Sleep and Daily Suicidal Ideation Among High-Risk Adolescents and Young Adults

In this podcast, we are joined by Dr. Jessica Hamilton, Assistant Professor in the Department of Psychology, Rutgers University, New Jersey, and Dr. Peter Franzen, Associate Professor of Psychiatry and Clinical and Translational Science at the University of Pittsburgh in Pennsylvania, discuss their JCPP paper, ‘Sleep influences daily suicidal ideation through affective reactivity to interpersonal events among high-risk adolescents and young adults’ (doi:10.1111/jcpp.13651). There is an overview of the paper, methodology, key findings, and implications for practice.

Discussion points include;

• How they went about examining sleep as a proximal risk factor for suicide
• Their finding that short sleep may impair how teens can regulate their already intense emotions
•  Implications of their findings are for CAMH professionals
• How they envisage their findings will translate into practice
• Resources that listeners may find of use
• Advice for parents or carers, CAMH professionals and policy makers.

In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances. Subscribe to ACAMH mental health podcasts on your preferred streaming platform. Just search for ACAMH on; SoundCloud, Spotify, CastBox, Deezer, Google Podcasts, Podcastaddict, JioSaavn, Listen notes, Radio Public, and Radio.com (not available in the EU). Plus we are on Apple Podcasts visit the link or click on the icon, or scan the QR code.

Dr. Hamilton is an Assistant Professor in the Department of Psychology. Her research focuses on identifying modifiable risk factors for the onset and worsening of adolescent depression and suicidality (i.e., ideation and behavior). Given that depression and suicidality increase during adolescence, Dr. Hamilton’s research applies a developmentally-informed approach to understand the unique factors that impact the development and course of depression and suicidality during this period. Her research centers on three interrelated questions: 1) which adolescents are most at risk?, 2) when are adolescents most at risk and through what malleable processes (e.g., sleep, social stress, rumination)?, and 3) How does technology both impact risk for suicidality and improve our ability to capture (and ultimately modify) these risk processes in real time? Integrating these questions, she is currently the PI on a NIMH-funded career development award (K01) that examines social media and sleep disruption in risk for suicidality among adolescents using an intensive monitoring design. Broadly, Dr. Hamilton’s research aims to harness the power of advancing technology (e.g., smartphone sensing, actigraphy, ecological momentary assessment (EMA), ambulatory psychophysiology) to better identify and detect suicide risk in the real world and in real time to inform prevention and early intervention programs among diverse youth. (Bio from Rutgers University)

Dr. Franzen is the Project Leader of Project 1 of the CARRS study. Dr. Franzen obtained a Bachelor of Science with college honors at Carnegie Mellon University. He then obtained his PhD in clinical psychology at the University of Arizona, which was followed by his clinical internship at Western Psychiatric Hospital and postdoctoral training in the Department of Psychiatry at the University of Pittsburgh School of Medicine, and joined the faculty there in 2007. Dr. Franzen’s research has been funded by the National Institutes of Health, The Pittsburgh Foundation, the American Foundation for Suicide Prevention, among others. His research program strives to better understand why and how sleep is so important for emotional health in adults in teens. (Bio and image from University of Pittsburgh)

Other resources

• Featured paper ‘Sleep influences daily suicidal ideation through affective reactivity to interpersonal events among high-risk adolescents and young adults’, (2022). Jessica L. Hamilton, Aliona Tsypes, Jamie Zelazny, Craig J.R. Sewall, Noelle Rode, John Merranko, David A. Brent, Tina R. Goldstein, Peter L. Franzen

Transcript

[00:00:29.972] Jo Carlowe: Hello. Welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today, I’m interviewing Dr. Jessica Hamilton, Assistant Professor in the Department of Psychology, Rutgers University, New Jersey and Dr. Peter Franzen, Associate Professor of Psychiatry and Clinical and Translational Science at the University of Pittsburgh in Pennsylvania.

Jessica and Peter are co-authors of the paper, ‘Sleep influences daily suicidal ideation through affective reactivity to interpersonal events among high-risk adolescents and young adults’ recently published in the Journal of Child Psychology and Psychiatry. This would be the focus of today’s conversation.

The JCPP is one of the three journals produced by the Association for Child and Adolescent Mental Health. ACAMH also produces JCPP Advances and the CAMH. If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with the rating or review, and do share with friends and colleagues. Jessica and Peter, welcome. Thank you for joining me. Why don’t you each start with a brief introduction about who you are and what you do?

