Original ArticleHours of sleep in adolescents and its association with anxiety, emotional concerns, and suicidal ideation
Introduction
Adequate sleep is essential for good health and optimal physical and cognitive performance [1], [2]. Insufficient sleep not only interferes with quality of life and general well-being, but it also may be hazardous to one’s health and the well-being of the public. There is evidence that sleep loss may affect emotional function [3] and chronically disrupted sleep may increase the risk for developing affective symptoms [4], [5]. In particular, high prevalence and comorbidity of anxiety and sleep problems suggest an important association between these two disorders. There is evidence of a bidirectional relationship in the course of disturbances (i.e., poor sleep increasing the risk for later anxiety disorder and primary anxiety developing into insomnia) [6]. Importantly, there is evidence that sleep complaints are more common in suicidal patients [7], [8]. Indeed insufficient sleep and sleep disturbances are common in depressive disorders and other psychopathologic conditions potentially associated with suicidal risk. In a large community sample of 5692 adults in the United States, the presence of sleep problems (e.g., early morning waking, difficulty initiating or maintaining sleep) was significantly related to each measure of suicidality, including suicidal ideation, suicide planning, and suicide attempts [9].
Sleep problems in children and adolescents are common and sleep disruption is associated with a wide range of behavioral, cognitive, and mood impairments [10]. Biologic studies indicate considerable changes in sleep architecture during adolescence, such as changes in melatonin secretion and a need for greater total sleep time, possibly due to maturational changes in the neuronal connectivity [11], [12]. Due to circadian changes, teenagers also have a delayed sleep pattern and prefer to go to sleep between 2:00 am and 6:00 am and wake up between 10:00 am and 1:00 pm [13]. However, despite a physiologic need for 9 h of sleep each night, teenagers on average only sleep 7 h per night [14] to meet the challenges of school, sports, part-time jobs, family, and friends [15].
Many clinical studies in adolescents have consistently reported that reduced hours of sleep are associated with emotional problems such as depressive and anxiety symptoms [16], [17], in addition to self-harm and suicidal ideation [18]. Poor sleep also has been correlated with increased aggression, irritability, and hostility in both adults and adolescents; conduct problems and bullying behavior in schoolchildren [19], [20], [21]; and habitual substance use [22], self-injurious behaviors [23], and suicide attempt overall [24], [25], [26]. It has been hypothesized that the relationship between sleep problems and aggression may be mediated by the negative effect of sleep loss on prefrontal cortical functioning, resulting in loss of control over emotions and regulation of aggressive impulses. Other potentially contributing mechanisms connecting sleep problems with aggression and violence have been linked to alterations in functioning of the central serotoninergic system and the hypothalamic–pituitary–adrenal-axis [5].
Given this evidence, our study was designed to investigate the effect of number of sleep hours on both emotional and behavioral problems in adolescents. Indeed we had a unique opportunity to analyze data collected on a large cohort of pupils (12,395 pupils from 11 European countries; average age, 15 years) extensively evaluated for emotional and behavioral problems, including anxiety, suicidal ideation and hyperactivity, together with information regarding average hours of sleep during school days. Because most studies mentioned above focused on clinical samples (i.e., adolescents with recognized emotional and behavioral problems), it was of interest to evaluate if the same association was present in adolescents recruited from community settings; this evaluation also enabled us to evaluate the potential benefit of widespread preventive interventions at the same time.
Section snippets
Description of study sample
The SEYLE study comprises a sample of 12,395 adolescents recruited from 179 randomly selected schools within 11 study sites in the following countries: Austria, Estonia, France, Germany, Hungary, Ireland, Israel, Italy, Romania, Slovenia, and Spain; Sweden served as the coordinating center [27]. All questionnaires were administered in the official languages of the respective countries. In each country, a list of all eligible schools within the study sites was generated according to specific
Results
There were 11,788 pupils who provided data on their number of sleep hours per night during school days (Monday–Friday). The main sociodemographic and psychopathologic features of the responding pupils stratified for countries are summarized in Table 1. Remarkable differences were observed in the number of sleep hours, conduct problems at the SDQ self-evaluation, and age.
Overall, adolescents reported sleeping an average of 7.7 ± 1.3 h per night (Monday–Friday). As reported in Table 1, the
Discussion
The major finding of our study was the correlation between reduced number of hours of sleep per night during school days and emotional problems, as well as the risk for suicidal ideation in adolescents. Due to the large sample size and the fact that the SEYLE sites have been shown to be representative of their respective countries [28], the findings reported here, which focused on the effect of sleep on adolescents’ emotional and behavioral adjustment, can be considered valid within each of the
Funding sources
The SEYLE project is supported through Coordination Theme 1 (Health) of the European Union Seventh Framework Program (FP7), Grant agreement nr. HEALTH-F2-2009-223091. The authors were independent of the funders in all aspects of study design, data analysis, and writing of this manuscript.
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.2013.11.780.
Acknowledgements
The SEYLE project is supported through Coordination Theme 1 (Health) of the European Union Seventh Framework Program (FP7), Grant agreement nr. HEALTH-F2-2009-223091.
The authors were independent of the funders in all aspects of study design, data analysis, and writing of this manuscript. The Project Leader and Coordinator of the SEYLE project is Professor in Psychiatry and Suicidology Danuta Wasserman, Karolinska Institute (KI), Head of the National Centre for Suicide Research and Prevention of
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