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Journal of Affective Disorders 217 (2017) 48–54

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Journal of Affective Disorders

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Research paper

Disentangling the effects of depression on trajectories of sleep problems MARK

from adolescence through young adulthood

Ling-Yin Changa, Hsing-Yi Changa, , Linen Nymphas Linb,c, Chi-Chen Wua, Lee-Lan Yena,d
Institute of Population Health Sciences, National Health Research Institutes, Zhunan Town, Miaoli County, Taiwan
Department of Psychiatry, En Chu Kong Hospital, New Taipei, Taiwan
Department of Psychology, Chung Yuan Christian University, Taoyuan, Taiwan
Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan


Keywords: Background: Little is known about the differential influences of between- and within-person effects of depression
Depression as well as its long-term impacts on sleep problems in adolescents. This study aims to disentangle these
Adolescents differences by estimating three effects of depression (i.e., long-term, immediate, and fluctuating).
Multilevel Methods: The sample included 1345 males and 1283 females in Taiwan. In multilevel models, the between- (i.e.,
Sleep problems
long-term and immediate) and within-person (i.e., fluctuating) effects were estimated by using the average and
time-varying scores of depression, respectively. The interactions between long-term and the other effects were
also tested to determine the moderating effects of long-term influences.
Results: Significant immediate and long-term effects of depression were found for both sexes, indicating that
adolescents with higher levels of depression were at increased risks for future sleep problems. For females only,
the long-term effects further exacerbated the negative influences of immediate effects of depression on sleep
problems. Moreover, the fluctuating effects were found to change over time in females and the influences were
more pronounced in young adulthood.
Limitations: The self-reported measures of both depression and sleep problems may produce common method
variance and bias the results. Our measurements were adapted from various existing scales to increase their
applicability; therefore, the internal consistency was not high.
Conclusions: Our findings provide insight regarding who is at risk for sleep problems and when this risk would
occur based on the effects of depression. They also highlight the importance of both immediate and long-term
effects of depression on development of sleep problems.

1. Introduction 2009; Johnson et al., 2000; Shanahan et al., 2014). However, only a few
studies have prospectively examined whether depression predicts later
Depression is a highly prevalent and disabling mental condition that sleep problems (Lovato and Gradisar, 2014), and the results are mixed.
often develops during childhood and adolescence (Zahn-Waxler et al., For example, the findings of a 10-year longitudinal study revealed that
2000). Research has demonstrated that 2.6% of children and adoles- depression established in early adolescence predicted difficulty initiat-
cents worldwide (approximately 47 million) have any depressive ing sleep during young adulthood (Hayley et al., 2015). Similarly,
disorders (Polanczyk et al., 2015). Evidence has further shown that another population-based longitudinal study showed that depression in
depression is associated with other negative health and behavioral adolescents was associated with development and persistence of sleep
outcomes, including obesity (Goodman and Whitaker, 2002), substance problems 4 years later (Patten et al., 2000). However, Kelly and El-
use (Measelle et al., 2006), and antisocial behavior (Measelle et al., Sheikh (2014) found no significant association between depressive
2006). The substantial number of youths with depression and its symptoms and sleep problems. Another study (Johnson et al., 2006)
associated negative consequences have made depression a public health utilizing a retrospective design also found that depressive symptoms did
priority (Whiteford et al., 2013). not predict the onset of insomnia. Two longitudinal studies (Kalak et al.,
Depression is also considered a potential risk factor for the devel- 2014; Wang et al., 2016) examining bidirectional association between
opment of sleep problems in children and adolescents (Alfano et al., psychological well-being and sleep problems in adolescents also yielded

Correspondence to: National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County 35053, Taiwan.
E-mail address: (H.-Y. Chang).
Received 1 November 2016; Received in revised form 6 March 2017; Accepted 25 March 2017
Available online 01 April 2017
0165-0327/ © 2017 Published by Elsevier B.V.
L.-Y. Chang et al. Journal of Affective Disorders 217 (2017) 48–54

