Clinical reviewA meta-analysis and model of the relationship between sleep and depression in adolescents: Recommendations for future research and clinical practice
Introduction
It is estimated that 20% of adolescents will experience a depressive episode by the age of 18 y [1], with the large majority (80%) experiencing a second episode within 5 y [2]. Similarly, up to 25% of adolescents report symptoms of sleep disturbance [3]. This rate increases substantially among adolescents suffering depression, with up to 73% also experiencing a comorbid sleep problem [4]. Both depression and sleep difficulties are associated with severe adverse effects including suicidal ideation, attempts and completions [5], school absenteeism and dropout [6], declines in academic performance [7] and cognitive functioning [8], and difficulties maintaining social relationships [9]. These adverse effects have profound consequences given the significant physiological and psychological changes occurring throughout this major developmental period [10]. Although the high comorbidity between depression and sleep disturbance is widely acknowledged [11], research is yet to evaluate the strength of the directional relationships in adolescent samples. Insight into these directions would facilitate our understanding of the development of either problem, and guide development of prevention and early intervention strategies to reduce their occurrence in young adulthood.
Literature exploring the relationship between depression and sleep disturbance in adolescents is heavily focused on the use of cross-sectional designs to compare the sleep of adolescents with depression to those without. These studies provide substantial support for an association between depression and sleep disturbance, particularly when sleep disturbance is assessed using self-report. Adolescents with depression consistently report significantly worse sleep ∗[11], [13], relative to adolescents with no symptoms of depression. Despite these subjective impressions, objectively (from polysomnography) these reports remain largely unsupported. A limited number of studies have supported the notion of less stage 1 and 2 sleep [14], more awakenings [15], and a shorter latency to rapid eye movement (REM) sleep ∗[14], [15], [16]. The majority of studies, however, indicate no significant differences [15], [16], [17], [18]. Given these studies are cross-sectional, any conclusions which may be drawn about the developmental interplay between sleep disturbance and depression are limited.
It is well established that sleep difficulties, such as insomnia, are predictive of depression in adults [19], [20]; however it remains unclear whether a similar directional relationship exists during adolescence. Existing research using adolescent populations (the current review identified eight studies) provides mixed support for the notion that sleep disturbance precedes depression. Emslie and colleagues found adolescents who experienced a recurrence of their depression at follow-up (35.3%) had increased sleep onset latency and decreased sleep efficiency 12 mo earlier [21]. A series of studies conducted by Rao and colleagues also found increased minutes of REM sleep, decreased latency to REM, and a higher REM density was predictive of a diagnosis of depression in a group of adolescents at 7-y follow-up ∗[22], ∗[23]. Using a quasi-experimental design, Rao et al. assessed the electroencephalographic (EEG) sleep of adolescents during an episode of depression as well as while in remission [24]. This pilot study (N = 5) revealed stable EEG sleep between episode and remission. Despite a decline in time spent awake across the night, no other significant changes were observed in sleep architecture or continuity. These results were replicated in a later study using the same methodology, with a larger sample (N = 16) [25].
Literature exploring the predictive value of depression for the development of sleep disturbance during adolescence is very limited. In a population-based study, Patten and colleagues examined factors associated with the development and persistence of sleep problems in 7960 adolescents [26]. Depressive symptoms significantly predicted the development and persistence of sleep problems at a 4-y follow-up. Adolescents who reported notable depressive symptoms were 50% more likely to develop sleep problems than those who did not report symptoms. In contrast, Simeon and colleagues included sleep disturbance as an outcome measure in their double-blind, placebo-controlled study for the treatment of adolescent depression with fluoxetine [27]. Although two-thirds of the adolescents treated with fluoxetine showed a marked clinical improvement on the majority of outcome measures (e.g., symptoms of depression and anxiety), sleep disturbance remained unchanged immediately following treatment and at a 24-mo follow-up.
The purpose of this review was to evaluate the strength of evidence for a directional relationship between sleep disturbance and depression in adolescents. A meta-analytic strategy was used to provide a quantitative summary of data from studies investigating the association between depression and sleep disturbance, those assessing the role of sleep disturbance in the development of depression, and those exploring the notion of depression as a precursor to sleep disturbance. Meta-analysis of similar and methodologically sound studies is considered to provide a high level of evidence [28], and potentially provides a more precise estimate of the underlying ‘true effect’ than any individual study alone [29].
Section snippets
Literature search and inclusion criteria
Electronic databases, including MEDLINE, OvidSP, PsycInfo, PubMed, and online journals (e.g., Journal of Affective Disorders, Pediatrics, Sleep, etc.) were used to identify and retrieve research articles exploring the relationship between sleep and depression in adolescent samples. The search terms used included “adolescent sleep AND depression”, and “adolescent depression AND sleep”. Relevant articles were also manually identified from the reference lists of retrieved articles. Articles were
The association between sleep disturbance and depression
The overall weighted effect sizes for each sleep variable between the MDD and non-clinical groups are shown in Table 2 below. A total of 84 effect sizes contributed to these analyses. Adolescents with MDD reported significantly more subjective symptoms of sleep disruption, including sleep disturbance (d+ = 1.34, 95% confidence interval (CI) = .53 to 2.19, p < .05), insomnia (d+ = 1.08, 95%CI = .49 to 1.70, p < .05), hypersomnia (d+ = .48, 95%CI = .26 to .69, p < .05), and sleep quality (d+
Discussion
The present study summarized data from published studies assessing the relationship between depression and sleep disturbance in adolescents and used a meta-analytic strategy to evaluate the strength of evidence for a directional relationship between these variables. These results provide support for an association between depression and sleep disturbance in adolescents. Specifically, adolescents diagnosed with depression report significantly more sleep disturbance when compared to non-clinical
Conclusion
The association between depression and sleep disturbance in adolescents was supported in the current quantitative summary of the literature. Adolescents with depression not only reported disturbed sleep but also objectively showed significantly more wakefulness in bed when compared to non-clinical adolescents. Examination of longitudinal and treatment studies suggests sleep disturbance is likely to predict depression rather than the converse. Based on this conclusion, we provide a model for
Conflicts of interest
Both authors report no competing interests.
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