Sleep Advances, 2024, 5, zpae028

https://doi.org/10.1093/sleepadvances/zpae028
Advance access publication 2 May 2024
Original Article

Original Article

Association between poor sleep and mental health

issues in Indigenous communities across the globe:
a systematic review
Dan Richard Fernandez1,*, , Rennie Lee1, Nam Tran2, Dure Sameen Jabran3, Stephanie King4, and Lisa McDaid1
1
Institute for Social Science Research, University of Queensland, Indooroopilly QLD, Australia,
2
Tobacco, Alcohol and Other Drugs Unit, Australian Institute of Health and Welfare, Bruce, ACT, Australia,
3
Frazier Institute, Translational Research Institute, University of Queensland, Woolloongabba, QLD, Australia and
4
Centre for Rural and Remote Health Murtupuni Campus, James Cook University, Mount Isa, QLD, Australia
*
Corresponding author. Dan Richard Fernandez, Institute for Social Science Research, University of Queensland, 80 Meiers Rd, Indooroopilly QLD 4068, Australia.
Email: d.fernandez@uq.edu.au.

Abstract
Study Objectives: Evidence from studies among non-Indigenous populations has established the association of poor sleep to mental
health issues and supported how improving sleep could reduce the risk of mental ill health. In contrast, for Indigenous people, who
experience disproportionate rates of mental ill health, the association between sleep and mental health and the potential of sleep
health in reducing the risk and severity of mental health issues have never been fully reviewed. Considering the literature gap, this
review assesses the association between sleep and mental health in Indigenous people.
Methods: Following PRISMA guidelines, a study was submitted to the PROSPERO database for registration (293798) prior to com-
mencing the review. Then academic databases were searched for relevant studies published up till 19 February 2023. Studies with
quantitative data on sleep and mental health association in Indigenous people were included and a narrative review/synthesis was
conducted.
Results: Seven studies, using carer/self-reports (six cross-sectional, one longitudinal) among three Indigenous groups (N = 3066)
met the inclusion criteria. In Indigenous Australian children, arousal problems were associated with aggression, and withdrawn
behavior, while early bedtime was associated with a lower risk of behavioral problems. In Native American young people, insom-
nia symptoms were associated with depressive symptoms in adults, short sleep was associated with affective disorders. Clinical
sleep issues, i.e. restless leg and apnea, were associated with depression. In Amerindian/Mestizo adults, restless leg syndrome
was associated with depression and anxiety. Overall, findings report the prevalence of poor sleep and mental health issues among
Indigenous communities across the globe. Six studies scored “moderate quality” and one study scored “high quality” in quality
assessment.
Conclusions: While there is limited research available, our finding suggests an association between poor sleep and mental health
issues in Indigenous people. Further investigation of the potential role of, and investing in, sleep health could help support mental
health.

Indigenous people, the custodians of the oldest continuing cul- and venereal diseases), and the dispossession of their ancestral
tures on the planet, descended from and identified with the lands [5–7]. Assimilation policies were also instituted based on
original inhabitants of a given region before it was conquered by the belief in white superiority, which sought for social, cultural,
colonial societies [1, 2]. Worldwide, over 470 million people iden- and spiritual practices to be erased [7, 8]. Assimilation was insti-
tify as Indigenous people (6% of the global population), living in tuted by forcibly removing Indigenous children from their fami-
70 countries from the Arctic to the South Pacific [1–3]. Indigenous lies and coercing them to adopt a white culture which included
people have strong connections to their land, community, and not speaking in their native languages and not using the names
culture, which are inextricably linked to their identities, and given by their parents [8]. Decades of unexpressed grief and
physical and spiritual well-being [1, 3]. anger have transferred through generations and have resulted
For centuries in Australia, Indigenous people lived uninter- in intergenerational trauma [9]. The impact of intergenerational
rupted until European colonization began [4]. Colonization trauma and historical as well as ongoing inequities, racism, and
resulted in violence (including genocide and massacres), the discrimination manifest in the form of adverse physical health
introduction of new diseases (e.g. smallpox, measles, influenza, outcomes, poor mental health and well-being, reduced quality

