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. Author manuscript; available in PMC: 2013 Mar 16.
Published in final edited form as: J Clin Child Adolesc Psychol. 2012 Mar 16;41(4):482–490. doi: 10.1080/15374416.2012.658613

Pain and sleep-wake disturbances in adolescents with depressive disorders

Caitlin B Murray 1, Lexa K Murphy 2, Tonya M Palermo 2,3, Gregory M Clarke 4
PMCID: PMC3538877  NIHMSID: NIHMS404704  PMID: 22420746

Abstract

Objective

The aims of this study were to: 1) assess and compare sleep disturbances (including daytime and nighttime sleep patterns) in adolescents with depressive disorders and healthy peers, 2) examine the prevalence of pain in adolescents with depressive disorders and healthy peers, and 3) examine pubertal development, pain intensity and depressive symptom severity as predictors of sleep disturbance.

Method

One hundred and six adolescents (46 depressed; 60 healthy), 12-18 years (M = 15.10 years; 67% female; 77% Caucasian) completed subjective measures of sleep, pre-sleep arousal, fatigue and pain. Participants also underwent ten days of actigraphic monitoring to assess nighttime and daytime sleep duration, sleep efficiency, and wake after sleep onset.

Results

Results indicated that youth with depression exhibited greater sleep disturbances on subjective and actigraphic sleep variables than healthy controls. Depressed youth also reported more frequent and severe pain than healthy youth. Linear regression analysis indicated that pain intensity and depressive symptoms predicted worse sleep quality across groups. The interaction term was also significant, such that adolescents with high levels of depressive symptoms had poor sleep quality when pain intensity levels were high.

Conclusions

These results indicate that sleep is important to assess in youth with depression, and that pain may be an important target for sleep intervention in this population.

Keywords: Depression, adolescents, sleep, pain, actigraphy

Sleep-wake disturbances are often associated with psychiatric comorbidity in children and adolescents. In particular, more than 90% of children and adolescents with depressive disorders report sleep problems (Ryan et al., 1987). Sleep in youth with depressive disorders is of particular importance, as studies indicate sleep disturbances are associated with longer depressive episodes, more severe symptomatology, and greater risk of suicide completion (Goldstein, Bridge, & Brent, 2008; Liu et al., 2007). However, few studies have comprehensively assessed sleep disturbances in adolescents with depressive disorders.

Previous research has found that on self-report, youth with depression frequently complain of insomnia symptoms, such as difficulty falling asleep and maintaining sleep (Dahl et al., 1996). A recent study suggested that up to 53% of adolescents with depression meet diagnostic criteria for insomnia (Liu, et al., 2007). In the limited number of studies investigating sleep hygiene (e.g., sleep inhibiting/facilitating practices) in adolescents with depression, findings have demonstrated that youth with depression go to bed later despite early school start times (Gangwisch et al., 2010), and consume more caffeine compared to healthy samples (Whalen et al., 2008). A few studies have used actigraphy (a measure of motion used as a proxy for sleep) finding some evidence of sleep onset and circadian rhythm abnormalities in this population (Armitage et al., 2004; Dahl, et al., 1996). For example, one study using both EEG and actigraphic measures revealed prolonged sleep latency in adolescents with depression (Dahl, et al., 1996). Other characteristics of sleep such as fatigue and daytime sleep patterns (e.g., napping) have not yet been described in youth although identified as important in adults with depression (Foley et al., 2007).

A limited number of studies have investigated clinical factors that may be associated with sleep disturbance in adolescents with depression beyond depression severity (Liu, et al., 2007). One possible modifiable factor related to sleep disturbances in this population is somatic symptoms, particularly recurrent aches and pains. Previous studies have demonstrated high rates of comorbidity of pain complaints and depression among clinical and non-clinical samples (Campo et al., 2004; Pine, Cohen, & Brook, 1996). For example, in a study of adolescents with depression, Egger et al. (1999) found that youth with depression reported 10 to 13 times more musculoskeletal and stomach pains compared to an age- and sex-matched healthy cohort. Pain has been shown to have deleterious effects on adolescent sleep (Ohayon, 2005; Palermo, Wilson, Lewandowski, Toliver-Sokol, & Murray, 2011), yet this association has not been explored in adolescents with depressive disorders. Additionally, because some studies have indicated that biological processes underlying puberty may influence sleep patterns in adolescents (Carskadon, Vieira, & Acebo, 1993), pubertal development may also be an important determinant of sleep in depressed youth.

Therefore, we conducted this study to provide a comprehensive examination of daytime and nighttime sleep patterns and characteristics in adolescents with depressive disorders in comparison to same age healthy peers. We hypothesized that adolescents with depressive disorders would have more nighttime sleep disturbances and altered daytime sleep and fatigue as determined by actigraphy and subjective measures compared to healthy youth. We expected that adolescents with depression would experience more frequent and intense pain compared to their healthy peers. Finally, we expected that more advanced pubertal development, increased pain intensity, and greater depressive symptoms would predict worse sleep quality across both groups.