[00:01:43.185] Dr. Jessica Hamilton: Hi. Thank you so much for having us. My name is Jessica Hamilton. And I am an Assistant Professor in the Department of Psychology at Rutgers University in New Jersey. And I’m the director of the Hamilton Lab. I’m a clinical psychologist by training. And my research focuses on identifying risk and protective factors for suicidal thoughts and behaviours in young people, particularly focused on sleep as an actionable target and an opportunity for intervention.

[00:02:06.818] Dr. Peter Franzen: Hi. I’m Peter. And I have a long-standing interest in understanding links between sleep and emotional health. So, what happens in folks when they don’t get enough sleep? What happens in clinical populations where sleep tends to be more impaired? So, I’ve started a series of work in looking specifically at sleep in youth who are currently suicidal, along with my colleague, Dr. Tina Goldstein. So, I just want to give a shout out to her because she and I designed and ran these studies together and then also had a great team of people to work with, including Dr. Hamilton here, on the project that we’re going to talk about today.

[00:02:44.910] Jo Carlowe: Great. Thank you very much. So, let’s turn to the project, the paper ‘Sleep influences daily suicidal ideation through affective reactivity to interpersonal events among high-risk adolescents and young adults’; this was recently published in the JCPP. Can you give us a brief overview of the paper? What did you look at?

[00:03:06.223] Dr. Peter Franzen: In this particular study, we wanted to examine sleep as a proximal risk factor for suicide. Let me just break down what the rationale is for why we want to understand sleep as a proximal risk factor. First, it’s important to note that youth suicide is an important concern. Rates are rising and rising the fastest amongst youth. It’s now in the United States the second leading cause of death in youth between the ages of 10 and 24.

There’s been a lot of research that’s really come a long way in identifying many risk factors for suicidal behaviour, but most of these risk factors are distal. They tell us something about who is at risk. For example, if you have a family history of suicide in your family, you’re at risk for also engaging in suicidal behaviour. Or certain psychiatric disorders tend to be associated with higher risks for suicidal behaviour. But again, these kinds of distal risk factors tell us who’s at risk. They don’t really tell us very much about when these people are at risk. And that’s what’s really going to be key for developing optimal targets for both suicide prevention and intervention.

Really, that’s what the experts in the field say, is that these targets need to be proximal. So, they need to be occurring close in time to the event. They need to be dynamic and observable. So, they need to be changing risk factors. And we need to be able to measure them, so that we can see that they’re happening. And finally, importantly, they need to be modifiable. So, are these risk factors that are happening close in time something we can do something about? And so, sleep really might fit the bill for all of these things if we can identify it as a factor that’s occurring near in time to intensifying suicidality. We know that sleep is dynamic on a daily basis. We can very clearly measure it with the host of different methods. Self-report. We can use objective measures, such as activity monitors. And we also know that there are a lot of good interventions out there that can help modify sleep.

In addition, there’s growing evidence that sleep is an important factor involved in suicide. But of course, I think this growing large evidence base is in a lot of studies that weren’t set up to specifically examine this. So, I’d say a vast majority of the studies only use self-report measures, so a lack of objective measures. A lot of them fail to control for depression. This is important because we know sleep problems go hand in hand with depression. Sleep problems are a risk factor for the development of depression. But even when you have depression, sleep tends to be bad. So, is it really all about depression, or is there something unique that sleep is doing that’s increasing risk for suicide? So that’s why I think it’s important that we control for depression in these studies.

Also, a lot of them are from either large epidemiological studies that are either retrospective or cross-sectional. So now, we’re just saying, OK, if we go back and say, well, did there seem to be a relationship between sleep and suicide? That’s not the same type of good evidence that we get from a prospective study, where we are carefully trying to measure these things in the first place and then measuring them out over time. And then also, I think it’s important that we start to understand what are the biological mechanisms? Through what pathways might sleep be leading to increasing suicidality and also developmental differences. So, this growing association that we know about sleep and suicide exists in both adults as well as in adolescent population.

Really what motivated this study was that what we think we need is prospective longitudinal studies that will examine multiple methods, so we can look at sleep in different ways, to quantify what aspects of sleep might enhance near term suicide risk, which therefore might help inform prevention and intervention.