inconsistent results. Specifically, one reported that sleep duration was a varying fluctuations in depression from one's average level of depres-
predictor of psychological well-being but provided no evidence for the sion and thus is examined to determine whether adolescents display
reverse relationship (Kalak et al., 2014), whereas the other found that increased (or decreased) depression from their average levels at one
early depression were predictive of higher levels of sleep problems point in time will influence the levels of sleep problems at later point in
(Wang et al., 2016). Because of the inconsistent findings across studies, time. The immediate and long-term effects of depression are between-
the prospective association between depressive symptoms and sleep person effects that capture averaged depression during adolescence and
problems remains unclear (Lovato and Gradisar, 2014). childhood, respectively, and are examined to determine whether an
In addition, studies that have examined the association between adolescent's averaged depression during a certain period can influence
depression and sleep problems in children and adolescents have almost later development of sleep problems. Therefore, the fluctuating effects
exclusively focused on testing a severity hypothesis, investigating focus on the timing of effects and thus inform when adolescents are at
whether youths with higher levels of depression are at increased risk risk whereas immediate and long-term effects focus on individual
for sleep problems than are those with lower levels of depression, and differences, which inform who is at risk. We further tested whether
thus inform who is at risk. However, current research has seldom long-term effects interacted with other effects of depression in predict-
determined when adolescents are at risk. Specifically, it is unclear ing sleep problems.
whether adolescents will demonstrate more sleep problems during Depression and sleep problems were assessed in a subsample
times when they experience a relative increase in depression. To participated in a prospective study spanning 2001 through 2014 in
enhance the understanding of the relationship between depression northern Taiwan. Previous studies using the same dataset have explored
and sleep problems and to better inform intervention strategies, determinants and health consequences of several adolescent health
examining both who is at risk (i.e., between-person differences) and outcomes including substance use, suicidal ideation, antisocial beha-
when the risk occurs (i.e., within-person differences) is suggested vior, social anxiety, and body mass index (Chang et al., 2016, 2017;
(Curran and Wirth, 2004; Hussong et al., 2010). Chen et al., 2014; Chiang et al., 2013; Hung et al., 2011; Lee et al.,
To date, only a few studies have examined the relative influences of 2006; Lin et al., 2014; Lue et al., 2010; Wu et al., 2007, 2016). Among
between-person and within-person effects of mental health symptoms them, six publications are more related to the current study, with four
on sleep problems. For example, Kouros and El-Sheikh used a daily (Lee et al., 2006; Lue et al., 2010; Wu et al., 2007, 2016) examined
diary method and actigraphy to examine the association between daily potential predictors of depression (i.e., social capital, family interac-
mood and sleep problems in a sample of 142 children and found a tion, expressed emotion, and unhealthy eating) and another two (Chang
significant within-person effect of mood on sleep (Kouros and El- et al., 2016, 2017) examined the direct and indirect effects of sleep
Sheikh, 2015). Specifically, adolescents with worse mood than their problems on antisocial behavior. No study has yet explored the long-
average levels had significantly higher levels of sleep activity and itudinal association between depression and sleep problems using the
longer time to fall asleep, yet there were no significant between-person same dataset.
associations between mood and sleep problems. In contrast, Van Dyk Based on the above literature, our hypothesis related to the
and colleagues found that the between-person effects of mental health fluctuating effects is that adolescents display increased levels of
symptoms on sleep problems were more influential than within-person depression, over their average levels, at one point in time will show
effects in children (Van Dyk et al., 2016). The equivocal findings and higher levels of sleep problems at later point in time. Our hypothesis
methodological limitations (e.g., study design that only allows for regarding the immediate effects is that adolescents show higher levels
examination of short-term prospective associations) of the existing of depression during adolescence will have elevated levels of sleep
studies reveal the necessity for more research to understand the problems during later study period compared to adolescents who have
between-person and within-person effects of depression on sleep lower levels of depression during adolescence. For the long-term effects,
problems in adolescents. we hypothesized that adolescents with higher levels of depression
Moreover, because depression at younger ages may increase the risk during childhood will have higher levels of sleep problems in the future
and severity of depression later in life (Hankin, 2006; Nolen-Hoeksema than others who show lower levels of depression during childhood. We
et al., 1992), it is important to consider the effects of childhood further hypothesized that the long-term effects will exacerbate the
depression (i.e., the long-term effects of depression) when examining negative influences of the other two effects of depression on develop-
the association between depression and sleep problems during adoles- ment of sleep problems such that the fluctuating and immediate effects
cence and young adulthood. Specifically, in line with the perspective of of depression on trajectories of sleep problems will be stronger for
the diathesis-stress model (Ingram and Luxton, 2005), depressed adolescents with higher levels of childhood depression than those with
adolescents who also experienced symptoms of depression during lower levels of childhood depression. Because of the developmental
childhood may be at increased risk for developing sleep problems than differences during adolescence across sexes, and because the evidence
are those who did not have childhood depression. Differential risk suggests sex differences in the manifestation and prevalence of various
profiles found among individuals with varying histories of depression psychiatric disorders in youths (Hankin, 2006; Van Damme et al.,
(e.g., individuals who had depression during childhood and adulthood 2014), we examined the effects of depression on trajectories of sleep
versus those who only had depression during adulthood) (Jaffee et al., problems separately for males and females. However, we had no
2002) further implied the possibility of heterogeneity in sleep problems specific hypothesis regarding sex differences in the effects of depression
attributed to depression that occurred during childhood and/or adoles- on sleep problems, given findings from the existing studies are scarce
cence (Weissman, 2002). However, sleep research that has considered and inconsistent (Sivertsen et al., 2014; Wang et al., 2016; White et al.,
the synergy of long-term and immediate effects of depression is 2016).
currently lacking.
2. Methods
1.1. The current study
2.1. Data and sample
To fill the gaps in the literature, we aimed to examine three effects
of depression on sleep problems that we referred to as fluctuating, The study data came from the Child and Adolescent Behaviors in
immediate, and long-term effects to determine the influences of within- Long-term Evolution (CABLE) project (Yen et al., 2002), a multi-wave
person (i.e., fluctuating effects) and between-person (i.e., immediate and longitudinal study of health and risk behaviors in children and
long-term effects) differences in depression. Specifically, the fluctuating adolescents. A total of 18 elementary schools were selected from urban
effects of depression is a within-person effect that represents time- and rural areas in northern Taiwan. The first and fourth grade students

