Social zeitgebers and circadian dysrhythmia are associated with severity of symptoms of PTSD and depression in trauma-affected refugees


The relation of aspects of rest–activity patterns, i.e., social zeitgebers, physical activity and circadian rhythm, to the severity of PTSD and depressive symptoms has not previously been studied. Doing so could provide valuable insight into possible targets for treatment. Our study explored these links in a population of 219 trauma-affected refugees diagnosed with PTSD who were seeking treatment. Data regarding social zeitgebers, such as affiliation with the labor market and contact with social network, and symptoms of PTSD and depression were collected from them. Furthermore, their levels of physical activity and circadian rest–activity parameters were calculated from actigraphy data. Bivariate correlation analyses and multiple linear regression analyses were performed to examine various aspects of rest–activity regarding relation to severity of PTSD and depressive symptoms. Several social zeitgebers were associated with severity of PTSD and depressive symptoms. The level of physical activity was unrelated to symptom severity, whereas a rest–activity pattern, with early onset of the most active 10 h, was associated with severity of PTSD, and a circadian rhythm with a large difference between periods of rest and activity was associated with severity of depression. Social zeitgebers, levels of physical activity and circadian rhythm parameters were all associated with each other. Social zeitgebers and circadian rhythm parameters were significantly related to the severity of PTSD and depressive symptoms—a relationship indicating that interventions targeting regularity of daily routines have a potential role in treating PTSD and depression in trauma-affected refugees.

Trial registration:, ID: NCT02761161, April 27, 2016.

This is a preview of subscription content, access via your institution.

Fig. 1

Data availability

The data that support the findings of this study are available from the corresponding author upon request.


  1. 1.

    UNHCR (2019) Trends at a Glance.

  2. 2.

    Silove D, Ventevogel P, Rees S (2017) The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry 16(2):130–139.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Giacco D, Laxhman N, Priebe S (2018) Prevalence of and risk factors for mental disorders in refugees. Semin Cell Dev Biol 77:144–152.

    Article  PubMed  Google Scholar 

  4. 4.

    Porter M, Haslam N (2005) Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. J Am Med Assoc 294(5):602–612.

    CAS  Article  Google Scholar 

  5. 5.

    Steel Z, Chey T, Silove D, Marnane C, Bryant RA, van Ommeren M (2009) Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA 302(5):537–549.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Chen W, Hall BJ, Ling L, Renzaho AM (2017) Pre-migration and post-migration factors associated with mental health in humanitarian migrants in Australia and the moderation effect of post-migration stressors: findings from the first wave data of the BNLA cohort study. The Lancet Psychiatry 4(3):218–229.

    Article  PubMed  Google Scholar 

  7. 7.

    Li SSY, Liddell BJ, Nickerson A (2016) The relationship between post-migration stress and psychological disorders in refugees and asylum seekers. Curr Psychiatry Rep 18(9):82.

    Article  PubMed  Google Scholar 

  8. 8.

    Priebe S, Domenico G, El-Nagib R (2016) Public health aspects of mental health among migrants and refugees: a review of the evidence on mental health care for refugees, asylum seekers and irregular migrants in the WHO European Region (2016). World Health Organization, Copenhagen

    Google Scholar 

  9. 9.

    Bogic M, Njoku A, Priebe S (2015) Long-term mental health of war-refugees: a systematic literature review. BMC Int Health Hum Rights.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Steel JL, Dunlavy AC, Harding CE, Theorell T (2017) The psychological consequences of pre-emigration trauma and post-migration stress in refugees and immigrants from Africa. J Immigr Minor Heal 19(3):523–532.

    Article  Google Scholar 

  11. 11.

    Nordbrandt MS, Sonne C, Mortensen EL, Carlsson J (2020) Trauma-affected refugees treated with basic body awareness therapy or mixed physical activity as augmentation to treatment as usual—a pragmatic randomised controlled trial. PLoS ONE 15(3):e0230300.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Bruhn M, Rees S, Mohsin M, Silove D, Carlsson J (2018) The range and impact of postmigration stressors during treatment of trauma-affected refugees. J Nerv Ment Dis 206(1):61–68.

    Article  PubMed  Google Scholar 

  13. 13.

