Lack of Sleep Impacts Mental Health Problems Among Adolescents

New data from a study suggest sleep problems could be a contributing factor as to why adolescents get admitted to a psychiatric ward.

The findings contribute toward the evolved understanding of how lack of sleep impacts psychiatric health, such as in previous research showing its association with increased risk of suicide.

“The moderate to large association between insomnia severity and self-harm is especially important given the prominence of emotional dysregulation and suicidality as reasons for the young people’s admission,” investigators wrote. “This observed relationship supports existing findings in adolescent inpatients…and raises the possibility that improving sleep could reduce risk events for young people during admission.”

After all, sleep is crucial for mental health. Columbia psychologist Elizabeth Blake Zakarin explained, “Sleep helps maintain cognitive skills, such as attention, learning, and memory, such that poor sleep can make it much more difficult to cope with even relatively minor stressors and can even impact our ability to perceive the world accurately.”²

The mixed-methods study, led by Laura Johnsen, a doctorate in clinical psychology at the Oxford Institute of Clinical Psychology Training, contained 2 studies—all with the intention of better understanding sleep disturbances in adolescent inpatients. The investigators wanted to see if insomnia is associated with admission length to psychiatric wards.¹

The first study was a cross-sectional design with preexisting data from routine outcome measures (ROMs). All data was collected when adolescents were admitted to an inpatient ward. It was mixed gender, and adolescents were aged 11-17 years. All adolescents had inpatient assessments and treatment.

Of the 100 participating adolescents, 76 were female, 23 were male, and 1 did not prefer to say. The mean age was 15.34 years, and 81% of the adolescents reported as White British.

Adolescents took 5 assessments, each being self-reported questionnaires.

The sleep condition indicator (SCI) assessed insomnia symptoms according to the Diagnostic and Statistical Manual of Mental Disorders. In adults, a score <16 shows severe insomnia. In the present sample, the internal consistency was α = .88.

Then, the Revised Child Anxiety and Depression Scale (RCADs) assessed affective symptoms. In the sample, the internal reliability was α = .96 for anxiety and α =.91 for depression.

The Strengths and Difficulties Questionnaire (SDQ) was a mental health screening, which included the following subscales: emotional, conduct, hyperactivity, and peer difficulties. In the present sample, the internal reliability was α =.69 for conduct and α =.72 for hyperactivity.

The Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) looked at psychiatric symptoms and indicators of social functioning in children. The assessment examined 3 areas of severity: self-harm, psychotic experience, and educational difficulties.

Finally, the Borderline Personality Features Scale for Children (BPFSC-11) screened for behaviors related to borderline personality disorder, including emotional dysregulation, negative relationships, and identity problems. Here, the internal consistent for the sample was α = .88.

“Although data on borderline personality disorder symptoms were only available for a small number of young people, the observed large association with insomnia is noteworthy and consistent with previous findings from adolescent inpatients showing that sleep difficulties at admission were associated with borderline features at discharge,” the team wrote.

According to the study, the most common reason adolescents were admitted into the hospital was emotion dysregulation, anxiety/depression, and eating disorders, although one-third (n = 31) of participants were admitted after attempting suicide.

Fifty percent (n = 50) of the adolescents screened positive for insomnia on the SCI. Another 23 participants were prescribed medication to help sleep issues, such as melatonin (n = 13), zopiclone (n = 8), quetipine (n = 1), and olanzapine (n= 1).

Among these 23 adolescents, on the SCI, 74% (n = 17) scored within the clinical range for insomnia.

Then on the RCADs, 44% scored in the clinical range for depression, while 35% scored in the clinical range for anxiety.

The study discovered a significant large association between greater insomnia severity and worse depression and anxiety. The analysis also demonstrated a large association between greater insomnia severity and higher levels of borderline traits (β = -0.70; 95% CI -1.12 to -0.25).

The second study was a qualitative analysis which provided 12 clinicians perspectives on sleep problems through focus groups and semi-structured interviews. Eight clinicians were in a single focus group, and participants included nurses, health care assistants, and occupational therapists. Seven of the clinicians were female and 3 were male.

The clinician perspectives fell into 3 themes: “the experience of sleep problems for adolescent patients on the ward,” “the perceived barriers and facilitators of sleep on the ward,” and “typical management of sleep problems by clinicians.”

The team included some notes from clinicians, like “4 hours per night I mean that’s not uncommon actually in our population (sic).”

While the team found that there was no association between insomnia prolonging admission duration, they noted adolescents on average tend to have a longer inpatient stay of 116 days, while adults on average have an inpatient stay of 49 days. Even though admission length did not hold importance, the team did find that sleep impacts adolescent’s mental health.

“The high prevalence of insomnia and association with a range of psychiatric symptomatology suggests sleep disruption is a significant problem in adolescent inpatients and there may be broad benefits to offering targeted sleep treatment,” the team wrote.

References

1. ^{Johnsen L, Bird JC, Salkovskis P, James AC, Stratford HJ, Sheaves B. Sleep disruption in adolescent inpatients: prevalence, associations with clinical outcomes, and clinician perspectives [published online ahead of print, 2023 Oct 3]. J Sleep Res. 2023;e14056. doi:10.1111/jsr.14056}
2. ^{Columbia University. How Sleep Deprivation Impacts Mental Health. Columbia University Department of Psychiatry. March 16, 2022. Accessed October 3, 2023 https://www.columbiapsychiatry.org/news/how-sleep-deprivation-affects-your-mental-health}