Method

Participants

Participants in the depression group were recruited from a pool of adolescents participating in an ongoing depression study at a medical center in the northwest U.S., or were identified from a pharmacy database indicating the use of antidepressants for a depressive disorder at this same medical center. Interested participants were screened by phone or in person by a member of the research team and were invited to participate in the study if they met the following criteria: (a) ages 12 to 18 years, (b) currently diagnosed major depression (MDD) or depressive disorder not otherwise specified (DNOS) using the Schedule for Affective Disorders for School-Age Children (K-SADS), (c) a score of 16 or above for males and 20 or above for females on the Center for Epidemiologic Studies Depression (CES-D) Scale, and (d) the ability to read and understand English. Exclusion criteria were (a) history of schizophrenia, acute psychotic disorders, or biopolar disorder I or II, (b) any serious comorbid chronic health condition (e.g., cancer), and (c) intellectual developmental disability. Of the 214 participants in the depression group who were screened, 134 were excluded due to ineligibility, 34 declined, and 46 were enrolled. The most common reason for ineligibility was absence of a currently diagnosed depressive disorder.

The healthy comparison group was recruited via advertisements for the study. Inclusion criteria were: (a) 12 to 18 years of age; (b) absence of depression according to CES-D cutoff and K-SADS; (c) absence of a serious chronic medical condition, a behavioral/emotional disorder, or developmental disability; (d) not currently receiving treatment for a sleep disorder; and (e) fluency in English. Of the 107 healthy participants who were screened, 41 were excluded due to ineligibility, six declined, and 60 were enrolled. The most common reason for ineligibility was diagnosis/current treatment of a behavioral/emotional disorder.

Procedure

The sponsoring institutions' Institutional Review Boards approved this study. After assessing for eligibility over the phone, written consent was obtained from caregivers and adolescents aged 18, and written assent was obtained from adolescents ages 12-17. All adolescents completed assessment batteries, described below. Parents completed a demographics form. Participants received gift certificates to local stores after completing study procedures. Parents and adolescents from both groups underwent a psychiatric interview (Children's Schedule for Affective Disorders and Schizophrenia present version [K-SADS-P]; depression, mania, psychosis, and PTSD supplements; Kaufman et al., 1997) with a member of the research team assessing adolescents' symptoms. Adolescents from both groups also completed a 10-day sleep assessment, which included actigraphy monitoring and an electronic daily sleep diary. The electronic sleep diary, completed on a Personal Digital Assistant (PDA), was used to provide self-report of sleep and to assist with actigraphy scoring (e.g., verifying records when the actiwatch was removed, daytime naps, etc.). The sleep diary included questions about bedtimes, wake times, and the frequency and duration of naps. Sleep assessment equipment was returned to study staff at the completion of the 10-day period via mail.

Measures

Demographics

Caregivers completed a demographics form assessing their adolescent's age, gender, race, and ethnicity, as well as their household income.

Pubertal development

Adolescent report of pubertal status was measured with the Pubertal Development Scale (PDS) (Petersen, Crockett, Richards, & Boxer, 1988). Responses on this 8-item measure range from 1 to 4 and are scored and categorized such that higher scores indicate more advanced pubertal status. Internal consistency in the current sample was adequate (α =.75 and .65 for boys and girls, respectively).

Depression

Depression was assessed using both a structured diagnostic interview (K-SADS) and a symptom questionnaire. The K-SADS is a semi-structured DSM-IV-based diagnostic interview to establish that the participant met criteria for major depression or depression not otherwise specified (DNOS). The K-SADS has shown excellent test-retest reliability and validity (Kaufman et al., 1997). Additionally, adolescents reported depressive symptoms in the past week using the Center for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977). The CES-D is scored by summing all items for a total score (0-60). Higher scores on this measure indicate more depressive symptoms. The CES-D has demonstrated adequate test-retest reliability as well as validity (Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000; Radloff, 1977). The internal consistency in the current sample was good (α = .83).

Pain

Using a body diagram, adolescents marked all locations where they experienced pain during the past three months, and indicated the location they most frequently experienced pain. Adolescents also rated their usual pain intensity, frequency, duration and location in the past three months. Pain intensity was assessed with an 11-point Numerical Rating Scale (0 = no pain to 10 = worst pain possible), which has demonstrated adequate reliability and validity in children and adolescents (von Baeyer, 2009). Pain frequency was rated on a 7-point scale (0 = not at all to 6 = daily) and pain duration was rated on a 4-point scale (1 = less than an hour to 4 = all day).

