Sleep Dysfunction Tied to Teen Psychiatric Disorders

Sleep and circadian dysfunction are associated with anxiety, depression, and suicidality in teens and should be regarded as a modifiable treatment target.

So said four sleep experts and researchers at the virtual annual meeting of the American Academy of Sleep Medicine (AASM) and the Sleep Research Society.

Interventions targeting sleep and circadian disturbances early in adolescence, they said, may improve daily functioning and long-term outcomes of co-existing mental disorders.

Adriane Soehner, Ph.D., an assistant professor of psychiatry at the University of Pittsburgh School of Medicine, presented findings showing that neuroimaging can be used to assess gray matter maturation throughout adolescence.

Imaging can capture neural restructuring that occurs in adolescence, which may increase vulnerability to aberrations in brain development. Deviations between chronological and predicted brain age could be used to predict atypical development and perhaps the risk for or presence of psychiatric illness, Soehner said.

An emerging research effort is looking at how adolescent brains develop over time and how that development correlates with psychiatric symptoms and with healthy and disturbed sleep.

Sleep Disturbance Worsens Anxiety

About 90% of children with anxiety enter adolescence with preexisting sleep problems including trouble falling asleep, staying asleep through the night, and experiencing nightmares, said Dana McMakin, Ph.D., an associate professor of child and adolescent clinical science and cognitive neuroscience at Florida International University in Miami.

As part of their multi-year, NIMH-funded Child Anxiety Treatment Study (CATS), McMakin and colleagues at the University of Pittsburgh explored whether targeting anxiety and sleep in peripuberty resolves these problems. They assessed 134 youth aged 9 to 14 years who had anxiety and participated in 16 sessions of either cognitive-behavioral therapy or client-centered therapy for anxiety; 56% of the youth were females.

Before starting treatment, 91% of participants had significant sleep difficulties. While both anxiety therapies reduced participants’ anxiety, McMakin said, 78% of treatment completers still had clinically disturbed sleep.

Of this group, 50 youth participated in an open trial of a sleep intervention targeting bedtime thoughts, feelings, and behaviors. This six- to eight-session intervention included instruction in a novel bedtime technique called “savoring,” which aims to activate positive emotions, reduce vigilance and arousal at bedtime, and replace worry and rumination with positive thoughts.

Participants were instructed to reflect on the best moments of their day and to replay them mentally at bedtime on an imaginary personal YouTube channel. If worrisome thoughts pop up, researchers told them to switch the channel.

Participants using this technique often reported they slept better and had fewer bad dreams. Their residual anxiety decreased, and four years later it was still lower and they continued to sleep better, McMakin said. The researchers are exploring further clinical applications of the savoring technique.

Poor Sleep Linked to Suicidality

Jessica Hamilton, Ph.D., an assistant professor of psychology at Rutgers University, discussed research showing that sleep disturbances and insufficient sleep appear to predict the risk of suicidal thoughts and behaviors and completed suicide in adolescents.

According to the Centers for Disease Control and Prevention, nearly 3 in 4 U.S. high school students sleep less than the recommended minimum of eight hours on school nights. Teens who average less than eight hours of sleep a night, Hamilton said, have a three times higher risk of suicide attempts than longer-sleeping peers.

Poor sleep impairs cognitive functions including decision making, attention, and self-regulation, she said, and also heightens emotions.

With grant funding from the American Foundation for Suicide Prevention and fellowship funding from the National Heart, Lung, and Blood Institute, Hamilton and colleagues in the Department of Psychiatry at the University of Pittsburgh Medical Center recruited 40 adolescents from an intensive outpatient program for depression and suicidality. The program included group and individual therapy and medication management three days a week in three-hour sessions for three months. Participants (80% female, 88% White, mean age 14.97 years) kept daily diaries to report suicidal thoughts, the intensity of such thoughts, and responses to negative social stressors on a 0-100 scale. They also wore a watch-like device on their wrist to track times of rest and activity.

Of this group, 82% reported suicidal ideation without a plan, 70% with a plan, and 48% with intent. Given the severity of the suicidality in these youngsters, researchers monitored them closely and interacted frequently with their clinicians.

Participants averaged about seven hours of sleep a night. They experienced adverse events on 84% of the days, typically rating stressors as 57/100 that day. Nights with less sleep than usual led to greater next-day stress responses.

The study highlights the importance of studying sleep at the individual level, Hamilton said, and evaluating how short sleep heightens next-day responses to social stressors and intensity of suicidal thoughts.

Finally, Lu Dong, Ph.D., an associate behavioral scientist at Rand Corp. in Santa Monica, Calif., and Allison Harvey, Ph.D., a professor of clinical psychology at the University of California, Berkeley, assessed use of an intervention developed by Harvey—the Transdiagnostic Sleep and Circadian Intervention (TranS-C)—to target diverse sleep and circadian problems. TranS-C includes coaching to help establish regular sleep-wake times and correct unhelpful sleep-related beliefs.

In a randomized, controlled trial funded by the National Institute of Child Health and Human Development, they gave 176 “night owl” teens with habitual late bedtimes six sessions of either TranS-C or psychoeducation about sleep and health, an active information-only control. While neither group adopted earlier bedtimes, teens receiving TranS-C reported better sleep, fewer symptoms of depression, and fewer physical health complaints after completing treatment and six months later.

In this study, conducted prior to the COVID-19 pandemic, participants still had to contend with early school start times, which are out of sync with teen biological rhythms. The findings, Dong said, highlight the importance of enacting public policy changes to start schools at 8:30 a.m. or later, as recommended by the American Academy of Pediatrics, AASM, and the AMA. ■