Sleep Loss, Social Rhythm Disruptions, and Depression

Regardless of what part of the world an individual resides in, sleep is something fundamental that every living being needs. However, for individuals with depression, they are more prone to sleep loss and abnormal sleep/wake patterns, which can affect the trajectory of their depression, along with the severity and frequency of depressive episodes. Individuals living with depression are more vulnerable to the unfavorable outcomes of even the mildest disruptions to their social rhythm; social rhythm is essentially the usual time and way an individual starts and ends their day. Objective: To study the relationship between sleep loss and depression on a cross-culture level. Method: Participants from different parts of the world with depression and participants without depression will report changes in mood, mental state and sleep based on the stability of their social rhythm, which will be measured using A Social Rhythm Metric (SRM)and average hours slept will also be measured. The General Behavior Inventory (GBI) will be used to screen participants. The Beck Depression Inventory-II (BDI-II) will be used to measure severity of depression. Positive and negative events will be measured using Life Events Scale (LES) and Life Event Interview Rating Form (LIRF) will be used to assess the extent of the effect or no effect the social rhythm disruption has on the participants’ social rhythm. Results: To be determined…Implications: Results will provide more information on how this issue can be addressed, in addition to promoting better sleep hygiene and sleep disruption interventions.

Literature Review

It is no surprise that sleep loss and sleep disruptions are something many individuals face. There are many different factors that contribute to disruptions in sleep/wake patterns. However, for some individuals, they are more vulnerable to those disruptions that interferes with their everyday routine or social rhythm and experiences more of those negative effects on normal functioning. A disruption can consist of an event happening that prevents the individual from doing what is usually done at a certain time, which throws their whole day off. According to the Social Rhythm Metric-Trait assessment, Social rhythm consists of the time and frequency an individual gets out of bed, what time they have breakfast/a beverage, first interaction with another person, etc., (Monk et al., 1990). An example of this could be a person usually leaving their house for work at 8 AM but something happens that causes them to leave a couple hours later than they usually do, which could detrimentally affect the rest of their days if they are an individual with depression or depressive symptoms. In past studies, researchers found that people diagnosed with bipolar spectrum disorder are more prone to sleep loss as a result of disruptions to their everyday routine or social rhythm, which also predicts the course of their manic/hypomanic episodes (Alloy et al., 2012). Although, there is much research done on the relationship between disruptions to social rhythm and bipolar spectrum disorder (BSD) patients, not much is studied on how Social Rhythm Disruption (SRD) affects sleep and depression on a global level. Depression is just as prevalent of a mental health disorder as BSD. Especially in developing countries, depression symptoms and depression are significantly more prevalent compared to developed countries (Wang et al., 2017). This study aims to examine the relationship between disruptions to social rhythm, sleep loss and depression on a cross-cultural level by studying individuals from different parts of the world.

Around the world, sleep patterns vary from culture to culture. There are many different factors as to why this might be. One reason is that significant differences were found in the frequency of distribution of clock gene alleles, which regulates sleep timing and physiological processes, among worldwide populations (Ciarleglio et al., 2008). This shows that on a cross-cultural level, social rhythm will also differ, which may possibly play a role on sleep loss and depression. In a study investigating sleep patterns in Chinese children, researchers found that the total sleep time was less than that for Western children (Jiang et al., 2007). Jiang et al (2007) also found that sleep problems that occur across different regions are a result of behavioral and health problems. According to research done by Franzen and Buysse (2008), there is a strong link between insomnia and depression; insomnia is often associated with the development and the course of depression, as well as severity and duration of depressive episodes. Insomnia and depression often goes hand-in-hand. The researchers also discuss that sleep disruptions and insomnia are bidirectionally-related, in which individuals with circadian rhythm disorders such as sleep phase syndrome, had or have a current history of depression (Franzen and Buysse, 2008). A person’s social rhythm or circadian rhythm clearly impacts their sleep/wake cycle, especially for someone diagnosed with depression.

In a study using findings from the China Kadoorie Biobank (CKB), which is a genomic databank consisting of questionnaires, physical data and blood samples collected from a half a million Chinese participants from ten regions in China, researchers found that there is a strong association between abnormal sleep disturbances, duration and depression (Sun et al., 2018). Both short and long sleep duration was linked with depression. This shows that even on a cross-culture level, there is a significant association with depression and an imbalance in the normal

sleep pattern and circadian rhythm. Sun et al. (2018) also note that a longer sleep duration combined with sleep disturbances had the most likelihood of depression, which indicates that there is a relationship between disruptions to sleep/wake patterns and depression. Results from another research indicates that individuals with major depressive disorder experience more sleep loss and are more susceptible to negative effects of changes in everyday routines when compared with healthy participants; the researchers note that near-future longitudinal research is needed to clarify the temporal relationship between those different variables (Haynes, McQuaid, Ancoli-Israel & Martin, 2006). A disruption in social rhythm might not affect people who are not diagnosed with depression and they will easily recover from it but for individuals with depression, they will suffer from it more. The researchers also found that even at least one disruptions to everyday routines in the depressed individuals elevated awake time and decreased the amount of time asleep in comparison to individuals who are not depressed (Haynes, McQuaid, Ancoli-Israel and Martin, 2006). This shows just how important maintaining social rhythm is and that a disruption in social rhythm affects sleep in depressed individual even if it is one minor change in their everyday routine.