Sleep and Fatigue Characteristics

Actigraphic Measures

The Actiwatch 64 (Phillips Respironics) was used to assess sleep patterns. The actiwatch is a wristwatch-like device that records sleep-wake patterns by monitoring movement (or lack of movement). Previous research indicates that at least five nights of actigraphy recording are necessary to obtain reliable sleep measures (Acebo et al., 1999). Participants in this study were asked to wear the Actiwatch continuously for ten consecutive days and wore it for an average of 9.33 days, (SD = 1.71).

Sleep measures obtained from actigraphy monitoring included: (1) total sleep time or the total amount of sleep in minutes each participant received from sleep onset to offset; (2) wake minutes after sleep onset (WASO), the total number of minutes adolescents were awake from sleep onset to offset; (3) sleep efficiency or the ratio of estimated total sleep time and total time spent in bed (expressed as a percentage) with values closer to 100 representing good sleep efficiency; and (4) daytime sleep duration (e.g., naps). Information about nap duration and number of adolescents who napped during their assessment was drawn from daytime actigraphy data and verified with electronic diary reports. Mean nap durations were calculated by averaging all naps across the assessment period. Nap data was coded only if present in daytime actigraphy data and confirmed in adolescents' sleep diaries. All actigraphic sleep variables were averaged over each participant's total assessment period.

Subjective Measures

Sleep Quality

Sleep quality was assessed with the Adolescent Sleep Wake Scale (ASWS; (LeBourgeois, Giannotti, Cortesi, Wolfson, & Harsh, 2005). The ASWS is a 32-item self-report scale that assesses perceived quality of sleep in five behavioral dimensions: going to bed, falling asleep, maintaining sleep, reinitiating sleep, and returning to wakefulness. Items assess the occurrence and frequency of various sleep behaviors in the past month along a 6-point scale (1 = never to 6 = always) with higher scores indicating better sleep quality. The internal consistency in the current sample was good (α = .81).

Insomnia

Insomnia was assessed with two items drawn from the ASWS: difficulty falling asleep (“I have trouble going to sleep”) and difficulty maintaining sleep (“After waking up during the night, I have trouble going back to sleep”). If adolescents responded “quite often,” “frequently, if not always,” or “always” to either one of these questions (indicating that this occurred > 60% of the time), they were considered to have insomnia symptoms. Thus, presence of insomnia symptoms (yes/no) was coded as a dichotomous variable. These criteria have been used in previous studies in adolescent populations (Palermo, Toliver-Sokol, Fonareva, & Koh, 2007; Palermo, et al., 2011).

Pre-sleep arousal

Adolescents reported pre-sleep arousal on the 16-item Pre-Sleep Arousal Scale (PSAS) (Nicassio, Mendlowitz, Fussell, & Petras, 1985) which measures the presence and intensity of somatic and cognitive arousal experienced prior to sleep onset during a typical week. Responses are scored using a 5-point scale (1 = not at all to 5 = extremely), with higher scores indicating greater arousal before bedtime. Somatic arousal was assessed with questions pertaining to somatic symptoms (i.e., tense muscles, cold extremities, heart palpitations) prior to sleep onset. Cognitive arousal was assessed with questions pertaining to worry, anxiety, and racing thoughts at bedtime. Adequate internal consistency has been established and test-retest reliability has been reported in healthy adolescents (Gregory, Willis, Wiggs, & Harvey, 2008). In this study, we used a slightly modified version used previously in work with adolescents (Palermo, et al., 2007; Palermo, et al., 2011). Reliability was excellent for the total scale in the current sample (α = .91).

Sleep Hygiene

Sleep hygiene was measured with the Adolescent Sleep Hygiene Scale (ASHS) (LeBourgeois, et al., 2005). The ASHS is a 24-item self-report scale that assesses sleep-facilitating and sleep-inhibiting practices in six conceptual dimensions: physiological (e.g., being very active one hour before bedtime), cognitive (e.g., doing things in bed like watching TV and reading), emotional (e.g., worrying about things happening at home or at school in bed), sleep environment (e.g., falling asleep in a brightly lit room), substances (e.g., having drinks with caffeine in the evening), and sleep stability (e.g., staying up more than one hour past usual bedtime). Items are scored on a 6-point scale (1 = always to 6 = never), with higher scores indicating better sleep hygiene. The ASHS has shown good internal consistency with adolescent populations (LeBourgeois, et al., 2005); and was also high in the current sample (α = .80).

Fatigue

Fatigue was assessed via adolescent self-report with the PedsQL Multidimensional Fatigue scale (Varni, Burwinkle, & Szer, 2004). This is an 18-item scale designed to assess the presence and severity of fatigue over the past month along three domains: general fatigue, sleep/rest fatigue, and cognitive fatigue. Responses are on a five-point scale (0 = never to 4 = almost always), with higher scores indicating fewer difficulties with fatigue. This scale has demonstrated excellent reliability and validity with children and adolescents (Varni, et al., 2004); the reliability in the current sample was also excellent (α = .95).