Submitted for publication: July 12, 2023; Revised: April 13, 2024
© The Author(s) 2024. Published by Oxford University Press on behalf of Sleep Research Society.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which
permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
2 | Sleep Advances, 2024, Vol. 5, No. 1

of life, and lower life expectancy than their counterparts [6, effective, and sustainable. For example, designing a holistic and
9–11]. culturally embedded mental health system, promoting cultural
The impact of intergenerational trauma as reflected by the relevant protective factors (e.g. traditional upbringings and main-
state of Indigenous people’s mental health is concerning [12]. A taining culture, and family and social support), culturally appro-
global overview of suicide rates in countries with colonial histo- priate service delivery, and the integration of traditional and
ries, such as Australia, Aotearoa/New Zealand, Canada, and the biomedical knowledge [12, 26–28].
United States report significantly higher rates of mental health In understanding the mental health issues affecting Indigenous
issues and death caused by suicide among Indigenous people people, it is imperative to consider every available strategy to
compared to their counterparts [13–19]. address them. In this review, mental health issues refer to “men-
While there are no available overall statistics on the current tal health conditions.” The World Health Organization’s WHO
worldwide trends of mental health and death caused by suicide explains that “mental health conditions” is the broader term
among Indigenous people, the country data reports are concerning. used to describe “mental disorders, psychosocial disabilities and
In Australia, statistics from the Australian Institute of Health and (other) mental states associated with significant distress, impair-
Welfare (AIHW) 2018–2019 highlights that one in four Indigenous ment in functioning, or risk of self-harm” [29].
Australians people reported mental health or behavioral condi- To address mental health issues/conditions, an under-­
tions, with anxiety as the most reported mental health condition recognized public health strategy is Sleep health [30]. Sleep health
(17%), followed by depression (13%). Psychological distress is also promotion impacts a wide range of health outcomes, including
identified as a concerning issue affecting one in three Indigenous mental health [30]. In fact, studies from non-Indigenous popu-
Australian adults, particularly those living in non-­remote areas lations have established a strong link between poor sleep and
[20]. The mental health issue in Indigenous Australian com- mental health issues [31–33], and established that improvement
munities is also a key contributor to high rates of deaths due to in sleep health can lead to improved mental health [34–36].
self-harm in Indigenous communities [15]. Among Indigenous Unfortunately, the contribution of poor sleep to mental health
Australians aged 5 to 17 years, suicide was over five times the issues in Indigenous people has not been fully reviewed [34, 36,
rate for non-Indigenous young people between 2010 and 2014 37]. Among the reasons is the paucity of studies on sleep-­mental
[21]. In 2021, figures from the Closing the Gap campaign report health among Indigenous. To the best of our knowledge, there is
that the suicide age-standardized rate for Aboriginal and Torres only one systematic review report on the association between
Strait Islander people increased to 27.1 per 100 000 people (for poor sleep and mental health issues among Indigenous people in
New South Wales, Queensland, Western Australia, South Australia North America [38]. It suggested that poor sleep is associated with
and the Northern Territory combined) from 25.1 per 100 000 peo- an increased risk of mental distress, depression, and anxiety [38].
ple in 2018 [22]. Similarly, the Māori, Indigenous people of New Aside from the limited literature, another challenge in study-
Zealand, are disproportionately affected by mental health issues ing the association between poor sleep and mental health issues
