www.jped.com.br
ORIGINAL
ARTICLE
The
mediator
role
of
psychological
morbidity
on
sleep
and
health
behaviors
in
adolescents
夽
Silvia
Helena
Modenesi
Pucci
∗,
Maria
da
Grac
¸a
Pereira
SchoolofPsychology,UniversidadedoMinho(UMinho),Braga,Portugal
Received17November2014;accepted25March2015 Availableonline26November2015
KEYWORDS
Adolescents; Psychological morbidity; Sleep;
Healthbehaviors
Abstract
Objective: Thisstudyexaminedthemediationroleofpsychologicalmorbidity,definedinthis
studyasdepression/anxiety,intherelationshipbetweenexcessivedaytimesleepinessandsleep
quality,andbetweensleephabitsandhealthbehaviors,inadolescents.
Methods: A totalof272students,between 12and18 yearsold,underwent apsychological
protocolassessingexcessivedaytimesleepiness,sleepquality, sleephabits,healthbehavior,
andpsychologicalmorbidity.
Results: Psychologicalmorbiditywasnotassociated withtherelationshipbetweenexcessive
daytimesleepinessandsleepquality,butwasassociated,withstatisticalsignificance,inthe
relationship betweensleephabitsandhealthbehaviors.Theseresultsemphasizetheroleof
psychologicalmorbidityinadolescenthealthbehaviors.
Conclusion: Analyzingthesymptomsofdepressionandanxietyinpediatricpatientsmayhelp
inamoreaccuratediagnosis,especiallyinrelationtosleepproblemsandhealthbehaviors.
©2015SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Allrightsreserved.
PALAVRAS-CHAVE
Adolescentes; Morbidade Psicológica; Sono;
Comportamentos desaúde
Opapelmediadordamorbidadepsicológicaemhábitosdesonoecomportamentos desaúdeemadolescentes
Resumo
Objetivo: Esteestudoanalisaopapelmediadordamorbidadepsicológica,definidanesteestudo
como depressãoeansiedade,narelac¸ãoentreasonolênciadiurnaexcessivaequalidadedo
sono,eentrehábitosdesonoecomportamentosdesaúde,emadolescentes.
Método: 272Estudantes,entre12e18anos,foramentrevistadosatravésdeumprotocolode
avaliac¸ãoqueacessoudadosacercadasonolênciadiurnaexcessiva,qualidadedosono,hábitos
desono,comportamentosdesaúdeemorbidadepsicológica.
夽
Please citethisarticleas:Pucci SHM, PereiraMG.The mediatorroleof psychologicalmorbidityon sleepand health behaviorsin adolescents.JPediatr(RioJ).2016;92:53---7.
∗Correspondingauthor.
E-mail:shmpucci@gmail.com(S.H.M.Pucci).
http://dx.doi.org/10.1016/j.jped.2015.03.008
Resultados: Osresultadosmostraramqueamorbidadepsicológicanãoestavaassociada,com
significânciaestatística,narelac¸ãoentreasonolênciadiurnaexcessivaequalidadedosono,
masestavaassociada,comsignificânciaestatística,narelac¸ãoentrehábitosdesonoe
com-portamentos de saúde. Esse resultado reforc¸a aimportância da morbidade psicológica nos
comportamentosdesaúdedosadolescentes.
Conclusão: Investigarsintomasdedepressãoeansiedadenasconsultaspediátricas,pode
aux-iliaroprofissionalnum diagnósticomaispreciso,principalmenteem relac¸ãoaproblemasde
sonoecomportamentosdesaúde.
©2015SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Todososdireitos
reservados.
Introduction
Adolescenceismarkedbyseveralbiopsychosocialchanges. Adolescenceisalsoaperiodwheresleepundergoesseveral structuralchanges,whichmaycauseproblemsinsleep qual-ity,andconsequently,anegativeimpactinseveralareasof anadolescent’slife,includingmental health.1 Itis known
thatsleepisessentialfortheproperfunctioningand
main-tenance of life,2 and recently it was concluded that a
majorfunctionofsleepistoallowneuronstoperformcell
maintenance.3 Despite thiscomplexfunction, adolescents
aresleeping lessthanwhatwasexpected.4Thisreduction
in quality and time of sleep may be due to several
fac-tors,includingpoorsleephabitsandpoorhealthbehaviors,
whichcanleadtonegativeconsequences,suchasexcessive
daytimesleepiness.