Data Analysis

All analyses were conducted with SPSS v 19.0. T-tests, MANOVAs, and chi-squared analyses were conducted to test differences in sociodemographic characteristics, pain characteristics, fatigue and sleep variables between groups. Partial η2 was computed to determine effect sizes and interpreted using Cohen's guidelines (> 0.2 = large, > 0.1 = medium, > 0.05 small). A linear regression was conducted to test clinical predictors of sleep disturbance. Because sleep quality was highly correlated with pain intensity and depression severity (p's < .05), this sleep variable was selected over alternative sleep variables in the final regression model. None of the actigraphic sleep variables were significantly related to pain intensity. Several other covariates were examined (e.g., gender, age, use of prescription medication), however these variables were not significantly correlated with any sleep variables and thus were not included in subsequent analyses.

Results

Description of the samples

A total of 106 youth (n = 46 depression group, n = 60 healthy group), ages 12-18 (M = 15.10, SD = 1.76) participated in this study. The majority of participants were female (67.0%), Caucasian (77.4%), and from middle class households. Chi-squared and t-test analyses indicated no differences in age, gender, ethnicity, race, family income, or pubertal status between the two groups. The majority of the total sample (86.7%) was at the mid- or post-pubertal stage of development. See Table 1 for additional descriptive data (e.g., depression severity and diagnoses).

Table 1. Sociodemographic characteristics.

Characteristic Depressed (n=46) n (%) or M (SD) Healthy (n=60) n (%) or M (SD) Total (n=106) n (%) or M (SD) p
Age (mean years) 15.35 (1.85) 14.83 (1.76) 15.10 (1.76) .74
Gender .17
 Male 18 (39.1 %) 17 (28.3%) 35 (33.0%)
 Female 28 (60.9 %) 43 (71.7%) 71 (67.0%)
Child Racial Background .26
 Caucasian 35 (76.1%) 47 (78.3%) 82 (77.4%)
 African American 1 (2.2%) 7 (11.7%) 8 (7.5%)
 Amer. Indian/Alaskan 3 (6.5%) 1 (1.7%) 4 (3.8%)
 Native
 Asian 1 (2.2%) 1 (1.7%) 2 (1.9%)
 Other/biracial 6 (13.1%) 4 (6.7%) 10 (9.4%)
Family Income .26
 < $29,999 2 (4.3%) 6 (9.9%) 8 (7.6%)
 $30,000 – $49,999 7 (15.2%) 7 (11.7%) 14 (13.2%)
 $50,000 – $69,999 13 (28.2%) 13 (21.7%) 26 (24.5%)
 > $70,000 21 (45.7%) 34 (56.7%) 55 (51.9%)
 Unknown
Pubertal Development 3 (6.5%) 0 (0.0%) 3 (2.8%)
 Total score 3.25 (.71) 3.04 (.71) 3.13 (.72) .76
 Categories .51
  Prepubertal 1 (2.2%) 5 (8.5%) 6 (5.7%)
  Early pubertal 4 (8.7%) 4 (6.8%) 8 (7.6%)
  Midpubertal 23 (50.0%) 31 (52.5%) 54 (51.5%)
  Postpubertal 18 (39.1%) 19 (32.2%) 37 (35.2%)
Depression
 Severity (CES-D- Total) 30.53 (5.88) 8.34 (6.12) 16.75 (12.37) <.001
 Diagnosis (K-SADS)
  MDD 29 (63.0%) -- 29 (27.3%) --
  DNOS 17 (37.0%) -- 17 (16.0%) --
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Group differences in sleep and fatigue characteristics

Actigraphic Measures

The two groups significantly differed on all actigraphic sleep values (Wilks' lambda = .76, F(6, 93) = 4.98, p < .001); these were small effect sizes (partial η2's 0.04 – 0.07), see Table 2. The depression cohort slept significantly less than the healthy group, p = .03. Adolescents with depressive disorders also had significantly lower sleep efficiency scores and higher WASO scores compared to the healthy cohort (p < .01 and p < .05, respectively). Half of the depression group took at least one nap during the assessment period and similarly, 38.3% of the healthy group took at least one nap (p = .10). However, on average adolescents with depression spent more time napping compared to the healthy sample (p < .01).

Table 2.

Group differences in sleep and fatigue characteristics.

