Associations between sleep duration and depression, mental health, physical health, and general health in U.S. adults: A population-based study

Mojisola Fasokun; Oluwasegun Akinyemi; Fadeke Ogunyankin; Phiwinhlanhla Ndebele-Ngwenya; Kaelyn Gordon; Seun Ikugbayigbe; Uzoamaka Nwosu; Mariam Michael; Kakra Hughes; Temitope Ogundare

doi:10.1371/journal.pone.0321347

Peer Review History

Original SubmissionMarch 5, 2025
6 Jun 2025 Decision Letter - Edward Chiyaka, Editor Dear Dr. Ndebele-Ngwenya, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== In addition to the comments raised by the reviewers, please also address the following in your revision: Please ensure that all citations adhere to the formatting style specified in the journal’s author guidelines especially in text citations. In the Methods section, authors stated: "Data from 2016 to 2023 were used for this study, ensuring a broad temporal scope to assess trends and associations between sleep duration." However, the analysis does not include any temporal stratification or trend assessment to justify the use of an eight-year dataset. The authors should either conduct appropriate time-series or stratified analyses to examine changes in sleep duration or related variables over time, or clarify why the temporal element was not explored despite the dataset's extended duration. A visual or statistical analysis of trends would significantly enhance the contribution of the study. While the Results section references the use of propensity score matching (PSM), the methodology is not adequately described in the Methods section. A clear explanation of the PSM process should be added, including: the rationale for using PSM, variables included in the matching algorithm, matching technique employed (e.g., nearest neighbor, caliper, 1:1 matching) and balance diagnostics used to assess matching quality. This information is essential for replicability and for readers to evaluate the robustness of the causal inferences drawn from the matched comparisons. In the Results section, Table 1 reports a total sample size (N) of 163,724, which appears inconsistent compared to the matched samples reported in the same table. Please clarify how this N was derived and ensure internal consistency across the manuscript. If Table 1 is meant to reflect the unmatched sample, explicitly label it as such and explain any exclusions or data processing steps that led to this specific N. Include line numbers. ============================== Please submit your revised manuscript by Jul 21 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: This is an automated report for PONE-D-25-11133. This report was solicited by the PLOS One editorial team and provided by ScreenIT. ScreenIT is an independent group of scientists developing automated tools that analyze academic papers. A set of automated tools screened your submitted manuscript and provided the report below. Each tool was created by your academic colleagues with the goal of helping authors. The tools look for factors that are important for transparency, rigor and reproducibility, and we hope that the report might help you to improve reporting in your manuscript. Within the report you will find links to more information about the items that the tools check. These links include helpful papers, websites, or videos that explain why the item is important. While our screening tools aim to improve and maintain quality standards they may, on occasion, miss nuances specific to your study type or flag something incorrectly. Each tool has limitations that are described on the ScreenIT website. The tools screen the main file for the paper; they are not able to screen supplements stored in separate files. Please note that the Academic Editor had access to these comments while making a decision on your manuscript. The Academic Editor may ask that issues flagged in this report be addressed. If you would like to provide feedback on the ScreenIT tool, please email the team at ScreenIt@bih-charite.de. If you have questions or concerns about the review process, please contact the PLOS One office at plosone@plos.org. Reviewer #2: The paper examined the impact of short sleep duration on depression, self-reported poor mental health days, and poor physical health days using large-scale data from the Behavioral Risk Factor Surveillance System. The paper is well written and results offer robust evidence of the detrimental impact of short sleep on physical and mental health. I recommend the authors address the following comments to make the paper more comprehensive and increase readability. 1) The period in which data was collected includes the COVID pandemic. Can the authors address how their findings were impacted by this time period and perhaps add an analysis that excludes these time period which likely biases the results? 2) The discussion should add more information regarding the prevalence of main study outcomes with respect to the current survey (e.g. does the number of poor mental health days in the US as measured by other surveys match the current results? See Udupa et al. 2023) 3) It would be very informative to add the impact of the co-variates (sex ,age etc.) on the outcome in each of the models (can be done as supplementary). 4) The analysis of physical health is a bit confusing - the survey asks about general physical activity (being active or not) yet the result present poor physical health days. Can the authors explain this difference? 5) Please add the exact phrasing used for the self-reported sleep duration question. Also, please add the number of participants to the study abstract. 6) Last, the study does not include any visual elements other than tables – can the authors find a way to visualize the results? ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: report_10.1101+2025.03.06.25323545.pdf https://doi.org/10.1371/journal.pone.0321347.r001
