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Sleep problems are major risk factors for the development of internalizing disorders and suicidal thoughts and behaviors in adolescents. Emerging evidence suggests that cognitive-behavioral interventions should be considered as a first-line treatment for adolescent sleep problems, and can also address associated mental health concerns. Specifically, several randomized controlled trials have demonstrated that cognitive-behavioral sleep interventions improve mental health in adolescents (particularly anxiety and depression) by improving sleep problems. Although sleep difficulties have been shown to be strong prospective predictors of suicide risk, further studies are needed that examine the efficacy of sleep improvement interventions in reducing suicidal thoughts and behaviors.

OBJECTIVE Determine whether automated changes in electronic screen color temperature of personal electronic devices is associated with changes in objective and self-reported indices of sleep and mental health in young adults, as well as determine feasibility and acceptability of the experimental manipulation. PARTICIPANTS A single-blind randomized controlled trial was conducted at a large public university in the Pacific Northwest region of the United States. Fifty-five participants (female=78%, mean age=19.45 years) who reported using a smartphone and/or laptop computer two hours before bedtime were randomized into either an experimental group (EG; n=29) or active control group (ACG; n=26). METHODS Both the EG and ACG had installed on their devices a piece of software that automatically lowers the color temperature of these devices' screens as the day progresses ("f.lux"). However, only the EG had the blue-light-reducing features activated, and participants were blind to condition. Before and after the one-week long experimental manipulation period, participants completed the Pittsburgh Sleep Quality Index (PSQI), Pediatric Daytime Sleepiness Scale (PDSS), Pre-Sleep Arousal Scale (PSAS), and Patient Health Questionnaire (PHQ) and wore an actiwatch for seven consecutive nights. RESULTS Participants in the EG did not show greater improvement in objective sleep, self-reported sleep, or mental health compared to participants in the ACG. Participants in the EG rated the software as more distracting and purposely disabled the software more often compared to participants in the ACG. CONCLUSIONS Automated diurnal variation in electronic screen temperature in personal devices did not improve sleep or mental health in young adults.

Early onset adolescent depression is related to poor prognosis and a range of psychiatric and medical comorbidities later in life, making the identification of a priori risk factors for depression highly important. Increasingly, dysregulated levels of immune and neuroendocrine markers, such as C-reactive protein (CRP) and cortisol, have been demonstrated as both precursors to and consequences of depression. However, longitudinal research with adolescent populations is limited and demonstrates mixed immuno-endocrine-depression links. This study explored the putative bidirectional relationship between salivary measures of cortisol and CRP, including the novel Cort:CRP ratio, and depression. Participants from the randomized control trial ‘Sleep and Education: learning New Skills Early’ (SENSE) Study were 122 adolescents at risk for depression (73 females) aged 12 to 16 years (M=12.71 years, SD=1.01 years) assessed at baseline (T1), post-intervention (T2), and a two-year follow-up (T3). Logistic regression results demonstrated that adolescents with higher T1 Cort:CRPmorn ratio levels were two-fold more likely to develop a first-onset depressive disorder from T2 to T3 as compared to adolescents with lower Cort:CRPmorn ratio levels, β=0.73, t(36)=2.15, p=.04, OR=2.08. This effect was not moderated by treatment condition (β=-1.38, t(13)=-1.33, p=.20) and did not change when controlling for known risk factors for depression, including sex, age, body-mass index, socio-economic status, T1 anxiety disorder, nor T1 sleep disturbance, anxiety, or depressive symptoms (β=0.91, t(31)=2.14, p=.04). Results highlight potential immuno-endocrine dysregulation as an underlying risk factor for adolescent first-onset depression, and may inform the development of targeted, preventative biobehavioral treatment strategies for youth depression.

