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Published in final edited form as: Sleep Health. 2023 Nov 25;10(1):65–68. doi: 10.1016/j.sleh.2023.10.017

Psychosocial Factors are Associated with Sleep Disturbances and Evening Chronotype among Women: a Brief Report from the American Heart Association Go Red for Women Strategically Focused Research Network

Brooke Aggarwal a,b, Giada Benasi b,c, Nour Makarem d, Zara Mayat a, Stephanie Byun a, Ming Liao a, Elsa-Grace Giardina a
PMCID: PMC10922278  NIHMSID: NIHMS1942857  PMID: 38007300

Abstract

Objectives:

To evaluate associations between psychosocial factors and sleep characteristics commonly linked to cardiovascular disease (CVD) risk among racially/ethnically diverse women.

Methods:

Women from the AHA Go Red for Women cohort (N=506, 61% racial/ethnic minority, 37±16y) were assessed using self-reported questionnaires. Logistic regression models were adjusted for age, race, ethnicity, education, and insurance.

Results:

Women with depression had ~3-fold higher odds of short sleep (95%CI=1.69-4.61), 2-fold higher odds of poor sleep quality and OSA risk (95%CI=1.42-3.70 and 1.34-4.24), 4-fold higher odds of insomnia (95%CI=2.42-6.59), and greater likelihood of having an evening chronotype (OR:2.62, 95%CI=1.41-4.89). Low social support was associated with insomnia (OR:1.79, 95%CI=1.18-2.71) and evening chronotype (OR:2.38, 95%CI=1.35-4.19). Caregiving was associated with short sleep (OR:1.73, 95%CI=1.08-2.77) and OSA risk (OR:2.46, 95%CI=1.43-4.22).

Conclusions:

Depression, caregiver strain, and low social support are significantly associated with poor sleep and evening chronotype, highlighting a potential mechanism linking these psychosocial factors to CVD risk.

Keywords: Cardiovascular Disease Prevention, Sleep, Caregiving, Social Support, Depression, Chronotype

1. Introduction

Common forms of psychosocial distress among women, such as depression, caregiver strain, and low social support(1-3), have been linked to higher risk of CVD(4,5). One potential mechanism for this link could be the negative impact of psychosocial distress on health behaviors, including sleep.

The American Heart Association (AHA) has recently recognized short sleep duration as one of eight essential metrics of poor cardiovascular health (CVH), along with poor diet quality, low physical activity, smoking, high body mass index, and elevated blood pressure, glucose, and lipids(6). Our previous work has shown that not only sleep duration but also sleep quality, insomnia, obstructive sleep apnea (OSA), and evening chronotype are associated with poor CVH(7,8). Psychosocial distress is closely related to these sleep factors and therefore potentially impacts CVH. For example, associations have been observed between depression and inadequate sleep duration(9), insomnia and OSA(10), and evening chronotype(11). Furthermore, caregiving responsibilities and strain have been associated with an increased risk of both depression and sleep disruption(3,12), with social support mediating these relationships(2).

However, the relationships between modifiable aspects of sleep and psychosocial distress have not been fully characterized among women. Given the intertwined nature of sleep and psychosocial distress and their independent associations with CVH, it is essential to investigate these relationships to improve methodology for prevention and treatment of sleep disturbances and psychological distress with a goal to reducing CVD burden.

This study aimed to investigate the associations between psychosocial CVD risk factors (depression, social support, and caregiver strain/responsibilities) and sleep, among a community-dwelling sample of racially/ethnically diverse women. We hypothesized that depression, caregiver responsibilities and strain, and low social support would be associated with short sleep duration, poor sleep quality, insomnia symptoms, and evening chronotype.

2. Participants and Methods

2.1. Study Population and Design

This was a cross-sectional analysis of baseline data from a 1-y prospective cohort study as part of the AHA Go Red for Women Strategically Focused Research Network at Columbia University Irving Medical Center (CUIMC). This observational study evaluated sleep patterns, caregiving, lifestyle, and psychosocial risk factors, and their relation to cardiovascular health in a cohort of female community members at various life stages. The sample size of 506 was chosen to be well-powered to detect changes in the primary outcome of the parent study, which was blood pressure. Participants were English- and Spanish-speaking women aged 20-79, recruited from Northern Manhattan between July 2016 and January 2018. Women with significant cognitive impairment and those pregnant or 6-month post-partum were excluded. Of the 3,123 screened participants , 530 were eligible and provided informed consent. Of these, 506 completed the baseline visit and were included in our analyses.

All participants gave written informed consent, and the study was approved by the CUIMC Institutional Review Board.

2.2. Assessment of Psychosocial Factors

Depression and social support were assessed using the Beck Depression Inventory Second Edition (BDI-II)(13) and the ENRICHD Social Support Inventory (ESSI)(14), respectively. Caregiving was assessed by self-reported answer to the question “To what extent are you involved in the care (such as assistance with daily activities, doctor visits, and/or medication) of a family member?”. The Caregiver Strain Index (CSI)(15) was used to identify strain among caregivers.