Revision 1
11 Aug 2025 Author Response We sincerely thank the reviewers for their thoughtful comments, detailed reviews, and valuable suggestions. We have implemented all the requested revisions and have outlined them below. In addition, we made a few other changes that we believe further enhance the clarity, relevance, and overall quality of the manuscript. Summary of Major Revisions: 1. New Analytical Approach: We revised the analytic design from a binary classification of sleep duration (short vs. recommended) to a three-category classification: o Short Sleep (≤5 hours), o Recommended Sleep (6–8 hours), and o Long Sleep (≥9 hours). This allows for a more nuanced evaluation of the association between sleep and health outcomes. 2. Expanded Health Outcomes (Now Four): We now include General Health Status (fair/poor vs. good/very good/excellent) as a fourth outcome in addition to: o Depression, o Poor mental health days, and o Poor physical health days. 3. Revised Sample Size and Flow Diagram: The analytic sample is now N = 318,000. A detailed study flow diagram (Figure 1) has been added to illustrate inclusion/exclusion criteria and missing data handling. 4. Precise Variable Definitions: We now clearly provide the exact BRFSS questions and operational definitions used to derive each variable and outcome, as requested. 5. Revised Manuscript Title: The title has been updated to: “Associations Between Sleep Duration and Depression, Mental Health, Physical Health, and General Health in U.S. Adults: A Population-Based Study” to better reflect the revised scope and objectives. Point-by-Point Responses Editorial Comments 1. Citation Formatting “Please ensure that all citations adhere to the formatting style specified in the journal’s author guidelines especially in-text citations.” Response: All references have been reformatted in accordance with PLOS ONE citation guidelines. In-text citations now use the correct numerical format. 2. Temporal Trend Justification “The analysis does not include any temporal stratification or trend assessment... A visual or statistical analysis of trends would significantly enhance the contribution of the study.” Response: We agree with this recommendation and have now included a temporal trend analysis to examine the changes in sleep duration and health outcomes across 2016–2023. A new section has been added to the Methods and Results, and the table is available in Table 2 and Supplementary Figure . 3. Propensity Score Matching (IPW) Methodology Description “The methodology is not adequately described… include rationale, variables, matching technique, and diagnostics.” Response: We have added a new subsection to the Methods section titled “Propensity Score Matching (Inverse Probability Weighting – IPW)”. This subsection outlines the rationale for using IPW to reduce selection bias inherent in observational data. We detail the covariates included in the propensity score model (age, sex, race, education, BMI, income, etc.), the matching algorithm used (1:1 nearest neighbor without caliper), and the approach for assessing covariate balance (standardized mean differences). In addition, we have provided the full Stata syntax used for implementing the IPW procedure to enhance transparency and reproducibility. 4. Sample Size Discrepancy (Table 1 vs. Text) “Clarify how the N = 163,724 was derived and ensure internal consistency.” Response: We have clarified that Table 1 originally reflected the matched sample. It has now been updated to explicitly indicate whether the characteristics pertain to the matched or unmatched population, and we have included the full analytic sample size of 318,000. Additionally, a study flowchart has been added to illustrate the sample derivation and exclusion criteria. A comprehensive description of all study variables, stratified by sleep category, is now provided. As we employed inverse probability weighting (IPW) rather than traditional propensity score matching, we did not construct separate matched and control groups; instead, the entire weighted sample was used for analysis. 5. Add Line Numbers “Include line numbers.” Response: Line numbers have been included in both the clean and tracked-changes versions of the revised manuscript. Reviewer #2 Comments Comment 1: COVID-19 Bias Potential “The period in which data was collected includes the COVID pandemic. Can the authors address how their findings were impacted…?” Response: We conducted a stratified analysis comparing the pre-pandemic (2016–2019) and pandemic (2020–2023) periods to assess potential variation in associations. Results remained consistent across both timeframes. Additionally, we included year and state fixed effects in our models to account for temporal and geographic variability. A binary variable for the COVID-19 pandemic period (“COVID”) was also created and included in the models to control for the specific effects of the pandemic years. These adjustments are detailed in the revised Methodology and Results section. Comment 2: Benchmark Outcomes with National Survey (e.g., Udupa et al. 2023) “Add more info regarding the prevalence of outcomes compared to other surveys…” Response: We have expanded the Discussion section to include comparisons of our findings with Udupa et al. (2023) and other national BRFSS-based studies. Our estimates are consistent with prior literature, reinforcing external validity. Comment 3: Impact of Covariates “Add the impact of covariates (sex, age, etc.) in the models – can be done in supplementary.” Response: We appreciate the reviewer’s insightful suggestion. While we agree that examining the independent effects of covariates such as sex, age, education, income, and race on each health outcome would be valuable, we have chosen not to include these detailed estimates in the current manuscript for several