[00:06:36.732] Dr. Jessica Hamilton: So, I’ll just add that we know that interpersonal stressors and negative social experiences in particular are often precipitating factors or triggers for having suicidal thoughts or engaging in suicidal behaviours. And these are also harder to predict, when someone might experience a negative social experience. So ultimately learning whether and how sleep impacts how people respond to these experiences is especially important.

And in this study, we were really curious about whether how someone sleeps, and how much someone sleeps, and these different components of sleep as Peter mentioned, actually impacts how someone regulates their interactions with others in terms of their emotional distress or their enjoyment or positive experiences and positive experiences with other people as well. And whether understanding this affective reactivity as we call it to interpersonal events could be a potential linking factor related to both shorter and poorer sleep and suicidal thoughts, especially on a daily basis and that more proximal mechanism, as Peter mentioned.

[00:07:38.690] Jo Carlowe: Before we go into the findings, I want to know how you sort of went about unpicking all of this. What can you tell us a little bit about the methodology you used?

[00:07:47.135] Dr. Peter Franzen: To look at whether sleep would be associated close in time with suicidal thoughts, we did this intensive longitudinal study in youth. They were between the ages of 13 to 22, and they were being treated in an intensive outpatient program. So, this outpatient program was either for secondary students or for college students, and involves treatment that’s three hours a day, three days a week. So, it’s more intensive treatment than just regular outpatient program. So, it could be these clinics are often used to either prevent people from having to go into the hospital or as a step-down for people who were in a psychiatric hospitalization, where they might need more care than just general like once a week outpatient care.

So that’s our population who we’re studying, and they were in the study with daily participation for up to three months. So as long as they continue to receive care in our clinic, we would study them as long as they agreed to be in the study. But if they left clinical care, we stopped following them. In total, participation lasted for up to three months. Average number of days that people were in the study were for 58 days. And our participant sample was largely female and White. So, it was 75% female and 76% White. All of these participants had major depression. 70% of them also had at least one anxiety disorder. Pretty common to see that comorbidity. 90% were on at least one psychiatric medication. 44% had made a past suicide attempt. So just giving you an idea of the sort of severity of the patient population.

During the course of the study, we would ask them daily whether they were experiencing any suicidal thoughts. 75% of the sample had at least one day that they endorsed having suicidal thoughts. But on average, it was 22% of study days. That ranged from 0 to 43%. So our most severely suicidal person was on almost half the days was reporting feeling suicidal. OK. To get at the methods, we also asked about we’re going to now measure daily levels of both suicidality and sleep.

For sleep, we measure that two ways. One with daily diary. So, we would send a link to participants in the morning, and they would fill out a diary that asked them what time they went to bed, how long it took them to fall asleep, what was the quality of their sleep. And then we also asked them to wear a wrist-worn actigraph. So, this is like a Fitbit or other commercially available device that will just report on how much activity people were having. And we can use that to infer when people were awake and asleep. And I think both are important. One, it’s nice to have objective data because I don’t think people are always good at being able to report accurately. Also, perceptions are important. So, I think it’s also important to ask people about how they were feeling. So, we do that in the morning.

In the evening, we would send another link to participants, about 45 minutes before their habitual bedtime. And in that evening diary, we ask people a set of questions in terms of how much suicidality, passive death wish, ideation, intent, attempt, so across the continuum of suicidality. And then we ask them just a few other questions. What was the worst their depression was that day? If they did endorse having a suicidal ideation, we asked them about how intense those thoughts were, around the time of day that they happened? And then we also asked them a couple of questions, partly motivated by my collaboration here with Dr. Hamilton, on how this impacted events the next day. Do you want to talk a little bit about that, Jess?

[00:11:05.250] Dr. Jessica Hamilton: Yeah, sure. So, we ultimately, as we mentioned, we’re interested in understanding more about the social experiences people have on a day to day basis. We asked about negative experiences or interactions that people might have with other people. So that include parents, peers, teachers, other members, other people in their family, as well as positive experiences or interactions that they might have with other people that day.

And we also asked teens to report and rate on a scale of 0 to 100 how distressing or upsetting those experiences were when they were a negative interaction with other people or how positive and rewarding or enjoyable those experiences were when they were involving a positive experience with other people. And so, we ultimately looked at these things every day, as Peter mentioned. And what allowed us to look at this even deeper at an individual level, because we recognize people have different average amounts of sleep and stress or net positive or negative experiences they might have.

