Sleep and Mood Disorders Among Youth.

This article reviews the literature on mood disorders and sleep disorders among children and adolescents. Research suggests that sleep plays an important role in the development, progression, and maintenance of mood disorder symptoms among children and adolescents. Sleep problems as early as maternal perinatal insomnia may predict and predate depression among youth. Children and adolescents who develop comorbid mood disorders and sleep problems represent a particularly high-risk group with more severe mood episode symptoms, higher rates of self-harm and suicidality, and less responsivity to treatment. Treatment research supports the idea that sleep problems can be improved through behavioral interventions.

Report from a randomized control trial: improved alignment between circadian biology and sleep-wake behavior as a mechanism of depression symptom improvement in evening-type adolescents with depressive symptoms.

STUDY OBJECTIVES: An evening circadian preference is common among adolescents. It is characterized by a behavioral predilection for later sleep and wake timing and is associated with higher rates of Major Depressive Disorder (MDD). The present study aims to (a) test the effectiveness of a cognitive behavioral sleep intervention (Transdiagnostic Sleep and Circadian Intervention; TranS-C) in a sample of adolescents with an evening circadian preference and clinically significant depressive symptoms and (b) evaluate improved alignment between circadian biology and sleep-wake behavior as a potential mechanism in the relationship between sleep and depression symptom improvement. METHODS: Adolescents with an evening circadian preference and clinically significant depressive symptoms were randomized to receive TranS-C (n = 24) or a psychoeducation condition (PE; n = 18). Alignment between circadian biology and sleep-wake behavior was measured using objective biological measurement. Measures of sleep and circadian rhythm were taken at pre- and posttreatment, and depression symptoms were measured at pre- and posttreatment and 6- and 12-month follow-up. RESULTS: Mixed effects modeling revealed that compared with an active control condition, TranS-C resulted in a significant reduction in MDD severity at 12-month follow-up. A MacArthur mediation analysis conducted to explore alignment between circadian biology and sleep-wake behavior as a mediator of depression severity reduction through 12-month follow-up revealed a significant interaction between change in alignment between circadian biology and sleep-wake behavior and treatment arm, indicating that improved alignment between circadian biology and sleep-wake behavior at posttreatment was associated with improvements in depression outcomes at 12-month follow-up under the treatment condition. CONCLUSIONS: These results provide novel evidence for improved alignment between circadian biology and sleep-wake behavior as a specific mechanism of depression improvement, provide key clues into the complex relationship between sleep and depression, and have significant clinical implications for adolescents with depression.

Recent advances in sleep and depression.

PURPOSE OF REVIEW: There is increasing interest in the connection between sleep disturbances and mood disorders. The purpose of this review is to summarize and evaluate current research on the role of sleep disturbance in the development of depression, as well as to describe recent advances in treatments that improve both sleep and depression symptoms. RECENT FINDINGS: Relevant publications included in this review cover a wide range of topics related to sleep and depression. Data from large longitudinal studies suggest that insomnia and evening circadian preference are unique risk factors for depression. Depression treatment studies indicate poorer outcomes for those with comorbid sleep disturbances. A few recent trials of cognitive behavioral therapy for insomnia and triple chronotherapy in unipolar depression have shown promising results. SUMMARY: Sleep disturbance is a modifiable risk factor in the development and maintenance of depression. In the context of current depression, although the data is mixed, some evidence suggests treating sleep disturbance can improve overall outcomes. Recent evidence also suggests that treating sleep disturbance may prevent the future depressive episodes.

Patterns of sleep disturbances and associations with depressive symptoms in autistic young adults.

Autistic individuals are at an increased risk for both sleep disturbances and depression. While studies in the general population and in autistic adults have drawn general links between sleep disturbances and mental health, few studies have examined the extent to which specific sleep problems may be implicated in the extremely high rates of depression among autistic adults. This study aimed to describe the patterns of sleep disturbances in autistic young adults, and their associations with depressive symptoms while controlling for relevant demographic factors. A sample of 304 legally independent adults (age 18-35 years old) with a childhood diagnosis of autism spectrum disorder self-reported on their average sleep behaviors during the past week and depressive symptoms on the Beck Depressive Inventory-II. A significant proportion (86.01%) of autistic young adults experienced at least one of the primary sleep disturbances of interest, including short total sleep time (39.59%), poor sleep efficiency (60.07%), and delayed sleep phase (36.18%). Additionally, lower sleep efficiency and delayed sleep phase were both associated with higher depressive symptoms. The associations between sleep and depressive symptoms identified in our study suggest that sleep treatments may hold potential for ameliorating depressive symptoms in autistic adults who also experience sleep problems. Further research using daily sleep diaries and objective measures of sleep behaviors, as well as longitudinal studies, are needed to understand how changes in sleep may relate to changes in depressive symptoms in autistic adults.