There is robust evidence of an association between insomnia, anxiety, and depression in adolescence. The aim of this review is to describe and synthesize potential mechanisms underlying this association and explore implications for the design of adolescent behavioral sleep interventions. Specifically, we examine whether insomnia symptoms are a mechanism for the development of internalizing symptoms in adolescence and whether sleep interventions are an effective treatment for both insomnia and internalizing symptoms in adolescence because they target the shared mechanisms underlying these disorders. Research using different methodologies points to the role of sequential, parallel, and interacting mechanisms. In this paper, we review a wide range of relevant biological (i.e., polymorphisms and dysregulation in serotonin, dopamine, and circadian clock genes; alterations in corticolimbic and mesolimbic brain circuits; cortisol reactivity to stress; inflammatory cytokine dysregulation; biased memory consolidation; changes in sleep architecture), psychological (i.e., cognitive inflexibility, interpretational biases, judgment biases, negative attribution styles, worry, rumination, biased attention to threat, dysfunctional beliefs and attitudes about sleep, misperception of sleep deficit), and social mechanisms (i.e., reduced and impaired social interactions, unhelpful parenting behaviors, family stress) and propose an integrative multilevel model of how these phenomena may interact to increase vulnerability to both insomnia and internalizing disorders. Several 'biopsychosocial' mechanisms hold promise as viable treatment targets for adolescent behavioral sleep interventions, which may reduce both insomnia and internalizing symptoms.

Objective The aim of this study was to test whether a cognitive-behavioral and mindfulness-based group sleep intervention would improve behavior problems in at-risk adolescents, and whether these improvements were specifically related to improvements in sleep. Method Secondary analysis of a randomized controlled trial conducted with 123 adolescent participants (female = 60%; mean age = 14.48, range 12.04–16.31 years) who had high levels of sleep problems and anxiety symptoms. Participants were randomized into either a sleep improvement intervention (n = 63) or an active control “study skills” intervention (n = 60). Participants completed sleep and behavior problems questionnaires, wore an actiwatch and completed a sleep diary for five school nights, both before and after the intervention. Results Parallel multiple mediation models showed that postintervention improvements in social problems, attention problems, and aggressive behaviors were specifically mediated by moderate improvements in self-reported sleep quality on school nights, but were not mediated by moderate improvements in actigraphy-assessed sleep onset latency or sleep diary-measured sleep efficiency on school nights. Conclusion This study provides evidence, using a methodologically rigorous design, that a cognitive-behavioral and mindfulness-based group sleep intervention improved behavior problems in at-risk adolescent by improving perceived sleep quality on school nights. These findings suggest that sleep interventions could be directed towards adolescents with behavior problems. Clinical Trial Registration This study was part of The SENSE Study (Sleep and Education: learning New Skills Early). URL: ACTRN12612001177842; http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=ACTRN12612001177842&isBasic=True .

Rationale Early-onset adolescent depression is related to poor prognosis and a range of psychiatric and medical comorbidities later in life, making the identification of a priori risk factors for depression highly important. Increasingly, dysregulated levels of immune and neuroendocrine markers, such as C-reactive protein (CRP) and cortisol, have been demonstrated as both precursors to and consequences of depression. However, longitudinal research with adolescent populations is limited and demonstrates mixed immuno-endocrine-depression links. Objective This study explored the putative bidirectional relationship between salivary measures of cortisol (Cort) and CRP, including the novel Cort:CRP ratio and depression. Methods Participants from the randomized control trial ‘Sleep and Education: learning New Skills Early’ (SENSE) Study were 122 adolescents at risk for depression (73 females) aged 12–16 years (M = 12.71 years, SD = 1.01 years) assessed at baseline (T1), post-intervention (T2), and a two-year follow-up (T3). Results Logistic regression results demonstrated that adolescents with higher T1 Cort:CRPmorn ratio levels were two-fold more likely to develop a first-onset depressive disorder from T2 to T3 as compared to adolescents with lower Cort:CRPmorn ratio levels, β = 0.73, t (36) = 2.15, p = .04, OR = 2.08. This effect was not moderated by treatment condition (β = −1.38, t (13) = -1.33, p = .20) and did not change when controlling for known risk factors for depression, including sex, age, body-mass index, socio-economic status, T1 anxiety disorder, nor T1 sleep disturbance, anxiety, or depressive symptoms (β = 0.91, t (31) = 2.14, p = .04). Conclusion Results highlight potential immuno-endocrine dysregulation as an underlying risk factor for adolescent first-onset depression, and may inform the development of targeted, preventative biobehavioral treatment strategies for youth depression.

