Diurnal cortisol slopes and mental and physical health outcomes: a systematic review and meta-analysis

Adam, Emma K.; Quinn, Meghan E.; Tavernier, Royette; McQuillan, Mollie T.; Dahlke, Katie A.; Gilbert, Kirsten E.

doi:10.1016/j.psyneuen.2017.05.018

Cited by 905Stress Responses and CortisolAdrenal Hormones and DisordersCircadian rhythm and melatonin

Diurnal cortisol slopes and mental and physical health outcomes: a systematic review and meta-analysis

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Adam, Emma K., Quinn, Meghan E., Tavernier, Royette, McQuillan, Mollie T., Dahlke, Katie A., Gilbert, Kirsten E.·2017·Psychoneuroendocrinology

DOI 10.1016/j.psyneuen.2017.05.018PMC PMC5568897

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Abstract

Changes in levels of the stress-sensitive hormone cortisol from morning to evening are referred to as diurnal cortisol slopes. Flatter diurnal cortisol slopes have been proposed as a mediator between chronic psychosocial stress and poor mental and physical health outcomes in past theory and research. Surprisingly, neither a systematic nor a meta-analytic review of associations between diurnal cortisol slopes and health has been conducted to date, despite extensive literature on the topic. The current systematic review and meta-analysis examined associations between diurnal cortisol slopes and physical and mental health outcomes. Analyses were based on 179 associations from 80 studies for the time period up to January 31, 2015. Results indicated a significant association between flatter diurnal cortisol slopes and poorer health across all studies (average effect size, r=0.147). Further, flatter diurnal cortisol slopes were associated with poorer health in 10 out of 12 subtypes of emotional and physical health outcomes examined. Among these subtypes, the effect size was largest for immune/inflammation outcomes (r=0.288). Potential moderators of the associations between diurnal cortisol slopes and health outcomes were examined, including type of slope measure and study quality indices. The possible roles of flatter slopes as either a marker or a mechanism for disease etiology are discussed. We argue that flatter diurnal cortisol slopes may both reflect and contribute to stress-related dysregulation of central and peripheral circadian mechanisms, with corresponding downstream effects on multiple aspects of biology, behavior, and health.

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Cortisol regulation plays a key mediating role in the relationship between stress exposure and later negative health outcomes.
“suggesting cortisol regulation plays a key mediating role in the relationship between stress exposure and later negative health outcomes (Adam et al., 2017; Chrousos and Gold, 1992; O ' Connor et al., 2021).”
From Effectiveness of stress management interventions to change cortisol levels: a systematic review and meta-analysis. (2024) · cites this paper as Adam et al., 2017
The Introduction (1.1 Overview) says researchers have suggested that stress-related alterations in cortisol regulation may mediate associations between stress exposure and later health outcomes. This supports a possible mediating role, but not the stronger characterization of cortisol regulation as a key mediator. (LLM, conf=0.83)
Experimental — accuracy not yet measured
The methods of cortisol collection are likely to impact study findings of intervention effectiveness.
“Determining the quality of the cortisol measurements in the included studies was imperative to consider because the methods of cortisol collection are likely to impact study findings of intervention effective ness (Adam et al., 2017).”
From Effectiveness of stress management interventions to change cortisol levels: a systematic review and meta-analysis. (2024) · cites this paper as Adam et al., 2017
The Results (section 3.4; page unavailable) report that objective monitoring of cortisol sample timing was associated with significantly different effect sizes, supporting the importance of collection methods. But the paper examines associations between diurnal cortisol slopes and health outcomes, not findings of intervention effectiveness. (LLM, conf=0.87)
Experimental — accuracy not yet measured
Chronic stress exposure is a major contributor to diurnal cortisol slope flattening.
“exposure to chronic stress is a major contributor that leads to slope flattening”
From Strong Enough to Suffer: Emotional Suppression, Stress Exposure, and Physiological Health Among Men Across the Life Course (2026) · cites this paper as Adam et al., 2017
The Introduction (§1.2; page unavailable) says adverse experience is associated with flatter diurnal cortisol slopes, and the Abstract describes flatter slopes as a proposed mediator of chronic psychosocial stress. The paper does not establish that chronic stress is a major cause of flattening: Discussion §4.4 calls for research to test whether reducing stress reverses it. (LLM, conf=0.87)
Experimental — accuracy not yet measured
Flatter diurnal cortisol slopes predict higher mortality risk, adverse cardiovascular outcomes, and higher levels of mental health symptoms.
“In a meta-analysis of diurnal cortisol slope and mental and physical health outcomes in 72 studies, Adam et al. (2017) found that flatter slopes in the morning were predictors of a higher mortality risk, adverse cardiovascular outcomes, and higher levels of mental health symptoms.”
From Strong Enough to Suffer: Emotional Suppression, Stress Exposure, and Physiological Health Among Men Across the Life Course (2026) · cites this paper as Adam et al., 2017
The Results (§3.3) report that flatter diurnal cortisol slopes predicted higher mortality risk, and the Discussion (§4.1) identifies significant associations with several mental-health outcomes. But cardiovascular outcomes were not significantly associated in the random-effects analysis (§3.3; §4.2), so the sentence overstates that finding. The Abstract reports 80 studies, not 72, and describes slopes across the day rather than specifically in the morning. (LLM, conf=0.91)
Experimental — accuracy not yet measured
Loneliness affects youth's diurnal cortisol, potentially causing chronic increases in cortisol in young adulthood, leading to higher risks of depression, anxiety, inflammation, and other adverse health outcomes.
“Loneliness affects youth’s diurnal cortisol, a key stress hormone [83, 84], potentially causing chronic increases in cortisol in young adulthood, leading to higher risks of depression, anxiety, inflammation, and other adverse health outcomes [85–87].”
From The prospective association of adolescent loneliness and low resilience with anxiety and depression in young adulthood: The HUNT study (2025) · cites this paper as [83]
The Discussion (§4.1; page unavailable) reports that flatter diurnal cortisol slopes are associated with depression, immune/inflammatory outcomes, and other poorer health outcomes. The Results (§3.3; page unavailable) find no significant association with anxiety and note a trend in the opposite direction. The paper does not establish that loneliness in youth causes chronically elevated cortisol in young adulthood or that such an increase leads to those outcomes. (LLM, conf=0.88)
Experimental — accuracy not yet measured