L.-Y. Chang et al. Journal of Affective Disorders 217 (2017) 48–54

were sampled and followed annually from 2001 to present. Informed economic stress was measured by an item asking about participants’
consent was obtained from the child's parent or guardian at baseline. perceptions about their family economy. The response categories
Response rates for each wave ranged between 67.11% and 95.24%. The ranged from good (1) to bad (3). An overall score of family economic
CABLE study was approved by the Internal Review Board of the stress during the study period was created by averaging the family
National Health Research Institutes (approval code: EC9009003; economic stress score at each wave from 2009 to 2014. Stressful life
EC1041109-E). events was assessed in 2009 and 2010 by a 14-item checklist that
The analysis sample was limited to those who were 14–16 years old included life events (e.g., “broken romantic relationship,””serious
in 2009 and completed any one of wave 9 through wave 14 surveys illness,” “house moving,” “parental unemployment,” “death of close
because trajectory outcomes were based on data from those six waves, family members”, “death of friends”) adapted from the Holmes and
resulting a total study sample of 2628 adolescents. Wave 8 data were Rahe Stress Scale (Holmes and Rahe, 1967). Response categories (1=
also included so that the lagged fluctuating and immediate effects of yes and 0= no) were first summed to a total score and then averaged
depression would be available for the time point prior to the start of the across 2 years to reflect a mean score of stressful life events. Higher
trajectory. Information regarding the long-term effects of depression scores indicated more stressful life events. Social anxiety was measured
was obtained during childhood (wave 1–6). Of those in the analysis with seven items adapted from the Social Anxiety Scale for Adolescents
sample, 55.56% (n=1460) participated in all six waves and 18.04% (La Greca and Lopez, 1998) at each wave from 2009 to 2014.
(n=474), 10.27% (n=270), 6.05% (n=159), and 4.87% (n=128) Participants were asked whether they had following experiences in
participated only in 5, 4, 3, and 2 waves, respectively. Attrition analyses the past two weeks: “I get nervous when I meet new people”, “I worry
showed that there was no significant difference regarding depression about being teased,” “I am afraid of talking to people I don’t know,” “I
and sleep problems between the analyzed sample and those who feel that others make fun of me,” “I am afraid that my peers talk about
dropped out of the study. me behind my back,” “I’m afraid that others will not like me,” “I am
afraid of answering questions or performing in front of many people.”
2.2. Measures Responses options ranged from 1 for “never” to 3 for “more times” and
were averaged to create a social anxiety score, with a higher score
2.2.1. Sleep problems indicating a higher level of social anxiety. Cronbach's α ranged from
During each wave from 2009 to 2014, participants self-reported 0.84 to 0.90.
sleep problems in the past month. As the original six items (i.e., “having
trouble sleeping,” “having sleep disruption,” “waking in the middle of 2.3. Analytic Strategy
the night or early morning,” “being unable to breathe comfortably,”
“having excessive daytime sleepiness,” and “taking medicine to help Data analysis involved three phases: imputation of missing data,
sleep”) used to assess sleep problems did not have satisfactory internal estimation of longitudinal trajectories of sleep problems, and hypoth-
consistency, we conducted an exploratory factor analysis using princi- esis testing. We first addressed the issue of missing data through
pal axis factoring with an oblique rotation to extract items that are multiple imputation using SAS PROC MI (SAS Institute Inc, 2011).
more representative of the construct of sleep problems. After a closer Data were stratified by sex before imputations and we followed a
examination for the content of the factors, we chose the factor with multiple imputation then deletion strategy to exclude the imputed
three items (i.e., “having trouble sleeping,” “having sleep disruption,” values of dependent variables from analyses to improve the quality of
and “waking in the middle of the night or early morning”) to indicate the estimates (von Hippel, 2007). Ten sets of missing values were
sleep problems. All responses were on a 5-point scale ranging from 1 for imputed using multiple-chain Markov Chain Monte Carlo methods.
“never” to 5 for “every day.” An overall sleep problem score was Next, we determined the optimal unconditional growth curve model
computed by averaging the three items, with higher scores indicating of sleep problems by using age as the primary metric of time to estimate
more sleep problems. Cronbach's α ranged from 0.56 to 0.68. the average trajectory of sleep problems from ages 14–21 (year
2009–2014). The optimal unconditional model was determined by
2.2.2. Depression examining and comparing the functional form of the trajectories (i.e.,
The measures for the immediate effects of depression were based on flat, linear, and quadratic) as well as specifying the random effects
participants’ self-reports of whether they had experienced any of six structure. The data were stratified by sex and parallel analyses were
depressive symptoms during the past 2 weeks at each wave from 2008 conducted for each stratum. All analyses were conducted using PROC
to 2013. The symptoms were measured using items adapted from the MIXED in SAS version 9.3 (SAS Institute Inc, 2011). For both sexes, the
Center for Epidemiological Studies Depression Scale for Children (CES- best-fitting unconditional model of sleep problems was a quadratic
DC) (Faulstich et al., 1986): “having a loss of appetite,” “feeling sad,” model with a homoscedastic error structure and included three random
“crying for no reason,” “feeling too tired to do things,” “feeling scared,” effects (random intercept, linear slope, and quadratic slope).
and “feeling hard to get started doing things.” Items were measured on Finally, we estimated a series of conditional multi-level models to
a 3-point scale and were averaged to create a depression score, with a test study hypotheses. We centered depression variables appropriately
higher score indicating a higher level of depression (Cronbach's α to disaggregate within-person fluctuating effects versus between-person
ranged from 0.79 to 0.82). The long-term effects of depression were immediate and long-term effects of depression (Raudenbush and Bryk,
measured with the same depression scale during times when partici- 2002). Specifically, within-person fluctuating effects were assessed
pants were in the childhood (2001−2006) and determined by aver- using time-varying depression scores that were person-mean centered
aging the scores across six waves (Cronbach's α ranged from 0.63 to by subtracting the person-specific mean of the depression scores from
0.75). each of that person's score at each wave such that they represented
fluctuations from one's average level. Between-person effects were
2.2.3. Covariates created by averaging each individual's depression scores across all
Biological sex was coded such that 1 indicated males and 2 indicated waves they participated in during childhood (2001–2006) and adoles-
females. Age was calculated based on the participants’ self-report of cence (2008–2013), respectively, and then grand-mean centering each
date of birth at each wave. Parent education was measured by the measure (i.e. subtracting the mean for the sample from each indivi-
participants’ report of the highest level of education attained by parents dual's score) to represent long-term and immediate effects of depres-
across waves, ranging from junior high school or less (0) to college or sion. Models were fit to each of the 10 imputed datasets and the
more (2). Family structure indicated whether the participants reported parameter estimates and standard errors were combined using SAS
living in a single-parent household during the study period. Family PROC MIANALYZE (SAS Institute Inc, 2011).