The lack of healthy sleep habits has been commonly
observedinstudieswithadolescents.Oneofthefactorsthat
iscloselylinkedwiththedeclineofhealthysleephabitsis
theuseofelectronics,whichhavealargenegativeimpact
onadolescent’ssleepquality5sincetheyareoneofthemain
distractionsthatcompetewithsleep.However,theproblem
may worsenwhen beyond the use of electronics,
adoles-centsmakeuseofpsychoactivesubstances,suchascaffeine
drinkstostayawakelonger,whichhaveanimpactonsleep
qualityandon daytimesleepiness.6 This typeof behavior
maybecomeaviciouscycle,i.e.,theadolescentneedsto
wakeupearlytogotoschool,willshowdaytimesleepiness
(reducedsleeptime),andthusneedscaffeinatedbeverages
tohelptostayawakeduringclass.
The literature shows a connection between excessive
daytimesleepinessandsleepdeprivation.7Moreover,a
sys-tematicreview found a strict relationship between sleep
problems and health risk behaviors, such as consumption
of psychoactive substances and unprotected sex.8
Fur-thermore,sleepproblemswereconnectedwithemotional
andbehaviorproblemsamongadolescents.8Previous
stud-ies have found that adolescents with less hours of sleep
showed higher levels of depressive symptoms and higher
prevalenceofanxietydisorders.9Literaturehasalsofound
high rates of comorbidity among adolescents that have
sleepproblems anddepression,i.e.,adolescentswho
suf-fer from sleep disorders also show depressive disorders
concomitantly.5
Arecentstudyfoundthatwhenyoungstudentshadafew
hoursofsleepduringtheweek,therewasconsiderablymore
self-reportsofcomplaintsregardinganxietyandtension.10
Ameta-analysisfoundthat20%ofadolescentssuffersfrom
depression and sleep problems.11 Literature has found a
relationship between psychological morbidity (depression
andanxietysolelyorcombined)andadolescents’sleep
dis-turbances.Psychologicalmorbidityisthedistresscausedby
thelackofphysicalandpsychologicalwell-being,whichhas
animpactontheindividual’shealth.Inthepresentpaper,
thetermpsychologicalmorbidityincludesthecombination
ofdepressionandanxiety.12
AccordingtotheStress-CopingModelfromMaesetal.13
illnessrelatedevents,diseasetreatment,anddemographic
characteristics are linked with emotional and cognitive
responses as well as coping, predicting psychological,
physical, and social consequences of illness. Coping is
also influenced by the individual’s internal and external
resources.BasedontheStress-CopingModel,inthisstudy,
emotional response was analyzed as psychological
mor-bidity, the health relatedevent considered wasexcessive
daytime sleepiness, and the psychological consequences
included both sleep quality and health behaviors. Sleep
habitswereconsidered aninternal resourcethat,through
coping, could alsoinfluence health behaviors. With these
goals in mind, the focus of this research was to analyze
the plausiblemediationroleof psychological morbidity in
therelationshipbetweenexcessivedaytimesleepinessand
sleepquality,aswell asthemediationroleof
psychologi-calmorbidityintherelationshipbetweensleephabitsand
healthbehaviors.
Methods
Participants
Measures
Pittsburgh Sleep Quality Index (PSQI).14 This instrument
assesses sleep quality during the previous month and
includes 19items.The PSQIis composedof seven
compo-nentsthatevaluatedaytimedysfunction,sleepmedication,
sleepdisturbances, sleepefficiency,sleep duration,sleep
latency, and sleep quality. Higher scores indicate worse
sleepquality.In thisstudy,only thetotalscale wasused,
andCronbach’salphawas0.60.
SleepHabits Questionnaire(SHQ).15 This 12-item
ques-tionnaire assesses the impact of behaviors that may
influencesleepinadolescents(e.g.:howmanytimesaweek
doyouplayvideo-gamesafterbedtime,howmanytimesa
weekdoyouread,study,ordohomeworkafterbedtime).
