship employees stuck at sea were related to the combination of worries, fears, and anxiety, which ultimately affected their sleep quality. This finding is in line with Alvaro et al. [88] who in their systematic review on sleep disturbances, anxiety, and depression point to causality between anxiety and sleep quality due to a specific condition where anxious individuals experience difficulties to fall asleep and they wake up frequently during their sleep. ...
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The current COVID-19 pandemic has evolved to unprecedented proportions. This research aimed to gain a deeper understanding of the psychological effects of the COVID-19 pandemic on cruise ship employees stuck at sea. Using an inductive qualitative approach, a synchronous online focus group was conducted with nine cruise ship employees who were stuck at sea during COVID-19 pandemic. The findings revealed that COVID-19 pandemic has managed to erase the feeling of joy from cruise ship employees who were stuck at sea while exposing weakness of cruise line companies such as poor human resource management leadership. Moreover, COVID-19 pandemic demonstrated that it is of paramount importance that cruise line companies create a comprehensive strategy in assisting their employees who are experiencing an anxiety disorder and depression. The managerial implications are outlined.
... L étude des données longitudinales pourrait nous permettre d étudier l évolution de la relation entre sommeil et cognition, mais également de déterminer dans quelle mesure la méditation ou l anglais pourrait bénéficier au fonctionnement cognitif, au sommeil, mais aussi à leur relation.Au-delà de l impact du style de vie et de la réserve cognitive sur le sommeil et la cognition,il existe d autres facteurs que nous n avons pas inclus dans nos analyses. En effet, de nombreux travaux ont mis en évidence un impact majeur des facteurs psychoaffectifs, tels que l anxiété et la dépression, sur le sommeil et la cognition(Blazer, 2003 ;Alvaro et al., 2013, pour revues). Compte tenu de l impact de la méditation sur la régulation desémotions et des ruminations (Goyal et al., 2014, pour revue) mais également sur la qualité Anderson, C., & Horne, J. A. . ...
Thesis
De nombreux travaux indiquent que le sommeil joue un rôle crucial dans la préservation des fonctions cognitives. Toutefois, l’avancée en âge s’accompagne de modifications de la qualité de sommeil, pouvant avoir un impact sur le processus de consolidation mnésique mais aussi sur le fonctionnement cognitif global. Parallèlement à cela, plusieurs études suggèrent qu’un style de vie sain, enrichi et cognitivement stimulant tout au long de la vie favoriserait le maintien d’un fonctionnement cognitif optimal à un âge avancé. Cependant, il n’y a à notre connaissance que peu de travaux ayant investigué l’impact du style de vie sur la relation entre le sommeil et la cognition au cours du vieillissement. Dans une première étude, nous avons montré un effet bénéfique du sommeil sur la consolidation et le rappel d’intentions de mémoire prospectives chez des sujets âgés. En revanche, nous n’avons pas mis en évidence un effet délétère de l’âge sur le sommeil et la mémoire prospective. Dans un second travail, nous avons évalué l’impact de différents facteurs du style de vie sur la relation entre sommeil et cognition chez une population de sujets âgés. Les résultats ont révélé que l’engagement cognitif au cours de la vie modulait le lien entre le sommeil lent profond et la cognition. Ainsi, tandis que les individus fortement stimulés cognitivement pourront être en mesure de maintenir un fonctionnement cognitif efficace, même en cas de troubles du sommeil affectant la quantité de sommeil à ondes lentes, les individus moins stimulés sur le plan cognitif apparaîtraient plus vulnérables aux effets négatifs d’une réduction de sommeil lent profond. L’ensemble de ces résultats indique que la cognition à un âge avancé dépendrait de la qualité de sommeil mais aussi de l’engagement cognitif au cours de la vie. Une réflexion sur l’existence d’une fenêtre temporelle critique a également été soulevée en vue d’approfondir ces résultats.
... Some studies have reported that sleep quality is positively associated with NA and negatively associated with PA (72,73). Although, some scholars argue that the relationship between sleep quality and affect may be bidirectional (74)(75)(76), previous research has also shown that both positive and negative affect can mediate the impact of expressive suppression on sleep quality (73,77). Another recent study showed that insomnia partially mediated a significant association of interpersonal stress and FoMO with mental health (78). ...
