Annual longitudinal survey at up to five time points reveals reciprocal effects of bedtime delay and depression/anxiety in adolescents

Anxiety, Sleep Problems, and Vigorous Physical Activity: Bidirectional Associations from Early Adolescence to Early Adulthood in Swedish Adolescents

Anxiety symptoms and sleep problems typically emerge during adolescence and are frequently intertwined. However, there is a dearth of knowledge concerning their reciprocal influence and whether physical activity might play a protective role in this relationship. The present study aims at filling this gap exploring also the moderating role of sex. 915 13-year-old Swedish adolescents (56% girls) answered a survey conducted four times: at ages 13 (T1), 16 (T2), 19 (T3), and 22 (T4). A random intercept cross-lagged panel model was used. At within-levels, sleep problems and anxiety symptoms had a bidirectional positive association in middle adolescence. Vigorous physical activity and anxiety symptoms showed a reciprocal negative association from middle adolescence. Vigorous physical activity and sleep problems were reciprocally associated only in late adolescence. Associations were the same for girls and boys. This study demonstrated that the relations between anxiety symptoms, sleep problems, and vigorous physical activity cannot be understood without adopting a developmental perspective and that middle adolescence is a crucial period to plan interventions to reduce anxiety symptoms and sleep problems.

Relationship between physical activity, screen-related sedentary behaviors and anxiety among adolescents in less developed areas of China

This study aimed to explore the association between physical activity, screen-related sedentary behaviors, and anxiety. The current study used latent profile analysis (LPA) to identify homogenous subtypes of anxiety among adolescents in less-developed areas of China. Data were aggregated from 6 schools in the less-developed areas of China in September 2018. In total, 900 students were evaluated using the 100-item Mental Health Test (MHT) and Youth Risk Behavior Surveillance System (YRBSS) questionnaire. The LPA was conducted to explore the potential classification of anxiety, which makes full use of all the sample data and explore heterogeneous classifications within groups. Logistic regression was used for the multifactor analysis. A P value <.05 was considered statistically significant. The entropy value suggested that the model with 3 latent profile was the best choice. There were 223 adolescents in the severe anxiety group, accounting for 24.78%. Logistics regression analysis of anxiety revealed that the risk of severe anxiety in boys was lower (odds ratio [OR] = 0.317, P < .001) than in girls. Students had a significantly lower probability of suffering from severe anxiety in using cellphones or computers ≤ 2 hours/day than those used cellphones or computers＞2 hours/day (OR = 0.391, P = .004). Decreasing screen-related sedentary behaviors should be a target of community and school-based interventions, because high screen-related sedentary behaviors were associated with higher odds of anxiety among adolescents in less developed area of China.

Device-measured sleep onset and duration in the development of depressive symptoms in adolescence

BACKGROUND

Sleep deprivation in adolescence is increasing in prevalence and may be linked to subsequent depression. Findings regarding associations between sleep duration, sleep onset time, and the development of depressive symptoms over time in adolescents are mixed, and rely on subjective measures of sleep.

METHODS

Sleep onset and duration were assessed using a combined heart rate monitor and accelerometer and self-report in 688 participants from the ROOTS study at age 15. Participants reported depressive symptoms at ages 14.5, 16, and 17.5, using the Mood and Feelings Questionnaire. Latent growth curve modelling was used to model development of depressive symptoms and test associations with baseline sleep onset and duration.

RESULTS

Cross-sectionally, falling asleep later and shorter sleep duration were both associated with higher depressive symptoms in males and females, using both device-measured and self-reported sleep. There were no longitudinal associations between baseline sleep duration and change in depressive symptoms. A later sleep onset-time was associated with a decrease in depressive symptoms over time, in females only, using device-measured sleep only.

LIMITATIONS

The current sample was more economically advantaged and ethnically white than the UK average, and with lower MFQ symptoms than the original cohort, which may reduce generalisability.