2.3. Assessment of Outcomes

Sleep duration and quality were assessed using the Pittsburgh Sleep Quality Index (PSQI)(16). Sleep duration was defined as adequate if ≥7 hours/night and inadequate if <7 hours/night(17). Insomnia symptoms, OSA risk, and chronotype were assessed using the Insomnia Severity Index (ISI)(18), the Berlin Questionnaire(19), and the Horne-Östberg Morningness-Eveningness Questionnaire(20), respectively.

2.4. Assessment of Other Covariates

A standardized health questionnaire evaluated self-reported sociodemographic factors including age, race, ethnicity, education, and health insurance. Participants were prompted to specify their race and ethnicity, highest level of education, and type of health insurance.

2.5. Statistical Analysis

Psychosocial factors, sleep, and chronotype were evaluated categorically: depressive symptoms (BDI-II score >13 vs. ≤13); low social support (ESSI score <18/score of 2 on at least two items without regard to the total score vs. not); caregiving responsibilities (primary/most/some of the time vs. occasionally/none); high caregiver strain (CSI score ≥7 vs. <7); short sleep duration (<7 vs. ≥7 hours/night); poor sleep quality (PSQI score >5 vs. ≤5); some level of insomnia (ISI score ≥8 vs. <8); OSA risk (high vs. low); and chronotype (evening vs. morning/intermediate type).

Multivariable logistic regression models assessed associations of psychosocial factors with odds of sleep disturbances and evening chronotype, adjusted for age, race/ethnicity (racial/ethnic minority vs. White/Non-Hispanic), education (<college vs. ≥ college), and insurance (no/public vs. private) after tests for statistical significance of the univariate associations. Separate models were run for each psychosocial and sleep-related factor. SAS version 9.4 (SAS Institute, Inc, Cary, NC) was used for analyses. A 2-sided p-value <0.05 was considered statistically significant.

3. Results

Most women identified as a racial/ethnic minority (61%), were single (71%), employed/students (85%), college educated or above (77%), and had private health insurance (76%). Mean age was 37±16y, with most being ≤55 y old (81%).

Nearly 1 in 5 had depressive symptoms, 27% had low social support, 21% were caregivers, and 29% of caregivers experienced high strain. Half had short sleep duration (<7h/night), 39% poor quality sleep (PSQI score >5), 38% some level of insomnia (ISI score ≥8), and 13% had an evening chronotype.

After adjusting for confounders, women reporting depressive symptoms had ~3-fold higher odds of short sleep duration (95%CI=1.69-4.61), 2-fold higher odds of poor sleep quality (95%CI=1.42-3.70) and high OSA risk (95%CI=1.34-4.24), and 4-fold higher odds of insomnia (95%CI=2.42-6.59) (Table 1). Women with depressive symptoms were more likely to have an evening vs. morning/intermediate chronotype (OR:2.62, 95%CI=1.41-4.89). No association was found between depression and long sleep duration (≥9 h/night).

Table 1.

Multivariable associations between psychosocial factors and sleep among women (N=506)

Sleep
measures		 Depression (BDI-II
score >13)		 Low social support
(ESSI score <18 or
a score of 2 on at
least two items)		 Caregiving
responsibilities
(primary/most/some
of the time)		 High caregiver
strain (CSI score
≥7)
OR (95% CI) P-value OR (95%
CI)		 P-
value		 OR (95% CI) P-
value		 OR (95%
CI)		 P-
value
Sleep duration (<7 h/night) 2.79 (1.69-4.61) <0.0001 1.29 (0.85-1.96) 0.229 1.73 (1.08-2.77) 0.023 2.09 (0.92-4.72) 0.077
Insomnia (ISI score ≥8) 3.99 (2.42-6.59) <0.0001 1.78 (1.18-2.71) 0.007 1.36 (0.86-2.15) 0.192 1.97 (0.90-4.29) 0.088
Sleep quality (PSQI score) 2.29 (1.42-3.70) 0.0001 1.27 (0.84-1.91) 0.257 1.43 (0.90-2.27) 0.126 2.02 (0.93-4.39) 0.076
OSA (high risk on the BQ) 2.38 (1.34-4.24) 0.003 1.48 (0.87-2.50) 0.147 2.46 (1.43-4.22) 0.001 3.48 (1.52-7.94) 0.003
Chronotype (eveningness on the MEQ) 2.62 (1.41-4.89) 0.002 2.38 (1.35-4.19) 0.003 0.90 (0.43-1.88) 0.783 0.89 (0.25-3.10) 0.851
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Abbreviations: BDI-II: Beck Depression Inventory Second Edition; BQ: Berlin Questionnaire; CSI: Caregiver Strain Index; ESSI: ENRICHD Social Support Inventory; ISI: Insomnia Severity Index ;MEQ: Morningness-Eveningness Questionnaire; OSA: Obstructive Sleep Apnea; PSQI: Pittsburgh Sleep Quality Index.

Logistic models were adjusted for age, race/ethnicity, education, and health insurance.

Bold values indicate p<0.05.