Cronbach’s alpha, in this sample, for the total scale was
0.70.
Modified Excessive Sleepiness Scale (MESSA).16 The
instrument assesses the propensity of adolescents to fall
asleepindifferentsituations,andiscomposedof13items.
Ahigherscoreindicatesthepresenceofexcessivedaytime
sleepiness.Inthisstudy,Cronbach’salphaforthetotalscale
was0.78.
Hospital Anxiety and Depression Scales (HADS).17 This
instrumentassessesthelevelsofdepressionandanxiety.It
has14itemsthatprovideapsychologicalmorbidityglobal
scalewithtwosubscales(anxietyanddepression).The
cut-offscoreforclinicaldepressionandanxietyis8,according
to the authors. The sum of the twosubscales provides a
score of psychological morbidity. In this study, only the
totalscalewasused.Cronbach’salpha,inthissample,was
0.76.
Health Behaviors Questionnaire (HBQ).18 This 24-item
instrument assesses health behaviors such as exercising,
healthydiet, oralhygiene, and regularmedicalcheckups.
Ahigherscoreindicateshealthierbehaviors. Inthisstudy,
Cronbach’salphaforthetotalscalewas0.70.
Procedure
ThestudywasapprovedbytheGeneralEducation Commit-tee. Datawascollected in twopublic high schools in the NorthofPortugal.Withineach school,classdirectorswho agreedtoparticipateofferedoneoftheirclassperiodsfor students’participation.Parentssignedaninformedconsent regarding their adolescent’s voluntary participation. The self-administeredquestionnaireswerecompletedduringthe classperiod,byoneoftheresearchers.
Dataanalysis
The calculation of sample size was based on Tabachnick and Fidell formula.19 The measurements were performed
usingthebootstrappingmethod.20 Bootstrappingis a
non-parametric statistical method, where it is possible to
achieve more accurate confidence intervals than
conven-tionalmethods. Parameterestimates werebased on3000
bootstrapsamples.Thebiascorrectedandaccelerated95%
confidenceintervalswerethenexamined,andifthe
confi-denceintervalsdidnotcontainzero,theindirecteffectwas
consideredsignificantatp<.05.
Results
Thesamplewascomposedof272highschooladolescents, between12and18yearsold(mean=15.48,SD=1.61),58% female,90%white.Ofthetotalsample,31%consumedone totwocupsofcoffee/dayand23%consumedenergydrinks. Inaddition,79%oftheadolescentshadmarriedparentsand 35%reportedhavingafamilymemberwithsleepproblems. Adolescentsreportedthat73%oftheirfathersdrankalcohol, aswellas51%oftheirmothers.Inaddition,31%offathers and15%ofmotherssmoked.
Psychologicalmorbidityasamediatorinthe relationshipbetweenexcessivedaytimesleepiness andsleepquality
Theindirecteffectofexcessivedaytimesleepinessonsleep qualitywasnot mediatedby psychologicalmorbidity (95% CI=0.009---0.047,p=ns)(Table1,Fig.1).
Psychologicalmorbidityasamediatorinthe relationshipbetweensleephabitsandhealth behaviors
Psychological morbidity was a significant mediator in the relationshipbetweensleephabitsandhealthbehaviors(95% CI=−0.044to−0.004,p=.02)(Table2,Fig.2).
Discussion
Thefirstaimofthepresentstudy wastoanalyzewhether psychological morbidity (depression and anxiety) was a mediator in the relationship between excessive daytime sleepiness and sleep quality in adolescents. The indirect effect of excessive daytime sleepiness on sleep quality wasnot mediated by psychological morbidity. This result was surprising, because as previously described, sleep is relatedtopsychologicalmorbidityinadolescentsandmood disorders.21 Studieshavefoundabidirectionalrelationship
betweenpsychologicalmorbidity,mentalhealth,andsleep
quality.22,23 Another study comparing depressed
adoles-centswithcontrolgroups,usingEEG,reportedinconsistent
Table1 Bootstrapanalysesofthestatisticalandmagnitudesignificanceofindirecteffect.
