The Relationship Between Insufficient Sleep and Depressive Symptoms in Chinese Adolescents: A National Survey of Contributing Factors

Abstract

Purpose
There is a lack of national studies examining the relationship between insufficient sleep and depression among Chinese adolescents, and previous research has not comprehensively considered related factors. This study aimed to investigate the prevalence of depressive symptoms in adolescents with insufficient sleep and explore the role of associated factors using a nationally representative sample in China.

Patients and Methods
A pen-and-paper survey was conducted among 24147 Chinese adolescents from November 2019 to January 2020. Data on depressive symptoms, maltreatment experiences, psychological resilience, demographic information, parent–child relationships, parental marital status, and sleep duration were collected.

Results
A total of 22231 valid questionnaires were analyzed. Among the respondents, 67.7% reported insufficient sleep, while 32.3% had sufficient sleep. The prevalence of depressive symptoms was 25.3% in adolescents with insufficient sleep, compared to 8.2% in those with sufficient sleep. Insufficient sleep was identified as an independent risk factor for depressive symptoms (OR = 3.058, 95% CI: 2.753–3.396, P < 0.001). In adolescents with sufficient sleep, being female, emotional abuse, physical abuse, sexual abuse, and physical neglect were significant risk factors for depressive symptoms (P < 0.05), while higher resilience scores and a good parent–child relationship were protective factors (P < 0.05). Among adolescents with insufficient sleep, additional risk factors included higher body mass index (BMI), older age, parental divorce, and living with a single parent (P < 0.05).

Conclusion
Insufficient sleep is significantly associated with depressive symptoms in Chinese adolescents. The adolescents with insufficient sleep, particularly those who are older, have a higher BMI, or come from divorced or single-parent households, require increased attention.

Full text

ORIGINAL RESEARCH
The Relationship Between Insufcient Sleep and
Depressive Symptoms in Chinese Adolescents:
A National Survey of Contributing Factors
Chuming Yan
1
, Wancheng Zheng
1
, Yun Du
1
, Yi Li
2
, Mengshu Wang
2
, Miao Qu
1
1
Neurology Department, Xuanwu Hospital of Capital Medical University, Beijing, People’s Republic of China;
2
Neurology Department, Third Afliated
Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
Correspondence: Miao Qu, Neurology Department, Xuanwu Hospital of Capital Medical University, Xicheng District, Beijing, 100053, People’s
Republic of China, Email qumiao@xwhosp.org
Purpose: There is a lack of national studies examining the relationship between insufcient sleep and depression among Chinese
adolescents, and previous research has not comprehensively considered related factors. This study aimed to investigate the prevalence
of depressive symptoms in adolescents with insufcient sleep and explore the role of associated factors using a nationally representa-
tive sample in China.
Patients and Methods: A pen-and-paper survey was conducted among 24147 Chinese adolescents from November 2019 to
January 2020. Data on depressive symptoms, maltreatment experiences, psychological resilience, demographic information, parent–
child relationships, parental marital status, and sleep duration were collected.
Results: A total of 22231 valid questionnaires were analyzed. Among the respondents, 67.7% reported insufcient sleep, while 32.3%
had sufcient sleep. The prevalence of depressive symptoms was 25.3% in adolescents with insufcient sleep, compared to 8.2% in
those with sufcient sleep. Insufcient sleep was identied as an independent risk factor for depressive symptoms (OR = 3.058, 95%
CI: 2.753–3.396, P < 0.001). In adolescents with sufcient sleep, being female, emotional abuse, physical abuse, sexual abuse, and
physical neglect were signicant risk factors for depressive symptoms (P < 0.05), while higher resilience scores and a good parent–
child relationship were protective factors (P < 0.05). Among adolescents with insufcient sleep, additional risk factors included higher
body mass index (BMI), older age, parental divorce, and living with a single parent (P < 0.05).
Conclusion: Insufcient sleep is signicantly associated with depressive symptoms in Chinese adolescents. The adolescents with
insufcient sleep, particularly those who are older, have a higher BMI, or come from divorced or single-parent households, require
increased attention.
Keywords: depressive symptoms, sleep duration, adolescent mental health, parent–child relationship
Introduction
Globally, depressive symptoms among adolescents are on the rise,
1
with approximately 20% experiencing depression
during puberty.
2,3
In China, about 19.85% of adolescents report depressive symptoms.
4
This underscores the importance
of investigating factors contributing to adolescent mental health challenges.
Research has established a correlation between mental health conditions and insufcient sleep duration.
5
The
American Academy of Sleep Medicine recommends that adolescents age 13 years and older should sleep no less than
8 hours per day.