Being a primary caregiver was associated with short sleep duration (OR: 1.73, 95%CI=1.08-2.77) and OSA risk (OR:2.46, 95%CI=1.43-4.22), while no associations were observed with insomnia, sleep quality, or evening chronotype. Among caregivers, those experiencing high caregiver strain had ~3-fold higher odds of OSA risk (95%CI=1.52-7.94).

Finally, low social support was associated with insomnia (OR:1.78, 95%CI=1.18-2.71) and evening chronotype (OR:2.38, 95%CI=1.35-4.19), but not with sleep duration, sleep quality, or OSA risk.

4. Discussion

Psychosocial distress and sleep problems were prevalent in our community sample of racially/ethnically diverse women. In this cohort, depressive symptoms, caregiver responsibilities and strain, and low social support were significantly associated with poor sleep patterns and evening chronotype.

Our results confirm previous associations of depressive symptoms with poor sleep and evening chronotype among women(9-11). We also found that caregivers were more likely to report short sleep duration and OSA risk, especially when experiencing caregiver strain. This aligns with systematic reviews and metaanalyses showing that, relative to non-caregivers, caregivers had shorter sleep duration(21,22). To our knowledge, the association between caregiving and OSA risk has not been previously studied. However, caregiver responsibilities can be considered a source of psychological distress, and a recent study found that patients with untreated OSA report higher depression and anxiety than healthy individuals(23). Similarly, in our study, OSA risk was associated not only with caregiver responsibilities and strain, but also with depressive symptoms.

Furthermore, we observed that low social support was associated with insomnia and evening chronotype. Despite the role of social support in sleep and chronotype having been rarely studied, our findings are in line with those of recently published studies showing higher sleep disturbances and evening chronotype in individuals reporting low perceived social support(24-26). These studies postulated that people with an evening chronotype may experience more social isolation due to being awake at hours when other are asleep(25,26), and may perceive lower levels of social support due to experiencing greater depressive symptoms, which could interfere with their ability to recognize or access social support. In line with these hypotheses, we found significant associations between evening chronotype and both depressive symptoms and low social support.

Our findings expand upon existing research by highlighting the link between sleep and psychosocial stressors that disproportionally affect women. In fact, women are not only twice as likely as men to experience major depression(27), but they also represent the majority of informal caregivers in our society, with greater risk for related psychological burden(3,12). Given the independent associations between psychosocial distress, sleep, and CVD risk(4,6-8), we propose that the observed link between psychosocial distress and poor sleep may represent a unique mechanism through which psychosocial factors influence CVD risk and a potential target for preventive interventions aimed at promoting CVH in women.

A limitation of this study is its cross-sectional design, which does not allow establishing the direction of associations between variables. It is likely that a complex association exists between psychosocial factors and sleep patterns, with many of these relationships being bi-directional. Another limitation is that our findings, while consistent with previous work, may be due to chance given the number of multiple comparisons and warrant confirmation in larger prospective studies. Finally, most women in our sample had high education levels, were employed or students, and had access to health care. Thus, the results may not be generalizable to those from different socioeconomic backgrounds. Nevertheless, study’s strengths include the substantial sample size, the ethnic/racial composition of the population, and the comprehensive characterization of psychosocial and sleep profiles using validated, widely used questionnaires. These methodological strengths enabled the investigation of the understudied complex relationship between multiple psychosocial factors and sleep characteristics in an urban setting.

5. Conclusions

In conclusion, our findings suggest significant associations between psychosocial stressors like depression, caregiver strain, and low social support with poor sleep and evening chronotype. Given the independent associations of psychosocial factors and sleep characteristics with CVD risk as observed in the literature, this highlights a potential mechanism linking psychosocial factors, or alternatively poor sleep, to CVD risk. Longitudinal observational studies should determine the temporality of these relations and inform how these associations could be leveraged in future interventions for the promotion of cardiovascular health. For instance, future studies may test whether comprehensive interventions targeting depression, social support, and/or caregiver strain may result in improved sleep patterns and better cardiometabolic health. Considering the significant role of women in caregiving, systemic policy changes, such as recognition of caregiving roles and provision of necessary resources, could also be an integral part of such interventions.

Funding:

This work was supported by a research grant from the American Heart Association (AHA16SFRN27960011) to BA. The work was also supported in part by AHA811531 (PI: BA) and Columbia University’s CTSA Grant # UL1TR001873 from NCATS, NIH. GB is supported by NIH Grant #2T32DK007559-32. NM is supported by National Heart, Lung, and Blood Institute Grant # R00-HL148511 and an American Heart Association Career Development Award (#855050). Funding agencies were not involved in study design, the collection, analysis and interpretation of data, the writing of the report, or the decision to submit the article for publication.

Footnotes

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The authors have no conflict of interest to declare.

Declarations of Interest: None.

CRediT Statement: Brooke Aggarwal: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – original draft. Giada Benasi: Writing – original draft. Nour Makarem: Data curation, Investigation, Project administration, Writing – review & editing. Zara Mayat: Data curation, Project administration, Writing – review & editing. Stephanie Byun: Data curation, Project administration, Writing – review & editing. Ming Liao: Formal analysis, Writing – review & editing. Elsa-Grace Giardina: Investigation, Resources, Writing – review & editing.

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