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The widespread use of social media on smartphones has lead to the fear of missing out (FoMO) and smartphone addiction among a minority of adolescents and adults. However, few studies have investigated the impact of trait affect on sleep quality via FoMO and smartphone addiction. The present study examined whether FoMO (trait-FoMO and state-FoMO) and smartphone addiction mediated the relationship between positive affect (PA)/negative affect (NA) and sleep quality, and the prevalence of sleep disturbance among Chinese university students. The sample comprised 1,164 university students and they completed a survey which included the Chinese Trait-State Fear of Missing Out Scale (T-SFoMOS-C), Mobile Phone Addiction Index (MPAI), International Positive and Negative Affect Scale Short-Form (I-PANAS-SF), and the Pittsburgh Sleep Quality Index (PSQI). The prevalence of sleep disturbance was found to be 15.98% among Chinese university students. The serial multiple mediation effects indicated that PA directly impacted on sleep quality, but the mediation effects of trait-FoMO and state-FoMO were not found. NA impacted on sleep quality via the mediation effects of trait-FoMO/state-FoMO and smartphone addiction. Negative affect was positively associated with poor sleep quality, which was partially mediated by FoMO and smartphone addiction among Chinese university students. Individuals with high negative affect were more likely to have high levels of FoMO and were more prone to smartphone addiction as well as experiencing poor sleep quality. These findings provide an evidence base for emotion management, prevention of smartphone addiction, and sleep improvement.
... Depression and related disorders, such as anxiety, affect nearly one-fifth of the global population and disproportionately affect young adults (Steel et al., 2014); studies of sleep patterns in depressed individuals highlight a robust relationship between sleep duration and depression, with extreme long and short sleep duration associated with increased depression (Watson et al., 2014;Zhai et al., 2015;Kalmbach et al., 2017). Individuals struggling with depression also report reduced sleep quality (Alvaro et al., 2013;Bakotic et al., 2017;Dinis and Bragança, 2018), and some studies have noted interactions between sleep quality and duration, suggesting more complex relationships between sleep variables and mood (Sandman et al., 2015;Bakotic et al., 2017;Kalmbach et al., 2017). ...
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Depression and its related mood disorders are a major global health issue that disproportionately affects young adults. A number of factors that influence depressive symptoms are particularly relevant to the young adult developmental stage, including sleep loss, poor sleep quality, and the tendency toward eveningness in circadian preferences. However, relatively few studies have examined the relationship between sleep and circadian phenotypes, and their respective influences on mood, or considered potential molecular mechanisms driving these associations. Here, we use a multi-year, cross-sectional study of 806 primarily undergraduates to examine the relationships between sleep-wake chronotype, sleep disturbance, depression and genotypes associated with the PER3 variable number of tandom repeats (VNTR) polymorphism—circadian gene variants associated with both chronotype and sleep homeostatic drive. In addition, we use objective, Fitbit-generated sleep structure data on a subset of these participants (n = 67) to examine the relationships between chronotype, depression scores, actual measures of sleep duration, social jetlag, and the percent of deep and rapid eye movement (REM) sleep per night. In this population, chronotype is weakly associated with depressive symptoms and moderately correlated with self-reported sleep disturbance. Sleep disturbance is significantly associated with depression scores, but objective sleep parameters are not directly correlated with Beck Depression Inventory (BDI-II) scores, with the exceptions of a moderate correlation between social jetlag and depression scores in females and a marginal correlation between sleep duration and depression scores. Multiple regression and path analyses reveal that chronotype effects on depressive symptoms in this population are mediated largely by sleep disturbance. The PER3 VNTR genotype significantly predicts depressive symptoms in a model with objective sleep parameters, but it does not significantly predict depressive symptoms in a model with chronotype or subjective sleep disturbance. Interestingly, PER35,5 genotypes, in males only, are independently related to chronotype and depression scores. Our results support hypotheses linking subjective sleep quality and chronotype and provide a first step in understanding how objective sleep structure may be linked to chronotype and depressive symptoms. Our results also suggest that circadian gene variants may show sex-specific effects linking sleep duration and sleep structure to depression.