Moderators of Cognitive Behavioral Treatment for Insomnia on Depression and Anxiety Outcomes.

PURPOSE OF REVIEW: With a focus on reviewing adequately powered randomized controlled trials, we present recent research on the potential of cognitive behavioral therapy for insomnia (CBT-I) to improve depression and anxiety outcomes among patients with insomnia and one of the following comorbid psychiatric disorders: major depressive disorder (MDD), generalized anxiety disorder (GAD), or posttraumatic stress disorder (PTSD). We also examine potential moderators of CBT-I on depression and anxiety outcomes in this population. RECENT FINDINGS: Despite high comorbidity rates, current behavioral and pharmacological treatments for MDD, GAD, and PTSD do not substantially target or improve insomnia symptoms; residual insomnia is exceedingly common even among patients who experience remission. Insomnia plays a critical role in the onset and maintenance of depression and anxiety, and treating insomnia with CBT-I may improve global outcomes for patients with MDD, GAD, and PTSD. CBT-I is superior to traditional depression/anxiety treatment in improving insomnia symptoms among patients with comorbid psychiatric disorders. Results are mixed on whether CBT-I (either alone or augmented with depression/anxiety treatment) is effective in improving overall MDD, GAD, and PTSD outcomes. Evening circadian preference and depression/anxiety symptom severity may moderate the effect of CBT-I on depression and anxiety outcomes.

Opportunities to Integrate Mobile App-Based Interventions Into Mental Health and Substance Use Disorder Treatment Services in the Wake of COVID-19.

The COVID-19 pandemic has heightened concerns about the impact of depression, anxiety, alcohol, and drug use on public health. Mobile apps to address these problems were increasingly popular even before the pandemic, and may help reach people who otherwise have limited treatment access. In this review, we describe pandemic-related substance use and mental health problems, the growing evidence for mobile app efficacy, how health systems can integrate apps into patient care, and future research directions. If equity in access and effective implementation can be addressed, mobile apps are likely to play an important role in mental health and substance use disorder treatment.

Internet use and its impact on internalizing disorder symptoms and sleep in adolescents with an evening circadian preference.

STUDY OBJECTIVES: This study sought to examine the relationship between internet use, sleep, and internalizing disorder symptoms in adolescents with an evening circadian preference. METHODS: One hundred seventy-two adolescents aged 10-18 years with an evening circadian preference completed a week of sleep diaries and questionnaires about internet use and internalizing disorder symptoms. RESULTS: Adolescents reported internet use for 3.81 hours on weekdays and 5.44 hours on weekends, with > 90% having access to both a computer with internet and a personal cell phone. A majority of adolescents used the internet from 4-8 pm (71%) and from 9-11 pm (62%). Common online activities included listening to music (77%), watching videos (64%), communicating with others (64%), and doing homework (58%). Late-night internet use (9-11 pm) was associated with more internalizing disorder symptoms. Middle-of-the-night internet use (midnight-5 am) was associated with a later bedtime, shorter total sleep time, and more internalizing disorder symptoms. Adolescents used the internet to fulfill social needs, to avoid or combat boredom, or for maladaptive activities. Using the internet for social interaction or avoidance/boredom was associated with higher internalizing disorder symptoms. Using the internet for maladaptive reasons was associated with more late-night and middle-of-the-night use. CONCLUSIONS: Adolescent internet use late at night and in the middle of the night is common. Internet use may be motivated by desires for social connection, by boredom/avoidance, or for maladaptive behaviors. Because middle-of-the-night internet use was associated with higher internalizing disorder symptoms and worse sleep, it presents as a potential target for intervention. CITATION: Asarnow LD, Gasperetti CE, Gumport NB, Harvey AG. Internet use and its impact on internalizing disorder symptoms and sleep in adolescents with an evening circadian preference. J Clin Sleep Med. 2021;17(10):2019-2027.

Sleep and Mood Disorders Among Youth.

This article reviews the literature on mood disorders and sleep disorders among children and adolescents. Research suggests that sleep plays an important role in the development, progression, and maintenance of mood disorder symptoms among children and adolescents. Sleep problems as early as maternal perinatal insomnia may predict and predate depression among youth. Children and adolescents who develop comorbid mood disorders and sleep problems represent a particularly high-risk group with more severe mood episode symptoms, higher rates of self-harm and suicidality, and less responsivity to treatment. Treatment research supports the idea that sleep problems can be improved through behavioral interventions.

