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Neurology, Psychiatry and Brain Research 30 (2018) 1–4

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Neurology, Psychiatry and Brain Research

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Association of mildly insufficient sleep with symptoms of anxiety and T


Kelly Sullivan , Collins Ordiah
Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, USA


Keywords: Objective/Background: Sleep disorders are common among people with depression and anxiety. This study ex-
Sleep duration amines the independent association of mild sleep insufficiency and symptoms of anxiety and depression among
Depression adults.
Anxiety Design/Methods: Data from the 2012 Behavioral Risk Factor Surveillance System (BRFSS), a cross-sectional
nationwide telephone-administered survey were used. Participants reported how often in the past month they
Mental health
felt nervous, hopeless, restless/fidgety, depressed, the number of days their mental health was “not good”, and
the number of hours of sleep they received per day. Covariates included age, sex, race, education, BMI, marital
status, exercise, employment and household income. Linear and ordinal logistic regression analyses included
survey weighting procedures.
Results: Data were examined for 20,851 participants (mean ± SE age = 47.47 ± 0.18 years; 49.64% men).
Each additional hour of sleep was associated with decreased odds (OR; 95% CI) of depression (0.77; 0.73–0.80),
hopelessness (0.79; 0.76–0.82), nervousness (0.80; 0.77–0.82), and feeling restlessness/fidgety (0.75; 0.72–0.77)
controlling for other covariates. Sleep duration was inversely associated with number of poor mental health days
(β = −1.06 ± 0.07 SE). One hour less than optimum sleep duration was associated with 60–80% higher odds
of depression, hopelessness, nervousness, and feeling restless/fidgety (p < 0.05).
Limitations: Temporality of these associations cannot be inferred due to the cross-sectional study design.
Conclusions: Sleep duration and mental health symptoms were strongly associated in this nation-wide, re-
presentative sample. Providers should be aware that even minor sleep insufficiency is associated with these

1. Introduction Although problems associated with severe insufficient sleep and its
association with depression, mood disorders, anxiety and psychiatric
Sleep disorders are a serious public health issue in need of increased disorders have been thoroughly elucidated over the past four decades,
awareness, as their influence on the health and social well being of very little work has been done to understand the possible association
individuals is pervasive. According to the Centers for Disease Control between mild sleep deficiencies and mood disorders. The objective of
(CDC) an estimated 50–70 million of American adults, approximately this study is to examine the association between symptoms of anxiety
25% of the population, have sleep or wakefulness disorder, which cost and depression with chronic insufficient sleep, with a focus on sleep
the US economy $30- 35 billion (Taylor, Lichstein, & Durrence, 2005). times that were less than optimal, but not technically insufficient, in
The indirect cost of sleep disorders to the economy is said to outweigh order to understand how seemingly mild sleep deficiencies could be
the direct cost in monetary terms, and greatly impacts the psychological associated with wellbeing.
and cognitive functioning of individuals.
Chronic or severe sleep problems have been linked to deficits in 2. Methods
daytime performance, fatigue, decreased immunity, depression, anxiety
disorders, worsened cognitive performance, increased accident risk, 2.1. Participants
and death (Durmer & Dinges, 2005). The effect of chronic suboptimal
sleep has been shown to have a greater impact on mood than motor, Data from the 2012 Behavioral Risk Factor Surveillance System
neuro-hormonal or cognitive function (Durmer & Dinges, 2005). (BRFSS) provided a unique opportunity to examine the correlates of this

Corresponding author at: Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, PO Box 8015, Statesboro, Georgia 30460, USA.
E-mail address: (K. Sullivan).
Received 17 January 2018; Received in revised form 28 February 2018; Accepted 27 March 2018
0941-9500/ © 2018 Elsevier GmbH. All rights reserved.
K. Sullivan, C. Ordiah Neurology, Psychiatry and Brain Research 30 (2018) 1–4