Author(s): Blake, Matthew J; Blake, Laura M; Schwartz, Orli; Raniti, Monika; Waloszek, Joanna M; Murray, Greg; Simmons, Julian G; Landau, Elizabeth; Dahl, Ronald E; McMakin, Dana L; Dudgeon, Paul; Trinder, John; Allen, Nicholas B | Abstract: BACKGROUND:The aim of this study was to test moderators of therapeutic improvement in an adolescent cognitive-behavioral and mindfulness-based group sleep intervention. Specifically, we examined whether the effects of the program on postintervention sleep outcomes were dependent on participant gender and/or measures of sleep duration, anxiety, depression, and self-efficacy prior to the interventions. METHOD:Secondary analysis of a randomized controlled trial conducted with 123 adolescent participants (femalen=n59.34%; mean agen=n14.48nyears, range 12.04-16.31nyears) who had elevated levels of sleep problems and anxiety symptoms. Participants were randomized into either a group sleep improvement intervention (nn=n63) or group active control 'study skills' intervention (nn=n60). The sleep intervention ('Sleep SENSE') was cognitive behavioral in approach, incorporating sleep education, sleep hygiene, stimulus control, and cognitive restructuring, but also had added anxiety-reducing, mindfulness, and motivational interviewing elements. Components of the active control intervention ('Study SENSE') included personal organization, persuasive writing, critical reading, referencing, memorization, and note taking. Participants completed the Pittsburgh Sleep Quality Index (PSQI), Spence Children's Anxiety Scale (SCAS), Center for Epidemiologic Studies Depression Scale (CES-D), and General Self-Efficacy Scale (GSE) and wore an actigraph and completed a sleep diary for five school nights prior to the interventions. Sleep assessments were repeated at postintervention. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612001177842; http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=ACTRN12612001177842aisBasic=True). RESULTS:The results showed that compared with the active control intervention, the effect of the sleep intervention on self-reported sleep quality (PSQI global score) at postintervention was statistically significant among adolescents with relatively moderate to high SCAS, CES-D, and GSE prior to the intervention, but not among adolescents with relatively low SCAS, CES-D, and GSE prior to the intervention. The results were consistent across genders. However, the effects of the sleep intervention on actigraphy-measured sleep onset latency and sleep diary-measured sleep efficiency at postintervention were not dependent on actigraphy-measured total sleep time, SCAS, CES-D, or GSE prior to the intervention. CONCLUSIONS:This study provides evidence that some sleep benefits of adolescent cognitive-behavioral sleep interventions are greatest among those with higher levels of anxiety and depressive symptoms, suggesting that this may be an especially propitious group to whom intervention efforts could be targeted. Furthermore, adolescents with lower levels of self-efficacy may need further targeted support (e.g. additional motivational interviewing) to help them reach treatment goals.