Independent variable
Mediator variable
Dependent variable
Bofmeanindirect
effect
SEofmean 95%CIofmeanindirect
effect(lowerandupper)
MESSA HADS PSQI 0.025 0.009 0.009---0.047
Psychological morbidity
Sleep quality a = –0.172a
c = 0.080a
b = –0.144a
a p ≤ 0.001. Excessive
daytime sleepiness
Figure1 Psychologicalmorbidityasamediatorintherelationshipbetweenexcessivedaytimesleepinessandsleepquality.
Table2 Bootstrapanalysesofthestatisticalandmagnitudesignificanceofindirecteffect.
Independent variable
Mediator variable
Dependent variable
Bofmeanindirect
effect
SEofmean 95%CIofmeanindirect
effect(lowerandupper)
SHQ HADS HBQ −0.021a 0.010 −0.044to−0.004
SHQ,SleepHabitsQuestionnaire;HADS,HospitalAnxietyandDepressionScale;HBQ,HealthBehaviorQuestionnaire.
aSignificantvalue.
conclusionsin termsof sleeppatterns.24 The authors
con-cludedthatnegativeruminationanddistressatbedtime,in
adolescents,further accentuatedtheinteractionbetween
psychological morbidity and insomnia. Anxiety disorders
tend tofollow the same patternsasdepression regarding
sleepproblems.Infact,adolescentswithanxietydisorders
complainaboutnighttimeawakeninganddifficultyinfalling
asleep.24 However,accordingtosomelongitudinalstudies,
sleepproblemspredictpsychologicalmorbidity,butthe
con-verseis nottrue.11 The present results arein accordance
withthosestudies,showingnocausaleffectbetween
psy-chologicalmorbidityandsleepquality.
Psychologicalmorbiditywasamediatorinthe
relation-shipbetweensleephabitsandhealthbehaviors.Paststudies
foundastrongrelationshipbetweenpsychological
morbid-ityandinternetaddiction,25 andbetweenwatchingmedia
(television,computergames,internet)andsleeppatterns.26
Furthermore,behaviorssuchasalcohol consumptionwere
alsoassociatedwithsleepproblems(e.g.insomnia),27 and
consumption ofcaffeinehasbeen associatedwiththe use
of electronics, showing an impactonthe sleepquality of
the adolescent.6 Sleep disordersimply a risk notonly for
mental health, but alsofor physical morbidity.28
Further-more, psychological morbidity (depression/anxiety), drug
consumption,andbehavioralproblemsaredifficultiesoften
reportedbyadolescentswithdisturbedsleep.29Therefore,
itcomesasnosurprisethatpsychologicalmorbidityplaysa
mediatorroleintherelationshipbetweensleephabitsand
health behaviors. Sleeprestrictionmayhave multiple risk
factors;thecumulativeburdenofthesefactorsmayaffect
the chronicity andthe frequency of sleep problems more
intensively.30
This study has several limitations that need to be
acknowledged.ThesamplewasonlyfromtheNorthofthe
country, which limits the generalization of the findings.
Cronbach’salphaofthePSQIwassatisfactory,butlow.
Fur-thermore,thesampleincludedonlyhighschooladolescents.
Futurelongitudinalstudiesshouldpursuehowpsychological
Psychological morbidity
Sleep habits
Health behaviors a = –0.058a
c = –0.006
a p ≤ 0,001. b p < 0,01.
b = 0.376b
morbidityplaysarolein theadolescent’slifestyle,andin thedevelopmentofsleepdisturbances.
The current studyhighlightsthe importanceof psycho-logical morbidity, sleep habits, and health behaviors in adolescents. According to the results, psychological mor-bidityhas an important mediatorrole betweensleep and adolescent’shealthbehaviors.Theawarenessofhealth pro-fessionalsindetectingsymptomsofdepressionandanxiety shouldbetakeninconsiderationinpediatricvisits, partic-ularly when sleepproblems and health risk behaviorsare involved.
Funding
ThepresentresearchwassupportedbyErasmusMundus15.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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