Elsevier

Sleep Medicine

Volume 30, February 2017, Pages 82-87
Sleep Medicine

Original Article
Is there an association between short sleep duration and adolescent anxiety disorders?

https://doi.org/10.1016/j.sleep.2016.02.007Get rights and content

Highlights

  • Short sleep duration at baseline increased the risk of future anxiety disorders twofold.

  • Anxiety disorders at baseline did not affect the future risk of short sleep duration.

  • These results mirror those we have found for short sleep duration and major depression.

Abstract

Objective

The purpose of this study is to provide the first data on the prospective, reciprocal association between short sleep duration and DSM-IV anxiety disorders among adolescents.

Methods

A community-based two-wave cohort study included 4175 youths aged 11–17 years at baseline, with 3134 of these followed up a year later, drawn from a metropolitan area with a population of over 4 million. Anxiety is defined as any DSM-IV anxiety disorder in the past year generalized anxiety: panic disorder, agoraphobia without panic, social phobia, and post-traumatic stress disorder. Short sleep duration is defined as ≤6 h of sleep per night.

Results/Conclusions

In multivariate analyses, short sleep duration every night at baseline predicted anxiety disorders at follow-up, controlling for anxiety at baseline. Examining the reciprocal association, anxiety disorders at baseline did not predict short sleep duration at follow-up. We are the first to examine the reciprocal effects for anxiety disorders and sleep duration among adolescents using prospective data. The data suggest that reduced quantity of sleep may increase risk for anxiety, but anxiety does not increase risk for decreased sleep duration.

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.

. ICMJE Form for Disclosure of Potential Conflicts of Interest form.

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)

  • D. Shaffer et al.

    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

    (2000)
  • R.E. Roberts et al.

    Sleepless in adolescence: prospective data on sleep deprivation, health and functioning

    J Adolesc

    (2009)
  • M.M. Ohayon et al.

    Prevalence and patterns of problematic sleep among older adolescents

    J Am Acad Child Adolesc Psychiatry

    (2000)
  • R.E. Roberts et al.

    Chronic insomnia and its negative consequences for health and functioning of adolescents: a 12-month prospective study

    J Adolesc Health

    (2008)
  • R.E. Roberts et al.

    Depression and insomnia among adolescents: a prospective perspective

    J Affect Disord

    (2013)
  • A. Sadeh et al.

    Sleep and psychological characteristics of children on a psychiatric inpatient unit

    J Am Acad Child Adolesc Psychiatry

    (1995)
  • D.N. Morrison et al.

    Sleep problems in adolescence

    J Am Acad Child Adolesc Psychiatry

    (1992)
  • E.E. Forbes et al.

    Objective sleep in pediatric anxiety disorders and major depressive disorder

    J Am Acad Child Adolesc Psychiatry

    (2008)
  • M.A. Carskadon et al.

    Regulation of adolescent sleep: implications for behavior

    Ann N Y Acad Sci

    (2004)
  • National Sleep Foundation

    2006 Sleep in America Poll

    (2006)
  • R.E. Roberts et al.

    Ethnic differences in symptoms of insomnia among adolescents

    Sleep

    (2006)
  • R.E. Roberts et al.

    Restricted sleep among adolescents: prevalence, incidence, persistence, and associated factors

    Behav Sleep Med

    (2011)
  • M.A. Carskadon

    Factors influencing sleep patterns of adolescents

  • H.R. Colten et al.

    Sleep disorders and sleep deprivation: an unmet public health problem

    (2006)
  • K. Fredriksen et al.

    Sleepless in Chicago: tracking the effects of adolescent sleep loss during the middle school years

    Child Dev

    (2004)
  • R.E. Roberts et al.

    Functioning of adolescents with symptoms of disturbed sleep

    J Youth Adolesc

    (2001)
  • C. Gillen-O’Neel et al.

    To study or to sleep? The academic costs of extra studying at the expense of sleep

    Child Dev

    (2013)
  • R.J. Kelly et al.

    Reciprocal relations between children’s sleep and their adjustment over time

    Dev Psychol

    (2014)
  • R.P. Millman

    Excessive sleepiness in adolescents and young adults: causes, consequences, and treatment strategies

    Pediatrics

    (2005)
  • N. Dagys et al.

    Double trouble? The effects of sleep deprivation and chronotype on adolescent affect

    J Child Psychol Psychiatry

    (2012)
  • Cited by (72)

    • Insomnia, sleep duration, and risk of anxiety: A two-sample Mendelian randomization study

      2022, Journal of Psychiatric Research
      Citation Excerpt :

      Observational studies in adolescents and medical students provide some evidence for a significant association of short sleep with anxiety. A one-year longitudinal study of 3,134 adolescents showed that short sleep at baseline could increase the risk of anxiety twofold at follow-up (Roberts and Duong, 2017). Moreover, in the longitudinal survey of single-egg twin adolescents in Japan, short sleep could predict the subsequent occurrence of depression and anxiety after controlling for the genetic and common environmental factors of twins (Matamura et al., 2014).

    View all citing articles on Scopus
    View full text