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Sleep problems and self-harm in adolescence

  • Mari Hysing (a1), Børge Sivertsen (a2), Kjell Morten Stormark (a3) and Rory C. O'Connor (a4)

Although self-harm and sleep problems are major public health problems in adolescence, detailed epidemiological assessment is essential to understand the nature of this relationship.


To conduct a detailed assessment of the relationship between sleep and self-harm in adolescence.


A large population-based study in Norway surveyed 10 220 adolescents aged 16–19 years on mental health, including a comprehensive assessment of sleep and self-harm.


Adolescents with sleep problems were significantly more likely to report self-harm than those without sleep problems. Insomnia, short sleep duration, long sleep onset latency, wake after sleep on set as well as large differences between weekdays versus weekends, yielded higher odds of self-harm consistent with a dose–response relationship. Depressive symptoms accounted for some, but not all, of this association.


The findings highlight a strong relationship between sleep problems and self-harm. Interventions to reduce adolescent self-harm ought to incorporate sleep problems as a treatment target.

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Corresponding author
Mari Hysing, Regional Centre for Child and Youth Mental Health and Child Welfare, Postboks 7810, 5020 Bergen, Norway. Email:
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Sleep problems and self-harm in adolescence

  • Mari Hysing (a1), Børge Sivertsen (a2), Kjell Morten Stormark (a3) and Rory C. O'Connor (a4)
Submit a response


Core Outcome Sets for Sleep Studies

Emma L Sellers, Psychology Graduate, Oxford Brookes University
William S Bolton, Medical Student, University of Leeds
04 August 2015

Dear Editor,

RE: Hysing M, Sivertsen B, Stormark KM, O'Connor RC. Sleep problems and self-harm in adolescence. Br J Psychiatry 2015; In print. 23rd July 2015.

We read this large cross-sectional population study by Hysing et al. with much interest. The authors recognise a strong relationship between sleep problems and self-harm, even when fully adjusted for several covariates including depression, and recommend that interventions could reduce self-harm by targeting sleep problems. Their cohort consisted of adolescents from Norway.

Sleep problems have been attributed to many psychiatric problems, including depression1, but measurement of sleep problems and associated variables remains largely subjective and heterogeneous across studies. Core outcome sets (COS) and information sets aim to optimise clinical application of study outcomes and improve the feasibility of meta-analysis, and they have been utilised in other areas of healthcare2.There appears to be no consensus COS examining sleep problems in adolescent populations, and perhaps application of a COS in this group will allow for standardised assessment of outcomes and variables.

Increasingly, electronic media use among this population has been linked to sleep problems.3 Electronic media use within this population is increasing year on year and the potential impacts on sleep and mental health are currently being investigated. As the authors mentioned, self-harm among adolescents is a common and increasing problem. Electronic media use may be related to self-harm not only through negatively impacting sleep, but also via increased environmental exposure to self-harm through undesirable web content4.

The authors report a participation rate of 53% and comment on how this problem limits the representativeness and accuracy of the findings. Identifying barriers to participation in similar studies would aid in the development of study methodology to overcome some of these challenges. Furthermore, this would improve the quality of the results and as the authors pointed out, Stormark et al. demonstrated higher rates of psychological problems in non-participants5. Investigating novel approaches to improve participation must be a priority for future research.

We would like to commend Hysing et al. for this high quality study, in particular for using validated questionnaires, examining several valid confounders and for expanding the literature in this area by assessing a wide range of sleep problems and sleep parameters. Sleep problems and self-harm are important areas of research in mental health. This study provides novel insight into the relationship between sleep and self-harm. We urge future investigators to aim to form an agreed COS for this area and to include electronic media factors in their information sets and outcome measure portfolio. This, together with improved access to participation, would improve the quality of evidence concerning this healthcare problem.


1Sivertsen, B., Harvey, A. G., Lundervold, A. J., & Hysing, M. Sleep problems and depression in adolescence: results from a large population-based study of Norwegian adolescents aged 16–18 years. European child & adolescent psychiatry 2014; 23: 681-689.

2Whistance RN, Forsythe RO, McNair AG, Brookes ST, Avery KN, Pullyblank AM, et al. Core Outcomes and iNformation SEts iN SUrgical Studies - ColoRectal Cancer Working Group. A systematic review of outcome reporting in colorectal cancer surgery. Colorectal Dis 2013; 15: 548-60.

3Cain N, Gradisar M. Electronic media use and sleep in school-aged children and adolescents: a review. Sleep Medicine 2010; 11: 735-742.

4Daine K, Hawton K, Singaravelu V, Stewart A, Simkin S, Montgomery P. The power of the web: A Systematic review of studies of the influence of the internet on self-harm and suicide in young people. PLoS ONE 2013; 8: e77555.

5Stormark KM, Heiervang E, Heimann M, Lundervold A, Gillberg C. Predicting nonresponse bias from teacher ratings of mental health problems in primary school children. J Abnorm Child Psychol 2008; 36: 411–9.

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