CONCLUSIONS

Adolescents who fall asleep later or sleep less have higher levels of depressive symptoms cross-sectionally, but do not show increases in depressive symptoms over time. Interventions targeting sleep onset and duration in adolescence may improve mental health in the short-term but the possibility of reverse causality should be explored further.

Adolescents' sleep and adjustment: Reciprocal effects

Reciprocal relations between sleep and adjustment were investigated. Participants included 246 adolescents (M = 15.80 years; 67.5% White, 32.5% Black/African American; 53% female, 47% male) at Time 1 (data collected 2012-2013), 227 at Time 2 (M = 16.78 years) and 215 at Time 3 (M = 17.70 years). Sleep-wake variables were measured with self-reports (sleepiness) and actigraphy (average sleep minutes and efficiency, variability in sleep minutes and efficiency). Adolescents reported on depression and anxiety symptoms, and parents reported on externalizing problems. Greater variability in sleep duration and efficiency as well as sleepiness predicted adjustment problems (range of R² : 36%-60%). Reciprocal relations were supported mostly for sleepiness (range of R² : 16%-32%). Results help understand bidirectional relations between sleep and adjustment.

Psychiatric Admissions of Children and Adolescents Across School Periods and Daylight-Saving Transitions

OBJECTIVES

This study sought to examine fluctuations in admissions to a child and adolescent inpatient psychiatry unit in relation to school breaks, school starts, as well as time change transitions in and out of Daylight-Saving Time (DST).

METHODS

Five years (2012-2017) of youth inpatient admissions to a pediatric hospital in Ontario were retrieved (n=2,498). A sub-sample was grouped weekly, starting on the Sunday of each week for a total of 260 weekly time bins. The number of admissions during in and out of school periods, school starts in the fall and winter semester, and time change transitions were compared.

RESULTS

Admissions were significantly higher during school periods as opposed to out of school periods, and significantly increased from prior- to post-school starts. No significant difference in admission rates were found in and out of DST changes. Weekly time series analyses for DST changes and monthly time series analyses for school starts did not identify a significant seasonality in admissions.

CONCLUSIONS

These findings suggest that school periods and school onset may be significant stressors associated with an increased rate of psychiatric admissions. The presence of potential compensating factors is proposed to explain the lack of relationship between pedopsychiatric admissions and time change transitions.

Longitudinal relationships among problematic mobile phone use, bedtime procrastination, sleep quality and depressive symptoms in Chinese college students: a cross-lagged panel analysis

BACKGROUND

Cross-sectional and longitudinal studies have found that problematic mobile phone use, bedtime procrastination, sleep quality, and depressive symptoms are strongly associated. However, studies are inconsistent regarding whether problematic mobile phone use predicts depressive symptoms or vice versa, and sleep factors have been infrequently focused on in this regard. In addition, few studies have examined the longitudinal associations and directions of effects between these factors. Therefore, this study aims to explore the longitudinal relationship among problematic mobile phone use, bedtime procrastination, sleep quality, and depressive symptoms in college students.

METHODS

Overall, 1181 college students completed questionnaires on problematic mobile phone use, bedtime procrastination, sleep quality, and depressive symptoms at two time points 12 months apart. A cross-lagged model was used to examine the longitudinal relationship between these factors.

RESULTS

Cross-lagged analyses showed significant bidirectional relationships of problematic mobile phone use with bedtime procrastination and depressive symptoms. Additionally, there were also significant bidirectional relationships of sleep quality with bedtime procrastination and depressive symptoms. Problematic mobile phone use predicted subsequent sleep quality one-way, and bedtime procrastination predicted subsequent depressive symptoms one-way.

CONCLUSIONS

This study further expands our understanding of the longitudinal and bidirectional relationships among problematic mobile phone use, bedtime procrastination, sleep quality and depressive symptoms and helps school mental health educators design targeted interventions to reduce problematic mobile phone use, sleep problems, and depressive symptoms among college students.

