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A meta-analysis and model of the relationship between sleep and depression in adolescents: Recommendations for future research and clinical practice
Abstract
The purpose of this review was to quantify the strength of evidence for a directional relationship between sleep disturbance and depression in adolescents. A literature search was conducted to identify research investigating the relationship between sleep disturbance and depression in adolescent samples (12-20 y). Twenty-three studies were identified; 13 explored associations between depression and sleep disturbance; seven examined the prospective role of sleep disturbance in the development of depression; and three investigated the role of adolescent depression in the development of subsequent sleep disturbance. Average weighted mean differences in sleep/depression-related outcome variables were calculated between adolescents with depression, and non-clinical adolescents, or those in remission. Adolescents with depression experienced significantly more wakefulness in bed (sleep onset latency, wake after sleep onset, number of awakenings and sleep efficiency), lighter sleep (more stage 1), and reported more subjective sleep disturbance. Overall effect sizes from longitudinal and treatment studies suggest sleep disturbance acts as a precursor to the development of depression. At follow-up, depressed adolescents had significantly longer sleep onset, more wake after sleep onset, and lower sleep efficiency compared to adolescents who were non-clinical, or had undergone remission. Little support was found for a predictive role of depressive symptoms in the development of sleep disturbance. Based on these findings we propose a model to understand the development of depression from initial sleep disturbance, provide recommendations for clinicians and recommendations for future research.
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“Physical activity and sleep duration are two volitational, lifestyle-related behaviors that have been identified as being associated with the prevalence of anxiety and depression among adolescents [9,10,11,12,13].”
From Academic Stress, Physical Activity, Sleep, and Mental Health among Chinese Adolescents (2021) · cites this paper as [10]
In the citing paper
“We note that no trials have tested whole-of-school approaches, or universal interventions like late school start times (an intervention that aligns with adolescents' circadian clock, improving the amount of sleep they get, and in turn their mood; Adolescent Sleep Working Group 2014; Gong 2020; Lovato 2014), or interventions that target broader social-cultural determinants.”
From Prevention of self-harm and suicide in young people up to the age of 25 in education settings (2024) · cites this paper as Lovato 2014
In the citing paper
“Poor sleep is a significant risk factor for depression across the lifespan”
From The effect of non-pharmacological sleep interventions on depression symptoms: a meta-analysis of randomised controlled trials (2019) · cites this paper as [21]
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“Although, a meta-analysis showed a stronger direction of effect from sleep problems to depression in adolescents, rather than the onset of sleep problems following depression (Lovato & Gradisar, 2014).”
InfluentialSelf-citationScott, J., Kallestad, H., Vedaa, O., Sivertsen, B., & Etain, B. (2021) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2021.101429 · Cited by 162
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“60 Research on adults with insomnia who also suffer from depression show that treatment of the sleep disorder also improves symptoms of depression, but the opposite is not true.”
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“For adolescents, there appears to be little evidence that depressive symptoms predict the development of sleep disturbances (Lovato & Gradisar, 2014), although prior insomnia in adolescents is associated with a four times higher risk of subsequent depression (Johnson, Roth, & Breslau, 2006).”
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“The literature suggests that sleep and emotions may be bidirectional, although there is some support for the finding that sleep predicts emotion (Hall, Levenson, & Halser, 2012) and is a stronger predictor of depression, rather than depression influencing sleep (Lovato & Gradisar, 2014).”
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“…to the impact of sleep loss onmood, impulsivity, or through other mechanisms, such as perfectionism (Boergers et al., 1998), nighttime rumination (Lovato and Gradisar, 2014; Miranda and NolenHoeksema, 2007), lack of positive expectations for the future (Chou et al., 2013), or failing to reach…”
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“Consequently, teenage sleep loss may promote young suicidality by increased impulsivity linked to the frontal lobe and emotional regulation circuitry that isn ’ t fully developed (24).”
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“Sleep disturbance often precedes the onset of depression and is improved upon remission.(1,2) In young people, delayed sleep phase, characterized primarily by sleep onset routinely occurring much later than average, is associated with short sleep duration,(3) which in turn represents a risk factor for obesity, chronic…”
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“There is a bidirectional relationship between sleep and mood, although sleep disturbances more often preceded depression than the reverse [44], supporting sleep as a modifiable target to reduce risk for poor mental health [45], including during stressful times like the pandemic.”