like anxiety, depression, and mental distress compared to non- among Indigenous people may be the differing perspectives on
Māori [16]. A study by Sullivan et al. (2017) reported up to 71% of mental health. Essentially, for Western, non-Indigenous people,
the participants aged 18–34 years reported problems with anxiety/ mental health is focused on “how individuals think and believe,
depression [17]. Consequently in 2018, despite the Government’s and how they adapt to and partake in regular day-to-day exist-
initiatives, Maori still have the highest suicide rates, at 21.7 per ence” [39]. While it may involve “associations with companions,
100 000, in contrast to 14.7 per 100 000 for non-Maori [23]. In the close family, and outsiders,” the focus is essentially on the indi-
United States of America, the Center for Disease Control reports vidual [39]. In contrast, for Indigenous people, mental health is
that American Indian/Native American people experience serious but a facet of an encompassing construct known as “social and
psychological distress 2.5 times more than the general population emotional wellbeing” (SEWB). National Strategic Framework for
over a month’s time [24]. And deaths caused by suicide among Aboriginal and Torres Strait Islander peoples’ Mental Health and
American Indian/Native American people between the ages of Social and Emotional Well-being 2017–2023 explains: “In broad
15–19 is more than double that of non-­Hispanic whites [24]. In terms, social and emotional well-being is the foundation for phys-
Canada, Indigenous people aged 15 years or older were less likely ical and mental health for Aboriginal and Torres Strait Islander
to report positive mental health compared to their non-Indigenous peoples. It is a holistic concept which results from a network of
counterparts [18]. Furthermore, the Survey of Safety in Public and relationships between individuals, family, kin, and community.
Private Spaces (2018) reported that less than half (45.8%) of the It also recognizes the importance of connection to land, culture,
First Nations population reported excellent or very good mental spirituality and ancestry, and how these affect the individual”
health while almost two-thirds (62.3%) of non-Indigenous people [40]. SEWB includes the “social, emotional, and cultural well-­
reported the same [19]. Meanwhile, in terms of deaths caused by being of the whole community throughout the entire life-course”
suicide Webster (2016) compares Canadian Government statistics [40]. This comprehensive perspective includes s­ ociety-level con-
and a study commissioned by the Inuit people (Indigenous peo- cepts such as social justice, equity, and rights, as well as tradi-
ple of Canada). Government statistics claim that suicide rates in tional knowledge, traditional healing, and connection to country
the four Inuit regions are more than six times higher than the rate [41, 42] and “encompass[es] mental health and physical, cultural,
in non-Indigenous regions [25]. The Canadian Government statis- and spiritual health” [42].
tics report, among Inuit youth, suicide is responsible for 40% of Furthermore, the same differing perspectives are observed
deaths, compared with only 8% in the rest of Canada [25]. In con- in sleep health. Fatima et al. (2021) observed that Indigenous
trast, the Inuit-commissioned study states that Inuit suicide rate is Australians’ conceptualization of sleep health was different from
11 times the Canadian average—or 55% higher than the Canadian the Western interpretation of sleep health. Fatima et al. (2021)
Government report [25]. observe that an important component of sleep health among
Considering these statistics, Indigenous communities, mental Indigenous people which is “the connection between dreams
health service providers, researchers, and policymakers are work- and sleep is not adequately captured in current (Western/main-
ing together to identify solutions that are culturally appropriate, stream) tools and resources to promote sleep health” (p. A33) [43].
 Fernandez et al. | 3

