Andrea Ballesio

Background According to the perseverative cognition (PC) hypothesis, the repetitive chronic activation of the cognitive representations of stressors are associated with a concomitant prolonged and sustained physiological stress response, including sleep disruption. Purpose We conducted a systematic review and structural equation modeling meta-analysis (meta-SEM) on PC as mediator of the association between perceived stress and subjective sleep disturbance (i.e., difficulties falling asleep or maintaining sleep). Methods PubMed, Scopus, Medline, CINAHL, and PsycInfo were searched up to September 2021. To test mediation, only longitudinal studies assessing the predictor (perceived stress) at T0, the mediator (PC) at T1, and the outcome (sleep disturbance) at T2, were eligible. Results Findings on 3,733 individuals (k = 8) showed a significant component effect of perceived stress on PC (β = 0.340, p < .001), which in turn was related to sleep disturbance (β = 0.258, p < .001). The direct effect of stress on sleep disturbance was significant (β = 0.133, p < .001). Lastly, the indirect effect between stress and sleep disturbance via PC supported the mediation hypothesis (β = 0.09, 95% CI 0.078–0.100). The mediation path remained significant (β = 0.03, 95% CI 0.020–0.036) after adjusting for baseline sleep disturbance. Further leave-one-out sensitivity and control analyses confirmed that all direct and indirect effects were not driven by any single study included in the meta-analysis, as well as their robustness when controlling for sex and age, respectively. Conclusions Overall, results of this meta-analysis indicate that PC may be one of the mechanisms explaining how perceived stressful experiences lead to subjective sleep disturbance.