6
However, the average sleep duration among Chinese adolescents falls signicantly short of this
recommendation, with 66.49% not getting enough sleep.
7
Insufcient sleep has been linked to an increased risk of
depression, anxiety,
8
and even suicide in adolescents.
9
For instance, a cross-sectional study involving 10185 Chinese
adolescents in Sichuan Province found that depression scores were 2.614 points higher in sleep-deprived students
compared to those with adequate sleep.
10
Similarly, another cross-sectional study of 7330 Chinese adolescents in
Zhejiang Province revealed that longer sleep duration was associated with fewer depressive symptoms.
11
Although
these studies have explored the link between insufcient sleep and depression in adolescents, they were limited by small
Nature and Science of Sleep 2025:17 55–67 55
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and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work
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Nature and Science of Sleep
Open Access Full Text Article
Received: 26 August 2024
Accepted: 21 December 2024
Published: 10 January 2025

sample sizes and a focus on only one province in China. This highlights the need for a nationwide survey with
representative samples from different provinces.
It is known that lack of sleep impairs cognition and negatively affects brain excitability and plasticity induction,
12
both of which are related to the psychopathology of depression, which is documented in people with night shift
workers.
13,14
Similarly, insufcient sleep in adolescents can also result in a decline in learning, memory, and mental
health. Therefore, investigating the relationship between insufcient sleep and adolescent depression, as well as the
underlying factors, is benecial for understanding the pathogenesis.
The family environment may also inuence adolescents’ susceptibility to the depressive effects of insufcient sleep.
15
Poor parent–child relationships, childhood abuse, and harsh parenting styles are associated with a higher incidence of
adolescent depression.
16,17
Additionally, adolescents with divorced or single parents are more likely to develop
depression.
18,19
A cohort study in China suggested that better parental relationships might mitigate the risk of depressive
symptoms in adolescents.
20
On the other hand, psychological resilience is a protective factor against environment-induced
depression in adolescents.
21
Therefore, it is crucial to consider these factors when researching adolescent mental health.
To the best of our knowledge, it is more informative to examine the effects of psychological resilience and family
environmental factors —such as maltreatment, parental marital status, and parent–child relationship— in a large sample
size when investigating the relationship between insufcient sleep and depression in a national sample of Chinese
adolescents.
This study is an exploratory investigation to verify the relationship between insufcient sleep and depression, and the
role of maltreatment, parent-child relationship and resilience etc. We aimed to determine the prevalence of depressive
symptoms among Chinese adolescents with insufcient sleep. Additionally, we examined the correlation between
insufcient sleep and depression, controlling for confounding factors such as psychological resilience, maltreatment,
parent–child relationship, and parental marital status. Finally, we investigated the factors inuencing depression in
adolescents with sufcient and insufcient sleep, respectively. Through this study, we aim to better understand the
psychological impact of insufcient sleep on adolescent depression and establish a basis for developing interventions to
improve adolescent mental health.
Materials and Methods
Study Design and Procedure
An onsite pen-and-paper survey using self-report questionnaire was conducted from November 2019 to January 2020
across China. A two-stage cluster sampling method was employed to select a nationally representative sample of junior
high schools. In the rst stage, 17 cities were randomly selected from the stratied regional framework based on the
administrative divisions of China (Southwest, Northeast, Southeast, Central, North and South). In the second stage, one
junior high school was randomly selected from the list provided by the education bureau in each city as the nal
sampling framework. Finally, the method of full sampling was used to investigate all the students aged 13–18 years old in
the selected junior high school. Students under the age of 13 were not included in the study. The survey was conducted in
the classroom, with experienced staff members responsible for distributing and collecting questionnaires on-site and
answering questions. Each student could only ll out the questionnaire once. Invalid questionnaires were identied based
on the following criteria: (1) completion rate of less than 90%, (2) conrmation by researchers that the student provided
meaningless answers, and (3) missing important data, such as age and sex.
The study received approval from the Ethics Committee of the Third Afliated Hospital of Beijing University of
Chinese Medicine (No. BZYSY-2019KYKTPJ-21). Prior to the survey, informed consents were obtained from both
students and their guardians. Data collection was condential, and the survey was conducted anonymously.
Survey Response and Participants
A total of 24147 questionnaires were collected in this survey. After excluding invalid questionnaires, 22231 valid
responses were retained, resulting in a validity rate of 92.1%. Among the 22231 adolescents surveyed, the average age
was 14.10 years (range 13 years-18 years), with 50.3% being males.