Sleep in youth with repeated self-harm and high suicidality: Does sleep predict self-harm risk?

OBJECTIVE: To elucidate processes contributing to continuing self-harm in youth at very high risk for suicide, focusing on sleep disturbance, a putative warning sign of imminent suicide risk. METHOD: 101 youth (ages 12-18) selected for high risk of suicide/suicide attempts based on suicidal episodes plus repeated self-harm (suicide attempts and/or nonsuicidal self-injury [NSSI]). Youth were assessed at baseline, 6-, and 12-month follow-ups on measures of self-harm, suicidality, sleep, and depression. RESULTS: Youth showed high rates of baseline sleep disturbance: 81.2% scored in the clinical range on the Pittsburgh Sleep Quality Index (PSQI); 81.2% reported an evening (night owl) circadian preference. PSQI score was associated with elevated levels of self-harm (suicide attempts and NSSI) contemporaneously and predicted future self-harm within 30 days. Rates of self-harm were high during follow-up: 45.0% and 33.7% at 6 and 12 months, respectively. CONCLUSIONS: Results underscore the need to move beyond an acute treatment model to prevent recurrent and potentially deadly self-harm, the importance of clarifying mechanisms contributing to elevated suicide/self-harm risk, and the potential promise of engaging sleep as a therapeutic target for optimizing treatment and elucidating mechanistic processes.

Depression and sleep: what has the treatment research revealed and could the HPA axis be a potential mechanism?

Research indicates that insomnia improvement plays a critical role in depression symptom improvement. In line with the National Institute of Mental Health Experimental Therapeutics approach recent research focuses on identifying specific mechanisms; the present manuscript aims to review recent research on one potential mechanism, dysfunction in the HPA axis which is a shared biological substrate of both depression and insomnia. Over the past five years, research demonstrated a relationship between sleep disturbance and cortisol reactivity and recovery following a stressor. Meanwhile, research on the relationship between depression and HPA axis functioning is less consistent and is dependent on measurement of HPA axis. Experimental research that aims to determine a causal pathway between sleep, depression and HPA axis functioning is needed.

Circadian Preference as a Moderator of Depression Outcome Following Cognitive Behavioral Therapy for Insomnia Plus Antidepressant Medications: A Report From the TRIAD Study.

STUDY OBJECTIVES: We previously presented results from a randomized controlled trial that examined the effects of antidepressant medication plus cognitive behavioral therapy for insomnia (CBT-I) among patients with major depressive disorder (MDD) and insomnia. The current secondary analysis aims to examine whether circadian preference moderated the reduction in depression and insomnia symptom severity during this trial. METHODS: A total of 139 adult participants with MDD and insomnia disorder were treated with antidepressant medication and randomized to receive 7 sessions of CBT-I or a control therapy (CTRL). Circadian preference (eveningness) was measured using the Composite Scale of Morningness (CSM). Depression symptom severity was assessed using the Hamilton Depression Rating Scale (HDRS); insomnia symptom severity was assessed using the Insomnia Severity Inventory (ISI). The moderating role of circadian preference on changes in HRSD and ISI was assessed via latent growth models within the framework of structural equation modeling. RESULTS: Greater evening preference was associated with smaller reduction in HDRS (P = .03) from baseline to week 6 across treatment groups. The interaction between CSM and treatment group was also significant (P = .02), indicating that participants with greater evening preference in the CTRL group had significantly smaller HDRS reduction than those with greater evening preference in the CBT-I group. Circadian preference did not share significant associations with ISI (all P > .30). CONCLUSIONS: Individuals with MDD and insomnia who have an evening preference are at increased risk for poor response to pharmacological depression treatment augmented with either CBT-I or CTRL behavioral insomnia treatment. However, evening types have better depression outcomes when treated with CBT-I than with CTRL for insomnia.

Cognitive Behavioral Therapy for Insomnia in Depression.

This article reviews the literature on cognitive-behavioral therapy for insomnia in adults and adolescents with depression. Recent research has expanded on previous research, which established that sleep problems are an important predictor of depression and that sleep problems are associated with more severe depression, more suicidality, and worse outcomes for treatment of depression. The relationship between sleep problems and depression is complex, likely bidirectional, and impactful. To further improve the lives of patients with depression who experience insomnia, it will be important to investigate which patients will do better in a sequential versus concomitant approach.