less extreme sleep deficiency. The CDC conducts this state-based survey Table 1
annually and provides a timely, reliable source of information related to Demographic, Sleep and Mood Characteristics.
health behaviors, preventive health practices and access to healthcare N = 20,851
(CDC, 2012). This telephone-administered survey includes a stratified
random sample of over 400,000 participants annually. Participants are Age (years, mean ± se) 47.47 ± 0.18
aged 18 years and older, US residents, and are not incarcerated or in- Sex Men 49.64%
Women 50.39%
stitutionalized. Detailed survey methodology and full-text ques- Education < High School 20.78%
tionnaires are available at HS grad 25.66%
Some college 30.22%
2.2. Measures College 23.35%
Marital Status Married/long-term relationship 55.84%
Not married 44.16%
Data from the inadequate sleep module provided the foundation for Exercise Yes 70.22%
the current analysis. One question asks participants “During the past No 29.78%
30 days, for about how many days have you felt you did not get enough Employed Yes 50.03%
rest or sleep?” (CDC, 2012). Participant responses were recorded as No 49.97%
Income < $35,000 63.75%
whole numbers representing the number of hours. For the present ≥$35,000 36.25%
analysis, sleep time was used as a continuous variable and was also Sleep Duration Hours daily (mean ± se) 7.04 ± 0.02
categorized based on guidelines from the National Sleep Foundation Optimum sleep (7–9 h) 60.55%
(NSF), with 7–9 h per day considered optimal, 6 h acceptable but low Low, but acceptable sleep (6 h) 23.83%
Insufficient sleep (≤5 h) 12.94%
(referred to as mildly insufficient in this analysis), and fewer than 6 h
Mental Health (in # Bad mental health days (mean ± se) 3.75 ± 0.09
deemed as insufficient (referred to as severely insufficient in this ana- past month) Depressed 24.60%
lysis) (Hirshkowitz, Whiton, & Albert, 2015). The BRFSS self-reported Hopeless 26.08%
sleep time has been shown to be a valid assessment of sleep duration Nervous 50.17%
(Jungquist et al., 2016). Restless 49.35%

Data from the Mental Health and Stigma module included the
Kessler 6 (CDC, 2012; Kessler, Green, & Gruber, 2010) to assess fre-
duration, while 12.94% reported insufficient sleep and 23.83% re-
quency of feeling nervous, hopeless, restless or fidgety and “so de-
ported low, but acceptable sleep duration (6 h).
pressed that nothing could cheer [them] up” within the past 30 days.
Participants categorized their responses as all of the time, most of the
time, some of the time, a little of the time or none of the time. Ad-
3.2. Sleep duration and mental health symptoms
ditionally, in the Healthy Days module, participants are asked to con-
sider their mental health, including stress, depression and emotional
In the linear regression model controlling for age, sex, race, edu-
problems, and estimate the number of days their mental health was not
cation, marital status, BMI, education, employment and income, sleep
good in the past month. This response was treated as a continuous
duration was inversely associated with the number of bad mental health
days (β= −1.06, 95% CI −0.91, −1.20), indicating each additional
hour of sleep correlated with nearly one more day of good mental
2.3. Analysis
health. Odds ratios examining sleep time as a continuous variable and
the ordinal presence or severity of each mental health symptom showed
Socio-demographic covariates for the analysis included age (con-
each additional hour of sleep was associated with approximately 20%
tinuous), race (white, black or other), education (less than high school,
decreased odds of mental health symptoms (depression OR (95%
high school graduate or college graduate), body mass index (BMI),
CI) = 0.77 (0.73–0.80); hopelessness OR = 0.79 (0.76–0.82); nervous-
marital status (married/cohabitating or single/widowed/divorced/se-
ness OR = 0.80 ( 0.77–0.82); feeling restlessness or fidgety OR = 0.75
parated), exercise (any or none), employment status (paid employment
(0.72–0.77), controlling for other covariates. When examining sleep
or no paid employment), and household income (less than $35,000
categorized as too little compared to optimal, that is 5 or fewer hours
annually or $35,000+ annually). Analyses were also stratified by sex in
daily compared to 7 to 9 h daily, sleeping too little was independently
order to evaluate potentially unique correlates of sleep duration and
associated with higher odds of each symptom, increasing the odds of
mood in each group. All participants with complete data for the vari-
each symptom three to four fold (Fig. 1).
ables of interest were included in the analysis. SAS software version 9.4
(SAS Institute Inc, 2001) was used to conduct linear and ordinal logistic
regression analysis incorporating survey weighting procedures. Because
depression is commonly associated with excess sleep, linear analysis
was restricted to participants who slept ≤10 h daily (which is classified
by the NSF as high, but acceptable). In order to identify the char-
acteristics independently associated with sleep duration, all covariates
were included in each model. The institutional review board of the
authors’ institution determined this study met requirements for exempt