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Measurement Instruments
Data on demographic characteristics were collected using a self-designed questionnaire, which included age, body mass
index (BMI), sex, boarding student or day student, parental marital status, and parent–child relationship.
Sleep duration was assessed with the question, “Over the past month, how many hours of sleep have you actually
gotten per day?”.
22
According to the American Academy of Sleep Medicine, adolescents aged 13–18 years old should get
no less than 8 hours of sleep per day.
6
Therefore, insufcient sleep was dened as <8 hours per day, and sufcient sleep
as ≥8 hours.
Depressive symptoms were assessed using the Patient Health Questionnaire for Depression (PHQ-9),
23
which has
a score range of 0–27. The PHQ-9 includes a 9-item self-report depression module using a 4-point Likert scale ranging
from 0 (not at all) to 3 (almost every day), which asks participants to rate their feelings over the past 2 weeks.
24
A score
of 10 was set as the cut-off for having depressive symptoms.
25,26
The scale showed high reliability among Chinese
adolescents (Cronbach’s α = 0.854), as well as a good discrimination for depressive symptoms (sensitivity = 0.90,
specicity = 0.94).
27
In this study, the Cronbach’s α for the PHQ-9 was 0.911.
Childhood maltreatment was evaluated using the Childhood Trauma Questionnaire (CTQ),
28
with total scores ranging
from 25 to 125. The CTQ contains 5 subscales to assess the 5 subtypes of childhood maltreatment. Each subscale consists
of 5 items using a 5-point Likert scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always). The cut-off scores for
each subscale were as follows: 8 for physical abuse, 9 for emotional abuse, 6 for sexual abuse, 8 for physical neglect, and
10 for emotional neglect.
29
The scale has been validated with high reliability among Chinese adolescents (Cronbach’s α =
0.852).
30
Psychological resilience was measured using the Chinese version of the Connor-Davidson Resilience Scale (CD-
RISC). The CD-RISC is a 25-item scale using a 5-point Likert-type response scale ranging from 0 (not true at all) to 4
(true nearly all of the time). Participants rate their feelings based on the past month.
31
The score range for the CD-RISC
is 0–100, with higher scores indicating greater resilience. The Chinese version of the CD-RISC has a good internal
consistency (Cronbach’s α = 0.97).
32
In this study, the Cronbach’s α for the CD-RISC was 0.928.
Statistical Analysis
All statistical analyses were conducted using SPSS version 25.0. Age was reported as mean ± standard deviation (SD).
Non-normally distributed continuous variables, such as BMI, PHQ-9 scores, resilience, and abuse scores, were reported
using median and interquartile ranges (IQRs). Statistical differences were assessed using the Student’s t or Mann–
Whitney U-test as appropriate. Count data, including sex, boarding student, parental marital status, parent–child relation-
ship, presence of depressive symptoms, and experience of abuse were described using numbers and percentages, with
statistical differences assessed using the chi-square test.
To elucidate the association between related factors and depression in all adolescents, logistic regression was
performed to identify risk and protective factors for depressive symptoms. Additionally, multivariate logistic regression
analysis was separately performed for adolescents with sufcient sleep and insufcient sleep to explore the differences in
depression-related factors.
Results
Participant Characteristics in Adolescents with Sufcient and Insufcient Sleep
Of the 22231 participants, 7188 (32.3%) reported sufcient sleep, while 15043 (67.7%) reported insufcient sleep
(Table 1).
Compared to adolescents with sufcient sleep, those with insufcient sleep were more likely to be girls (54% vs
40.8%, P <0.001) and were slightly older (14.16 years vs 13.97 years, P <0.001). Additionally, adolescents with
insufcient sleep had higher BMI, a lower rate of boarding student, poorer parent–child relationships, and incomplete
parental marital status (all P <0.05, Table 1).
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Psychological Outcomes in Adolescents with Sufcient and Insufcient Sleep
A total of 4389 (19.7%) adolescents exhibited depressive symptoms. Adolescents with insufcient sleep had higher
median PHQ-9 (IQR) scores (4 [8] vs 2 [5], P <0.001) and higher prevalence of depressive symptoms (25.3% vs 8.2%,
P <0.001) compared to those with sufcient sleep. Although the prevalence of physical neglect was similar between the
two groups (P =0.454), the physical neglect score was higher among adolescents with insufcient sleep (P =0.014). Rates
and scores for physical abuse, sexual abuse, emotional abuse, and emotional neglect were all higher among the
adolescents with insufcient sleep (all P <0.05). Conversely, resilience scores were signicantly lower in the insufcient
sleep group (51 [23] vs 59 [26], P <0.001, Table 2).