L.-Y. Chang et al. Journal of Affective Disorders 217 (2017) 48–54

In the first model, we included all control variables (i.e., parental Table 2
education, family structure, family economic stress, stress life event, Multi-level models testing the association between depression and sleep problems.
and social anxiety) and three effects of depression (i.e., fluctuating,
Males Females
immediate, and long-term effect) to predict trajectories of sleep
problems. We also included interactions between within-person depres- b SE b SE
sion measure and time variables (i.e., age and age2) to test whether the
Model 1
fluctuating effects of depression on sleep problems vary by age.
Age −0.54*** 0.05 −0.74*** 0.05
Significant interactions were retained in the model. In the second Age2 0.47*** 0.04 0.66*** 0.04
model, we added two interactions to the model (i.e., long-term effects Father's education level (reference: junior
× fluctuating effects and long-term effects × immediate effects) to test high or less)
whether the long-term effects moderated the fluctuating and immediate Senior high or vocational school −0.01 0.03 0.00 0.03
College or more −0.00 0.03 −0.00 0.04
effects of depression on sleep problems. Again, significant interactions
Mother's education level (reference: junior
were retained in the model and post hoc analyses were used to probe high or less)
the nature of significant interactions. In our models, standardized Senior high or vocational school 0.03 0.03 −0.08* 0.03
regression coefficient was used as an effect size obtaining by multi- College or more 0.01 0.04 −0.08* 0.03
Single-parent family (reference: two-parent −0.00 0.02 0.02 0.02
plying the regression coefficient by the ratio of the standard deviation
of the predictor to the standard deviation of the outcome variable Family economic stress 0.02 0.02 0.05** 0.02
(Nieminen et al., 2013). Stressful life event 0.02 0.02 0.03 0.02
Social anxiety 0.04*** 0.01 0.04** 0.01
Within-person differences
Fluctuating effects of depression 0.00 0.01 0.06 0.04
3. Results
Fluctuating effects of depression × age ─ ─ −0.22* 0.10
Fluctuating effects of depression × age2 ─ ─ 0.18* 0.07
3.1. Sample characteristics Between-person differences
Immediate effects of depression 0.25*** 0.02 0.26*** 0.02
Long-term effects of depression 0.06** 0.02 0.06** 0.02
Descriptive statistics of study variables at baseline are presented in
Model 2
Table 1. Approximately half of the sample were males (51.18%). The Interaction effects
most frequently reported parental education level was senior high Fluctuating × long-term effects of −0.01 0.01 0.00 0.01
school. For both sexes, approximately 20% of the participants came depression
from a single-parent household. The mean scores of childhood depres- Immediate × long-term effects of 0.03 0.02 0.07*** 0.02
sion were similar across sexes (males: 1.47; females: 1.48; t=−1.37,
p=0.17). However, females reported higher levels of depression and Age2 = age× age, b=standardized regression coefficient, SE= standard error
sleep problems than males at baseline (depression: 1.71 > 1.48, * p < 0.05
t=−12.33, p < 0.001; sleep problems: 1.55 > 1.44, t=−4.76, ** p < 0.01
p < 0.001). *** p < 0.001

3.2. Effects of depression on trajectories of sleep problems

Table 1
Table 2 presents the results for each type of depression effect on
Descriptive statistics of study variables in 2009. trajectories of sleep problems for males and females, respectively.
Model 1 presents the main effects of fluctuating, immediate, and
Males (n=1345) Females (n=1283) long-term effects of depression. Model 2 shows the results testing
whether long-term effects of depression interacted with other types of
n (%) Mean (SD) n (%) Mean (SD)
effects in influencing the development of sleep problems.
Father's education level
Junior high or less 139 (11.55) 141 (12.00)
Senior high school 609 (50.62) 604 (51.40)
3.2.1. Fluctuating effects
College or more 455 (37.82) 430 (36.60)
Mother's education The time-varying nature of the fluctuating effects of depression was
level illustrated in Fig. 1 by using a few participants. The figure shows that
Junior high or less 106 (8.64) 120 (9.88)
Senior high school 732 (59.66) 753 (62.03)
College or more 389 (31.70) 341 (28.09)
Family structure
Two-parent family 1076 1031
(80.12) (80.55)
Single-parent family 267 (19.88) 249 (19.45)
Age 14.67 14.67
(0.47) (0.47)
Family economic 2.72 (0.63) 2.79 (0.62)
Stressful life event* 0.61 (0.86) 0.68 (0.86)
Social anxiety*** 1.38 (0.44) 1.51 (0.48)
Childhood depression 1.47 (0.27) 1.48 (0.27)
Depression*** 1.48 (0.41) 1.71 (0.46)
Sleep problems** 1.44 (0.55) 1.55 (0.58)

Note: Numbers do not sum to the total number because of missing values.
* p < 0.05.
** p < 0.01.
*** p < 0.001 for sex differences using χ2 test for categorical variables and t-test for Fig. 1. Illustration of within-person time-varying fluctuations in depression scores across
continuous variables six waves.