Article
Objective To assess dairy Ca intake and investigate its relationship with insomnia and other common co-morbidities including anxiety, depression and musculoskeletal pain (MSP) among university students. Design Cross-sectional study. Setting University, Irbid, Jordan. Participants Male and female individuals ( n 1000), aged 20·87 ± 2·69 years. Results Low dairy Ca intake (<1000 mg/d) was reported by 96·5 % of participants, and moderate to severe insomnia reported by 15·6 % of participants. Abnormal anxiety and depression scores were reported by 26·2 and 18·0 % of participants, respectively. MSP was reported by 42·9 % of participants. Participants with moderate to severe insomnia had lower dairy Ca, higher anxiety and depression scores and higher measures of MSP compared to participants with no insomnia ( P -values < 0·05). Dairy Ca was weakly inversely correlated with Insomnia Severity Index (ISI) score, depression score and measures of MSP ( P -values < 0·05). Regression analysis indicated that insomnia was predicted by low dairy Ca, anxiety, depression, MSP and smoking ( P -values < 0·05). Both anxiety and depression were predicted by increased ISI score ( P -values < 0·05), while depression alone was predicted by low dairy Ca ( P -value < 0·01). MSP was predicted by increased ISI and anxiety scores ( P -values < 0·05). Conclusions Low dairy Ca was highly prevalent and associated with insomnia and depression among university students. Individuals should be advised to increase dietary Ca intake to achieve the recommended daily amount. Further research is required to investigate a potential causal relationship between low Ca and both insomnia and its related co-morbidities.
Article
Eveningness has been associated with maladaptive behavior, poor sleep quality, and psychological disorder. However, while much research has utilized unidimensional measures of morningness-eveningness, the current study aimed to test associations between negative emotionality (depression, anxiety, and stress/DAS) and the circadian rhythm components of morning affect/alertness, eveningness, and amplitude of diurnal variation (distinctness). Associations with maladaptive metacognitive beliefs, neuroticism, conscientiousness, and sleep quality were also investigated, and possible indirect (mediation) effects between the circadian rhythm components and negative emotionality were explored. A sample of 625 Chinese university students (aged 18–33, mean = 19.78; 189 males) completed validated questionnaire measures in an online survey. Morning affect was positively correlated with conscientiousness, and negatively correlated with neuroticism, poor sleep quality, and aspects of maladaptive metacognitive belief (including belief in the uncontrollability and danger of thoughts). Distinctness generally showed the opposite associations. DAS was negatively correlated with morning affect, and positively correlated with eveningness and distinctness. However, after controlling for morning affect the correlations with eveningness were near zero. With either morning affect or distinctness as the predictor for negative emotionality (combined DAS scores), significant indirect effects were found through neuroticism, sleep disturbances, and belief in the uncontrollability and danger of thoughts. These results are consistent with other recent findings that indicate morning affect/alertness, and a stronger amplitude of diurnal variation, may both be more strongly related to negative emotionality than is eveningness preference. They also highlight that these relationships may involve associations with aspects of personality, sleep quality, and also maladaptive metacognitive beliefs. Further research is needed to establish the directions of possible causal relationships, which may help to inform interventions for psychological distress and disorder.
Along with its economic prosperity, China faces a fast increasing rate of drug use. This study aimed to explore the relationship between perceived stress and sleep quality among Chinese drug users while considering rumination as a mediator and resilience as a moderator. Measuring scales, including the Connor–Davidson Resilience Scale, the Ruminative Response Scale, the Perceived Stress Scale, and the Pittsburg Sleep Quality Index, were used to collect information from 104 Chinese drug users. The mediating analysis documented that the effect of perceived stress on sleep quality was mediated via rumination significantly. Resilience acts as a significant moderator on the relationship between perceived stress and poor sleep quality. Simple slope analysis further suggests that participants with a low level of resilience experienced more sleep disturbances given the same level of perceived stress compared to those with a high level of resilience. These findings indicated that psychological intervention that improves drug users’ resilience and reduces their rumination is helpful to release their stress and improve their sleep quality.