Relationship Between Insufcient Sleep and Depression
To identify the relationship between insufcient sleep and depression, logistic regression analysis was conducted
(Table 3). Model 1 (univariate logistic regression) was unadjusted, while Model 2 (multivariate logistic regression)
was adjusted for demographic characteristics including age, sex, BMI, boarding status, parental marital status, and
parent–child relationship. Model 3 (multivariate logistic regression) further adjusted for psychological outcomes includ-
ing resilience and abuse experiences in addition to the adjustments made in Model 2. Model 1 revealed an association
between insufcient sleep and a higher likelihood of depressive symptoms (OR = 3.812, 95% CI: 3.476–4.18, P <0.001).
In Model 2, adolescents with insufcient sleep continued to show a higher likelihood of depressive symptoms (OR =
3.317, 95% CI: 3.013–3.653, P < 0.001). Finally, Model 3 demonstrated that insufcient sleep remained a signicant
factor for depressive symptoms (OR = 3.058, 95% CI: 2.753–3.396, P < 0.001). Additionally, higher BMI, older age,
being female, parental divorce, physical neglect, physical abuse, sexual abuse, and emotional abuse were all identied as
risk factors for depressive symptoms (all P <0.05). In contrast, higher resilience and better parent–child relationships
were protective factors against depression (all P < 0.001).
Differences in Depression-Related Factors Between Adolescents with Sufcient Sleep
and Insufcient Sleep
Multivariate logistic regression analyses were performed using the signicant variables (P<0.05) from Model 3 to
explore depression-related factors among adolescents with sufcient sleep and insufcient sleep, respectively (Figure 1).
Table 1 Demographic Characteristics in Adolescents with Sufcient and Insufcient Sleep
Variables Total
(n=22231)
Sufcient sleep
(n=7188)
Insufcient sleep
(n=15043)
Z/t/χ2 p
Age (mean±SD) 14.10±0.92 13.97±0.92 14.16±0.91 −14.570 <0.001
Sex (girls, %) 11,050(49.7) 2933(40.8) 8117(54.0) 336.674 <0.001
BMI, median (IQR) 19.53(5) 19.38(6) 19.53(5) −2.481 0.013
Boarding student (Yes,%) 5205(23.4) 1793(24.9) 3412(22.7) 13.888 <0.001
Parental marital status (N,%) 52.818 <0.001
Married 19904(89.5) 6584(91.6) 13,320(88.5)
Divorced 1197(5.4) 287(4.0) 910(6.0)
Remarried 785(3.5) 218(3.0) 567(3.8)
Single-parent 345(1.6) 99(1.4) 246(1.6)
Parent–child relationship (N, %) 209.023 <0.001
Poor 666(3.0) 147(2.0) 519(3.5)
Average 5273(23.7) 1330(18.5) 3943(26.2)
Good 16292(73.3) 5711(79.5) 10,581(70.3)
Abbreviations: BMI, Body Mass Index; PHQ-9, Patient Health Questionnaire for depression.
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Table 2 Psychological Outcomes in Adolescents with Sufcient and Insufcient Sleep
Variables Total
(n=22231)
Sufcient sleep
(n=7188)
Insufcient sleep
(n=15043)
Z/χ2P
PHQ-9, median (IQR) 4(7) 2(5) 4(8) −46.465 <0.001
Depressive symptom (Yes,%) 4389(19.7) 586(8.2) 3803(25.3) 900.586 <0.001
Resilience, median (IQR) 53(25) 59(26) 51(23) −24.771 <0.001
Emotional abuse score,
median (IQR)
6(4) 6(3) 7(4) −20.994 <0.001
Emotional abuse experience
(Yes,%)
5847(26.3) 1388(19.3) 4459(29.6) 267.852 <0.001
Physical abuse score,
median (IQR)
5(1) 5(1) 5(1) −7.205 <0.001
Physical abuse experience
(Yes,%)
3085(13.9) 880(12.2) 2205(14.7) 23.743 <0.001
Sex abuse score,
median (IQR)
5(0) 5(0) 5(0) −2.527 0.011
Sex abuse experience
(Yes,%)
2553(11.5) 768(10.7) 1785(11.9) 6.68 0.01
Emotional neglect score,
median (IQR)
10(8) 9(8) 11(8) −10.782 <0.001
Emotional neglect experience (Yes,%) 12,114(54.5) 3543(49.3) 8571(57.0) 115.873 <0.001
Physical neglect score,
median (IQR)
8(4) 8(4) 8(4) −2.467 0.014
Physical neglect experience (Yes,%) 12,232(55.0) 3929(54.7) 8303(55.2) 0.562 0.454
Abbreviations: BMI, Body Mass Index; PHQ-9, Patient Health Questionnaire for depression.