Sleep and Fatigue Characteristics Depressed (n=46) % or M(D) Healthy (n=60) % or M(SD) p Partial η2
Actigraphy Variables
Time asleep (min) 6hr 36.41m (46.6m) 6hr 54.14m (37.3m) .03 .04
Sleep efficiency 81.82 (6.4) 85.12 (4.0) <.01 .07
Wake after sleep onset (WASO) 73.03 (29.6) 61.49 (18.0) .01 .06
Nap duration (min) 1hr 1.44m (77.2m) 26.92 m (43.2m) <.01 .07
Subjective Values*
Sleep Hygiene (ASHS)
 Physiological 1.34 (0.6) 1.09 (0.7) .04 .03
 Cognitive 2.54 (1.0) 1.99 (0.7) <.01 .09
 Emotional 2.00 (1.0) 0.87 (0.7) <.001 .29
 Sleep Environment 1.30 (0.9) 0.65 (0.7) <.001 .12
 Substances 0.15 (0.5) 0.05 (0.3) .20 .02
 Sleep Stability 2.67 (1.1) 1.89 (0.9) <.001 .12
 Total 1.67 (0.6) 1.09 (0.4) <.001 .24
Sleep Quality (ASWS)
 Going to bed 3.08 (1.0) 4.09 (1.0) <.001 .19
 Falling asleep 3.24 (1.1) 4.48 (.8) <.001 .32
 Maintaining sleep 3.69 (1.2) 4.68 (.8) <.001 .21
 Reinitiating sleep 4.08 (1.0) 5.15 (.6) <.001 .31
 Returning to wakefulness 2.52 (.9) 3.38 (.9) <.001 .17
 Total 3.32 (.83) 4.36 (.6) <.001 .34
Pre-Sleep Arousal (PSAS)
 Cognitive 24.33 (6.9) 15.12 (4.5) <.001 .38
 Somatic 17.18 (5.6) 10.76 (2.8) <.001 .39
 Total 41.51 (11.0) 25.88 (6.6) <.001 .45
Fatigue (PedsQL - Fatigue)
 General 47.92 (18.3) 77.90 (13.2) <.001 .48
 Sleep/Rest 48.20 (15.8) 70.13 (15.8) <.001 .32
 Cognitive 44.32 (18.2) 79.10 (15.7) <.001 .52
 Total 49.07 (14.9) 86.91 (13.3) <.001 .52
Insomnia (from ASWS)
 1) Difficulty falling asleep (>60% time) 28 (66.6%) 11 (18.6%) <.001 .44
 2) Difficulty staying asleep (>60% time) 19 (43.2%) 5 (8.5%) <.001 .36
 Either 1) or 2) 32 (72.7%) 13 (22.0%) <.001 .48
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*

N=45 (depressed group); 49 (healthy group)

Subjective Measures

Compared to healthy peers, adolescents with depression self-reported poorer sleep including worse sleep hygiene (Wilks' lambda = .63, F(6,96) = 9.45, p < .001), poorer sleep quality (Wilks' lambda = .63, F(5,98) = 11.40, p < .001), higher pre-sleep arousal (Wilks' lambda = .56, F(2, 101) = 40.28, p < .001), and more difficulties with fatigue (Wilks' lambda = .46, F(3,100) = 39.61, p < .001). The effect sizes for total scales were large (partial η2's 0.24 to .52). Insomnia was significantly more common in adolescents with depression (72.7 %) compared to healthy adolescents (22.0%; χ2 = 21.94, p <.001).

Group differences in pain

Adolescents with depression reported experiencing pain in multiple locations, most commonly the head and extremities (e.g., leg pain). These aches and pains were higher intensity (t(103) = 4.03, p < .001), occurred more frequently (t(102) = 4.23, p < .001) and lasted for longer time periods (t(101) = 2.61, p < .01) in youth with depression compared to healthy youth (see Table 3). The majority of the depression sample (58.7%) reported pain occurring at least two to three times per week over the previous three months, compared to 23.3% of the healthy sample.

Table 3. Group differences in pain.

Pain characteristic Depressed (n=46) n (%) or M (SD) Healthy (n=60) n (%) or M (SD) Total (n=106) n (%) or M (SD) p
Primary Pain Locationa
 Head 14 (30.5%) 10 (16.7%) 24 (20.8%) .73
 Abdomen 5 (10.9%) 7 (11.7%) 12 (11.3%)
 Back 9 (29.5%) 11 (18.3%) 20 (18.8%)
 Chest 1 (2.2%) 4 (6.7%) 5 (4.7%)
 Extremities 14 (30.4%) 16 (26.7%) 30 (26.3%)
 No Location 3 (6.5%) 12 (20.0%) 15 (14.1%)
Usual Pain Intensityb 4.78 (2.09) 3.12 (2.08) 3.81 (2.21) <.001
Pain Frequencyc
 None 3 (6.5%) 10 (16.6%) 13 (12.3%) <.001
 <1×/mo 2 (4.3%) 14 (23.3%) 16 (15.1%)
 <1-3×/mo 8 (17.4%) 13 (21.7%) 21 (19.8%)
 Once a week 6 (13.0%) 9 (15.0%) 15 (14.2%)
 2-3 ×/week 11 (23.9%) 8 (13.3%) 19 (17.9%)
 3-6 ×/week 7 (15.2%) 4 (6.7%) 11 (10.4%)
 Daily 9 (19.6%) 2 (3.3%) 11 (10.4%)
Pain Durationd
 < 1 hr 12 (26.1%) 37 (61.7%) 49 (46.2%) <.01
 A few hrs 16 (34.8%) 10 (16.7%) 26 (24.5%)
 Half the day 10 (21.7%) 6 (10.0%) 16 (15.1%)
 All day 8 (17.4%) 7 (11.7%) 15 (14.2%)
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a