Treating insomnia in depression: Insomnia related factors predict long-term depression trajectories.

OBJECTIVE: Insomnia and major depressive disorders (MDD) often co-occur, and such comorbidity has been associated with poorer outcomes for both conditions. However, individual differences in depressive symptom trajectories during and after treatment are poorly understood in comorbid insomnia and depression. This study explored the heterogeneity in long-term depression change trajectories, and examined their correlates, particularly insomnia-related characteristics. METHOD: Participants were 148 adults (age M ± SD = 46.6 ± 12.6, 73.0% female) with insomnia and MDD who received antidepressant pharmacotherapy, and were randomized to 7-session Cognitive Behavioral Therapy for Insomnia or control conditions over 16 weeks with 2-year follow-ups. Depression and insomnia severity were assessed at baseline, biweekly during treatment, and every 4 months thereafter. Sleep effort and beliefs about sleep were also assessed. RESULTS: Growth mixture modeling revealed three trajectories: (a) Partial-Responders (68.9%) had moderate symptom reduction during early treatment (p value < .001) and maintained mild depression during follow-ups. (b) Initial-Responders (17.6%) had marked symptom reduction during treatment (p values < .001) and low depression severity at posttreatment, but increased severity over follow-up (p value < .001). (c) Optimal-Responders (13.5%) achieved most gains during early treatment (p value < .001), continued to improve (p value < .01) and maintained minimal depression during follow-ups. The classes did not differ significantly on baseline measures or treatment received, but differed on insomnia-related measures after treatment began (p values < .05): Optimal-Responders consistently endorsed the lowest insomnia severity, sleep effort, and unhelpful beliefs about sleep. CONCLUSIONS: Three depression symptom trajectories were observed among patients with comorbid insomnia and MDD. These trajectories were associated with insomnia-related constructs after commencing treatment. Early changes in insomnia characteristics may predict long-term depression outcomes. (PsycINFO Database Record

The Impact of Sleep Improvement on Food Choices in Adolescents With Late Bedtimes.

PURPOSE: The aim was to investigate the effect of sleep improvement on desire for and intake of weight gain-promoting foods in adolescents with late bedtimes. METHODS: A sample of 42 adolescents with late bedtimes was enrolled in an intervention designed to improve sleep. Their desire for and intake of food in the morning was assessed at before and after treatment. RESULTS: Adolescents with earlier bedtimes at post-treatment relative to pretreatment increased their caloric intake of low glycemic index, fruit, and dairy foods at post-treatment. This effect was not observed in adolescents who did not improve their bedtime at post-treatment. CONCLUSIONS: These findings suggest that advancing bedtimes earlier can improve breakfast choices, an important meal for obesity prevention during adolescence.

Evidence for a Possible Link between Bedtime and Change in Body Mass Index.

OBJECTIVES: The aim of the current study was to examine the longitudinal relationship between bedtimes and body mass index (BMI) from adolescence to adulthood in a nationally representative sample. DESIGN: Three waves of data from the National Longitudinal Study of Adolescent Health were used to assess the bedtimes and BMI of 3,342 adolescents between 1994 and 2009. Hypotheses were tested with hierarchical linear models using a two-level, random intercept and slopes model. RESULTS: Later average bedtime during the workweek, in hours, from adolescence to adulthood was associated with an increase in BMI over time (b = 0.035 kg/m(2) per min later bedtime per 6 years; standard error = 0.016; t = 2.12, degrees of freedom = 3,238, P < 0.05). These results remained significant after controlling for demographic characteristics and baseline BMI. Although sleep duration, screen time, and exercise frequency did not attenuate the relationship between workday bedtime and BMI over time, fast-food consumption was recognized as a significant partial mediator of the relationship between bedtimes and BMI longitudinally. CONCLUSIONS: The results highlight bedtimes as a potential target for weight management during adolescence and during the transition to adulthood.

Insomnia as a transdiagnostic process in psychiatric disorders.

Insomnia is a major public health concern, and is highly comorbid with a broad range of psychiatric disorders. Although insomnia has historically been considered a symptom of other disorders, this perspective has shifted. Epidemiological and experimental studies suggest that insomnia is related to the onset and course of several psychiatric disorders. Furthermore, several randomized controlled trials show that cognitive behavioral therapy for insomnia delivered to individuals who meet diagnostic criteria for insomnia and another psychiatric disorder improves the insomnia as well as the symptoms of the comorbid psychiatric disorder. Taken together, these results encompassing a range of methodologies have provided encouraging evidence and point toward insomnia as a transdiagnostic process in psychiatric disorders.