We actually used a person-centred approach, which is an analytic approach, where we actually take out their average amount across the entire study. So, we’re really looking at here are kind of those daily fluctuations or changes in having more sleep than usual or less sleep than usual is one example, or having more negative emotional responses to stress than usual, or more enjoyable or fewer rewarding experiences, at least perceived emotionally that day.

And so, in our findings, that’s important to recognize as we’ll talk about, is looking at the individual level, taking into account that people are different compared to themselves. So, what we’re comparing is how people are different from their own self on a day to day basis.

[00:12:40.567] Jo Carlowe: Let’s turn to the findings.

[00:12:42.150] Dr. Jessica Hamilton: We have a few different findings here I’ll highlight, which is that shorter sleep compared to how a teen usually sleeps, so when a teen had less sleep than usual, they had more emotional reactivity or heightened emotional distress, or simply stated, felt worse the next day when they experienced a negative social or interpersonal event, such as those involving peers, family, or teachers the next day. And this heightened emotional distress to those social events was associated with having more likelihood of a suicidal thought that same day and more intense suicidal thoughts when they did have them.

And this suggests that short sleep may impair how teens can regulate their already intense emotions, as we know from adolescent development, following these social stressors, and that this is a pathway through which shorter sleep can increase the risk of suicidal thoughts in teens. But also interesting, we found that worse sleep quality compared to a teen’s usual amount or kind of perception of sleep also lead teens to have reduced enjoyment or positive emotional experiences when they had positive social interactions with other people that next day. And that this lower responsiveness to these positive events were also associated with a greater likelihood of having suicidal thoughts that day.

So, in short, our findings suggest that shorter and poorer sleep may indirectly lead to suicidal thinking among at risk teens and young adults through its effects on both increasing negative emotions to negative social events and reducing positive emotional responses to positive social events. Ultimately being a double edged sword, thereby not only just increasing risk, but also reducing potential protective factors that can protect against suicide risk. And as I mentioned, we found this on a day-to-day basis and using behavioural measures of sleep to more objectively capture sleep duration than self-report.

[00:14:35.820] Jo Carlowe: What are the implications of this finding for CAMH professionals?

[00:14:39.493] Dr. Jessica Hamilton: So, our findings really highlight the importance of targeting both sleep, and I’d say emotion regulation skills in prevention, and intervention settings with young people, especially those who may already be at risk for depression and suicide. And that improving sleep especially can be an effective target for improving emotion regulation as we found, and also for suicide prevention, and just generally improving outcomes in young people in treatment; since we know that sleep can improve mood, emotion regulation, impulsivity, and general well-being.

So, we’d like to emphasize too that CAMH professionals should regularly assess sleep health in teens and young adults with whom they work and understand that sleep does change, right? It changes a lot on a day-to-day basis. So, it’s important to check in regularly with young people to promote sleep, and help them recognize its importance, and also problem solve when and how sleep is going wrong, so we can actively work with them to improve it. And of course, sleep should be a core part of intervention and prevention programs when working with young people.

[00:15:38.500] Jo Carlowe: I also want to ask about the implications for schools and professionals in education because presumably, they get quite good visibility as to whether people are [INAUDIBLE].

[00:15:47.288] Dr. Peter Franzen: What we know is that getting insufficient and irregular sleep is extremely common in youth. And those are risk factors for the development of problems like depression and suicidal thinking. I think that these problems exist in the sort of normative population, and that the relationships might get exacerbated in people who already have developed psychiatric disorders. I think that promoting healthy school start times and being able to do educational campaigns for both parents, teachers, and students about why sleep is so important, that it’s going to impact how we feel, how irritable we are, how well we get along with other people. I think just the general promotion of sleep health is one of the things that schools can do.

[00:16:37.230] Jo Carlowe: And does that also apply to parents and young people themselves then?

[00:16:41.242] Dr. Jessica Hamilton: Yeah, absolutely. And I’d like to recognize that sleep is not always easy to do, especially in a society that’s ever moving and regularly is conveying the message to young people that through our policies and actions, that we don’t necessarily value their sleep. And science does support how critical sleep is to their mental health, and it does need to be a priority. And so, improving sleep can improve, as Peter said, how well they regulate their emotions as we found in our paper, how they interact with other people, as well as how well they perform in school, athletics, and also their general mood.