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“However, this is contested; a well-conducted meta-analysis suggests sleep problems exist only as a precursor to mental health disorders, and that current evidence for such disorders being predictive of poor sleep is weak (Lovato & Gradisar, 2014).”
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“However, based on recent reports in this field (Lovato and Gradisar, 2014; Wong et al., 2004), we find this direction of influence to be less plausible.”
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“, 2015), and systematic reviews and meta-analyses (Belmon et al., 2019; Cain and Gradisar, 2010; Carter et al., 2016; Hale and Guan, 2015; Lovato and Gradisar, 2014) demonstrating the adverse effects of lack of adequate sleep on physical and mental health.”
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“Furthermore, a recent meta-analysis examining the relationship between sleep problems and depression among adolescents (Lovato & Gradisar, 2014) concluded that (in the majority of cases) sleep problems start earlier than the symptoms of psychological distress.”
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“While it is difficult to ascertain the causality between sleep and mood from this study, there is significant literature that supports the impact of sleep on depression [49].”
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“Along these lines, in their meta-analysis, Lovato and Gradisar (2014) proposed that increased wakefulness before sleep onset could promote rumination and reinforce depressive thinking styles, which in turn, perpetuates longer sleep latency.”
BackgroundInfluentialAssociations Among Screen Time, Sleep Duration and Depressive Symptoms Among Chinese Adolescents.
Wang, W.-X., Du, X., Guo, Y.-F., Li, W., Zhang, S., Zhang, W.-H., McIntyre, R., Tamura, J. K., Guo, L., & Lu, C.-Y. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.01.082 · Cited by 65
Scott, A. J., Webb, T. L., & Rowse, G. (2017) · BMJ Open · doi:10.1136/bmjopen-2017-016873 · Cited by 72
Pesonen, A., Gradisar, M., Kuula, L., Short, M. A., Merikanto, I., Tark, R., Räikkönen, K., & Lahti, J. M. T. (2018) · Journal of Affective Disorders · doi:10.1016/j.jad.2018.11.077 · Cited by 75
Vandendriessche, A., Ghekiere, A., Cauwenberg, J. V., Clercq, B. D., Dhondt, K., DeSmet, A., Tynjälä, J., Verloigne, M., & Deforche, B. I. (2019) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph16061072 · Cited by 72
“Moreover, our results are in line with a previous study, in which better sleep quantity and quality were related to a better mental health status in adolescents [32,33].”
ResultZafar, F., Alam, L. F., Vivas, R. R., Wang, J., Whei, S. J., Mehmood, S., Sadeghzadegan, A., Lakkimsetti, M., & Nazir, Z. (2024) · Cureus · doi:10.7759/cureus.56472 · Cited by 84
“Additionally, increased activity is also related to lower depression [81,82].”
BackgroundBrand, S., Kirov, R., Kalak, N., Gerber, M., Pühse, U., Lemola, S., Correll, C. U., Cortese, S., Meyer, T., & Holsboer‐Trachsler, E. (2015) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s74905 · Cited by 66
Prevention of internalizing disorders and suicide via adolescent sleep interventions
Blake, M. J., & Allen, N. B. (2019) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2019.08.027 · Cited by 70
Wang, W., Du, X., Guo, Y., Li, W., Teopiz, K. M., Shi, J., Guo, L., Lu, C., & McIntyre, R. S. (2021) · Sleep Medicine · doi:10.1016/j.sleep.2021.03.009 · Cited by 66
Burani, K., Klawohn, J., Levinson, A. R., Klein, D. N., Nelson, B. D., & Hajcak, G. (2019) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2019.1630834 · Cited by 70
Blake, M. J., Snoep, L., Raniti, M. B., Schwartz, O., Waloszek, J. M., Simmons, J. G., Murray, G., Blake, L. M., Landau, E. R., Dahl, R. E., et al. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.10.006 · Cited by 71
Sleep and eating disorders: current research and future directions
Cooper, A. R., Loeb, K. L., & McGlinchey, E. L. (2019) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2019.11.005 · Cited by 62
Association between Sleep Habits and Problems and Internet Addiction in Adolescents
Kawabe, K., Horiuchi, F., Oka, Y., & Ueno, S. (2019) · Psychiatry Investigation · doi:10.30773/pi.2019.03.21.2 · Cited by 59
Cliffe, B., Croker, A., Denne, M., Smith, J., & Stallard, P. (2020) · JMIR Mental Health · doi:10.2196/14842 · Cited by 56
“Although there is a bidirectional relationship between sleep and mental health [5], there is evidence to suggest that sleep difficulties may precede the development of depression and anxiety [8-10].”