Healthy n = 52,

b

Healthy n = 59;

c

Healthy n = 58;

d

Healthy n = 57

Clinical predictors of sleep quality

The linear regression model accounted for 44% of the variance in sleep quality (F(4,93) = 8.25, p < .001). Higher pain intensity (β = -0.09, p < .05) and greater depressive symptoms (β = -0.04, p < .001) predicted worse sleep quality across both groups. The interaction term was also significant (β = -0.01, p = .05). Simple slope tests revealed that adolescents with high levels of depressive symptoms (+1 SD) had poor sleep quality when pain intensity levels were high (+1 SD).

Discussion

While previous studies have found discrepancies between subjective and objective measures of sleep disturbance in depressed youth (e.g., Bertocci et al., 2005), the results of this study indicate deficits in sleep both subjectively and actigraphically. Actigraphy data indicated lower sleep efficiency, more time awake after sleep onset, and reduced total sleep time in youth with depression. Moreover, subjective sleep data demonstrated that 72.7% of adolescents in the depression group reported insomnia symptoms, slightly higher rates than those found in previous studies of youth with depression (Liu, et al., 2007; Yorbik, Birmaher, Axelson, Williamson, & Ryan, 2004).

Sleep represents an important domain of current research in adolescents with depressive disorders, yet few studies have investigated possible modifiable factors associated with sleep disturbances in this population. Results from this study indicate that the majority of our sample of adolescents with depression experienced frequent and intense pain (mainly headache and musculoskeletal pain), and that high levels of pain intensity and depression predicted worse sleep quality. These results highlight the need for future investigations to examine the potentially negative impact of recurrent pain on treatment of adolescents with depressive disorders. Adult research indicates that pain may have adverse effects on depression treatment response (Bair et al., 2004; DeVeaugh-Geiss et al., 2010), thus recognizing and managing comorbid pain may be important in enhancing treatment and remission rates in youth with depression. Additionally, although pubertal status was not related to sleep disturbance in this study, such findings may be explained by low variation in pubertal development in our study population.

A relatively understudied area of sleep research in adolescents with depression is daytime sleep disturbance, including excessive sleepiness, fatigue, and napping. Our findings suggest that adolescents with depression have high levels of fatigue across all domains (general, cognitive, and sleep/rest) and spend more time sleeping during the day compared to healthy adolescents. Within the adult literature, fatigue and depression commonly co-occur (Arnold, 2008; Leone, 2010) and their co-occurrence is related to greater functional impairment than either depression or fatigue alone (see review, Leone, 2010). The impact of adolescent fatigue and daytime sleep patterns on functional impairment in adolescents with depression deserves further exploration.

These results should be interpreted in light of this study's limitations, including sample selection and size, and cross-sectional design. Participants were recruited from a medical center in the Pacific Northwest, and do not reflect great diversity in race, ethnicity, or socioeconomic status. Because the cohort with depressive disorders was recruited from an outpatient depression center, they may not be representative of non treatment-seeking populations of adolescents with depression. In addition, research with adults and teens has supported the bi-directionality of sleep and pain, with sleep affecting subsequent pain as well as pain affecting nighttime sleep (Affleck, Urrows, Tennen, Higgins, & Abeles, 1996; Lewandowski, Palermo, De la Motte, & Fu, 2010). Future longitudinal studies are needed to further examine these interrelationships. Finally, other clinical factors not examined in this study may be important to consider in the context of sleep disturbances in youth with depression, such as anxiety. The role of anxiety symptoms will be important to consider in future studies investigating sleep and depression.

Given the prevalence and impact of sleep disturbances in adolescents with depressive disorders, further examination of the etiology of sleep dysfunction in this population is critical. Studies are emerging in the adult population indicating that treating insomnia may ameliorate the severity of depression symptomatology and other negative health-related outcomes (see Howland, 2011). Pain management could be a useful component in such cognitive-behavioral interventions. Psychological treatment studies of sleep disturbances and examination of modifiable clinical and psychosocial factors that may reduce sleep disturbances in adolescents with depression should become a priority.