L.-Y. Chang et al. Journal of Affective Disorders 217 (2017) 48–54

the depression scores fluctuated over times across six waves and
provide some support for the within-person differences in depression.
The results of the multilevel growth curve model show that the
fluctuating effects of depression on trajectories of sleep problems were
not significant for males (Model 1). For females, the fluctuating effects
were significant only when interacting with time variables, indicating
that the influences of fluctuating effects of depression on sleep problems
varied across ages (fluctuating effects×age: b =−0.22, p < 0.05;
fluctuating effects × age2: b =0.18, p < 0.05). Post hoc analyses were
conducted to probe the fluctuating effects of depression on sleep
problems at different ages. For better illustration, females were divided
into two groups with one had high levels (one standard deviation above
the mean) and the other had low levels (one standard deviation below Fig. 3. The interaction between the immediate and long-term effects of depression on
the mean) of fluctuating effects of depression. Specifically, females with sleep problems among females. b = standardized regression coefficients. SE = standard
high fluctuating effects of depression had higher initial levels of sleep error.
problems, faster rates of decreases in sleep problems from ages 14–18,
and earlier and more rapid upward trends of sleep problems during depression and sleep problems was stronger for females with high than
young adulthood than those who had low fluctuating effects of low levels of childhood depression (Fig. 3: b=0.31 and 0.19, respec-
depression. The results showed that the differences in the mean scores tively).
for sleep problems between groups gradually increased after age 19
years and became significant after age 20 years (Fig. 2), indicating that 4. Discussion
the fluctuating effects of depression in females were more evident when
they entered young adulthood. To the best of our knowledge, this is the first longitudinal study
disentangling the between-person and within-person effects of depres-
3.2.2. Immediate effects sion on the trajectories of sleep problems while considering the direct
As shown in Model 1, there were significant immediate effects of and moderated effects of the long-term influences of depression. For
depression on sleep problems for both sexes (males: b =0.25, males and females, we found significant immediate and long-term
p < 0.001; females: b =0.26, p < 0.001), indicating that adolescents effects of depression on the development of sleep problems. Fluctuating
who had higher levels of depression experienced more sleep problems effects of depression were only significant for females when also
later. The results of Wald tests further show stronger immediate effects considering time variables. For females, the long-term effects of
than fluctuating effects of depression on sleep problems (males: Z- depression further exacerbated the negative influences of immediate
value: 11.18, p < 0.001; females: Z-value=4.76, p < 0.001). effects of depression on sleep problems.
Consistent with previous findings (Hayley et al., 2015; Patten et al.,
3.2.3. Long-term effects 2000; Van Dyk et al., 2016), we found strong immediate effects of
The results of Model 1 show that the long-term effects of depression depression on the development of sleep problems. Several reasons were
on sleep problems were significant for both males and females (b proposed for the link between depression and sleep problems. Theore-
=0.06, p < 0.01 for both sexes), indicating that childhood depression tically, individuals with depression, which is associated with symptoms
increased the risks for sleep problems later in adolescence and young such as ruminating thought processes and unexplained pain, often show
adulthood. However, our study hypotheses regarding interactions emotional arousal and distress that might disrupt sleep (Dahl, 1996).
between the long-term effects and the other two effects of depression Evidence has found that depression might lead to the development of
on sleep problems were only partially supported. Specifically, the long- sleep problems by increasing the use of maladaptive coping strategies in
term effects interacted only with immediate effects of depression in the face of adversity (Nguyen-Rodriguez et al., 2015). In addition,
predicting sleep problems among females (b =0.07, p < 0.05). Simple depression has been found to be associated with emotional regulation
slopes analyses revealed that the negative influences of immediate (Silk et al., 2003) which have also been linked to sleep problems
effects of depression on sleep problems were exacerbated by the long- (Matthews et al., 2016). We further found stronger immediate than
term effects such that the association between immediate effects of fluctuating effects of depression, suggesting that the between-person
differences in depression may matter more than if adolescents fluctu-
ated from their average levels of depression in regard to sleep problems.
Our study also found that the influences of fluctuating effects of
depression on sleep problems in females changed over time.
Specifically, the fluctuating effects of depression became more pro-
nounced during young adulthood compared to the effects during late
adolescence. The trajectories of sleep problems also show more repaid
upward growth during young adulthood in females with high fluctuat-
ing effects than low fluctuating effects of depression, whereas the
declining trends during adolescence, which were consistent with
previous findings on development of sleep problems (Wang et al.,
2016), were similar between two groups. Our results suggest that
during young adulthood, females were at increased risk for sleep
problems when they experienced more depression than their average
levels, thereby providing valuable information for interventions regard-
ing when adolescents are at risk. The observed pronounced fluctuating
effects of depression at times of transition from late adolescence to
young adulthood were consistent with the accentuation model (Caspi
Fig. 2. Change over time in the fluctuating effects of depression on trajectories of sleep and Moffitt, 1991), which proposes that dispositional characteristics
problems in females. (e.g., depression) of individuals are most likely to be expressed during

