Original ArticleIs there an association between short sleep duration and adolescent anxiety disorders?
Introduction
Sleep restriction, or short sleep duration, is sleep time less than the average basal level of about nine hours per night for adolescents [1]. In 2006, the National Sleep Foundation revised its guidelines for 14–17-year olds to 8–10 h [2]. Studies indicate that many adolescents do not obtain adequate nocturnal sleep in the U.S. [3], [4], [5] as well as in many countries around the world [6]. This latter review found that adolescents in Asian, European, and North American samples slept for 7.64 h, 8.44 h, and 7.46 h, respectively. As many as one-fourth of adolescents report sleeping ≤6 h per night [7]. The National Sleep Foundation’s 2006 [2] survey found that only one of five adolescents gets nine hours of sleep on school nights and 45% sleep less than eight hours on school nights [2]. A typical high school senior slept 6.9 h on school nights. More recently, the Foundation has published guidelines recommending 8–10 h of sleep for teenagers [8].
Available evidence suggests that disturbed sleep and restricted sleep are associated with deficits in functioning across a wide range of indicators of psychological, interpersonal, and somatic well-being. For example, adolescents with disturbed sleep report more depression, anxiety, anger, inattention and conduct problems, drug and alcohol use, impaired academic performance, and suicidal thoughts and behaviors. They also have been reported to have more fatigue, less energy, worse perceived health, and symptoms such as headaches, stomachaches and backaches [7], [9], [10], [11], [12].
More recent studies have further extended these findings. A prospective, three-wave study of adolescents found that youths who curtail sleep to study exhibit more cognitive problems at school [13]. In a second prospective study, Kelly and El-Sheikh [14] found that reduced sleep duration predicted greater depression, anxiety, and externalizing symptoms over time. Psychological symptoms also predicted changes in sleep, but to a lesser extent [14]. A large national, cross-sectional study found youths who slept less than eight hours per night were more likely to report substance use, have suicidal thoughts, feel sad or hopeless, not being physically active, and to drink more soda pop [15].
Laboratory studies in particular have documented impaired cognitive function, daytime sleepiness, and fatigue as a consequence of reduced sleep [9], [16], [17]. Experimental studies of sleep restriction and its effects have been rare. A study found combined sleep restriction at home and in the laboratory reduced adolescents’self-ratings of positive affect, increased negative affect, and increased negative mood in response to a challenge [18], [19], [20]. A more rigorous experiment with adolescents found that sleep restriction resulted in adolescents rating themselves as more tense/anxious, angry/hostile, confused and fatigued, and as less rigorous [21].
However, most epidemiologic data on these associations emanate from prevalence or cross-sectional surveys. Thus, the question of whether, for example, short sleep duration increases the risk of functional impairment among adolescents, or emotional, behavioral, and interpersonal problems increase the risk of shorter sleep duration, remains unclear.
Roberts et al. examined the effects of deep restriction among adolescents and found that short sleep (≤6 h) increased subsequent risk for school problems, low life satisfaction, poor perceived health, depressed mood, drug use, and poor grades [22]. Other studies have also found that sleep problems, including sleep restriction, increased the odds of subsequent mental health problems [22], [23], [24], [25], [26] including depressed mood.
But what about the association between short sleep duration of adolescents and clinical anxiety (eg, DM anxiety disorders)? The number of studies is limited, but in their recent review, Willis and Gregory [27] concluded there was sufficient evidence of concurrent and longitudinal associations between sleep difficulties and anxiety in both community and clinical samples. However, few of the studies used prospective, community-based designs, focused on sleep duration, anxiety disorders, or on adolescents. For example, Gregory et al. [28] found that among children aged five to nine years with persistent sleep problems, nearly half developed an anxiety disorder as an adult.Goldman-Mellor et al. [29] reported that anxiety symptoms during childhood and/or adolescence strongly predicted insomnia in adulthood. Kelly and El-Sheikh [14] found sleep disturbance at age eight years predicted anxiety, depression, and internalizing symptoms five years later, which in turn predicted changes in sleep.
In the most recent study, Shanahan, Copeland, Angold, Bondy, and Costello [30], using data from the Great Smoky Mountains Study, found that a greater number of sleep problems predicted subsequent generalized anxiety disorder, generalized anxiety disorder/depression symptoms, and oppositional defiant disorder. In turn, generalized anxiety disorder and/or depression and oppositional defiant disorder predicted increased sleep problems. Sleep duration was not included in their study.
To our knowledge, no study to date has examined the prospective association between sleep duration and DM-IV anxiety disorders among adolescents.
Hence, our study focuses on examining the prospective association between short sleep duration and anxiety disorders in adolescence. Using data from a two-wave cohort study of youths 11–17 years at baseline, Teen Health 2000 (TH2K), we examine the reciprocal association between restricted sleep and anxiety disorders, for example, whether short sleep increases the risk for anxiety disorders, whether anxiety increases the risk for short sleep, or if there is an association at all. The answers to these questions have both etiologic and clinical implications. If there are reciprocal effects, then each partially accounts for the other. Understanding the epidemiology of one requires understanding the other. However, if there is bi-directionality, clinically the presence of one suggests assessment and possible intervention for the other. We may need to focus on both for optimal effect.