BackgroundPublic health burden of sleep disorders: underreported problem
Filip, I., Tidman, M. M., Saheba, N., Bennett, H., Wick, B., Rouse, N. C., Patriche, D., & Radfar, A. (2016) · Journal of Public Health · doi:10.1007/s10389-016-0781-0 · Cited by 62
“Furthermore, of adolescents with depression, 73% also have a sleep disorder or sleep dysfunction that preceded their depressive symptoms (Lovato and Gradisar 2014; Liu et al. 2007).”
BackgroundBlake, M. J., Schwartz, O., Waloszek, J. M., Raniti, M. B., Simmons, J. G., Murray, G., Blake, L. M., Dahl, R. E., Bootzin, R. R., McMakin, D. L., et al. (2017) · SLEEP · doi:10.1093/sleep/zsx061 · Cited by 64
“development of anxiety and depression in adolescence more than the reverse.(15,16) Adolescence is, therefore, a critical developmental window for understanding the mechanisms of sleep disturbance to inform early intervention.”
BackgroundBlake, M. J., Blake, L. M., Schwartz, O., Raniti, M. B., Waloszek, J. M., Murray, G., Simmons, J. G., Landau, E. R., Dahl, R. E., McMakin, D. L., et al. (2017) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12842 · Cited by 66
Zou, L., Wu, X., Tao, S., Xu, H., Xie, Y., Yang, Y., & Tao, F. (2019) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2019.00822 · Cited by 66
“A metaanalysis found that adolescents with major depressive disorder have poor sleep quality, including more sleep disruptions, sleep disturbances, insomnia, and hypersomnia (26).”
BackgroundTonon, A. C., Constantino, D. B., Amando, G. R., de Abreu, A. C. O. V., Francisco, A. P., de Oliveira, M. A. B., Pilz, L. K., Xavier, N. B., Rohrsetzer, F., Souza, L., et al. (2022) · SLEEP · doi:10.1093/sleep/zsac104 · Cited by 59
Wahlstrom, K., & Owens, J. (2017) · Current Opinion in Psychiatry · doi:10.1097/yco.0000000000000368 · Cited by 49
Quality of life and mood in children with cystic fibrosis: Associations with sleep quality
Vandeleur, M., Walter, L. M., Armstrong, D., Robinson, P. J., Nixon, G. M., & Horne, R. S. C. (2017) · Journal of Cystic Fibrosis · doi:10.1016/j.jcf.2017.11.021 · Cited by 56
“In adolescents there is however emerging evidence that sleep problems might predict future depression [38].”
BackgroundBjorvatn, B., Jernelöv, S., & Pallesen, S. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.639198 · Cited by 57
“…are conceivably a part of the diagnostic criteria of several psychiatric disorders (Costantini et al., 2020), it is fairly well demonstrated that insomnia constitutes a risk factor for the development of depression and anxiety in particular (Lovato and Gradisar, 2014; Sivertsen et al., 2014).”