And so ultimately, if sleep is a problem for you, it’s important to work with a mental health professional to improve it. And there are really effective treatments that can help improve sleep, including cognitive behavioural therapy for insomnia and brief behavioural therapy for insomnia. And both Peter and I are actively working in our own research to improve sleep treatments for young people and to make them more scalable across levels, which we’re happy to chat more about as well.

[00:17:39.312] Jo Carlowe: Because I do want to ask that about how you envisage your findings will translate into practice. Can you talk a bit about this?

[00:17:46.340] Dr. Peter Franzen: I think there’s several different ways that we can see this happening. So, one, if we see that sleep is in fact a proximal risk factor, then perhaps we need to start trying out real time detection. So, this could happen in different ways. It could happen via daily diary that’s completed on your phone, or wearing an activity monitor, or even passive cell phone sensing. If we’re doing real time detection and we start to see aberrant patterns in sleep, then that could alert parents and providers or could send a prompt to teens to engage in safety skills or engage in their safety plan.

So, I think that that’s sort of can we be doing real time monitoring if in fact, sleep is a proximal risk factor? But as also, Dr. Hamilton was saying, that there are really well known effective behavioural sleep and circadian interventions that exist. We know that we can improve sleep. What we don’t know so much is whether we can improve sleep and really see a big change in depression and suicidality. So, I think that that’s something we need to establish. Often many studies who use sleep interventions specifically exclude people who are suicidal from their studies in the first place because they’re sort of afraid to get involved in the topic, which really does not help us know what’s going to be best for intervention.

But you can imagine that sleep disturbances could be an optimal risk factor to target for a couple of reasons. We can change them. They’re modifiable. They can be identified and targeted by across a range of professionals in youth-centred settings, such as schools or doctor’s offices. So, we could potentially be broadening the reach of suicide prevention efforts. Focusing on sleep, that might be more acceptable to adolescents, who due to the stigmas about mental health. So, sleep might be a sort of safer approach or gateway into treatment. Like suicide, sleep problems are transdiagnostic. In other words, sleep problems exist across numerous psychiatric disorders. And the types of sleep problems that they have, it’s not all just about insomnia, but there really are different dimensions of sleep. So, sleeping at weird times, irregular times, not getting enough sleep, sleeping too much. All of these are different factors. So given that these types of sleep complaints and problems are really common, common in a bunch of different disorders, it sort of renders them universal targets regardless of diagnosis. So, we can treat sleep across many different disorders.

[00:20:03.097] Jo Carlowe: Jessica and Peter, is there anything else in the paper that you’d like to highlight?

[00:20:07.750] Dr. Jessica Hamilton: I think the only thing I’ll add is that this study was conducted kind of naturalistically as part of young people’s course of treatment. And so actually, they partnered well with the clinicians involved in concluding kind of how we monitored suicide risk. And so that was obviously given the sample, especially such a core part of ensuring safety of the young people and also kind of embedding some of the findings as we were building them with the clinicians.

And so, Peter, for instance, we would share the actigraphy to be able to share some of those reports with the clinicians themselves about sleep. And from their self-report, getting that information also helped improve some of their own treatment approaches and knowledge of their clients’ sleep. I think that that’s also something that is important to know in terms of how we approach the study and also just how research can also pair naturally with clinical practice as well to improve overall treatment of youth.

[00:20:58.710] Jo Carlowe: Are you planning some follow up research that you can share with us?

[00:21:02.085] Dr. Jessica Hamilton: Yeah, so I’m currently at Rutgers University, as I mentioned. And I just founded my lab here in January 2021. And I’m actively working on a Career Development Award funded by the National Institute of Mental Health in the US. And this study aims to dive deeper to better understand the nature of the relationship between sleep and suicidal ideation. And we’re similarly using an intensive monitoring design for two months and recruiting teens from the community. Many of whom we found, without necessarily actively recruiting them, are also at very high risk for suicide. Many have had suicidal thoughts regularly and have had prior suicide attempts as well.

And so, in this study, we’re exploring the role of social media specifically, as I mentioned earlier, including understanding the patterns of social media use through a smartphone sensing, in which we actually put an app on teen’s phones to understand their patterns of use across the day and within days. And then also exploring their experiences, as we mentioned before, on social media and in person to better understand the nature of the social experiences they’re having, and how that might intersect with sleep to ultimately confer risk or potentially at times, protect teens. Since social media can also be a source of strength and community, better understand how it can promote overall well-being in young people.