Table 3 Logistic Regression Analysis Models of the Relationship Between Insufcient Sleep and Depression
Among All Adolescents
Variable Model 1 OR (95% CI) Model 2 OR (95% CI) Model 3 OR (95% CI)
Insufcient sleep(1=no) 3.812(3.476–4.18)
c
3.317(3.013–3.653)
c
3.058(2.753–3.396)
c
BMI 1.013(1.008–1.019)
c
1.007(1.001–1.012)
a
Age 1.098(1.055–1.142)
c
1.088(1.041–1.137)
c
Sex (1=boy) 1.75(1.625–1.884)
c
1.536(1.412–1.67)
c
Boarding student (1=no) 1.089(1–1.185)
a
1.084(0.986–1.192)
Parent’s marital status (1=Married)
Divorced 1.547(1.346–1.778)
c
1.291(1.104–1.51)
b
Remarried 1.773(1.499–2.097)
c
1.148(0.95–1.387)
Single-parent 1.717(1.328–2.219)
c
1.305(0.985–1.73)
Parent–child relationship(1=poor)
Average 0.398(0.335–0.473)
c
0.854(0.704–1.037)
Good 0.103(0.087–0.122)
c
0.495(0.407–0.602)
c
Resilience 0.954(0.952–0.957)
c
Emotional abuse experience
(1=no)
4.088(3.739–4.47)
c
Physical abuse experience (1=no) 1.415(1.27–1.577)
c
Sex abuse experience (1=no) 1.505(1.346–1.684)
c
Emotional neglect experience (1=no) 0.985(0.889–1.092)
Physical neglect experience (1=no) 1.151(1.048–1.265)
b
Note:
a
P <0.05,
b
P < 0.01,
c
P < 0.001.
Abbreviation: BMI, Body Mass Index.
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For adolescents with sufcient sleep, being female was a risk factor for depression (OR = 1.254, 95% CI: 1.042–1.51,
P =0.017). Adolescents who experienced emotional abuse (OR = 3.789, 95% CI: 3.094–4.64, P < 0.001), sexual abuse
(OR = 1.302, 95% CI: 1.023–1.657, P =0.032), physical abuse (OR = 1.66, 95% CI: 1.321–2.085, P < 0.001), and
physical neglect (OR = 1.24, 95% CI: 1.009–1.525, P =0.041) also had higher likelihood for depressive symptoms. In
contrast, higher resilience scores (OR = 0.978, 95% CI: 0.973–0.982, P < 0.001) and a good parent–child relationship
(OR = 0.598, 95% CI: 0.393–0.909, P = 0.016) were protective factors against depression (Table 4).
For the adolescents with insufcient sleep, in addition to the factors mentioned above, older age (OR = 1.147, 95%
CI: 1.091–1.205, P < 0.001) and higher BMI (OR = 1.007, 95% CI: 1.001–1.014, P = 0.035) increased the risk of
depressive symptoms. Parental divorce (OR = 1.318, 95% CI: 1.108–1.569, P = 0.002) and living with a single parent
(OR = 1.432, 95% CI: 1.04–1.972, P = 0.028) were also identied as risk factors for depressive symptoms in adolescents
with insufcient sleep (Table 5).
Discussion
The aim of this study was to investigate the prevalence of depressive symptoms in Chinese adolescents with insufcient
sleep and explore the role of associated factors. We also compared the differences in inuencing factors of depression in
adolescents with sufcient and insufcient sleep. Our study yielded several key ndings: (1) Among Chinese adoles-
cents, the prevalence of insufcient sleep was 67.7%, which signicantly increased the incidence of depressive
symptoms. (2) For adolescents with sufcient sleep, being female and having experiences of maltreatment were risk
factors for depression, while a better parent–child relationship and psychological resilience served as protective factors.
(3) For adolescents with insufcient sleep, older age, higher BMI, parental divorce, and single-parent status also increase
the risk of depression.
The Prevalence of Insufcient Sleep and Its Effect on Depressive Symptoms in
Adolescents
A national survey in the United States found that the prevalence of insufcient sleep was 31.2% among adolescents aged
13–17 years.
33
However, regional studies in China have reported that the prevalence of insufcient sleep ranged from
Figure 1 Depression-related factors of sufcient sleep vs insufcient sleep.
Abbreviation: BMI, Body Mass Index.
