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

Contents lists available at ScienceDirect

Neurology, Psychiatry and Brain Research

journal homepage: www.elsevier.com/locate/npbr

Association of mildly insufficient sleep with symptoms of anxiety and T

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

A R T I C LE I N FO A B S T R A C T

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
Insomnia
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
symptoms.

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

https://doi.org/10.1016/j.npbr.2018.03.001
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 http://www.cdc.gov/brfss 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
variable.
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
status.

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.

2
K. Sullivan, C. Ordiah
Table 2
Sex-Specific Odds of Symptoms with 1 h Insufficient Sleep.
OR (95% CI) (6 h cf. 7–9 h sleep)
Men Women
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)
Nervous 1.49 (1.27–1.74) 1.72 (1.51–1.96)
Restless 1.69 (1.44–1.98) 1.82 (1.60–2.07)
Odds of each symptom are adjusted for age, race, education, marital status,
BMI, education, employment, income.
3.3. One hour less than optimal sleep and mental health
Further analysis focused on participants who reported 6 h of sleep
daily, which isn’t as extreme of a deficiency, but isn’t necessarily suf-
ficient. While there was not as strong of an association as with severe
sleep insufficiency, one hour less than optimum sleep duration was
associated with 60–80% increased odds of each symptom compared to
optimum sleep time (Fig. 1).
3.4. Stratified analysis
Women consistently show stronger magnitudes of association than
men, with the greatest sex-disparity for the association of depression
and insufficient sleep (Table 2). The linear association between sleep
duration and # of bad mental health days was seen in both men and
women, but additional sleep time was more strongly correlated with the
frequency of mental health symptoms among women (Men β = −0.84,
95% CI −0.63 to −1.05; Women β = −1.27, 95% CI −1.07 to
−1.46).
4. Discussion
In both continuous and categorical analysis, an association between
insufficient sleep and increased odds of feeling depressed, hopeless,
restless, and nervous, was present, controlling for other covariates.
Insufficient sleep (≤5 h/day) increased the odds of these symptoms by
3–4 fold, while less than optimum but not technically insufficient sleep
(6 h/day) increased the odds of these symptoms by 60–80%.
These data provide insight into the association of psychological
symptoms and mild sleep deficiency. Many previous studies have fo-
cused on the extremes, often intentionally induced, sleep deficiency,
but chronic mild sleep restriction is more common in the general po-
pulation and these data likely offer a more accurate depiction of real
life conditions for many people. Although the odds of depression or
anxiety were not as great among this group compared to individuals
with more extreme sleep deprivation, there was an increased associa-
tion of such symptoms compared to individuals who slept for 7–9 h.
This association is further supported by the inverse association between
sleep duration and number of bad mental health days.
Several other studies have investigated effects of mild sleep depri-
vation in select populations. One study examined college students in the
last quarter of their semester and found the bulk of students who slept
for only 6 h due to study activities reported increased physical health
complaints and feelings of anxiety, depression, anger, fatigue, and
confusion (Taylor et al., 2005; Pilcher, Ginter, & Sadowsky, 1997).
Likewise, the American Cancer Society has shown individuals who slept
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
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 &
Kripke, 2004).
While the effects of insufficient sleep on mental health have been
widely studied, it is also documented that mental health disturbances
3
Neurology, Psychiatry and Brain Research 30 (2018) 1–4
can cause sleep disorders. Increased negative mood has consistently
been highlighted with respondents reporting feeling of fatigue, irrit-
ability, anxiety, depression, confusion and loss of vigor (Pilcher &
Huffcutt, 1996). A recent meta-analysis study showed that the effects
on feeling of being fatigued and mood changes are more significant
than cognitive and motor performance (Pilcher & Huffcutt, 1996).
In the present study, women appeared to have stronger associations
of negative mood and sleep deprivation compared to men, which is
similar to previous clinical studies (Voderholzer, Al-Shajlawi, & Weske,
2003) (Backhaus, Mueller-Popker, & Hajak, 1998). Previous studies
show a higher prevalence of insomnia among women, especially during
peri-menopause (Ohayon & Roth, 2003). These differences may be due
to the neurologic effects of sex hormones, but could also be a con-
sequence of depression and anxiety. Recent data have shown an ab-
sence of any difference in objective measures of sleep continuity, slow
wave sleep, and amount of REM sleep for both healthy and unhealthy