How does the COVID-19 affect mental health and sleep among Chinese adolescents: a longitudinal follow-up study

OBJECTIVE

The Corona Virus Disease-19 (COVID-19) pandemic has evolved into the largest public health event in the world. Earlier COVID-19 studies have reported that the pandemic caused widespread impacts on mental health and sleep in the general population. However, it remains largely unknown how the prevalence of mental health problems and sleep disturbance developed and interacted in adolescents at different times in the epidemic.

METHODS

831 teenagers (aged 14-19) underwent a longitudinal follow-up study to evaluate the prevalence of mental health problems and sleep disturbance among adolescents before, during, and after the COVID-19 breakout in China and to explore the interaction between mental health and sleep across the three measurements. The chronotype, anxiety and depression level, sleep quality, and insomnia were investigated during each measurement.

RESULTS

The adolescents had delayed sleep onset and sleep offset time, longer sleep duration during the quarantine than before and after the epidemic, whereas their chronotype tended to morning type during the epidemic. Yet, the highest prevalence of anxiety, depression, poor sleeper, and insomnia symptoms were observed before but not during the COVID-19 breakout. The females and adolescents who were eveningness type showed significantly higher anxiety and depression levels, poorer sleep quality, and severe insomnia status than the males and the intermediate and morning types. Sleep disturbance was positively associated with mental problems among three measurements. Pre-measured depression level significantly predicted sleep disturbance level at follow-ups.

CONCLUSION

These findings suggested that adolescents' high prevalence of mental health and sleep problems occurred before the COVID breakout and decreased during and after the epidemic. Gender and chronotype were significant risk factors associated with affective and sleep disturbances. Depression positively predicted later sleep problems, but not vice versa.

Confidence interval-based sample size determination formulas and some mathematical properties for hierarchical data

The use of hierarchical data (also called multilevel data or clustered data) is common in behavioural and psychological research when data of lower-level units (e.g., students, clients, repeated measures) are nested within clusters or higher-level units (e.g., classes, hospitals, individuals). Over the past 25 years we have seen great advances in methods for computing the sample sizes needed to obtain the desired statistical properties for such data in experimental evaluations. The present research provides closed-form and iterative formulas for sample size determination that can be used to ensure the desired width of confidence intervals for hierarchical data. Formulas are provided for a four-level hierarchical linear model that assumes slope variances and inclusion of covariates under both balanced and unbalanced designs. In addition, we address several mathematical properties relating to sample size determination for hierarchical data via the standard errors of experimental effect estimates. These include the relative impact of several indices (e.g., random intercept or slope variance at each level) on standard errors, asymptotic standard errors, minimum required values at the highest level, and generalized expressions of standard errors for designs with any-level randomization under any number of levels. In particular, information on the minimum required values will help researchers to minimize the risk of conducting experiments that are statistically unlikely to show the presence of an experimental effect.

A Latent Profile Analysis of Anxiety among Junior High School Students in Less Developed Rural Regions of China

The purpose of this study is to understand the potential types of anxiety among middle school students by analyzing the current situation of middle school students’ anxiety and its influencing factor. This study used a multistage stratified cluster random sampling to investigate students in grades 9 to 12. Mplus 7.4 was used for latent profile analysis. A total of 900 junior high school students were investigated. The junior high school students were divided into three subgroups by latent profile analysis. A total of 223 junior high school students experienced severe anxiety, accounting for 24.78%. Multivariate logistic regression analysis revealed that males are more likely to develop moderate and severe anxiety. The development of severe anxiety (OR = 0.562, p < 0.05) is less likely for students in schools with adequate mental health support. Students who were confident with their academic performances were less likely to develop moderate anxiety (OR = 0.377, p < 0.05). Students with extreme academic pressure are more likely to develop moderate anxiety (OR = 6.523, p < 0.05) and severe anxiety (OR = 11.579, p < 0.05). It is recommended that mental health counseling be set up in schools and to provide professional counselors to prevent serious anxiety for students. This paper also demonstrates a need to reduce students’ academic pressure.