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44.0% to 55.0% among middle school students,
34
which is signicantly higher than that in American adolescents. In our
study, 67.7% of Chinese adolescents reported insufcient sleep, suggesting that this issue is more prevalent in China. As
a Confucian country, China places a particular emphasis on academic performance, which may contribute to this high
prevalence of insufcient sleep. Academic pressure and a heavy burden of homework are common in China.
8
For
example, 34.7% of Chinese adolescents spent more than 10 hours per day studying, and 44.2% engaged in extracurricular
learning tasks.
35
Another Chinese cohort study demonstrated that 24.4–77.3% of junior high school students complete
their homework after 9 p.m., increasing the risk of depression due to reduced sleep durations.
34
Therefore, insufcient
sleep is a signicant issue among Chinese adolescents, likely driven by academic pressure.
In our study, we found that adolescents with insufcient sleep were of an older age, which may be due to increased
academic stress.
34
Additionally, a higher proportion of adolescents with insufcient sleep were females, which may stem
Table 4 Multivariate Logistic Regression Analysis of Depressive
Symptoms Among Adolescents with Sufcient Sleep
Variable OR 95% CI P
BMI 1.005 0.993–1.017 0.451
Age 0.96 0.871–1.06 0.421
Sex (1=boy) 1.254 1.042–1.51 0.017
Parent’s marital status (1=Married)
Divorced 1.109 0.746–1.65 0.608
Remarried 0.888 0.562–1.405 0.613
Single-parent 1.042 0.529–2.053 0.906
Parent–child relationship (1=poor)
Average 0.981 0.646–1.488 0.927
Good 0.598 0.393–0.909 0.016
Resilience 0.978 0.973–0.982 <0.001
Emotional abuse experience (1=no) 3.789 3.094–4.64 <0.001
Physical abuse experience (1=no) 1.66 1.321–2.085 <0.001
Sex abuse experience (1=no) 1.302 1.023–1.657 0.032
Physical neglect experience (1=no) 1.24 1.009–1.525 0.041
Abbreviation: BMI, Body Mass Index.
Table 5 Multivariate Logistic Regression Analysis of Depressive
Symptoms Among Adolescents with Insufcient Sleep
Variable OR 95% CI P
BMI 1.007 1.001–1.014 0.035
Age 1.147 1.091–1.205 <0.001
Sex (1=boy) 1.617 1.469–1.778 <0.001
Parent’s marital status (1=Married)
Divorced 1.318 1.108–1.569 0.002
Remarried 1.209 0.976–1.498 0.082
Single-parent 1.432 1.04–1.972 0.028
Parent–child relationship (1=poor)
Average 0.793 0.632–0.994 0.044
Good 0.465 0.37–0.583 <0.001
Resilience 0.944 0.94–0.947 <0.001
Emotional abuse experience (1=no) 4.083 3.695–4.511 <0.001
Physical abuse experience (1=no) 1.343 1.187–1.52 <0.001
Sex abuse experience (1=no) 1.585 1.393–1.802 <0.001
Physical neglect experience (1=no) 1.111 1.004–1.23 0.042
Abbreviation: BMI, Body Mass Index.
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from the earlier changes in sleep structure and hormone levels during puberty in girls.
36
Moreover, we observed a lower
prevalence of insufcient sleep among boarding students, which may be attributed to the electronic device limitations and
the earlier bedtimes in schools.
37
A longitudinal study also demonstrated a positive association between parent-child
relationships and adolescent sleep duration,
38
which is consistent with our ndings.
Our study also found that 25.3% of adolescents with insufcient sleep exhibited depressive symptoms, compared to
only 8.2% of those with sufcient sleep (P < 0.001). Adolescents who did not get enough sleep were at higher risk of
experiencing depressive symptoms (OR=3.058) compared to those with sufcient sleep. A regional study in China
revealed that the prevalence of depression among adolescents who slept ≥9 hours, 8–9 hours, 7–8 hours, and <7 hours
per day was 20.49%, 27.55%, 37.80% and 52.66%, respectively.
11
Additionally, another study among Americans
demonstrated that the rate of a positive depression screen was higher for those with insufcient sleep (OR =1.58).
39
Although the exact mechanism linking insufcient sleep and depressive symptoms remains unclear, several potential
explanations exist, including altered neurodevelopment,
40,41
increased limbic system activity, endocrine and immune
system disorders.
42,43
Among these mechanisms, neurocognitive factors and emotional memory need a special focus.
Insufcient sleep is associated with impairments in cognitive function, including learning and executive function.
44
Sleep deprivation has been demonstrated to impair cognitive performance and induce alterations in brain excitability and
plasticity.