Many studies have shown the detrimental effects of sleep loss, sleep disturbances and social rhythm disruptions (SRD) on the trajectory and severity of mental health disorders, such as bipolar spectrum disorder (BDS), but not many studies have looked into just how it affects people diagnosed with depression or display depressive symptoms, which is just as pervasive of a mental health disorder, on a cross-cultural level. Due to various factors, including but not limited to genetic factors, people around the world have different sleep/wake patterns so disruptions in social rhythms would affect them differently as well. This study aims to study the

relationship between social rhythm disruptions, sleep loss and sleep disturbances on individuals with depression on a global perspective.

Method

Participants

Participants for this study will be recruited through online posts and flyers posted on various bulletins in different coffee shops and cafes. The post will state “Participants needed for study on sleep and social rhythm.” The sample will consist of 50 individuals total, from the ages of 18-40 years old. The sample will consist of people who are native and non-native to the United States. Half of the group will be those who have been previously diagnosed with depression by their psychiatrist and/or primary doctor. The other half will be the control group; they consist of healthy participants that have no history or family history of depression. Exclusion criteria will include individuals with a reported history of substance abuse. This study will utilize a purposive sampling; individuals with and without a reported history of depression will be a part of the study.

Materials

The General Behavior Inventory (GBI) (Depue & Klein, 1988; Depue, Krauss, Spoont, & Arbisi, 1989; Depue et al., 1981). The GBI will be used to screen participants. It is a 73-item self-report inventory that measures the presence of clinical symptoms for depression and manic mood disorders on a four-point scale. A sample item is “Have there been periods lasting several days or more when you lost almost all interest in people close to you and spent long times by yourself?” with scoring on a 4-point Likert-type scale (0 = never or hardly ever; 3 = very often/almost constantly) to report how often they experience a behavior over the past year.

A Social Rhythm Metric (SRM) (Monk et al., 1990). This instrument will be used to measure social rhythm, which is the time and frequency an individual gets out of bed, what time they have breakfast/a beverage, first interaction with another person, etc., (Monk et al., 1990). A sample item is time “out of bed”.

The Beck Depression Inventory-II (BDI-II) (Beck, A.T., Steer, R.A., & Brown, G.K., 1996). This will be used to measure severity of depression. An example of the items is “Sadness, with 0 indicating not feeling sad, 1 indicating feeling sad much of the time, 2 indicating feeling sad all the time and 3 indicating feeling so sad or unhappy that it is unbearable”.

Life Events Scale (LES) (Holmes, T. H., & Rahe, R. H., 1967). This will be used to measure positive and negative events. A score of 300+ indicates that an individual is at risk of illness, score of 150-299+ indicates risk of illness is moderate (reduced by 30% from the above risk) and score of 150- indicates only a slight risk of illness. A sample item consist of “Death of a close family member” with a mean score of 100.

Life Event Interview Rating Form (LIRF) (Alloy et al., 2006). This instrument will be used to assess the extent of the effect or no effect the social rhythm disruption has on the participants’ social rhythm.

Procedures

Participants will be recruited through flyers posted on various coffee shops and cafes, along with online posts on different social media platforms. They will be selected randomly and matched on age, sex and ethnicity. No specific age, sex or ethnicity is preferred. Each participant will be given a consent form and assessments to complete. Individuals will be asked to complete the self-assessments based on what group they belong to. The participant’s emotional state and trajectory of depression will be measured using a Lifetime Psychiatric Diagnostic Interview. They will be asked to report sleep/wake patterns and to keep a sleep diary. Participants will be asked to make no changes to current activities and diet. The Beck Depression Inventory-II (BDI-II) will be used to measure severity of depression. Social Rhythm Disruptions will be assessed using Life Event Interview Rating Form (LIRF; Alloy et al., 2006). Participants will be asked to report every social rhythm disruption and its effect. Life Events Scale (LES) consist of 193 positive and negative events; it will be used to assess events that participants report. The study will be conducted over a six week time period ensure accuracy of results.

A follow-up assessment that will consist of completing the three measures will be due every two weeks to note changes in mood and trajectory of depression and depressive episodes as a result of changes in social rhythm, social rhythm disruptions and average amount of hours slept. For the control group, a follow-up assessment will be due to study the changes in mood, emotional state in response to differences reported in social rhythm, social rhythm disruptions and total hours slept on average. These changes will be compared between the two groups to analyze differences between sleep patterns, emotional state and course of depression and depressive episode for the group that consist of participants diagnosed with depression.