L.-Y. Chang et al. Journal of Affective Disorders 217 (2017) 48–54

transition event in the life course, especially when situations are is at risk for sleep problems but also when they are at risk. By using sex-
characterized by novelty, ambiguity, and challenge. Because young stratified data, this study enhanced the current understanding of
adulthood is marked by important transitions such as increased potential sex differences. Finally, we applied multiple imputation
independence, changes in social roles, and transitions from school to techniques to minimize attrition effects and controlled for important
work, it may also represent a time comprising increased susceptibility covariates to ensure the robustness of study findings.
to the influence of depression on sleep problems (Schulenberg et al., There are also several limitations of the current study. First, our
2004). Evidence has provided support that the influences of psychiatric measures of sleep problems were based on self-report. Because psycho-
problems on health outcomes appeared to be most pronounced at times logically distressed individuals would be more likely to over-report
of transition (Cerda et al., 2016). Likely, the rapid upward trends of sleep problems (Vanable et al., 2000), the use of objective measures,
sleep problems during young adulthood observed in the current study such as actigraphy, along with self-reporting might help improve the
may in part due to the stronger influences of fluctuation in depression measures of sleep problems. The self-reported measures of both sleep
during this transition period. Because no other study has examined the problems and depression may also produce common method variance
age differences in within-person effects of depression on sleep pro- and bias the results. In addition, our measurements were adapted from
blems, more research is needed to verify our results so that the factors various existing scales to increase their applicability to adolescents in
that might contribute to these differences can be understood. Taiwan; therefore, validity data were not available and internal
The fluctuating effects of depression were limited to females, consistency was not very high. Finally, the study sample was recruited
perhaps reflecting the sex differences in both susceptibility and from schools in northern Taiwan and was characterized by nonclinical
associated factors in depression. Evidence has suggested that females levels of depression and sleep problems. Therefore, generalizability of
were more susceptible to the influences of depression than were males the study findings to other populations may be limited.
(Radloff and Rae, 1979). Therefore, females may be at increased risk for
sleep problems when they experience elevated levels of depression. 5. Conclusions
Furthermore, females are more likely than males to have ruminative
responses to depression that may amplify their symptoms and prolong This study demonstrates the importance of both immediate and
depression (Nolenhoeksema, 1991), thus leading to a higher risk of long-term effects of depression on sleep problems. Timely recognition
sleep problems. However, males have a greater tendency to use and treatment of depression are important for the reduction of sleep
distracting responses (Nolenhoeksema, 1991) and could be less affected problems, especially for females because their sleep is further affected
by fluctuations in depressed moods. It is also possible that the within- by the fluctuations in depression status. Future studies should continue
person effects of depression in males only become evident after the examining mechanisms linking depression to sleep problems and sex
symptoms being present over a certain period of time. In addition, a differences in those pathways.
methodological reason for not detecting fluctuating effects of depres-
sion in males may be that the time interval between the assessments of References
depression (i.e., 1 year) may not be appropriate. A shorter or longer
time interval may be needed for males to detect the influences of Alfano, C.A., Zakem, A.H., Costa, N.M., Taylor, L.K., Weems, C.F., 2009. Sleep problems
fluctuating effects of depression on sleep problems. and their relation to cognitive factors, anxiety, and depressive symptoms in children
and adolescents. Depress. Anxiety 26, 503–512.
The perspectives of developmental psychopathology theory recog- Caspi, A., Moffitt, T.E., 1991. Individual differences are accentuated during periods of
nized the contributions of both immediate and long-term influences social change: the sample case of girls at puberty. J. Pers. Soc. Psychol. 61, 157–168.
(Schulenberg et al., 2003). Correspondlingly, our study found that the Cerda, M., Prins, S.J., Galea, S., Howe, C.J., Pardini, D., 2016. When psychopathology
matters most: identifying sensitive periods when within-person changes in conduct,
development of sleep problems was influenced by depression occurring affective and anxiety problems are associated with male adolescent substance use.
during both childhood and adolescence. By identifying a risk factor for Addiction 111, 924–935.
sleep problems that occurs earlier, the current findings contribute to Chang, L.Y., Wu, C.C., Lin, L.N., Yen, L.L., Chang, H.Y., 2016. The effects of sleep
problems on the trajectory of antisocial behavior from adolescence through early
better specification of the cause of sleep problems and indicate the adulthood in Taiwan: family functioning as a moderator. Sleep 39, 1441–1449.
necessity of early intervention for depression to prevent later sleep Chang, L.Y., Wu, W.C., Wu, C.C., Lin, L.N., Yen, L.L., Chang, H.Y., 2017. The role of sleep
problems. Moreover, consistent with the views of the diathesis-stress problems in the relationship between peer victimization and antisocial behavior: a
five-year longitudinal study. Soc. Sci. Med. 173, 126–133.
model (Ingram and Luxton, 2005), we found that the negative
Chen, C.Y., Wu, C.C., Chang, H.Y., Yen, L.L., 2014. The effects of social structure and
influences of immediate effects of depression on sleep problems were social capital on changes in smoking status from 8th to 9th grade: results of the Child
stronger in females with higher levels of childhood depression than in and Adolescent Behaviors in Long-term Evolution (CABLE) study. Prev. Med. 62,
other females with lower levels of childhood depression. Therefore, the 148–154.
Chiang, Y.C., Lee, T.S., Yen, L.L., Wu, C.C., Lin, D.C., Hurng, B.S., Chang, H.Y., 2013.
current findings suggest that greater attention must be given to females Influence of stressors and possible pathways of onset of seventh graders' suicidal
who have demonstrated childhood depression and who also demon- ideation in urban and rural areas in Taiwan. BMC Public Health 13, 1233.
strate current depression because they are at higher risks for sleep Curran, P.J., Wirth, R.J., 2004. Interindividual differences in intraindividual variation:
balancing internal and external validity. Measurement 2, 219–247.
problems. In addition, efforts to improve the sleep problems of females Dahl, R.E., 1996. The regulation of sleep and arousal: development and psychopathology.
by targeting current depression may be more effective when also Dev. Psychopathol. 8, 3–27.
considering childhood depression. Faulstich, M.E., Carey, M.P., Ruggiero, L., Enyart, P., Gresham, F., 1986. Assessment of
depression in childhood and adolescence: an evaluation of the center for
epidemiological studies Depression scale for children (CES-DC). Am. J. Psychiatry
4.1. Strengths and limitations 143, 1024–1027.
Goodman, E., Whitaker, R.C., 2002. A prospective study of the role of depression in the
development and persistence of adolescent obesity. Pediatrics 110, 497–504.
This study has several strengths. The longitudinal nature of the data
Hankin, B.L., 2006. Adolescent depression: description, causes, and interventions.
allowed us to examine developmental trajectories of sleep problems Epilepsy Behav. 8, 102–114.
from late adolescence through young adulthood. Also, we were able to Hayley, A.C., Skogen, J.C., Sivertsen, B., Wold, B., Berk, M., Pasco, J.A., Overland, S.,
2015. Symptoms of depression and difficulty initiating sleep from early adolescence
examine the independent and synergetic influences of different effects
to early adulthood: a longitudinal study. Sleep 38, 1599–1606.
of depression on sleep problems and to determine whether the Holmes, T.H., Rahe, R.H., 1967. The social readjustment rating scale. J. Psychosom. Res.
associations being examined varied over time. The examination of 11, 213–218.
long-term effects of depression further sheds light on the cascading Hung, C.C., Chiang, Y.C., Chang, H.Y., Yen, L.L., 2011. Path of socialization and cognitive
factors' effects on adolescents' alcohol use in Taiwan. Addict. Behav. 36, 807–813.
effects of depression on sleep problems. Moreover, our study was the Hussong, A.M., Huang, W., Curran, P.J., Chassin, L., Zucker, R.A., 2010. Parent
first to disentangle the between-person and within-person effects of alcoholism impacts the severity and timing of children's externalizing symptoms. J.
depression on sleep problems, thus enabling assessment of not only who Abnorm. Child Psychol. 38, 367–380.