12
There is evidence that sleep deprivation is associated with impaired synaptic plasticity in the hippocampus,
45
which can result in modications in protein synthesis, metabolism, neuronal loss and elevated glucocorticoid levels.
46,47
Moreover, impaired plasticity is associated with the psychopathology of depression. At the neurocognitive level,
impaired cognitive exibility and prefrontal inhibition have been identied as potential contributing factors in the
development of depression.
48,49
At the molecular level, neuroplasticity impairment, including neuronal atrophy and
synaptic inhibition in the medial prefrontal cortex and hippocampus, represents a principal mechanism underlying the
development of depression.
50,51
Furthermore, sleep disorders may act as a risk factor for the onset of depression by impairing the processing of
emotional memories. Sleep deprivation has been demonstrated to affect the regulation of cortical limbic emotional
circuits, with a negative impact on emotional memory consolidation.
52
Insufcient sleep impairs the retention of positive
affective memories, while the long-term negative experiences are preserved,
53
all of which are associated with the
psychopathology of depression.
Factors Associated with Depressive Symptoms in the Adolescents with Sufcient
Sleep
Our study found that among adolescents with sufcient sleep, being female and experiencing maltreatment were risk
factors for depression, while higher resilience and parent–child relationship were protective factors.
Studies have consistently shown that depression occurs at higher rates in girls.
54,55
This sex difference may be due to
several factors. First, the effect of estrogen on the regulation of the hypothalamic-pituitary-adrenal axis can result in
greater sensitivity to stress in girls, while androgens in boys may play a protective role.
56
Additionally, genetic
vulnerability may contribute to sex differences in depression. For example, a signicant interaction between the serotonin
transporter gene and stress has been identied in girls.
57
Moreover, compared to boys, girls are more likely to ruminate
and have internalizing problems, making them more vulnerable to stress.
58
These factors may contribute to the greater
vulnerability to depression observed in girls during adolescence.
Maltreatment has been identied as a signicant risk factor for adolescent mental health problems.
59
Maltreatment
may lower self-esteem and foster negative, pessimistic thinking, exacerbating the severity and duration of psychological
symptoms during puberty.
60
Among the ve forms of abuse, emotional abuse is most strongly linked to depression,
61
which aligns with our ndings.
Resilience, the ability to positively adjust to negative conditions, is a critical factor in regulating depression.
21
A longitudinal study of Chinese adolescents showed that high resilience reduced the severity of depression induced by
adverse events.
62
Therefore, enhancing psychological resilience in adolescents is crucial for preventing depressive
symptoms. Our study also found that a good parent–child relationship protected adolescents from depression.
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A national cohort study in China found that a better parent–child relationship provided adolescents with greater perceived
social support and self-esteem.
20
Furthermore, a positive parent–child relationship can mitigate the harmful effects of
parental distress on adolescents’ internalizing symptoms.
63
Improving parenting styles can help alleviate internalizing
problems in children, including depressive symptoms.
64
Factors Associated with Depressive Symptoms in the Adolescents with Insufcient
Sleep
Among adolescents with insufcient sleep, in addition to the factors mentioned above, older age, higher BMI, parental
divorce, and single parent status also increased the risk of depression.
First, our study found that adolescents with insufcient sleep were older. Academic burden and insufcient sleep
duration often increase with age,
65
and academic stress can exacerbate psychological burdens in adolescents.
66
Therefore,
the combination of increasing academic stress and insufcient sleep as adolescents age is more likely to cause
depression. Second, insufcient sleep can lead to adverse health outcomes, such as overweight and obesity.
8
In our
study, higher BMI was associated with insufcient sleep. A meta-analysis found that the risk of being overweight or
obese was 58% higher in children with a shorter sleep duration.
67
Meanwhile, the risk of depression increased by 40%
among obese adolescents.
68
Insufcient sleep not only leads to decreased activity and increased food intake but also
affects metabolic hormones related to hunger and appetite, such as leptin, insulin, and cortisol,
69
which play important
roles in the association between obesity and depression.
70
Additionally, adolescents with higher BMI are more likely to
be dissatised with their body image, leading to more symptoms of depression.
71
Furthermore, adolescents with a high
BMI are at an increased risk of developing obstructive sleep apnea, with a prevalence of 60%.
72
Obstructive sleep apnea
can exacerbate pathological processes such as cerebral small vessel disease and blood-brain barrier dysfunction through
intermittent hypoxia, causing perfusion insufciency, endothelial dysfunction, and neuroinammation. This ultimately
leads to an exacerbation of depressive symptoms.
73
Therefore, maintaining a healthy weight may help mitigate depres-
sion caused by insufcient sleep.