BackgroundInsomnia symptoms and short sleep duration predict trajectory of mental health symptoms
Biddle, D. J., Hermens, D. F., Lallukka, T. M., Aji, M., & Glozier, N. (2018) · Sleep Medicine · doi:10.1016/j.sleep.2018.10.008 · Cited by 54
Sleep and mental health in children and adolescents
Short, M. A., Bartel, K., & Carskadon, M. A. (2019) · Elsevier eBooks · doi:10.1016/b978-0-12-815373-4.00032-0 · Cited by 60
Olbrich, S., Tränkner, A., Surova, G., Gevirtz, R., Gordon, E., Hegerl, U., & Arns, M. (2015) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2015.12.001 · Cited by 53
Ahmadpanah, M., Akbari, T., Akhondi, A., Haghighi, M., Jahangard, L., Bahmani, D. S., Bajoghli, H., Holsboer‐Trachsler, E., & Brand, S. (2017) · Psychiatry Research · doi:10.1016/j.psychres.2017.07.030 · Cited by 62
“Second, sleep was not assessed, though several studies have shown poor sleep to be causally related to poor mental health (Lovato and Gradisar, 2014), and that, compared to males, females complain more about insomnia (Zhang and Wing, 2006).”
Taking a Break from Social Media Improves Wellbeing Through Sleep Quality
Graham, S., Mason, A., Riordan, B. C., Winter, T. J., & Scarf, D. (2021) · Cyberpsychology Behavior and Social Networking · doi:10.1089/cyber.2020.0217 · Cited by 53
“13 For example , meta-analyses have demonstrated that sleep quality is predictive of depression 14 and may be a unique risk factor for suicidal thoughts and behaviors.”
Ghaleiha, A., Davari, H., Jahangard, L., Haghighi, M., Ahmadpanah, M., Rabiei, M. A. S., Bajoghli, H., Holsboer‐Trachsler, E., & Brand, S. (2016) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-016-0685-6 · Cited by 53
“Lovato and Gradisar [40]), it is conceivable that TD indirectly causes depression via its impact on sleep.”
BackgroundGoril, S., Zalai, D., Scott, L., & Shapiro, C. M. (2016) · Sleep Medicine · doi:10.1016/j.sleep.2016.06.002 · Cited by 51
“There is mounting evidence concerning the association between sleep disorders and depression in children and adolescents (46-48).”
Zhao, J., Xu, J., He, Y., & Xiang, M. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.12.123 · Cited by 51
Bosch, R., Pagerols, M., Prat, R., Español‐Martín, G., Rivas, C., Dolz, M., Haro, J. M., Ramos‐Quiroga, J. A., Ribasés, M., & Casas, M. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19074120 · Cited by 47
“These results are consistent with studies showing that sleep disturbances can predict later depression and anxiety [38,39].”
ResultKeller, L. K., Grünewald, B., Vetter, C., Roenneberg, T., & Schulte‐Körne, G. (2017) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-017-0977-z · Cited by 45
Peach, H. D., Gaultney, J. F., & Ruggiero, A. R. (2018) · The Journal of Primary Prevention · doi:10.1007/s10935-018-0526-7 · Cited by 52
Latina, D., Bauducco, S., & Tilton‐Weaver, L. C. (2020) · Journal of Sleep Research · doi:10.1111/jsr.13190 · Cited by 47
“In addition, adolescents who report NSSI and/or sleep difficulties are likely to experience depressive symptoms (e.g. Lovato & Gradisar, 2014).”
Background
Metadata
- Authors
- Lovato, N., & Gradisar, M.
- Affiliations
- Flinders University (AU)
- Corresponding author
- Lovato, Nicole
- Venue
- Sleep Medicine Reviews
- Publisher
- Elsevier BV
- Published
- 2014-12
- Volume
- 18
- Issue
- 6
- Pages
- 521-529
- ISSN
- 1087-0792 (ISSN-L)
- OpenAlex
- W2064090130
- Cited by
- 594
- References
- 98
- Citations by year
- 2026: 59 · 2025: 65 · 2024: 61 · 2023: 59 · 2022: 64 · 2021: 58 · 2020: 42 · 2019: 62 · 2018: 43 · 2017: 33 · 2016: 27 · 2015: 15 · 2014: 4
- FWCI
- 3.50
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Sleep Medicine Reviews (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Life Sciences › Neuroscience › Cognitive Neuroscience › Sleep and Wakefulness Research
- Keywords
- sleep disorders, adolescent depression, sleep latency, wake after sleep onset, sleep efficiency, depression onset, remission, clinical guidelines
- MeSH terms
- Adolescent, Child, Depression, Major Depressive Disorder, Humans, Models, Theoretical, Sleep Wake Disorders, Young Adult
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