L.-Y. Chang et al. Journal of Affective Disorders 217 (2017) 48–54

Ingram, R.E., Luxton, D.D., 2005. Vulnerability-Stress Models. In: Hankin, B.L., Abela, SAS Institute Inc, 2011. SAS Software, Version 9.3. SAS Institute Inc., Cary, NC.
J.R.Z. (Eds.), Development of Psychopathology: A Vulnerability-stress Perspective. Schulenberg, J.E., Maggs, J.L., O'Malley, P.M., 2003. How and why the understanding of
SAGE Publications, Inc, Thousand Oaks, CA. developmental continuity and discontinuity is important. In: Mortimer, J.T.,
Jaffee, S.R., Moffitt, T.E., Caspi, A., Fombonne, E., Poulton, R., Martin, J., 2002. Shanahan, M.J. (Eds.), Handbook of the Life Course. Kluwer Academic/Plenum
Differences in early childhood risk factors for juvenile-onset and adult-onset Publishers, New York, pp. 413–436.
depression. Arch. Gen. Psychiatry 59, 215–222. Schulenberg, J.E., Sameroff, A.J., Cicchetti, D., 2004. The transition to adulthood as a
Johnson, E.O., Chilcoat, H.D., Breslau, N., 2000. Trouble sleeping and anxiety/depression critical juncture in the course of psychopathology and mental health. Dev.
in childhood. Psychiatry Res. 94, 93–102. Psychopathol. 16, 799–806.
Johnson, E.O., Roth, T., Breslau, N., 2006. The association of insomnia with anxiety Shanahan, L., Copeland, W.E., Angold, A., Bondy, C.L., Costello, E.J., 2014. Sleep
disorders and depression: exploration of the direction of risk. J. Psychiatr. Res. 40, problems predict and are predicted by generalized anxiety/depression and
700–708. oppositional defiant disorder. J. Am. Acad. Child Adolesc. Psychiatry 53, 550–558.
Kalak, N., Lemola, S., Brand, S., Holsboer-Trachsler, E., Grob, A., 2014. Sleep duration Silk, J.S., Steinberg, L., Morris, A.S., 2003. Adolescents' emotion regulation in daily life:
and subjective psychological well-being in adolescence: a longitudinal study in links to depressive symptoms and problem behavior. Child Dev. 74, 1869–1880.
Switzerland and Norway. Neuropsychiatr. Dis. Treat. 10, 1199–1207. Sivertsen, B., Harvey, A.G., Lundervold, A.J., Hysing, M., 2014. Sleep problems and
Kelly, R.J., El-Sheikh, M., 2014. Reciprocal relations between children's sleep and their depression in adolescence: results from a large population-based study of Norwegian
adjustment over time. Dev. Psychol. 50, 1137–1147. adolescents aged 16-18 years. Eur. Child Adolesc. Psychiatry 23, 681–689.
Kouros, C.D., El-Sheikh, M., 2015. Daily mood and sleep: reciprocal relations and links Van Damme, L., Colins, O.F., Vanderplasschen, W., 2014. Gender differences in
with adjustment problems. J. Sleep. Res. 24, 24–31. psychiatric disorders and clusters of self-esteem among detained adolescents.
La Greca, A.M., Lopez, N., 1998. Social anxiety among adolescents: linkages with peer Psychiatry Res. 220, 991–997.
relations and friendships. J. Abnorm. Child Psychol. 26, 83–94. Van Dyk, T.R., Thompson, R.W., Nelson, T.D., 2016. Daily bidirectional relationships
Lee, T.S., Chang, H.C., Yen, L.L., Wu, W.C., 2006. Social capital of family and school-its between sleep and mental health symptoms in youth with emotional and behavioral
relationship with elementary school children's internalizing behavioral problems. problems. J. Pediatr. Psychol. 41, 983–992.
Formosa J. Ment. Health 19, 231–253. Vanable, P.A., Aikens, J.E., Tadimeti, L., Caruana-Montaldo, B., Mendelson, W.B., 2000.
Lin, L.J., Chang, H.Y., Luh, D.L., Hurng, B.S., Yen, L.L., 2014. The trajectory and the Sleep latency and duration estimates among sleep disorder patients: variability as a
related physical and social determinants of body mass index in elementary school function of sleep disorder diagnosis, sleep history, and psychological characteristics.
children: results from the child and adolescent behaviors in long-term evolution Sleep 23, 71–79.
study. J. Obes. 2014, 728762. von Hippel, P.T., 2007. Regression with missing Y’s: An improved stratey for analyzing
Lovato, N., Gradisar, M., 2014. A meta-analysis and model of the relationship between multiple imputed data, In: Xie, Y. (Ed.), Sociological Methodology 2007, Vol 37, pp.
sleep and depression in adolescents: recommendations for future research and clinical 83–117.