Another important but largely unexplored aspect of sleep updated in February 2023. In addition, conference papers, con-
health is how sleep loss which inevitably results in dream ference poster abstracts, and reports were also considered. The
loss (due to shortened rapid eye movement REM sleep) affects search strategy included controlled vocabulary terms and key-
Indigenous people [44]. In general, according to research, while words, e.g. “poor sleep”; “sleep disorder”; “inadequate sleep”; “anx-
reduced REM/dreaming—including REM sleep and dream recall— iety”; “mental health issues”; “psychological issues”; “Indigenous”;
is closely associated with depression, appropriate REM/dreams “First Nations Peoples.” While there are multiple ways to define
facilitate healthy emotional processing [44, 45]. However, for “poor sleep,” for the purpose of this review, we have defined poor
Indigenous people, REM/dream loss has even deeper implica- sleep as problems in any dimension of sleep, i.e. quality, timing,
tions because their SEWB is inextricably linked to culture [46]. duration, efficiency, and sleepiness during waking hours interfer-
Indigenous communities in different parts of the world have doc- ing with the refreshing and restorative nature of sleep [49]. Issues
umented how creativity and knowledge in their cultures have in mental health among Indigenous peoples were identified
been shaped by revelation through dreams [46]. For example, through a non-validated self-report [50] and scores from carer/
among Indigenous Australians, an account of artist Roy Bagay self-reported validated instruments such as the Child Behavior
Wiggan, a Bardi Elder who creates objects of art or Ilma, totems Checklist (CBL) [51], and Depression Anxiety Stress Scales–21
used in ceremonial dance and ritual [47], recounts how Ilma is (DAS-21) [52]. Considering the diversity of Indigenous peoples
revealed to him by deceased relations in dreams [46]. Similarly, across the globe, it is difficult to have an all-encompassing defi-
Aubrey Tigan, a respected elder and lawman of the Bardi and nition that captures the rich and unique cultural values, beliefs,
Djawi peoples, shared recounts of an old man in his dreams who and practices of different Indigenous people groups. Nonetheless,
would keep coming and telling him to carve that shell [48]. Hence to define the scope of this work, in this review, we followed the
for Indigenous peoples, the effect of dream loss may impact cul- United Nations’ interpretation of the term “Indigenous peoples”
ture which in turn affects SEWB. as the ethnic group who descended from and identified with the
Considering the disproportionately high rates of mental health original inhabitants of a given region [53]. The published identi-
issues in Indigenous communities and the deeper implication of fied studies that met inclusion criteria were collated.
sleep health to Indigenous culture, it is important to review the
evidence on the role of sleep in the mental health of Indigenous
people to guide future research and inform strategies for integrat-
Data extraction and quality assessment
ing sleep in mental health programs and services. To accomplish The importing and first screening of titles was conducted by the
this, all available studies assessing the association of sleep (both first author (DRF) using the management software Covidence
quantity and quality) and mental health issues of Indigenous [54]. After removing the duplicate articles, two reviewers (DRF
people which were measured both subjectively and objectively and DSJ) conducted the second screening by independently
were considered. reviewing the studies. Studies meeting the inclusion criteria
In recognizing the lack and the gap in the literature, this review were selected. Disagreements in study inclusion/exclusion were
aims to (1) assess the state of the literature on sleep and mental resolved through consensus. Next, the following key data from
connection in Indigenous communities, (2) explore the strength the selected studies were extracted by the first author (DRF): (1)
and direction of association between poor sleep and mental general information (author’s name, publication year), (2) study
health outcomes, and (3) highlight key gaps in the literature to aims, (3) study and participants’ characteristics (design, sample
offer recommendations for future research. size, demographics), (4) data collection methods/tools (5) findings,
(6) limitations, and (7) strengths. A Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) flowchart dia-
gram shows the number of articles retrieved, screened, excluded,
Materials and Methods
and selected (Figure 1).
Systematic review protocol This review is guided by strengths-based approaches recogniz-
We finalized the PRISMA (Preferred Reporting Items for ing the cultural strength of Indigenous people, including connec-
Systematic Reviews and Meta-Analyses) checklist and protocol tion to country and culture, spirituality, ancestral ties, resilience,
which were then submitted for registration to the PROSPERO kinship, community leadership, and governance [55]. This review
database (293 798) in December 2021. Literature searches were is also guided by the expertise and experience of an Indigenous
commenced thereafter. Australian coauthor and cultural mentor (SK) to ensure that
the interpretation and reporting of study findings are culturally
Search strategy and selection criteria respectful and responsive to Indigenous peoples’ historical and
In our online and manual search, we included all published contemporary circumstances. The methodological quality (risk of
studies if the study explored the role of poor sleep in mental bias) of the studies was assessed using the National Institutes of
health issues, focused on Indigenous people, and was published Health (NIH): Quality Assessment Tool for Observational Cohort
in the English language. Studies were excluded if the association and Cross-Sectional Studies [56]. The NIH tool comprises 14 items
between poor sleep and mental health was explored in a group of assessing the selection and non-response bias (external validity),
people with underlying medical conditions, pregnant women, or measurement bias, and analysis bias (internal validity). Based
shift workers; the study explored sleep and mental health issues on the quality assessment scores, studies were grouped as “high
for Indigenous and non-Indigenous peoples but did not provide quality” (low risk of bias), “moderate quality” (moderate risk of
separate data for Indigenous people; or the article was published bias), and “poor quality” (high risk of bias). Two reviewers (DRF
as clinical guidelines, opinion piece or letter to the editor. First and DSJ) independently assessed the risk of bias. Each study
author (DRF) searched key academic databases, e.g. CINAHL; was assessed for Indigenous leadership and involvement in the
Cochrane; Elsevier/Science Digest; ProQuest; PsycINFO; PubMed; research process. Hence, the level of involvement, participation
SCOPUS; Google Scholar, and the web page of the Indigenous in community benefits, and adherence to local cultural protocols
Health InfoNet, from December 2021 to February 2022 and were highlighted. For this, the adapted version of the Aboriginal
4 | Sleep Advances, 2024, Vol. 5, No. 1