Discussion

It is anticipated that individuals, regardless of being from western or nonwestern countries, that are diagnosed with depression are more susceptible to sleep loss and sleep disturbances in comparison with healthy individuals. In Chinese participants from ten different regions in China, researchers found that there is a strong link between irregular sleep patterns and depression (Sun et al., 2018) and through the use of longitudinal studies on participants living in Detroit and other metropolitan areas (Breslau, Roth, Rosenthal & Andreski, 1996), Franze and Buysse (2008) concluded that the large population of individuals with depression experience sleep problems, which may suggest a relapse in depression and depression-like symptoms. Based on these results, the study will conclude there is a relationship between abnormal sleep patterns and depression. Disruptions to social rhythm cycles proved to have a large impact on the sleep of participants with depression (Riemann, Berger and Voderholzer, 2001). Using the Social Rhythm Metric (Monk et al., 1990), social rhythm will be measured to show how irregular social rhythm is associated with sleep problems in patients with depression. Many other studies also show the link between sleep alterations and depression; poor sleep quality is often one of the top complaints from depression patients (Tsumo, Besset and Richie, 2005).

Limitations of this study will include the use of self-reports, such as Beck Depression Inventory-II (BDI-II) (Beck, A.T., Steer, R.A., & Brown, G.K. , 1996) and Social Rhythm Metric (SRM) (Monk et al., 1990) for some assessments, which may have inaccuracies. Strengths of this study will include strong face and criterion validity in the present study; data will be carefully collected and analyzed between the control group and the group with depression to study average amount of hours slept and patterns. There will also be a wide-range of participants from different parts of the world, which will be representative of the overall general population.

For future studies, incorporating a larger population size for the participants and using more instruments such as brain scans, that will look at the onset of depression and sleep problems in a biological aspect, will be useful in ensuring accuracy. This present study will suggest the importance of healthy hygiene for maintaining a stable mental health in mentally-healthy individuals and possible preventions of more severe depressive episodes in individuals already diagnosed with depression. More interventions should be carried out to aid with sleep problems and the matter should be taken more seriously. Sleep, social rhythm, and mental health disorders are all strongly tied together and should be taken into consideration when discussing treatments for depression and other mental health disorders.

References

1. Beck, A.T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961) An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571.
2. Breslau, N., Roth, T., Rosenthal, L., & Andreski, P., (1996). Sleep disturbance and psychiatric disorders: A longitudinal epidemiological study of young Adults. Biological Psychiatry, 39(6), 411-418.
3. Ciarleglio, C. M., Ryckman, K. K., Servick, S. V., Hida, A., Robbins, S., Wells, N., … Johnson, C. H. (2008). Genetic Differences in Human Circadian Clock Genes among Worldwide Populations. Journal of Biological Rhythms, 23(4), 330–340.
4. Franzen, P., & Buysse, D. (2008). Sleep disturbances and depression: Risk relationships for subsequent depression and therapeutic implications. Dialogues in Clinical Neuroscience., 10(4), 473-481.
5. Haynes, P. I., Mcquaid, J., R. S., Ancoli-israel, & Martin, M.J. L, (2006). Disrupting life events and the sleep-wake cycle in depression. Psychological Medicine, 36(10), 1363–1373.
6. Jiang, F. , Shen, X. , Yan, C. , Wu, S. , Jin, X. , Dyken, M. & Lin‐Dyken, D.,(2007), Epidemiological study of sleep characteristics in Chinese children 1–23months of age. Pediatrics International, 49: 811-816. doi:10.1111/j.1442-200X.2007.02449.x
7. Monk, T. H., Kupfer, D. J., Frank, E., & Ritenour, A. M. (1991). The Social Rhythm Metric (SRM): Measuring daily social rhythms over 12 weeks. Psychiatry Research, 36(2), 195-207. http://dx.doi.org/10.1016/0165-1781(91)90131-8
8. Riemann, D., Berger, M., & Voderholzer, U. (2001). Sleep and depression — results from psychobiological studies: An overview. Biological Psychology, 57(1-3), 67-103. doi:10.1016/s0301-0511(01)00090-4.
9. Tsuno, N., Besset, A., & Ritchie, K. (2005). Sleep and Depression. The Journal of Clinical Psychiatry, 66(10), 1254-1269.
10. Sun, X., Zheng, B., Lv, J., Guo, Y., Bian, Z., Yang, L., … Yu, C. (2018). Sleep behavior and depression: Findings from the China Kadoorie Biobank of 05 million Chinese adults.
11. Journal of Affective Disorders, 229, 120–124. https://doi.org/10.1016/j.jad.2017.12.058
12. Wang, Y., Chen, Z., Guo, F., Huang, Z., Jiang, L., Duan, Q., & Zhang, J. (2017). Sleep patterns and their association with depression and behavior problems among Chinese adolescents in different grades. PsyCh Journal., 6(4), 253-262.
13. Wang, J., Wu, X., Lai, W., Long, E., Zhang, X., Li, W., … Lin, H. (2017). Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis. BMJ open, 7(8), e017173. doi:10.1136/bmjopen-2017-017173