practice. Sleep Med. Rev. 18, 521–529. Wang, B., Isensee, C., Becker, A., Wong, J., Eastwood, P.R., Huang, R.C., Runions, K.C.,
Lue, B.H., Wu, W.C., Yen, L.L., 2010. Expressed emotion and its relationship to adolescent Stewart, R.M., Meyer, T., Bruni, L.G., Zepf, F.D., Rothenberger, A., 2016.
depression and antisocial behavior in northern Taiwan. Taiwan Yi Xue Hui Za Zhi Developmental trajectories of sleep problems from childhood to adolescence both
109, 128–137. predict and are predicted by emotional and behavioral problems. Front. Psychol. 7,
Matthews, K.A., Hall, M.H., Cousins, J., Lee, L., 2016. Getting a good night's sleep in 1874.
adolescence: do Strategies for coping with stress matter? Behav. Sleep. Med. 14, Weissman, M.M., 2002. Juvenile-onset major depression includes childhood- and
367–377. adolescent-onset depression and may be heterogeneous. Arch. Gen. Psychiatry 59,
Measelle, J.R., Stice, E., Hogansen, J.M., 2006. Developmental trajectories of co-occurring 223–224.
depressive, eating, antisocial, and substance abuse problems in female adolescents. J. White, K.H., Rumble, M.E., Benca, R.M., 2016. Sex differences in the relationship between
Abnorm. Psychol. 115, 524–538. depressive symptoms and actigraphic assessments of sleep and rest-activity rhythms
Nguyen-Rodriguez, S.T., Lisha, N.E., Spruijt-Metz, D., Sun, P., Rohrbach, L.A., Sussman, in a population-based sample. Psychosom. Med.
S., 2015. Coping mediates the effects of depressive symptoms on sleep problems. Am. 0000000000000434.
J. Health Behav. 39, 183–190. Whiteford, H.A., Degenhardt, L., Rehm, J., Baxter, A.J., Ferrari, A.J., Erskine, H.E.,
Nieminen, P., Nehtiniemi, H., Vähäkangas, K., Huusko, A., Rautio, A., 2013. Standardised Charlson, F.J., Norman, R.E., Flaxman, A.D., Johns, N., Burstein, R., Murray, C.J.,
regression coefficient as an effect size index in summarising findings in Vos, T., 2013. Global burden of disease attributable to mental and substance use
epidemiological studies. Epidemiol. Biostat. Public Health 10 (e8854−e8851). disorders: findings from the Global Burden of Disease Study 2010. Lancet 382,
Nolen-Hoeksema, S., Girgus, J.S., Seligman, M.E., 1992. Predictors and consequences of 1575–1586.
childhood depressive symptoms: a 5-year longitudinal study. J. Abnorm. Psychol. Wu, W.C., Kao, C.H., Yen, L.L., Lee, T.S., 2007. Comparison of children's self-reports of
101, 405–422. depressive symptoms among different family interaction types in northern Taiwan.
Nolenhoeksema, S., 1991. Responses to depression and their effects on the duration of BMC Public Health 7, 116.
depressive episodes. J. Abnorm. Psychol. 100, 569–582. Wu, W.C., Luh, D.L., Lin, C.I., Chiang, Y.C., Hung, C.C., Wang, S., Wu, C.C., Hurng, B.S.,
Patten, C.A., Choi, W.S., Gillin, J.C., Pierce, J.P., 2000. Depressive symptoms and Chang, Y.H., Yen, L.L., Chang, H.Y., 2016. Reciprocal relationship between unhealthy
cigarette smoking predict development and persistence of sleep problems in US eating behaviours and depressive symptoms from childhood to adolescence: 10-year
adolescents. Pediatrics 106, E23. follow-up of the child and adolescent behaviors in long-term evolution study. Public
Polanczyk, G.V., Salum, G.A., Sugaya, L.S., Caye, A., Rohde, L.A., 2015. Annual research Health Nutr. 19, 1654–1665.
review: a meta-analysis of the worldwide prevalence of mental disorders in children Yen, L.L., Chen, L., Lee, S.H., Hsiao, C., Pan, L.Y., 2002. Child and adolescent behaviour in
and adolescents. J. Child Psychol. Psychiatry 56, 345–365. long-term evolution (CABLE): a school-based health lifestyle study. Promot. Educ.
Radloff, L.S., Rae, D.S., 1979. Susceptibility and precipitating factors in depression: sex 33–40.
differences and similarities. J. Abnorm. Psychol. 88, 174–181. Zahn-Waxler, C., Klimes-Dougan, B., Slattery, M.J., 2000. Internalizing problems of
Raudenbush, S.W., Bryk, A.S., 2002. Hierarchical Linear Models: Applications and Data childhood and adolescence: prospects, pitfalls, and progress in understanding the
Analysis Methods, Second ed. Sage, Thousand Oaks, CA. development of anxiety and depression. Dev. Psychopathol. 12, 443–466.