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Are flatter diurnal cortisol rhythms associated with major depression and anxiety disorders in late adolescence? The role of life stress and daily negative emotion
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The Effect of Shift Rotation on Employee Cortisol Profile, Sleep Quality, Fatigue, and Attention Level
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Dysregulated diurnal cortisol pattern is associated with glucocorticoid resistance in women with major depressive disorder
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Depressive Symptoms Predict Mucosal Wound Healing
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Diurnal rhythms of free estradiol and cortisol during the normal menstrual cycle in women with major depression
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Blunted Diurnal Cortisol Pattern Is Associated With Frailty: A Cross-Sectional Study of 745 Participants Aged 65 to 90 Years
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Associations of ghrelin with eating behaviors, stress, metabolic factors, and telomere length among overweight and obese women: Preliminary evidence of attenuated ghrelin effects in obesity?
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EMOTION—CORTISOL TRANSACTIONS OCCUR OVER MULTIPLE TIME SCALES IN DEVELOPMENT: IMPLICATIONS FOR RESEARCH ON EMOTION AND THE DEVELOPMENT OF EMOTIONAL DISORDERS
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Diurnal cortisol profiles and evening cortisol in post-pubertal adolescents scoring high on the Children's Depression Inventory
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Flattened Circadian Cortisol Rhythm in Type 2 Diabetes
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Cortisol Patterns Are Associated with T Cell Activation in HIV
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Salivary cortisol patterns and cognitive speed in major depression: a comparison with allergic rhinitis and healthy control subjects
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Gender Specific Correlations of Adrenal Gland Size and Body Fat Distribution: A Whole Body MRI Study
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Examining the association between salivary cortisol levels and subclinical measures of atherosclerosis: The Multi-Ethnic Study of Atherosclerosis
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No PTSD-related differences in diurnal cortisol profiles of genocide survivors
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Health anxiety moderates the daytime cortisol slope
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Co-occurring manic symptomatology influences HPA axis alterations in depression
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Depressive symptoms and cortisol variability prior to surgery for suspected endometrial cancer
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Salivary cortisol and depression in public sector employees: Cross-sectional and short term follow-up findings
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The SF-36 component summary scales and the daytime diurnal cortisol profile
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Effect of day-to-day variations in adrenal cortex hormone levels on abdominal symptoms
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Cortisol profile and depressive symptoms in older adults residing in Brazil and in Canada
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Authors: Adam, E. K., Quinn, M. E., Tavernier, R., McQuillan, M. T., Dahlke, K. A., & Gilbert, K. E.
Affiliations: Northwestern University (US)
Wesleyan University (US)
American Institutes for Research (US)
Washington University in St. Louis (US)
Corresponding author: Adam, Emma K.
ORCID: Adam, Emma K.
Quinn, Meghan E.
McQuillan, Mollie T.
Gilbert, Kirsten E.
Venue: Psychoneuroendocrinology
Publisher: Elsevier BV
Published: 2017-09
Volume: 83
Pages: 25-41
ISSN: 0306-4530 (ISSN-L)
DOI: 10.1016/j.psyneuen.2017.05.018
PMC: PMC5568897
OpenAlex: W2618888428
Cited by: 905
References: 161
Citations by year: 2026: 113 · 2025: 115 · 2024: 104 · 2023: 100 · 2022: 133 · 2021: 112 · 2020: 128 · 2019: 59 · 2018: 38 · 2017: 2
FWCI: 5.47
Type: journal article
Language: en
Open access: green
europepmc.org
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
Locations: Psychoneuroendocrinology (publishedVersion)
PubMed (publishedVersion)
Europe PMC (PubMed Central) (acceptedVersion)
PubMed Central (acceptedVersion)
Funders: National Institute on Alcohol Abuse and Alcoholism (R21AA021073)
National Institute of Mental Health (T32MH100019)
Topics: Life Sciences › Neuroscience › Behavioral Neuroscience › Stress Responses and Cortisol
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
Life Sciences › Neuroscience › Endocrine and Autonomic Systems › Circadian rhythm and melatonin
Keywords: diurnal cortisol slope, cortisol, psychosocial stress, mental health, physical health, immune function, inflammation, circadian rhythm, health outcomes
MeSH terms: Circadian Rhythm, Emotions, Female, Humans, Hydrocortisone, Hypothalamo-Hypophyseal System, Male, Mental Health, Pituitary-Adrenal System, Saliva, Stress, Psychological

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Diurnal cortisol slopes and mental and physical health outcomes: a systematic review and meta-analysis

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