Figure 1. Screening of literature on the association between poor sleep and mental health issues among Indigenous people.

and Torres Strait Islander Quality Appraisal Tool was used [57]. [60], and one study used non-validated single-item based meas-
This tool comprises 14 items assessing the adherence with ethical ures to assess sleep issues [50]. To assess the prevalence of men-
and methodological standards specific Indigenous research. tal health issues, the majority of studies used validated measures
Based on the scores, Indigenous leadership and involvement such as the Strengths and Difficulties Questionnaire [60], the
in the research was categorized as “low,” “moderate,” and “high.” Child Behavior Checklist (CBL) [51], Semi-Structured Assessment
Two reviewers (DRF and DSJ) independently assessed Indigenous for the Genetics of Alcoholism (SSAGA-II) [63] Personal Health
leadership and involvement. When a consensus was not reached, Questionnaire (PHQ-9) [61], Depression Anxiety Stress Scales–21
Indigenous coauthor and cultural mentor (SK) arbitrated. (DAS-21) [52], Center of Epidemiologic Studies Depression Scale
for Children (CES-DC) [64].
Data analysis
Considering the heterogeneity in research design of the studies,
we utilized narrative review/synthesis for our data analysis. The Short sleep duration
narrative review/synthesis is a qualitative approach wherein the There was variation in the definition of short sleep in the stud-
findings of other studies are combined without using statistical ies included in the review. While for adolescents, short sleep was
methods [58, 59]. conceptualized as sleeping for less than 8 hours, for adults, short
sleep was defined as sleeping for less than 6 hours [63]. Short
sleep duration was reported in the sample populations of two
Results studies included in the review. In adolescents, short sleep was
Of 330 screened research articles, seven studies; one longitudinal reported among 29·3% (N = 80) people from the Native American
study [60], and six cross-sectional studies [50–52, 61–63] published community in North Carolina, USA [62]. However, the prevalence
between 2008 and 2021, with a total population of 3075 [1295 chil- of short sleep in adults was comparatively lower, as only 16%
dren (ages 6.3–11), 321 adolescents (ages 11.1–18), young adults (N = 356) of adults from an Native American community from
(ages 18.1–26), and, 1459 adults (ages 31.35–59.5)] met the inclu- eight contiguous rural Indian reservations in the United States
sion criteria. All the studies were community-based and utilized reported sleeping for less than 6 hours per night [63].
purposive sampling. Three studies were from the United States of
America [50, 62, 63], two from Australia [36, 51], one from Canada
[61], and one from Ecuador [52]. Two studies focused on children Sleep problems and insomnia symptoms
[36, 51], two studies on adolescents/youth and young adults [50, Sleep problems and insomnia symptoms were reported in the
62], and three studies focused on adults [52, 61, 63] (Table 1). sample populations of three studies in the review. Total sleep
problems (arousal problems, sleep–wake transition problems,
Poor sleep and mental health issues excessive daytime sleepiness, and hyperhidrosis) were prevalent
All the studies used either parent/carer or self-reports to record among 32% (N = 25) Indigenous Australian children participants
sleep and mental issues. To assess sleep, two studies utilized [51]. Insomnia symptoms (trouble falling asleep or staying asleep
Epworth Sleepiness Scale [61, 62], one study utilized the Pittsburgh at least once a week almost every day, or every day in the previ-
Sleep Quality Index [63], one study utilized the International ous month) were prevalent among 25% (N = 232) of adolescent
Restless Legs Syndrome Study Group field instrument [52], one and young adult Native American participants from 132 schools
study utilized the Sleep Disturbance Scale for Children [51], one in the United States [50]. While among adults, 17·2% (N = 438) of
study utilized parent-reported child’s sleep patterns and issues the participants from a Native American group reported insom-
(duration, weekday bedtimes, wake-time, and sleep problems) nia symptoms [61].
 Fernandez et al. | 5

Table 1. Characteristics of Included Studies Covering Poor Sleep and Mental Health Issues of Indigenous Communities Across the
Globe [50–52, 60–63]

Author Study aim and Participant Study design Study variables Key findings Strengths and
(year) location demographics limitation/s