The impact of bedtime procrastination on depression symptoms in Chinese medical students

PURPOSE

Depression symptoms are closely related to inadequate sleep and are experienced by medical students at an increased rate. Bedtime procrastination is considered a new, important predictor of sleep deficiency. However, whether there is a correlation between bedtime procrastination and depression symptoms remains unclear. This study aimed to examine the impact of bedtime procrastination on depression symptoms among medical students.

METHODS

A total of 419 Chinese medical students were invited to participate in this study, and 401 participants (mean age, 19.48 years; range, 17-23 years) were included in the final statistical analysis. Depression symptoms and bedtime procrastination were assessed using the Beck Depression Inventory-II (BDI-II) and the Bedtime Procrastination Scale (BPS), respectively.

RESULTS

The prevalence of depression symptoms in Chinese medical students was 26.9%. The mean BPS scores were significantly higher in the depressed group than in the non-depressed group. Binary logistic regression analysis identified that bedtime procrastination was an independent contributor to the prevalence of depression symptoms. Further correlation and multiple linear regression analyses demonstrated that the BDI scores were significantly and positively associated with the BPS scores in students without depression, while the BDI scores correlated with male students experiencing depression.

CONCLUSIONS

Depression symptoms, which become more prevalent among Chinese medical students, are found to independently associate with bedtime procrastination. In particular, the severity of depression symptoms shows a positive correlation with increased bedtime procrastination before developing into depression, and it shows correlation with sex only in a state of depression.

The bidirectional association between sleep problems and anxiety symptoms in adolescents: a TRAILS report

BACKGROUND

Previous studies have suggested a bidirectional association between sleep problems and anxiety symptoms in adolescents. These studies used methods that do not separate between-person effects from within-person effects, and therefore their conclusions may not pertain to within-person mutual influences of sleep and anxiety. We examined bidirectional associations between sleep problems and anxiety during adolescence and young adulthood while differentiating between person effects from within-person effects.

METHODS

Data came from the Dutch TRacking Adolescents' Individual Lives Survey (TRAILS), a prospective cohort study including six waves of data spanning 15 years. Young adolescents (N = 2230, mean age at baseline 11.1 years) were followed every 2-3 years until young adulthood (mean age 25.6 years). Sleep problems and anxiety symptoms were measured by the Youth Self-Report, Adult Self-Report and Nottingham Health Profile. Temporal associations between sleep and anxiety were investigated using the random intercept cross-lagged panel model.

RESULTS

Across individuals, sleep problems were significantly associated with (β = 0.60, p < 0.001). At the within-person level, there were significant cross-sectional associations between sleep problems and anxiety symptoms at all waves (β = 0.12-0.34, p < 0.001). In addition, poor sleep predicted greater anxiety symptoms between the first and second, and between the third and fourth assessment wave. The reverse association was not statistically significant.

CONCLUSIONS

Within-person associations between sleep problems and anxiety are considerably weaker than between-person associations. Yet, our findings tentatively suggest that poor sleep, especially during early and mid-adolescence, may precede anxiety symptoms, and that anxiety might be prevented by alleviating sleep problems in young adolescents.

Precursors of delayed sleep phase in adolescence: a population-based longitudinal study

STUDY OBJECTIVE

The aim of this study was to assess sleep behavior, sleep problems and mental health in childhood as possible candidate precursors for the development of delayed sleep phase (DSP) during adolescence.

METHODS

A longitudinal cohort study of 2200 children at age 7-9 (T1), 11-13 (T2), and 16-19 (T3) years. DSP was assessed at T3, and mental health problems by the Strength and Difficulties Questionnaire and time in bed and sleep problems at T1 and T2. Logistic regression analyses were used to examine associations between sleep and mental health at T1 and T2, and subsequent DSP at T3. Estimated marginal means were computed to compare mental health at T1 and T2 in adolescents with and without DSP.