Author(s): Blake, Matthew; Schwartz, Orli; Waloszek, Joanna M; Raniti, Monika; Simmons, Julian G; Murray, Greg; Blake, Laura; Dahl, Ronald E; Bootzin, Richard; McMakin, Dana L; Dudgeon, Paul; Trinder, John; Allen, Nicholas B | Abstract: ObjectivesThe aim of this study was to test whether a cognitive behavioral and mindfulness-based group sleep intervention would improve sleep and anxiety on school nights in a sample of at-risk adolescents. We also examined whether benefits to sleep and anxiety would be mediated by improvements in sleep hygiene awareness and presleep hyperarousal.MethodsSecondary analysis of a randomized controlled trial conducted with 123 adolescent participants (female = 60%; mean age = 14.48) who had high levels of sleep problems and anxiety symptoms. Participants were randomized into a sleep improvement intervention (n = 63) or active control "study skills" intervention (n = 60). Preintervention and postintervention, participants completed the Pittsburgh Sleep Quality Index (PSQI), Spence Children's Anxiety Scale (SCAS), Sleep Beliefs Scale (SBS), and Presleep Hyperarousal Scale (PSAS) and wore an actiwatch and completed a sleep diary for five school nights.ResultsThe sleep intervention condition was associated with significantly greater improvements in actigraphy-measured sleep onset latency (SOLobj), sleep diary measured sleep efficiency (SEsubj), PSQI, SCAS, SBS, and PSAS, with medium to large effect sizes. Improvements in the PSQI and SCAS were specifically mediated by the measured improvements in the PSAS that resulted from the intervention. Improvements in SOLobj and SEsubj were not specifically related to improvements in any of the putative treatment mechanisms.ConclusionsThis study provides evidence that presleep arousal but not sleep hygiene awareness is important for adolescents' perceived sleep quality and could be a target for new treatments of adolescent sleep problems.

This systematic review and meta-analysis examined the efficacy of adolescent cognitive–behavioral sleep interventions. Searches of PubMed, PsycINFO, CENTRAL, EMBASE, and MEDLINE were performed from inception to May 1, 2016, supplemented with manual screening. Nine trials were selected (n = 357, mean age = 14.97 years; female = 61.74%). Main outcomes were subjective (sleep diary/questionnaire) and objective (actigraphy) total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE), and wake after sleep onset (WASO). There were a small number of randomized controlled trials (RCTs; n = 4) and a high risk of bias across the RCTs; therefore, within sleep condition meta-analyses were examined (n = 221). At post-intervention, subjective TST improved by 29.47 min (95% CI 17.18, 41.75), SOL by 21.44 min (95% CI −30.78, −12.11), SE by 5.34% (95% CI 2.64, 8.04), and WASO by a medium effect size [d = 0.59 (95% CI 0.36, 0.82)]. Objective SOL improved by 16.15 min (95% CI −26.13, −6.17) and SE by 2.82% (95% CI 0.58, 5.07). Global sleep quality, daytime sleepiness, depression, and anxiety also improved. Gains were generally maintained over time. Preliminary evidence suggests that adolescent cognitive–behavioral sleep interventions are effective, but further high-quality RCTs are needed. Suggestions for further research are provided.

Background Sleep problems are a major risk factor for the emergence of depression in adolescence. The aim of this study was to test whether an intervention for improving sleep habits could prevent the emergence of depression, and improve well-being and cardiovascular indices amongst at-risk adolescents. Methods/Design A longitudinal randomised controlled trial (RCT) is being conducted across Victorian Secondary Schools in Melbourne, Australia. Adolescents (aged 12–17 years) were defined as at-risk for depression if they reported high levels of anxiety and sleep problems on in-school screening questionnaires and had no prior history of depression (assessed by clinical diagnostic interview). Eligible participants were randomised into either a sleep improvement intervention (based on cognitive behavioral and mindfulness principles) or an active control condition teaching study skills. Both programs consisted of seven 90 minute-long sessions over seven weeks. All participants were required to complete a battery of mood and sleep questionnaires, seven-days of actigraphy, and sleep diary entry at pre- and post-intervention. Participants also completed a cardiovascular assessment and two days of saliva collection at pre-intervention. Participants will repeat all assessments at two-year follow up (ongoing). Discussion This will be the first efficacy trial of a selective group-based sleep intervention for the prevention of depression in an adolescent community sample. If effective, the program could be disseminated in schools and greatly improve health outcomes for anxious adolescents. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12612001177842. Date of Registration: 06-Nov-2012. Electronic supplementary material The online version of this article (doi:10.1186/s40359-015-0096-x) contains supplementary material, which is available to authorized users.