Children at risk for depression: memory biases, self-schemas, and genotypic variation.

BACKGROUND: Daughters of depressed mothers are at increased risk for developing a depressive disorder. We know relatively little, however, about the specific factors that contribute to this elevated risk. The present study investigated the effects of familial risk for depression and the 5-HTTLPR and COMT Val158Met polymorphisms, which have been associated with risk for depression, on biases in endorsement of and memory for positive and negative adjectives. METHODS: Following a negative mood induction, 60 girls between the ages of 10 and 14 who had recurrent depressed mothers (high risk for depression) and 91 age-matched daughters of never-disordered mothers (low risk for depression) completed a Self-Referent Encoding Task in which they decided whether negative and positive adjectives described them. Following the task they were asked to recall as many of the adjectives as they could. RESULTS: Despite the absence of significant group differences in endorsement of positive or negative adjectives, high-risk girls with the COMT Val158Met Val/Val polymorphism recalled more positive (but not negative) words that they had endorsed than did high-risk girls who were homozygous for the Met allele. COMT was not associated with recall of valenced adjectives in low-risk girls. Across risk groups, 5-HTTLPR polymorphism was not associated with recall of valenced adjectives. LIMITATIONS: Even with over 150 participants, there were relatively small numbers in some of the cells of this study, limiting its statistical power. CONCLUSIONS: These results suggest that assessing the interaction of familial risk status and COMT polymorphism is important in understanding the development of depressive disorders.

Basic sleep and circadian science as building blocks for behavioral interventions: a translational approach for mood disorders.

Sleep and circadian functioning has been of particular interest to researchers focused on improving treatments for psychiatric illness. The goal of the present paper is to highlight the exciting research that utilizes basic sleep and circadian science as building blocks for intervention in the mood disorders. The reviewed evidence suggests that the sleep and circadian systems are a) disrupted in the mood disorders and linked to symptoms, b) open systems that can be modified, c) the focus of interventions which have been developed to effectively treat sleep disturbance within mood disorders, and d) intimately linked with mood, such that improvements in sleep are associated with improvements in mood. Although significant positive treatment effects are evident, more research is needed to fill the gap in our basic understanding of the relationship between sleep and mood.

The effects of bedtime and sleep duration on academic and emotional outcomes in a nationally representative sample of adolescents.

PURPOSE: The overall aim of this study was to clarify and better characterize the sleep/circadian patterns of adolescents in a nationally representative sample. METHODS: We used three waves of data from the National Longitudinal Study of Adolescent Health to assess sleep/circadian patterns of 2,700 adolescents in grades seven through 12. RESULTS: Late school year bedtime was associated with shorter total sleep time cross-sectionally, whereas late summertime bedtime was not. Moreover, late school year bedtime was not associated with late summertime bedtime cross-sectionally. Late school year bedtime in Wave I (1994-1995) was associated with worse educational outcomes and emotional distress 6-8 years later. In addition, late summertime bedtime in Wave II (1996) was associated with more emotional distress at Wave III (2001-2002). Short total sleep time was not associated longitudinally with changes in emotional and academic functioning. Across Waves I and II, more than three quarters of adolescents who went to sleep at 11:15 a.m. or later during the school year or 1:30 a.m. or later during the summer reported sleeping fewer than the recommended 9 hours. CONCLUSIONS: These findings underscore the significance of evaluating and monitoring bedtime in adolescents and the importance of intervention strategies that target bedtimes in an effort to reduce associated functional impairments, and improve academic and emotional outcomes.

Circadian rhythms and psychiatric illness.

PURPOSE OF REVIEW: The present review provides a conceptual introduction to sleep and circadian research in psychiatric illness, and discusses recent experimental and intervention findings in this area. RECENT FINDINGS: In this review, studies published since January 2011 on circadian disturbance and psychiatric illness have been summarized. SUMMARY: Exciting new results have increasingly utilized objective and validated instruments to measure the circadian system in experimental studies. Since 2011, treatment research has still predominantly utilized self-report measures as outcome variables. However, research in the treatment domain for sleep/circadian disturbances comorbid with psychiatric illness has advanced the field in its work to broaden the validation of existing sleep treatments to additional patient populations with comorbid sleep/circadian disruptions and address how to increase access to and affordability of treatment for sleep and circadian dysfunction for patients with psychiatric disorders, and how to combine psychosocial treatments with psychopharmacology to optimize treatment outcomes.