RESULTS

Sleeping less than 9 hours per night at age 11-13 was significantly associated with DSP at 16-19 years (adjusted odds ratio = 3.37). Sleep problems at 11-13 years of age were more frequent among those who developed DSP compared to children who did not develop DSP (20% vs. 12%) but the results did not remain significant when controlling for early mental health problems. Sleep problems and mental health at 7-9 years of age was not related to later DSP. In the crude analyses, all Strengths and Difficulties Questionnaire (SDQ) subscales at 11-13 years was significantly associated with later DSP, but in the fully adjusted analysis, only the SDQ total score and hyperactivity subscale remained statistically significant.

CONCLUSION

Children with DSP in adolescence possess identifiable risk indicators in childhood.

Association between bedtime and self-reported illness among college students: a representative nationwide study of China

OBJECTIVE

This study was to examine the association between bedtime and self-reported illness among Chinese college students.

METHODS

Participants were 11,942 students, who were identified through a multistage survey sampling process. Sleep and illness status were obtained by self report. Both unadjusted and adjusted methods were considered in the analyses.

RESULTS

The logistic regression model found that late bedtime was positively associated with self reported short and long-term illness (OR: 3.70 and 1, 79) after adjusting for demographic characteristics, short sleep duration, and mental disorders.

CONCLUSIONS

This study is the first to find a positive relationship between late bedtime and self reported illnesses in China or elsewhere. The findings underscore the importance of educating college students about the importance of sleep.

Healthy lifestyle habits benefit remission of recurrent aphthous stomatitis and RAS type ulceration

In a clinical setting, it is not practical to separate recurrent aphthous stomatitis (RAS) from RAS-type ulceration in every case, so both conditions have been considered together for the purpose of this article. Due to the lack of consistently effective therapeutic options for RAS, other approaches to treat the disease are considered here, beginning with an analysis of possible aetiological factors. The aetiology of RAS, the most common mucosal disease, remains undefined thus far. A few researchers have proposed psychological disorders as a major factor impacting RAS. Some systemic diseases and lifestyle habits are also reported to be associated with RAS; these also impact mental health. I believe that all habits contributing to mental health might also benefit patients with RAS. I suggest that practitioners of oral medicine should recommend a healthy lifestyle to patients with RAS, before prescribing medicines.

The direction of the relationship between symptoms of insomnia and psychiatric disorders in adolescents

BACKGROUND

This study assessed the direction of the relationship between symptoms of insomnia disorder, depression, various anxiety disorders and obsessive compulsive disorder (OCD) in adolescents after controlling for age, gender, chronotype, and outcome variable at baseline.

METHODS

Data was collected in eight high schools in Adelaide, South Australia, at two time-points approximately 6 months apart. The study was completed by 318 and 255 high school students at baseline and follow-up, respectively, aged 12-18 (M=14.96, SD=1.34) in grades 7-11 at baseline. Hierarchical regression analyses were used to assess each relationship, the first model controlling for age, gender and chronotype, and the second controlling for outcome variable at baseline.

RESULTS

Insomnia symptoms predicted and were predicted by symptoms of each psychiatric disorder in model 1. In model 2, insomnia symptoms predicted symptoms of depression, and vice-versa. Symptoms of insomnia also predicted symptoms of separation anxiety disorder (SAD) once SAD, but not vice-versa, in model 2. Symptoms of obsessive compulsive disorder (OCD) and social phobia (SP) predicted symptoms of insomnia disorder in model 2, but not vice-versa. Insomnia symptoms were no longer related to symptoms of other anxiety disorders in model 2.

LIMITATIONS

The use of self-report measures, and potential predisposing, precipitating, perpetuating or preventative factors were not assessed.

CONCLUSIONS

Symptoms of insomnia disorder are bidirectionally related to depressive symptoms independent from baseline symptoms, and unidirectionally related to symptoms of OCD and SP where OCD and SP are independent risk-factors of the development of insomnia symptoms.