Our study also suggested that parental divorce or single-parent status might increase the risk of depressive symptoms
among the adolescents with insufcient sleep. We found that adolescents with divorced or single parents had a higher rate
of insufcient sleep (P<0.001). A national cross-sectional study in Lebanon showed that adolescents with divorced
parents experienced more severe depression and suicidal ideation.
74
Children from single-parent families might experi-
ence more childhood stress and higher level of rumination.
75
Moreover, a study in America found that family breakdown
disrupted biological rhythms of sleep, increasing the risk of adolescent depression.
76
Therefore, both parents play an
integral role in the healthy upbringing of adolescents. The presence of a complete family unit is benecial in improving
adolescent mental health. These ndings suggest that adolescents with insufcient sleep are more likely to suffer from
academic, family, and health-related pressures, leading to an increased probability of depression. Therefore, reducing
academic stress, improving the family environment, and promoting healthier lifestyles may improve the mental health of
adolescents, particularly those with insufcient sleep.
Furthermore, adolescents with insufcient sleep in our study had lower resilience scores (P< 0.001), consistent with
previous studies.
77
Insufcient sleep impairs the functioning of the prefrontal cortex, which is associated with resilience,
leading to decreased ability to handle stress.
78
In fact, ndings from a study in Australia suggested that sleep duration
mediated depression in adolescents through psychological resilience.
79
This may also explain why adolescents with
insufcient sleep are more likely to experience depression in the face of additional pressures from family, school, and
health. Therefore, interventions in the family or school environment that strengthen psychological resilience and increase
sleep duration may help prevent the occurrence of depression.
80
Limitations and Strengths
There are several limitations of this study. First, this is a cross-sectional study and no causal inference can be made. The
results can only be interpreted as association rather than causal relationships. Future longitudinal studies are needed to
address this issue. Second, although the assessments were self-reported and may be subject to reporting bias, previous
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studies have found good correlations between self-reported and device-measured sleep duration.
81
Future studies could
replicate these ndings using wearable device monitoring. Third, we dened insufcient sleep in adolescents as
a condition characterized by less than eight hours of sleep per day, which did not consider the impact of individual
differences. Subsequent studies can incorporate more indicators, such as whether daytime functions can be maintained
and sleep is fragmented or not, to address this issue. Finally, some factors were not included in this study, such as
economic status and use of electronic devices, which should be considered in future studies. Socioeconomic status and
sleep problems have joint effects on depression, especially in those with low socioeconomic status and sleep
deprivation.
82
Furthermore, prolonged mobile phone use has been linked to an elevated risk of depression in adolescents,
which is partially mediated by insufcient sleep duration.
83
Thus, the results in our study should be interpreted with
caution.
However, this study also has several strengths. First, we explored the relationship between sleep and mental health
status based on a nationally representative sample of Chinese adolescents. Second, all evaluations were conducted
through an on-site pen-and-paper survey, ensuring relatively high data quality and response rates. Moreover, we
considered a range of factors related to depressive symptoms, including boarding student, resilience, parent–child
relationship, parental marital status, and maltreatment.
Conclusion
In conclusion, insufcient sleep is highly prevalent among Chinese adolescents. Our study highlights the signicant role
of insufcient sleep in contributing to depressive symptoms among this population, providing preliminary and explora-
tory evidence for the correlation between sleep duration and mental health. Adolescents with insufcient sleep are more
likely to experience depressive symptoms, particularly those who are older, have a higher BMI, or come from divorced or
single-parent households. Promoting a healthy school and family environment, along with enhancing psychological
resilience, may help reduce the incidence of depressive symptoms among adolescents.
Data Sharing Statement
The datasets used during the current study are available from the corresponding author on reasonable request.
Ethics Approval and Informed Consent
The study received approval from the Ethics Committee of the Third Afliated Hospital of Beijing University of Chinese
Medicine (No. BZYSY-2019KYKTPJ-21). Informed consents were obtained from both students and their guardians. Our
study adheres to the principles of the Declaration of Helsinki.
Acknowledgments
We would like to thank Editage (www.editage.cn) for English language editing.
Author Contributions
All authors made a signicant contribution to the work reported, whether that is in the conception, study design,
execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically
reviewing the article; gave nal approval of the version to be published; have agreed on the journal to which the article
has been submitted; and agree to be accountable for all aspects of the work.
Funding
This work was supported by Capital’s Funds for Health Improvement and Research [SF2020-1-2011]; National Natural
Science Foundation of China [81973759].
Disclosure
The author(s) report no conicts of interest in this work.
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