Froese Assess the 438 adults Cross- Independent variable/s: self- The risk for Strengths:
et al. prevalence of (56% sectional reported sleepiness depression was validated
(2008) sleep symptoms females, measured utilizing the significantly measures for
[61] and the mean age Epworth Sleepiness correlated in data collection
relationships 43.2 years, Scale (ESS); symptoms of participants Limitations:
between sleep- SD ± 14.3) Obstructive Sleep Apnea and reporting restless leg Cross-
related symptoms restless leg syndrome syndrome (OR: 1.82; sectional
and depression Outcome: self-reported 95% CI: 0.53 to 3.12,), design
among Native depression measured insomnia symptoms
American/ using the Personal Health (OR: 4.49; 95% CI:
American Indians Questionnaire (PHQ-9) 3.14 to 5.83), and
from three First Other variables: age and sex, apnea (OR: 2.46; 95%
Nations North anthropometric data (neck CI: 0.47 to 4.46)
American groups circumference and BMI)
(Gitxsan, Nisga’a, and self-reported medical
and Tsimshian) in history (smoking habit,
British Columbia, alcohol use, use of anti-
Canada. depressant medication, use of
prescription sleep medication,
use of herbal, health food,
traditional sleep remedies;
diabetes, hypertension, and
heart attack)
Blunden Assess the 25 children Cross- Independent variable: parent- Arousal problems were Strengths:
et al. association (56% males, sectional reported sleep problems; positively correlated validated
(2010) between sleep mean age: arousal problems, sleep– with externalized measures for
[51] problems and 8.8 years, wake transition problems, behaviors data collection
emotional and SD ± 1.4) excessive daytime sleepiness, (r = 0.32, p-value: Limitations: small
behavioral hyperhidrosis, and total sleep .02), specifically sample, low
problems in 50 problems assessed using the aggression participation
First Nations and Sleep Disturbance Scale for (r = 0.37, p-value:.009), rate (30.6%),
non-Indigenous Children withdrawn behavior parent/carer
children from Dependent variable/s: parent- (r = 0.31, p-value:.02) report, cross-
Darwin in the reported behavior issues and total sectional
Northern Territory and school performance behaviors (r = 0.43, design
and Palmerston in assessed using a validated p-value:.001)
Australia measure Child Behavior
Checklist (CBL)
Covariates: parent-reported
age, sex, and parental
education
Arnold Examine the impact 80 youth Cross- Independent variable/s: self- Multivariable Strengths:
et al. of sleep and (59.5% sectional reported sleepiness regression result validated
(2013) other factors females, measured through the suggests that time measures for
[62] on depressive mean Epworth Sleepiness Scale in bed is not linked data collection
symptoms and age 13.7, (ESS) and average time in with depressive Limitations:
suicidality among SD ± 13.7) bed (TIB) per night. symptoms Cross-
American Indian Outcome: Depressive symptoms (β: − 0.501, sectional
adolescents from were measured using the p-value:.71), but design
the Lumbee tribe Center of Epidemiologic significantly reduced
in Robeson or Studies Depression Scale for the odds of suicidal
a neighboring Children (CES-DC) ideation (OR:0.62,
county North Covariates: age, sex, grade p-value:04)
Carolina, USA. in school, and sexual
orientation, weight and body
mass index, mental illness,
self-esteem, and cultural
connectedness
Farrell Examine the 232 Cross- Independent variable/s: Insomnia symptoms Limitations:
(2013) relationship adolescent sectional self-reported insomnia were significantly cross-sectional
[50] between sleep and young symptoms, i.e. trouble associated with design, non-
disturbances adults (57% falling asleep or staying depression (OR: validated
and suicidality females asleep. 4.87, 95% CI: 2.4 to tools for data
in students mean age, Dependent variable/s: self- 9.89), but did not collection
American Indians/ 15.34 years, reported depressive significantly predict
Native Americans SD ± 1.81) symptoms, suicidal ideation, suicidal ideation
students from and suicide attempts (OR: 1.96, 95% CI:
132 schools in the Covariates: age and sex 0.96 to 4.02) or
United States suicide attempts
(OR: 1.25, 95% CI:
0.38 to 4.14)
6 | Sleep Advances, 2024, Vol. 5, No. 1

Author Study aim and Participant Study design Study variables Key findings Strengths and
(year) location demographics limitation/s