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Previous research has demonstrated an association between suicidality and sleep, suggesting that sleep disturbances may exacerbate mood dysregulation in participants suffering from mood disorders. The purpose of this study was to investigate the impact of sleep disturbances and insomnia on depression and suicidality in a nontreatment seeking sample of college students. Results indicated that insomnia and nightmares were significant predictors of symptoms of depression, while only nightmares significantly predicted suicidal ideation. Further analysis indicated that participants with elevated scores on insomnia, nightmares, or both experienced differing levels of depression and suicidal ideation. Future directions and treatment implications are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Study Objectives To establish the direction and etiology of longitudinal associations between sleep problems and depression symptoms in children. Design Data on twins aged 8 and 10 years were obtained. At assessments, parents completed the Child Sleep Habits Questionnaire, and twins completed the Children’s Depression Inventory. Setting Participants were mainly interviewed at the Institute of Psychiatry, London. Patients or Participants Three hundred twin pairs initially enrolled in the study. Interventions N/A. Measurements and Results A genetically informative cross-lagged model examined links between sleep and depression. Sleep problems at age 8 predicted depression at age 10 (partial regression coefficient [95% confidence intervals] = 0.10 [0.01-0.18]). The converse was not found. Stability of sleep problems across time was mainly due to genes (46% of the genetic influence on sleep at 10 was due to the same genetic influence on sleep aged 8). Stability of depression was mainly due to nonshared environmental influences (19% of the nonshared environmental influence on depression at 10 was due to the same nonshared environmental influence on depression at age 8). The cross-lagged association between sleep problems at 8 and depression at 10 years was largely due to genes, although this finding was nonsignificant. Conclusions This study adds to our understanding of the temporal precedence of sleep problems and depression and the risks underlying their associations. There are implications regarding the value of specifying genes linked to sleep problems and potential opportunities for informing early intervention strategies in high-risk groups at key points in the progression to developing more serious problems.
Book
As soldiers and combat veterans have returned from the wars in Iraq and Afghanistan traumatic brain injury (TBI) has been identified as the "signature injury" of those wars. TBI is also in the news on a daily basis due to sports injuries. This new edition has been revised and updated from the 2005 first edition to reflect the exponential expansion of research and clinical data amassed in the intervening years. Each chapter was written and reviewed by the foremost authorities in neuropsychiatry, neurology, rehabilitation medicine, and the other specialties who assess, diagnose, and treat these patients. The revisions and additions to this comprehensive volume were made to ensure that the scope and coverage is both up-to-date and down-to-earth. Key features include: New chapters on epidemiology, neuropathology, and genetics of TBI; new chapter on TBI in the military emphasizing the unique feature of blast injury; A new chapter on posttraumatic stress disorder (PTSD), which emphasizes the common co-occurrence of TBI and PTSD in both combat and other settings; Enhanced coverage of psychopharmacology and psychotherapy for the psychiatric symptoms associated with TBI; Information on the social ramifications of TBI so that clinicians will better understand and help their patients cope with the complex legal, financial, and insurance-based struggles their patients who have sustained TBI encounter; Each chapter concludes with essential points and key references to focus attention and consolidate learning; A foreword written by Bob Woodruff (the ABC World News correspondent who sustained a TBI while covering the war in Iraq) and his wife, Lee Woodruff, who underscore that although this volume is intended to be read primarily by professionals, patients and families may also find the information in the textbook to be of keen interest and practical application.
Article
Textbook of Traumatic Brain Injury is a comprehensive collection of information on the important topic of traumatic insult to the central nervous system. It is an expanded and enriched version of Neuropsychiatry of Traumatic Brain Injury, published in 1994.
Objective: Previous studies have shown associations between sleep disturbance and the onset of depression and anxiety. However, this relationship may reflect an underlying vulnerability, such as temperament or cognitive style, which accounts for an association between the two. This study aimed to evaluate the relationship between sleep disturbance and the onset of a mental disorder after a 4-year follow-up, and whether this was accounted for by ruminative style and neuroticism. Method: The nine-item Patient Health Questionnaire was used to assess the criteria for major depression, generalized anxiety disorder (GAD) and panic disorder (PD) in a community cohort of 3636 young and middle-aged Australian adults, free of any disorder at baseline, over a 4-year period. Sleep disturbance was based on a factor derived from the sleep items of the Goldberg Depression and Anxiety Scales. The associations between baseline sleep disturbance and a new episode of the assessed disorders were estimated and the impact of temperament and cognitive style on these associations was evaluated. Results: Self-reported sleep disturbance was significantly associated with an onset of major depressive disorder [MDD; odds ratio (OR) = 1.33, p = 0.006], GAD (OR = 1.37, p < 0.001) and PD (OR = 1.62, p < 0.001) after 4 years. However, the relationship for MDD was attenuated to nonsignificance (OR = 1.19, p = 0.116) after adjusting for neuroticism (measured by the Eysenck Personality Questionnaire-Revised) and rumination (measured by the adapted Ruminative Style scale). Conclusions: These data suggest that the often-observed association between sleep disturbance and depression onset may be linked to an underlying ruminative style and/or neuroticism. However, the fact that the effect of sleep disturbance on PD and GAD onset was not accounted for by personality factors is a novel finding and suggests a potential role of early identification in selective preventive interventions.