References

  1. Acebo C, Sadeh A, Seifer R, Tzischinsky O, Wolfson AR, Hafer A, Carskadon MA. Estimating sleep patterns with activity monitoring in children and adolescents: how many nights are necessary for reliable measures? Sleep. 1999;22:95–103. doi: 10.1093/sleep/22.1.95. [DOI] [PubMed] [Google Scholar]
  2. Affleck G, Urrows S, Tennen H, Higgins P, Abeles M. Sequential daily relations of sleep, pain intensity, and attention to pain among women with fibromyalgia. Pain. 1996;68:363–368. doi: 10.1016/s0304-3959(96)03226-5. [DOI] [PubMed] [Google Scholar]
  3. Armitage R, Hoffmann R, Emslie G, Rintelman J, Moore J, Lewis K. Rest-activity cycles in childhood and adolescent depression. J Am Acad Child Adolesc Psychiatry. 2004;43:761–769. doi: 10.1097/01.chi.0000122731.72597.4e. [DOI] [PubMed] [Google Scholar]
  4. Arnold LM. Understanding fatigue in major depressive disorder and other medical disorders. Psychosomatics. 2008;49:185–190. doi: 10.1176/appi.psy.49.3.185. [DOI] [PubMed] [Google Scholar]
  5. Bair MJ, Robinson RL, Eckert GJ, Stang PE, Croghan TW, Kroenke K. Impact of pain on depression treatment response in primary care. Psychosomatic Medicine. 2004;66:17–22. doi: 10.1097/01.psy.0000106883.94059.c5. [DOI] [PubMed] [Google Scholar]
  6. Bertocci MA, Dahl RE, Williamson DE, Iosif AM, Birmaher B, Axelson D, Ryan ND. Subjective sleep complaints in pediatric depression: a controlled study and comparison with EEG measures of sleep and waking. Journal of the American Academy of Child & Adolescent Psychiatry. 2005;44(11):1158–1166. doi: 10.1097/01.chi.0000179057.54419.17. [DOI] [PubMed] [Google Scholar]
  7. Campo JV, Bridge J, Ehmann M, Altman S, Lucas A, Birmaher B, Brent DA. Recurrent abdominal pain, anxiety, and depression in primary care. Pediatrics. 2004;113:817–824. doi: 10.1542/peds.113.4.817. [DOI] [PubMed] [Google Scholar]
  8. Carskadon MA, Vieira C, Acebo C. Association between puberty and delayed phase preference. Sleep. 1993;16:258–262. doi: 10.1093/sleep/16.3.258. [DOI] [PubMed] [Google Scholar]
  9. Chorpita BF, Yim L, Moffitt C, Umemoto LA, Francis SE. Assessment of symptoms of DSM-IV anxiety and depression in children: a revised child anxiety and depression scale. Behaviour Research and Therapy. 2000;38:835–855. doi: 10.1016/s0005-7967(99)00130-8. [DOI] [PubMed] [Google Scholar]
  10. Dahl RE, Ryan ND, Matty MK, Birmaher B, al-Shabbout M, Williamson DE, Kupfer DJ. Sleep onset abnormalities in depressed adolescents. Biological Psychiatry. 1996;39:400–410. doi: 10.1016/0006-3223(95)00190-5. [DOI] [PubMed] [Google Scholar]
  11. DeVeaugh-Geiss AM, West SL, Miller WC, Sleath B, Gaynes BN, Kroenke K. The adverse effects of comorbid pain on depression outcomes in primary care patients: results from the ARTIST trial. Pain Med. 2010;11:732–741. doi: 10.1111/j.1526-4637.2010.00830.x. [DOI] [PubMed] [Google Scholar]
  12. Egger HL, Costello EJ, Erkanli A, Angold A. Somatic complaints and psychopathology in children and adolescents: stomach aches, musculoskeletal pains, and headaches. Journal of the American Academy of Child & Adolescent Psychiatry. 1999;38:852–860. doi: 10.1097/00004583-199907000-00015. [DOI] [PubMed] [Google Scholar]
  13. Foley DJ, Vitiello MV, Bliwise DL, Ancoli-Israel S, Monjan AA, Walsh JK. Frequent napping is associated with excessive daytime sleepiness, depression, pain, and nocturia in older adults: findings from the National Sleep Foundation ‘2003 Sleep in America’ Poll. Am J Geriatr Psychiatry. 2007;15:344–350. doi: 10.1097/01.JGP.0000249385.50101.67. [DOI] [PubMed] [Google Scholar]
  14. Gangwisch JE, Babiss LA, Malaspina D, Turner JB, Zammit GK, Posner K. Earlier parental set bedtimes as a protective factor against depression and suicidal ideation. Sleep. 2010;33:97–106. doi: 10.1093/sleep/33.1.97. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Goldstein TR, Bridge JA, Brent DA. Sleep disturbance preceding completed suicide in adolescents. Journal of Consulting and Clinical Psychology. 2008;76:84–91. doi: 10.1037/0022-006X.76.1.84. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Howland RH. Sleep interventions for the treatment of depression. J Psychosoc Nurs Mental Health Services. 2011;49:17–20. doi: 10.3928/02793695-20101208-01. [DOI] [PubMed] [Google Scholar]