[00:22:14.830] Jo Carlowe: Is there anything else in the pipeline for either of you that you’d like to mention?

[00:22:18.852] Dr. Peter Franzen: We’re trying to look at this sleep-suicide association in a number of different ways. So we’re doing a larger study now of the study we were just talking about, so we can get a larger sample. We’re looking at various markers of autonomic nervous system as well. The idea is with enough people, we can start to look at how various dimensions of sleep health might be interacting with each other or might be able to use different techniques, such as machine learning to figure out if there are specific kinds of patterns that are most associated with increasing suicide risk, which might help us further guide suicide intervention and prevention strategies.

In my lab, we’re also doing a longitudinal study in people who haven’t developed depression and suicide, but to look at how sleep changes over time and how that may start to predict increases because adolescence is a really dynamic and vulnerable period for the onset of these kinds of problems. And then finally, with my colleague Dr. Goldstein, we have been further adapting this transdiagnostic sleep and circadian intervention and specifically trying to use some implementation science techniques to adapt it for minoritized populations.

So, in the US, looking at Black and Hispanic youth who have disparities in both sleep, they tend to have worse sleep, but also disparities in rates of both suicidal thoughts and even death by suicide. So how can we sensitively tailor our interventions for populations that might be uniquely at risk? LGBTQ individuals would be another example of people who are at sort of unique risk with disparities in both sleep health, as well as problems with suicidal thinking.

[00:24:01.140] Dr. Jessica Hamilton: And building on this, I’m also working on developing a brief online single session intervention for teens to ultimately improve the scalability of strategies to improve sleep, which is actually in collaboration with Dr. Maria Loades and Faith Orchard at the University of Bath and Sussex. And we’re working with them to ultimately improve the interventions we already know that work, and take some of those strategies and skills, and be able to more widely disseminate them.

And also, with the goal of helping to reduce these disparities that we see in sleep that exist. And we hope that will help teach teens more about better sleep hygiene, tips to improve their sleep, and also to make more informed decisions about their sleep, to really place more value on sleep as well. So, our ultimate hope is to partner with schools, doctors, mental health providers to disseminate this intervention to young people with sleep problems who may not otherwise be able to access care.

And it’s not intended to take away the care they might otherwise get, but really, wait lists are long. You know that many teens don’t get the help they need. And so, this is one scalable intervention that we’re working to ultimately promote. And hopefully, it can also serve not as an intervention, but also as a prevention program as well if we know that by targeting sleep, we can improve the likelihood of these mental health outcomes developing, which is the ultimate goal.

[00:25:12.690] Jo Carlowe: It sounds fantastic. Are there any resources that you can signpost our listeners to?

[00:25:18.335] Dr. Jessica Hamilton: We have great resources on our website, including tips for healthy sleep and suicide prevention resources. So that’s on thehamiltonlab.org. And also sleep.pitt.edu has a number of tools and measures that are bringing in online for actually clinicians to be able to use to better measure sleep in their patients or in their clients. And that’s important to be able to monitor sleep on a daily basis using sleep diaries, as well as sleep quality over time. And so those are two resources I’d recommend to check out to just understand more about sleep, as well as more general mental health resources as well.

[00:25:50.530] Jo Carlowe: Finally, what take home message do you each have for our listeners?

[00:25:54.957] Dr. Peter Franzen: For me, the take home message is that I think sleep is really important and really key for our emotional function. And this is true not just for individuals currently experiencing suicidality, but across people and across the lifespan. Also, I think a take home message just for me is a big shout-out to all the people who participated in the study. So, our families and youth who were willing to go through this for three months. There are a lot of people who helped us as investigators on the study and so, my gratitude to them.

[00:26:25.038] Dr. Jessica Hamilton: My takeaway message would be that sleep is important. And we need to do more as a society to work together to ensure that young people know this and also to build an infrastructure that will support them in getting good quality sleep, which will ultimately improve both sleep and the mental health of young people. Similarly, I’d like to thank Peter and Tina, so Dr. Goldstein and Dr. Franzen, for their instrumental support in helping me do this study with them. And also the patients and families for their role and participating. And of course, JCPP for publishing our paper and giving it exposure, so that we can talk about the findings and the important work that we’re doing to ultimately help improve sleep.

[00:27:01.590] Jo Carlowe: Jessica and Peter, Thank you so much. For more details on Dr. Jessica Hamilton and Dr. Peter Franzen, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review. And do share with friends and colleagues.