Castillo Assess the 665 adults Cross- Independent variable: self- Restless leg syndrome Strengths:
et al. association (42% males, sectional reported restless legs was associated with validated
(2014) between restless mean age syndrome assessed significantly higher measures for
[52] leg syndrome and 59.5 years using validated measure odds of depression data collection
mental health SD ± 12.6) International Restless Legs (OR: 4.5, 95% CI: 2.2 Limitations:
issues in 665 First Syndrome Study Group to 9.7;), anxiety (OR: Cross-
Nations people (IRLSSG) field instrument 3.6, 95% CI: 1.7 to sectional
from Atahualpa Dependent variable/s: self- 7.7), and stress (OR: design
in rural coastal reported depression anxiety 3.3 95%CI: 1.5-7.6)
Ecuador in South and stress assessed using
America Depression Anxiety Stress
Scales–21
Covariates: age and sex
Ehlers Assess interaction 356 adults Cross- Independent variable: self- Participants who had Strengths:
et al. between sleep and (54% sectional reported sleep quality short sleep (< 6 h) validated
(2017) anxiety, and females; measured utilizing the had a significantly measure for
[63] affective disorders mean age Pittsburgh Sleep Quality higher experience sleep quality
in American 31.35 years Index (PSQI) of anxiety (16%) and assessment
Indian community SD ± 14.4) Dependent variable: self- affective disorders Limitations:
sample from reported major affective (16%) than their cross-sectional
eight contiguous and anxiety disorders, counterparts. design
rural Indian measured utilizing the Semi-
reservations in the Structured Assessment for
United States the Genetics of Alcoholism
(SSAGA-II)
Covariates: age, sex, education,
civil status, household
income, occupation,
American Indian ancestry,
cultural identification,
physical and medical data
(body mass index, current
drinking frequency, current
drinking quantity, self-
reported diabetes, use of
sleep medication, nicotine
dependence, alcohol use
disorder, cannabis use
disorder, and stimulant use
disorder)`
Fatima Assess the role of 1270 children Longitudinal Independent variable: sleep Children in the Early Strengths:
et al. sleep trajectories (49.4% wave 5 to trajectories derived from sleepers//early riser Longitudinal
(2021) (4½ to 6 years) males, wave 10 parent-reported sleep trajectory had lower design large
[60] in emotional mean age: of the duration, weekday bedtimes, odds of being in the population
and behavioral 6.3 years, Footprints wake-time, and sleep high emotional and study, data
problems (9½ SD ± 1.5) in Time problems behavioral problem collected
to 11 years) in cohort Dependent variable/s: parent- trajectory group. across 11
1270 Aboriginal (2015-2019) reported emotional and (OR: 0.48, 95% CI: remotes
and Torres Strait behavioral problems 0.28 to 0.82) communities
Islander children (assessed using in Australia,
in Australia Strengths and Difficulties validated
Questionnaire) measure for
Covariates: Parent-reported outcome
age, sex and family size, assessment
structure, and composition; Limitations:
and cultural attachment. parent-
reported data,
non-validated
measure for
assessing sleep
issues

Restless leg syndrome and obstructive sleep (N = 438) in adult participants from three Native American
apnea groups in Canada [61]. Whereas the prevalence of RLS varied
The two clinical sleep issues explored in the sample popula- from 6% (N = 665) among adults of Amerindian/Mestizo descent
tion of three studies in this review were restless leg syndrome participants from Ecuador [52] to 17·7% (N = 438) of Native
(RLS) and obstructive sleep apnea (OSA). OSA varied from 6·3% American adults [61].
 Fernandez et al. | 7

