Sleep disordered breathing symptoms are associated with depressive symptoms: A longitudinal study of Chinese adolescents
Introduction
Adolescence is a critical stage in psychophysical development from childhood to young adulthood. Depression is one of the most common mental disorders, which rising from around 5% in early adolescence to as high as 20% by the end of adolescence in the world wide (Tang et al., 2019; Thapar et al., 2012). Globally, depression is the fourth leading cause of disability among adolescents aged 15-19, and the fifteenth leading cause of disability among adolescents aged 10-14 (World Health Organization (WHO) 2020). Depressive symptoms have negative impact on academic performance, sleep, and psychosocial functioning (Baglioni et al., 2011; Shapero et al., 2013; Verboom et al., 2014), and are a significant predictor of suicidal behavior (Hawton et al., 2012).
Depressive symptoms are associated with multiple psychosocial, developmental and biological factors (Magklara et al., 2015; Malhi and Mann, 2018), and may be the consequence of the complex interaction of environmental and genetic factors (Kwong et al., 2019). Effective prevention and intervention of depressive symptoms depend on identifying modifiable risk factors. One of the potential modifiable risk factors is sleep disordered breathing (SDB) symptoms.
SDB symptoms are prevalent among adolescents, which cover a large spectrum of respiratory abnormalities from habitual snoring, to partial or complete airway obstruction, named the obstructive sleep apnea syndrome (OSAS) (Sinha and Guilleminault, 2010). The prevalence of SDB symptoms ranged from 2% to 20% in adolescents in previous studies (Bonuck et al., 2011; Johnson and Roth, 2006; Lumeng and Chervin, 2008). However, there is evidence that SDB symptoms are often overlooked and grossly underdiagnosed (Foldvary-Schaefer and Waters, 2017). Some studies have suggested that SDB symptoms are associated with depressive symptoms. Kralovic et al. found that habitual snorers had significantly more depressive symptoms than non-snorers after controlling for potential confounders in children and adolescents (ages 6-17) (Kralovic et al., 2012). However, majority of existing epidemiological studies in adolescents are cross-sectional, have a small sample size, and their conclusions are not consistent (Crabtree et al., 2004; Ting et al., 2011; Yilmaz et al., 2013). Longitudinal studies have begun to emerge (Beebe et al., 2012; Bonuck et al., 2012). For example, one population-based longitudinal study found that early-life SDB symptoms had strong effects on subsequent emotional symptoms (Bonuck et al., 2012). However, previous longitudinal studies were mainly focused on younger children and did not adjust for sleep-related variables (i.e., insomnia symptoms and sleep duration) (Beebe et al., 2012; Bonuck et al., 2012). Studies have revealed that sleep-related variables have significant impact on depressive symptoms (Liu et al., 2020a; Zhang et al., 2018). In addition, most previous studies have been mainly conducted in Western adolescents. Sleep behaviors are affected not only by biological and psychological factors but also by psychosocial, cultural and family factors (Liu et al., 2005). The findings from Western peers may not be generalized to Chinese adolescents.
Based on the previous cross-sectional and a few longitudinal studies of SDB-depressive symptoms link, we conducted a large epidemiological study in Chinese adolescents about the association between SDB symptoms and depressive symptoms. This exploratory hypothesis-generating study was condcuted to examine (1) if SDB symptoms were associated with depressive symptoms at baseline after controlling for adolescent, family factors and sleep-related variables (i.e., insomnia and night sleep duration); (2) if SDB symptoms at baseline were significant predictors of persistent (i.e., depressive symptoms at both baseline and 1-year follow-up) and incident depressive symptoms after controlling for adolescent, family factors and sleep-related variables (i.e. insomnia and night sleep duration); (3) if the associations between SDB symptoms and depressive symptoms were similar for boys and girls.
Section snippets
Participants and procedure
Shandong Adolescent Behavior and Health Cohort (SABHC) is a 3-wave longitudinal study (2015-2017) conducted in Shandong, China. In brief, three high schools and five middle schools in Shandong were selected after consideration of social demographics, representativeness of students in the region, prior study collaboration, convenience for follow-up, and budget to conduct the cohort study. A total of 11831 7-11th graders from the target schools completed a self-administered adolescent health
Sample characteristics
Among 11831 adolescents at baseline, 8629 adolescents were expected to be followed up 1 year later, and 7072 (82.0%) adolescents were resurveyed. Mean age was 14.97 (SD=1.46) at baseline and 50.9% were boys. Table 1 shows baseline adolescent and family characteristics. Most of the sample characteristics did not significantly differ between adolescents who were expected to be followed up and who were followed up successfully 1 year later (Table 2) (P > 0.05).
SDB symptoms at baseline
Table 3 shows SDB symptoms among
Discussion
To our knowledge, this is one of the few longitudinal studies of SDB and depressive symptoms in a large sample of Chinese adolescents. Our major findings are: (1) both elevated frequency of SDB symptoms (i.e., sometimes and often) and SDB score were independently associated with depressive symptoms in the cross-sectional analysis after controlling for adolescent and family covariates and sleep-related variables; (2) elevated frequency of SDB symptoms and SDB score at baseline were
Role of the funder
The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Financial disclosure
All authors have no financial relationships relevant to this article to disclose.
Authors' contribution
Cun-Xian Jia and Xianchen Liu provided the conception of research design. Shujuan Liu, Zhenzhen Liu, Zeying Wang and Baopeng Liu took part in the early investigation. Cun-Xian Jia, Zhenzhen Liu, Zeying Wang, Shuo Cheng, Baopeng Liu and Xianchen Liu participated writing-review and editing process. Shujuan Liu completed formal analyses and wrote the article. All authors contributed to and have approved the final manuscript.
Declaration of Competing Interest
All authors have no conflict of interest to disclosure.
Acknowledgments
The authors would like to thank the staffs of Lijin, Yanggu, and Zoucheng County Centers for Disease Control and Prevention and the Education Bureau for their support and help. The authors would also like to thank all students for their voluntary participation and all participating school teachers for their help with data collection in the study.
Funding
This work was funded by Shandong University School of Public Health Third Level Discipline Infrastructure Project Fund (grant No. 2017-08), and
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