3. Results

3.1. Sample characteristics

A total of 20,851 adults were analyzed. Demographic, sleep and

mental health characteristics of the sample are shown in Table 1. Par-
ticipants averaged 47.47 ± 0.18 (SE) years of age and 49.64% were
male. The majority of participants, 60.55%, reported optimum sleep Fig. 1. Symptoms Associated with Low Sleep Duration.

K. Sullivan, C. Ordiah Neurology, Psychiatry and Brain Research 30 (2018) 1–4

Table 2 can cause sleep disorders. Increased negative mood has consistently
Sex-Specific Odds of Symptoms with 1 h Insufficient Sleep. been highlighted with respondents reporting feeling of fatigue, irrit-
OR (95% CI) (6 h cf. 7–9 h sleep) ability, anxiety, depression, confusion and loss of vigor (Pilcher &
Huffcutt, 1996). A recent meta-analysis study showed that the effects
Men Women on feeling of being fatigued and mood changes are more significant
than cognitive and motor performance (Pilcher & Huffcutt, 1996).
Depressed 1.57 (1.26–1.95) 2.01 (1.70–2.37)
Hopeless 1.54 (1.26–1.88) 1.77 (1.51–2.08) In the present study, women appeared to have stronger associations
Nervous 1.49 (1.27–1.74) 1.72 (1.51–1.96) of negative mood and sleep deprivation compared to men, which is
Restless 1.69 (1.44–1.98) 1.82 (1.60–2.07) similar to previous clinical studies (Voderholzer, Al-Shajlawi, & Weske,
2003) (Backhaus, Mueller-Popker, & Hajak, 1998). Previous studies
Odds of each symptom are adjusted for age, race, education, marital status,
show a higher prevalence of insomnia among women, especially during
BMI, education, employment, income.
peri-menopause (Ohayon & Roth, 2003). These differences may be due
to the neurologic effects of sex hormones, but could also be a con-
3.3. One hour less than optimal sleep and mental health
sequence of depression and anxiety. Recent data have shown an ab-
sence of any difference in objective measures of sleep continuity, slow
Further analysis focused on participants who reported 6 h of sleep
wave sleep, and amount of REM sleep for both healthy and unhealthy
daily, which isn’t as extreme of a deficiency, but isn’t necessarily suf-
subjects with primary insomnia (Voderholzer et al., 2003). However
ficient. While there was not as strong of an association as with severe
differences in sleep latency were noted which point towards perceptual
sleep insufficiency, one hour less than optimum sleep duration was
differences that may explain the increased prevalence of sleep dis-
associated with 60–80% increased odds of each symptom compared to
turbances among women.
optimum sleep time (Fig. 1).
5. Limitations
3.4. Stratified analysis
Although this study included a large, representative sample of US
Women consistently show stronger magnitudes of association than adults, it is limited by its design. As a cross-sectional study, temporality
men, with the greatest sex-disparity for the association of depression cannot be inferred; prospective studies are needed to understand the
and insufficient sleep (Table 2). The linear association between sleep causal association between sleep loss and mood disturbances. The di-
duration and # of bad mental health days was seen in both men and rectionality of the association between sleep and mental health symp-
women, but additional sleep time was more strongly correlated with the toms is likely to vary individually, and understanding if sleep dis-
frequency of mental health symptoms among women (Men β = −0.84, turbance is causing mental health concerns or vice-versa is critical to
95% CI −0.63 to −1.05; Women β = −1.27, 95% CI −1.07 to determining proper treatment. Recall bias and misclassification are
−1.46). likely since data were self-reported and often subjective, relying heavily
on the perception of the individual. Also, other comorbidities or med-
4. Discussion ications that might have affected participants’ sleep, including possible
treatments for anxiety, depression, or sleep disorders were not avail-
In both continuous and categorical analysis, an association between able. Finally, it is important to distinguish sleep duration and sleep
insufficient sleep and increased odds of feeling depressed, hopeless, quality, as they are not synonymous. Although self-reported sleep
restless, and nervous, was present, controlling for other covariates. duration in BRFSS data has been shown to be valid, the survey ques-