Mental health issues (OR: 4·5, 95% CI: 2·2 to 9·7), anxiety (OR: 3·6, 95% CI: 1·7 to 7·7), and
The mental health issues identified in the included studies were stress (OR: 3·3 95% CI: 1·5 to 7·6) [52].
behavioral problems, affective disorders, and suicidal ideation
Study quality and Indigenous leadership and
and attempts.
engagement in research
Behavioral problems Quality assessment and Indigenous leadership and ownership of
research were assessed for each study. The key factors affecting
Behavioral problems (aggression, withdrawn behavior, and high
the study quality include non-representative, nonrandom sample,
emotional problems) were reported in two studies covering
lack of longitudinal data to assess causal links and self-reported
Indigenous Australian children [60]. The prevalence of behavioral
self or parent data. All but one study used validated measures
issues varied from 57% (N = 25) children from Darwin, Australia
for data collection [50]. Also, the studies adjusted for key covar-
and 10·4% (N = 1270) children from the Footprints in Time—The
iates, e.g. age, gender, socioeconomic status, parental education,
Longitudinal Study of Indigenous Children cohort [60].
cultural identity/connectedness, and health history in the regres-
Affective disorders sion model. Six studies rated “moderate quality” (moderate risk
of bias) [50–52, 61–63] and one study rated “high quality” (low risk
There were five studies reporting the common affective disorders
of bias) [60].
of depression and anxiety in the context of poor sleep. The preva-
Indigenous leadership and involvement in the research pro-
lence of depression in the sample population of Native American
cess were assessed using the adapted version of the Aboriginal
adolescents and youth varied from 18% (N = 232) [50] to 30.8%
and Torres Strait Islander Quality Appraisal Tool [57]. However,
(N = 80) [62]. In the adult population studied, the prevalence of
the information provided in the papers was insufficient to effec-
depression varied from 11% (N = 665) in Amerindian/Mestizo
tively evaluate Indigenous leadership and involvement. The first
adults from Ecuador [61] to 88.8% (N = 338) in Native American
author (DRF) reached out to corresponding authors for further
adults from Canada [61]. There was a prevalence of Diagnostic
information. The three authors who responded reported the
and Statistical Manual of Mental Health (DSM)-5 disorders among
extent of Indigenous leadership and involvement in research as,
35·8% (N = 356) Native American adults from eight reservations
“low” [63], “moderate” [51], and “high” [60], respectively.
in the United States [63]. The prevalence of anxiety disorders
in two adult sample populations varied from 14% (N = 665) in
Amerindian/Mestizo adults from Ecuador [52] to 23·3% (N = 356)
Native American adults from the United States [63] Discussion
This is the first systematic review to assess the association
Suicidal ideation and suicide attempts between poor sleep and mental health issues among Indigenous
In one study among Native American adolescents and young peoples globally and inform efforts to improve mental health.
adult sample populations, suicidal ideation was reported at 18% The findings of this review suggest an association between sleep
(N = 232) 95% CI: NR, while suicide attempts were reported at 6% and mental ill health among Indigenous peoples. However, con-
(N = 232; 95% CI: NR) [50]. sidering that we found only seven studies from three Indigenous
communities in four countries, indicates that the role of poor
Association between poor sleep and mental sleep to mental health among Indigenous people remains
health issues under-researched.
In a sample population of Indigenous Australian children, arousal In all studies included in this review, high rates of poor sleep
problems were positively correlated with aggression (r = 0·37, (short sleep duration, sleep problems, and insomnia symp-
p-value: ·009), withdrawn behavior (r = 0·31, p-value:·.02) and toms, RLS, and OSA) were reported among Indigenous groups.
total behavioral problems (r = 0·43, p-value:·001) [51]. Farrell This finding is confirmed in a review by Yiallourou et al., (2021)
et al. reported that in a sample population of Native American who report that Indigenous people from high-income countries
adolescents and young adults, insomnia symptoms were signif- (Australia, Canada, New Zealand, and the United States) have
icantly associated with depression (OR: 4·87, 95% CI: 2·4 to 9·89) poor sleep quantity and quality [65]. Although the lack of evi-
but not suicidal ideation (OR: 1·96, 95% CI: 0·96 to 4·02) or suicide dence and the diversity of the included Indigenous communi-
attempts (OR: 1·25, 95% CI: 0·38 to 4·14) [50]. The potentially pro- ties precluded a meta-analysis, the findings of this review are
tective effect of sleep in the young population was highlighted in supported by evidence from non-Indigenous communities. For
two studies. One study of Indigenous Australian children found example, meta-analytic evidence, based on longitudinal studies,
that early bedtime was associated with lower odds of emotional suggests insomnia as a key predictor of depression and other
and behavioral problems (OR: 0·48, 95% CI: 0·28 to 0·82) [60]. mental health conditions, e.g. anxiety disorders, bipolar disorder,
Another study involving Native American adolescents reported and suicide [66].
that adequate sleep duration significantly reduced the odds of The review does suggest that improving sleep could be
suicidal ideation (OR: 0·62, p-value:.04) [62]. an approach used to reduce the risk of mental health issues.
Among a sample population of Native American adults, short Evidence from Indigenous children in Australia suggests that
sleep (<6 hours) was significantly associated with anxiety prob- early bedtime is associated with lower odds of emotional and
lems [63]. Evidence from Native American groups highlighted that behavioral problems [67] and a cross-sectional study involv-
the risk of depression was significantly increased in participants ing Native American adolescents suggests that adequate sleep
reporting RLS (OR: 1·82; 95% CI: 0·53 to 3·12), insomnia symptoms duration significantly reduced the odds of suicidal ideation [62].
(OR: 4.49; 95% CI: 3·14 to 5·83) and apnea (OR: 2·46; 95% CI: 0·47 These findings are supported by a meta-analysis of 16 studies of
to 4·46) [61]. Likewise, Castillo et al. (2014) reported that among non-Indigenous children and youths from 40 different countries,
a study population of Amerindian/Mestizo adults from Ecuador, which reported longer sleep duration was associated with better
RLS was associated with significantly higher odds of depression emotional regulation, and better quality of life/well-being [68].
8 | Sleep Advances, 2024, Vol. 5, No. 1

Understanding the state of sleep health and its associa- (Validation [Equal], Writing—review & editing [Supporting]),
tion with mental health in both Indigenous people and non-­ and Lisa McDaid (Conceptualization [Equal], Supervision
Indigenous people provides insights into strategies to improve [Equal], Writing—original draft [Equal], Writing—review & edit-
sleep. In non-­Indigenous populations, to improve sleep health ing [Equal]).
(thereby, improve mental health) systematic reviews have sug-
gested strategies like behavioral/non-pharmacologic sleep
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