reasons. First, incorporating these results across all four outcome variables would significantly expand the number of tables (we currently present six tables), potentially overwhelming readers and detracting from the study’s main focus—examining associations between sleep duration and health outcomes. Second, the purpose of this study was to evaluate sleep duration as the primary exposure of interest, while adjusting for key covariates. Including full covariate-specific estimates may shift focus away from our central objective. That said, we fully acknowledge the importance of these covariate effects and have adjusted for all suggested variables in our multivariable models. To address this important line of inquiry, we are actively planning a separate follow-up study that will comprehensively evaluate the independent impact of sociodemographic covariates on depression, mental health, physical health, and general health status using the BRFSS dataset. We hope this rationale is acceptable and appreciate your understanding. Comment 4: Clarify Use of ‘Poor Physical Health Days’ vs. Physical Activity “The survey asks about physical activity, yet you report poor physical health days.” Response: We clarified that our outcome was BRFSS-reported number of poor physical health days, not physical inactivity. The specific question wording is now quoted in the Methods section. Comment 5: Add Exact Question Wording & Abstract Sample Size “Please add the exact phrasing used for sleep duration… and participant number in the abstract.” Response: We have added the precise BRFSS item: “On average, how many hours of sleep do you get in a 24-hour period?” to the Methods section, and the final sample size (N = 318,000) is now included in the Abstract. Comment 6: Add Visualizations Beyond Tables “Can the authors find a way to visualize the results?” Response: We have included the following visualizations to support our findings and enhance interpretability: • Supplementary Figure 1: A line graph illustrating the weighted proportion of each sleep duration category (Short, Recommended, Long) among U.S. adults across BRFSS survey years 2016–2023. • Supplementary Figure 2: A bar chart displaying the estimated prevalence of self-reported depression across sleep categories, derived from inverse probability weighting (IPW) models. These figures highlight both temporal trends in sleep patterns and the adjusted associations between sleep duration and depression. • A flow diagram showing the analytic sample derivation (Figure 1). Additional ScreenIT & Editorial Compliance Updates • Study Flow Chart: Added (Supplementary Figure 1). • Inclusion/Exclusion Criteria: Individuals were excluded if they had missing data on sleep duration, any study outcomes, or covariates. Additionally, participants under the age of 18 were excluded from the analysis. • Sex as a Variable: Included in descriptive stats and multivariable models. • Open Data: Minimal dataset will be provided upon acceptance. De-identified BRFSS data and codebook are publicly available. • ORCID ID for Corresponding Author: Updated in Editorial Manager profile. ________________________________________ We hope the comprehensive revisions and additions have addressed all comments satisfactorily. We are grateful for the opportunity to revise and improve our work and look forward to your favorable consideration. Sincerely, Oluwasegun Akinyemi, MD, MSc. PhD Senior Research Fellow Howard University College of Medicine Oluwasegun.akinyemi@howard.edu (309) 255-8284 Attachments Attachment Submitted filename: Response to Reviewers_Sleep7232025.docx https://doi.org/10.1371/journal.pone.0321347.r002
30 Oct 2025 Decision Letter - Valentina Alfonsi, Editor Associations Between Sleep Duration and Depression, Mental Health, Physical Health, and General Health in U.S. Adults: A Population-Based Study PONE-D-25-11133R1 Dear Dr. Ndebele-Ngwenya, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Valentina Alfonsi, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #2: Yes ****** Reviewer #2: I thank the authors for their comprehensive response and revision of the manuscript. I have a few follow-up questions regarding the new analyses – 1) the sleep categories used in the study are suggested to be informed by the American Academy of Sleep Medicine and the Centers for Disease Control and Prevention, both endorse 7 to 9 hours of sleep as optimal for adult health. It is therefore unclear why 6 hours of sleep is not included in the short sleep category and 9 hours is considered long rather than recommended sleep. This is especially relevant when considering the young cohort in the study (18-25) which routinely sleep more than 8 hours when sleep is free from constrains (e.g. Motomura et al. 2017, Klerman et al. 2008). I would therefore recommend reanalyzing the data using the following categories which are more aligned with current guidelines – • Short sleep: ≤6 hours, • Recommended sleep: 7–9 hours, • Long sleep: ≥10 hours. 2) When discussing long sleep please address current studies revealing a potential bias in self-reported sleep duration such that a proportion of self-reported long sleepers are in-fact getting insufficient sleep when measured objectively (e.g. Wang et al 2025, Health Data Science) 3) Table 1 – headlines refer to years instead of hours of sleep for all sleep categories. Please revise. 4) There is a typo in the abstract (adults’ instead of adults). ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #2: No ******** https://doi.org/10.1371/journal.pone.0321347.r003
Formally Accepted
Acceptance Letter - Valentina Alfonsi, Editor PONE-D-25-11133R1 PLOS ONE Dear Dr. Ndebele-Ngwenya, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Valentina Alfonsi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0321347.r004

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