  17. Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, Ryan N. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry. 1997;36:980–988. doi: 10.1097/00004583-199707000-00021. [DOI] [PubMed] [Google Scholar]
  18. LeBourgeois MK, Giannotti F, Cortesi F, Wolfson AR, Harsh J. The relationship between reported sleep quality and sleep hygiene in Italian and American adolescents. Pediatrics. 2005;115:257–265. doi: 10.1542/peds.2004-0815H. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Leone SS. A disabling combination: fatigue and depression. Br J Psychiatry. 2010;197:86–87. doi: 10.1192/bjp.bp.109.076604. [DOI] [PubMed] [Google Scholar]
  20. Lewandowski AS, Palermo TM, De la Motte S, Fu R. Temporal daily associations between pain and sleep in adolescents with chronic pain versus healthy adolescents. Pain. 2010;151:220–225. doi: 10.1016/j.pain.2010.07.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Liu X, Buysse DJ, Gentzler AL, Kiss E, Mayer L, Kapornai K, Kovacs M. Insomnia and hypersomnia associated with depressive phenomenology and comorbidity in childhood depression. Sleep. 2007;30:83–90. doi: 10.1093/sleep/30.1.83. [DOI] [PubMed] [Google Scholar]
  22. Nicassio PM, Mendlowitz DR, Fussell JJ, Petras L. The phenomenology of the pre-sleep state: the development of the pre-sleep arousal scale. Behaviour Research and Therapy. 1985;23:263–271. doi: 10.1016/0005-7967(85)90004-x. [DOI] [PubMed] [Google Scholar]
  23. Ohayon MM. Relationship between chronic painful physical condition and insomnia. J Psychiatr Res. 2005;39:151–159. doi: 10.1016/j.jpsychires.2004.07.001. [DOI] [PubMed] [Google Scholar]
  24. Palermo TM, Toliver-Sokol M, Fonareva I, Koh JL. Objective and subjective assessment of sleep in adolescents with chronic pain compared to healthy adolescents. Clinical Journal of Pain. 2007;23:812–820. doi: 10.1097/AJP.0b013e318156ca63. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Palermo TM, Wilson AC, Lewandowski AS, Toliver-Sokol M, Murray CB. Behavioral and psychosocial factors associated with insomnia in adolescents with chronic pain. Pain. 2011;152:89–94. doi: 10.1016/j.pain.2010.09.035. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Pine DS, Cohen P, Brook J. The association between major depression and headache: results of a longitudinal epidemiologic study in youth. Journal of Child and Adolescent Psychopharmacology. 1996;6:153–164. doi: 10.1089/cap.1996.6.153. [DOI] [PubMed] [Google Scholar]
  27. Radloff LS. The CES-D scale: A self-report depression measure for research in the general population. Applied Psychological Measurement. 1977;1:385–401. [Google Scholar]
  28. Ryan ND, Puig-Antich J, Ambrosini P, Rabinovich H, Robinson D, Nelson B, Twomey J. The clinical picture of major depression in children and adolescents. Archives of General Psychiatry. 1987;44:854–861. doi: 10.1001/archpsyc.1987.01800220016003. [DOI] [PubMed] [Google Scholar]
  29. Teicher MH, Glod CA, Harper D, Magnus E, Brasher C, Wren F, Pahlavan K. Locomotor activity in depressed children and adolescents: I. Circadian dysregulation. Journal of the American Academy of Child & Adolescent Psychiatry. 1993;32(4):760–769. doi: 10.1097/00004583-199307000-00009. [DOI] [PubMed] [Google Scholar]
  30. Varni JW, Burwinkle TM, Szer IS. The PedsQL Multidimensional Fatigue Scale in pediatric rheumatology: reliability and validity. Journal of Rheumatology. 2004;31:2494–2500. [PubMed] [Google Scholar]
  31. von Baeyer CL. Numerical rating scale for self-report of pain intensity in children and adolescents: recent progress and further questions. European Journal of Pain. 2009;13:1005–1007. doi: 10.1016/j.ejpain.2009.08.006. [DOI] [PubMed] [Google Scholar]
  32. Yorbik O, Birmaher B, Axelson D, Williamson DE, Ryan ND. Clinical characteristics of depressive symptoms in children and adolescents with major depressive disorder. Journal of Clinical Psychiatry. 2004;65:1654–1659. doi: 10.4088/jcp.v65n1210. [DOI] [PubMed] [Google Scholar]

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