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Our findings suggest that sleep is causally related to the experience of mental health difficulties.
The extent to which sleep is causally related to mental health is unclear. One way to test the causal link is to evaluate the extent to which interventions that improve sleep quality also improve mental health. We conducted a meta-analysis of randomised controlled trials that reported the effects of an intervention that improved sleep on composite mental health, as well as on seven specific mental health difficulties. 65 trials comprising 72 interventions and N = 8608 participants were included. Improving sleep led to a significant medium-sized effect on composite mental health (g+ = −0.53), depression (g+ = −0.63), anxiety (g+ = −0.51), and rumination (g+ = −0.49), as well as significant small-to-medium sized effects on stress (g+ = −0.42), and finally small significant effects on positive psychosis symptoms (g+ = −0.26). We also found a dose response relationship, in that greater improvements in sleep quality led to greater improvements in mental health. Our findings suggest that sleep is causally related to the experience of mental health difficulties. Future research might consider how interventions that improve sleep could be incorporated into mental health services, as well as the mechanisms of action that explain how sleep exerts an effect on mental health.
Does improving sleep lead to better mental health? A meta-analysis of randomised controlled trials
Problems sleeping are common. A review of several hundred epidemiological studies [1] concluded that nearly one-third of the general population experience symptoms of insomnia (defined as difficulties falling asleep and/or staying asleep), between 4% and 26% experience excessive sleepiness, and between 2% and 4% experience obstructive sleep apnoea. Additionally, a recent study of over 2000 participants reported that the prevalence of ‘general sleep disturbances’ was 32% [2] and Chattu et al. concluded on the basis of a large systematic review of the evidence that public and health professionals need to be more aware of the adverse effects of poor sleep [3]. Mental health problems are also common, with around 17% of adults experiencing mental health difficulties of varying severities [4], and evidence from large nationally representative studies suggesting that mental health difficulties are on the increase [5]. Sleep and mental health are, therefore, global public health challenges in their own right, with each having substantive impacts on both individuals and society [3,6,7]. However, problems sleeping and mental health difficulties are also intrinsically linked [8,9]. It was previously assumed that mental health difficulties led to problems sleeping [10,11]; however, the reverse may also be true [12], such that poor sleep contributes to the onset, recurrence, and maintenance of mental health difficulties [[13]∗, [14], [15]∗, [16], [17]]. Therefore, the extent to which there is a causal relation between (poor) sleep and (worse) mental health and the possibility that interventions designed to improve sleep might be able to reduce mental health difficulties warrants investigation.
Evidence on the relationship between sleep and mental health
The association between sleep and mental health is well documented [9,13,[18], [19], [20], [21], [22], [23]∗]. For example, people with insomnia are 10 and 17 times more likely than those without insomnia to experience clinically significant levels of depression and anxiety, respectively [24]. Furthermore, a meta-analysis of 21 longitudinal studies reported that people with insomnia at baseline had a two-fold risk of developing depression at follow-up compared with people who did not experience insomnia [13]. Although research most commonly studies the associations between insomnia and depression and anxiety, there is also evidence that problems sleeping are associated with a variety of mental health difficulties. For example, poor sleep has also been associated with post-traumatic stress [25], eating disorders [26], and psychosis spectrum experiences such as delusions and hallucinations [23,27]. Studies have also found that specific sleep disorders, such as sleep apnoea [28], circadian rhythm disruption [29], restless leg syndrome [30], excessive daytime sleepiness and narcolepsy [31,32], sleepwalking [33], and nightmares [34] are all more prevalent in those experiencing mental health difficulties.
Unfortunately, most research on the association between sleep and mental health is observational in design. While informative, inferring causation from such studies is difficult. For example, cross-sectional designs tell us that variables are associated in some way, but they cannot say whether one variable precedes the other in a causal chain [35]. Longitudinal designs provide stronger evidence, but are prone to residual confounding [[36], [37], [38]] and other forms of bias that limit causal inference [[39], [40], [41], [42], [43]]. The best evidence is provided by studies that randomly allocate participants to experimental and control conditions to minimise the effects of potential confounds [44,45]. Therefore, to establish whether sleeping problems are causally associated with mental health difficulties, it is necessary to experimentally manipulate sleep to see whether changes in sleep lead to changes in mental health over time (i.e., the interventionist approach to causation, [46]).
Many RCTs have examined the effect of interventions designed to improve sleep (typically cognitive behavioural therapy for insomnia, CBTi), on mental health (typically depression and anxiety). There have also been attempts to meta-analyse some of these RCTs and quantify their effects on mental health outcomes [[47]∗, [48], [49], [50]]. However, even these meta-analyses do not permit robust conclusions as to the causal impact of sleep on mental health outcomes for several reasons. First, previous reviews have included studies that did not successfully manipulate sleep (i.e., the intervention did not improve sleep relative to controls). It is not possible to conclude whether sleep is causally linked to mental health if the experimental manipulation of sleep is unsuccessful [51]. Indeed, these studies simply tell us that it can sometimes be difficult to improve sleep in the first place. Second, reviews have tended to examine the effect of interventions targeting sleep on mental health at the first post-intervention time point. This is problematic for two reasons; 1) there is no temporal lag between the measurement of sleep and measurement of mental health (a key tenet of causal inference); and 2) effects are limited to the short-term where they are likely to be strongest. Third, the focus of previous reviews has been limited to depression and anxiety only, and typically limited to CBTi interventions. Therefore, the effect of improving sleep on other mental health outcomes, using different approaches to intervention, is limited. Finally, to date there has been no or limited attempts to investigate variables that influence – or moderate – the impact of interventions that improve sleep on mental health. It is crucial that the impact of such variables is systematically examined to understand whether the effect of improving sleep on mental health differs across populations, settings, and study designs.
The present review: an interventionist approach to causation
The present review sought to address these issues to provide an accurate and robust estimate of the effect of changes in sleep quality (i.e., as a result of an intervention) on changes in mental health. To test this empirically, we identified randomised controlled trials that successfully manipulated sleep in an intervention group relative to controls, and then measured mental health at a later follow-up point. We did not limit the scope of interventions to CBTi, or the measures of mental health to solely depression and/or anxiety. Instead, we included any intervention designed to improve sleep that produced a statistically significant effect on sleep quality relative to controls and examined the effect of that improvement in sleep on any subsequent mental health outcome. To better isolate the effect of improved sleep on mental health, we excluded interventions that included specific elements targeting mental health (e.g., CBT elements for depression). Given the (potentially) high degree of heterogeneity between studies that this approach might create, we examined the effect of different study characteristics and outcomes using moderation analyses. Our primary hypothesis is that interventions that significantly improve sleep will lead to significantly improved mental health at follow-up.