Section snippets
Sample
This study includes secondary analyses of data from a prospective study of adolescent psychiatric disorders. The sample was selected from households in the Houston metropolitan area enrolled in two local health maintenance organizations. This sampling strategy was used because the original intent was to link medical record data from HMO records with the survey data on adolescents. One youth, aged 11–17 years, was sampled from each eligible household, oversampling for ethnic minority households.
Results
There was little association between anxiety disorders and sleep duration at Wave 1 (Table 2). In multivariate analyses, sleep duration on weeknights and anxiety disorders were associated, but not when major depression was added to the model.
However, the cohort analyses present a quite different picture. Controlling for covariates, sleep duration on weeknights did not significantly increase the risk of anxiety disorders. However, short sleep duration every night of the week doubled the risk of
Conclusions
To summarize, using data from a two-wave cohort, we found that short sleep duration every night of the week at baseline increasedthe risk of subsequent anxiety disorders twofold. There was a 1.42 odds of an increased risk for short sleep only on weeknights, but this was not significant (p > 0.05). Anxiety disorders at baseline did not increase the subsequent risk of short sleep duration. Ours is the first study to examine the association between sleep duration and adolescent anxiety disorders
Conflict of interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2016.02.007.
Acknowledgment
The authors acknowledge Catherine R. Roberts, PhD, at the University of Texas School of Medicine (retired), for assistance in the design and conduct of the study and collection and management of the data.
References (61)
- et al.
Sleep, circadian rhythms, and delayed phase in adolescence
Sleep Med
(2007) - et al.
The association of insomnia with anxiety disorders and depression: exploration of the direction of risk
J Psychiatr Res
(2006) - et al.
Recent worldwide sleep patterns and problems during adolescence: a review and meta-analysis of age, region, and sleep
Sleep Med
(2011) - et al.
National Sleep Foundation’s sleep time duration recommendations: methodology and results summary
Sleep Health
(2015) - et al.
Relationships between hours of sleep and health-risk behaviors in US adolescent students
Prev Med
(2011) - et al.
Pathways to adolescent health sleep regulation and behavior
J Adolesc Health
(2002) - et al.
Sleep problems in childhood: a longitudinal study of developmental change and association with behavioral problems
J Am Acad Child Adolesc Psychiatry
(2002) - et al.
Anxiety disorders and sleep in children and adolescents
Sleep Med Clin
(2015) - et al.
Sleep problems predict and are predicted by generalized anxiety/depression and oppositional defiant disorder
J Am Acad Child Adolesc Psychiatry
(2014) - et al.
Psychiatric diagnostic interviews for children and adolescents: a comparative study
J Am Acad Child Adolesc Psychiatry
(2012)
NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses
J Am Acad Child Adolesc Psychiatry
Sleepless in adolescence: prospective data on sleep deprivation, health and functioning
J Adolesc
Prevalence and patterns of problematic sleep among older adolescents
J Am Acad Child Adolesc Psychiatry
Chronic insomnia and its negative consequences for health and functioning of adolescents: a 12-month prospective study
J Adolesc Health
Depression and insomnia among adolescents: a prospective perspective
J Affect Disord
Sleep and psychological characteristics of children on a psychiatric inpatient unit
J Am Acad Child Adolesc Psychiatry
Sleep problems in adolescence
J Am Acad Child Adolesc Psychiatry
Objective sleep in pediatric anxiety disorders and major depressive disorder
J Am Acad Child Adolesc Psychiatry
Regulation of adolescent sleep: implications for behavior
Ann N Y Acad Sci
2006 Sleep in America Poll
Ethnic differences in symptoms of insomnia among adolescents
Sleep
Restricted sleep among adolescents: prevalence, incidence, persistence, and associated factors
Behav Sleep Med
Factors influencing sleep patterns of adolescents
Sleep disorders and sleep deprivation: an unmet public health problem
Sleepless in Chicago: tracking the effects of adolescent sleep loss during the middle school years
Child Dev
Functioning of adolescents with symptoms of disturbed sleep
J Youth Adolesc
To study or to sleep? The academic costs of extra studying at the expense of sleep
Child Dev
Reciprocal relations between children’s sleep and their adjustment over time
Dev Psychol
Excessive sleepiness in adolescents and young adults: causes, consequences, and treatment strategies
Pediatrics
Double trouble? The effects of sleep deprivation and chronotype on adolescent affect
J Child Psychol Psychiatry
Cited by (73)
Sleep and Mental Health Problems in Children and Adolescents
2023, Sleep Medicine ClinicsInsomnia, sleep duration, and risk of anxiety: A two-sample Mendelian randomization study
2022, Journal of Psychiatric ResearchCitation Excerpt :In other aspects of sleep health, it is obvious that individuals with insomnia often have a short sleep duration (Buysse, 2013). In many previous studies, sleep duration was also related to anxiety in adolescents and adults (Kalmbach et al., 2019; Kim et al., 2020; Roberts and Duong, 2017; Zhou et al., 2020). Adequate sleep is essential for maintaining and promoting individuals’ physical and mental health.
Stress-related psychopathology during the COVID-19 pandemic
2022, Behaviour Research and TherapyDepression and anxiety as mediators of the relationship between sleep disturbance and somatic symptoms among adolescents on a psychiatric inpatient unit
2024, Clinical Child Psychology and Psychiatry