subjects with primary insomnia (Voderholzer et al., 2003). However
differences in sleep latency were noted which point towards perceptual
differences that may explain the increased prevalence of sleep dis-
turbances among women.
5. Limitations
Although this study included a large, representative sample of US
adults, it is limited by its design. As a cross-sectional study, temporality
cannot be inferred; prospective studies are needed to understand the
causal association between sleep loss and mood disturbances. The di-
rectionality of the association between sleep and mental health symp-
toms is likely to vary individually, and understanding if sleep dis-
turbance is causing mental health concerns or vice-versa is critical to
determining proper treatment. Recall bias and misclassification are
likely since data were self-reported and often subjective, relying heavily
on the perception of the individual. Also, other comorbidities or med-
ications that might have affected participants’ sleep, including possible
treatments for anxiety, depression, or sleep disorders were not avail-
able. Finally, it is important to distinguish sleep duration and sleep
quality, as they are not synonymous. Although self-reported sleep
duration in BRFSS data has been shown to be valid, the survey ques-
tions are not specific to distinguish lack of sleep opportunity from other
reasons for inadequate sleep (Jungquist et al., 2016). This limitation
might explain the small magnitude of effect observed for the association
of sleep duration and bad mental health days.
6. Conclusions
Despite these limitations, these findings provide insight into the
potential comorbidities associated with chronic, mildly insufficient
sleep. These results provide health care providers an additional sentinel
in the management of patients, and possible opportunities to address
sub-threshold symptoms. Awareness of the mental health challenges
associated with insufficient sleep is important given the interrelated
nature of these symptoms. Given the high prevalence of mildly in-
sufficient sleep and mental health concerns, providers should routinely
screen for issues in this population. Determining the directionality of
these overlapping issues offers a streamlined treatment approach to
enhance both sleep and mental health. Educating patients on the risks
of importance of optimum sleep duration may offer an opportunity to
also improve mental health. In other patients, treating mental health
concerns could yield improved sleep.
Author contributions
K.S. conceived and designed the study and conducted the analysis.
All authors contributed to interpretation of data, participated in
drafting and revising the manuscript, and gave final approval of the
version to be submitted.
K. Sullivan, C. Ordiah
Declarations of interest
None.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
References
Backhaus, J., Mueller-Popker, K., Hajak, G., et al. (1998). Prevalence, diagnosis and
treatment of insomnia in general practice. Journal of Sleep Research, 7, 13.
Centers for Disease Control and Prevention (CDC) (2012). Behavioral risk factor surveil-
lance system survey data. Atlanta, Georgia: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention.
Durmer, J. S., & Dinges, D. F. (2005). Neurocognitive consequences of sleep deprivation.
Seminars in Neurology, 25(01), 117–129. http://dx.doi.org/10.1055/s-2005-867080.
Grandner, M. A., & Kripke, D. F. (2004). Self-reported sleep complaints with long and
short sleep: A nationally representative sample. Psychosomatic Medicine, 66(2),
239–241. http://dx.doi.org/10.1097/01.psy.0000107881.53228.4d.
Hirshkowitz, M., Whiton, K., Albert, S. M., et al. (2015). National Sleep Foundation’s
updated sleep duration recommendations. Sleep Health, 1(4), 233–243.
Jungquist, C. R., Mund, J., Aquilina, A. T., Klingman, K., Pender, J., Ochs-Balcom, H.,
Neurology, Psychiatry and Brain Research 30 (2018) 1–4
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.
org/10.5664/jcsm.5570.
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
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
pills: Is increased mortality associated? Archives of General Psychiatry, 36(1),
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. http://dx.doi.org/
10.1016/s0022-3956(02)00052-3.
Pilcher, J. J., & Huffcutt, A. I. (1996). Effects of sleep deprivation on performance: A
meta-analysis. Sleep, 19(4), 318–326. http://dx.doi.org/10.1093/sleep/19.4.318.
Pilcher, J. J., Ginter, D. R., & Sadowsky, B. (1997). Sleep quality versus sleep quantity:
Relationships between sleep and measures of health, well-being and sleepiness in
college students. Journal of Psychosomatic Research, 42(6), 583–596. http://dx.doi.
org/10.1016/s0022-3999(97)00004-4.
SAS Institute Inc (2001). SAS system for windows [computer program]. Version 8. Cary, NC:
SAS Institute Inc.
Taylor, D. J., Lichstein, K. L., Durrence, H. H., et al. (2005). Epidemiology of insomnia,
depression, and anxiety. Sleep, 28(11), 1457–1464.
Voderholzer, U., Al-Shajlawi, A., Weske, G., et al. (2003). Are there gender differences in
objective and subjective sleep measures? A study of insomniacs and healthy controls.
Depression and Anxiety, 17(3), 162–172.