Insufficient sleep (≤5 h/day) increased the odds of these symptoms by tions are not specific to distinguish lack of sleep opportunity from other
3–4 fold, while less than optimum but not technically insufficient sleep reasons for inadequate sleep (Jungquist et al., 2016). This limitation
(6 h/day) increased the odds of these symptoms by 60–80%. might explain the small magnitude of effect observed for the association
These data provide insight into the association of psychological of sleep duration and bad mental health days.
symptoms and mild sleep deficiency. Many previous studies have fo-
cused on the extremes, often intentionally induced, sleep deficiency, 6. Conclusions
but chronic mild sleep restriction is more common in the general po-
pulation and these data likely offer a more accurate depiction of real Despite these limitations, these findings provide insight into the
life conditions for many people. Although the odds of depression or potential comorbidities associated with chronic, mildly insufficient
anxiety were not as great among this group compared to individuals sleep. These results provide health care providers an additional sentinel
with more extreme sleep deprivation, there was an increased associa- in the management of patients, and possible opportunities to address
tion of such symptoms compared to individuals who slept for 7–9 h. sub-threshold symptoms. Awareness of the mental health challenges
This association is further supported by the inverse association between associated with insufficient sleep is important given the interrelated
sleep duration and number of bad mental health days. nature of these symptoms. Given the high prevalence of mildly in-
Several other studies have investigated effects of mild sleep depri- sufficient sleep and mental health concerns, providers should routinely
vation in select populations. One study examined college students in the screen for issues in this population. Determining the directionality of
last quarter of their semester and found the bulk of students who slept these overlapping issues offers a streamlined treatment approach to
for only 6 h due to study activities reported increased physical health enhance both sleep and mental health. Educating patients on the risks
complaints and feelings of anxiety, depression, anger, fatigue, and of importance of optimum sleep duration may offer an opportunity to
confusion (Taylor et al., 2005; Pilcher, Ginter, & Sadowsky, 1997). also improve mental health. In other patients, treating mental health
Likewise, the American Cancer Society has shown individuals who slept concerns could yield improved sleep.
for fewer than 7 h per day were 2.8 times more likely to die than their
counterparts who slept for 7–7.9 h; and those who reported sleeping for Author contributions
10 or more hours were 1.8 times likely to die than their counterpart
who slept for 7–7.9 h (Kripke, Simons, & Garfinkel, 1979; Grandner & K.S. conceived and designed the study and conducted the analysis.
Kripke, 2004). All authors contributed to interpretation of data, participated in
While the effects of insufficient sleep on mental health have been drafting and revising the manuscript, and gave final approval of the
widely studied, it is also documented that mental health disturbances version to be submitted.

K. Sullivan, C. Ordiah Neurology, Psychiatry and Brain Research 30 (2018) 1–4

Declarations of interest et al. (2016). Validation of the behavioral risk factor surveillance system sleep
questions. Journal of Clinical Sleep Medicine, 12(March (3)), 301–310. http://dx.doi.
None. Kessler, R. C., Green, J. G., Gruber, M. J., et al. (2010). Screening for serious mental
illness in the general population with the K6 screening scale: Results from the WHO
Funding World Mental Health (WMH) survey initiative. International Journal of Methods in
Psychiatric Research, 19(S1), 4–22.
Kripke, D. F., Simons, R. N., Garfinkel, L., et al. (1979). Short and long sleep and sleeping
This research did not receive any specific grant from funding pills: Is increased mortality associated? Archives of General Psychiatry, 36(1),
agencies in the public, commercial, or not-for-profit sectors. 103–116.
Ohayon, M. M., & Roth, T. (2003). Place of chronic insomnia in the course of depressive
and anxiety disorders. Journal of Psychiatric Research, 37(1), 9–15.
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