    Sonne C, Carlsson J, Bech P, Elklit A, Mortensen EL (2016) Treatment of trauma-affected refugees with venlafaxine versus sertraline combined with psychotherapy - a randomised study. BMC Psychiatry 16(1):383.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Carlsson J, Sonne C, Vindbjerg E, Mortensen EL (2018) Stress management versus cognitive restructuring in trauma-affected refugees—a pragmatic randomised study. Psychiatry Res 266:116–123.

    Article  PubMed  Google Scholar 

  15. 15.

    Grandin LD, Alloy LB, Abramson LY (2006) The social zeitgeber theory, circadian rhythms, and mood disorders: review and evaluation. Clin Psychol Rev 26(6):679–694.

    Article  PubMed  Google Scholar 

  16. 16.

    Baron KG, Reid KJ (2014) Circadian misalignment and health. Int Rev Psychiatry 26(2):139–154.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Haynes PL, Gengler D, Kelly M (2016) Social rhythm therapies for mood disorders: an update. Curr Psychiatry Rep 18:8.

    Article  Google Scholar 

  18. 18.

    Moss TG, Carney CE, Haynes P, Harris AL (2015) Is daily routine important for sleep? An investigation of social rhythms in a clinical insomnia population. Chronobiol Int 32(1):92–102.

    Article  PubMed  Google Scholar 

  19. 19.

    Boland EM, Goldschmied JR, Kelly MR, Perkins S, Gehrman PR, Haynes PL (2019) Social rhythm regularity moderates the relationship between sleep disruption and depressive symptoms in veterans with post-traumatic stress disorder and major depressive disorder. Chronobiol Int 36(10):1429–1438.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Baandrup L, Fasmer OB, Glenthøj BY, Jennum PJ (2016) Circadian rest–activity rhythms during benzodiazepine tapering covered by melatonin versus placebo add-on: data derived from a randomized clinical trial. BMC Psychiatry 16:1.

    Article  Google Scholar 

  21. 21.

    Jones SH, Hare DJ, Evershed K (2005) Actigraphic assessment of circadian activity and sleep patterns in bipolar disorder. Bipolar Disord 7(2):176–186.

    Article  PubMed  Google Scholar 

  22. 22.

    Lyall LM et al (2018) Association of disrupted circadian rhythmicity with mood disorders, subjective wellbeing, and cognitive function: a cross-sectional study of 91 105 participants from the UK Biobank. The Lancet Psychiatry 5(6):507–514.

    Article  PubMed  Google Scholar 

  23. 23.

    Ehlers CL, Frank E, Kupfer DJ (1988) Social zeitgebers and biological rhythms: a unified approach to understanding the etiology of depression. Arch Gen Psychiatry 45(10):948–952.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Ehlers CL (1992) Social zeitgebers, biological rhythms and depression. Neuropharmacol Clin.

    Article  Google Scholar 

  25. 25.

    Germain A, Kupfer DJ (2008) Circadian rhythm disturbances in depression. Hum Psychopharmacol 23(7):571–585.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Foster RG, Peirson SN, Wulff K, Winnebeck E, Vetter C, Roenneberg T (2013) Sleep and circadian rhythm disruption in social jetlag and mental illness. Progr Mol Biol Transl Sci.

  27. 27.

    World Health Organization (1992) The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelins.

  28. 28.

    Richards A, Kanady JC, Neylan TC (2020) Sleep disturbance in PTSD and other anxiety-related disorders: an updated review of clinical features, physiological characteristics, and psychological and neurobiological mechanisms. Neuropsychopharmacology 45(1):55–73.

    Article  PubMed  Google Scholar 

  29. 29.

    Tsanas A, Woodward E, Ehlers A (2020) Objective characterization of activity, sleep, and circadian rhythm patterns using a wrist-worn actigraphy sensor: Insights into posttraumatic stress disorder. JMIR mHealth uHealth 8(4):2020.

    Article  Google Scholar 

  30. 30.

    Agorastos A, Kellner M, Baker DG, Otte C (2014) When time stands still: an integrative review on the role of chronodisruption in posttraumatic stress disorder. Curr Opin Psychiatry 27(5):385–392.

    Article  PubMed  Google Scholar 

  31. 31.

    Chen A, Rosenbaum S, Wells R, Gould K, Ward PB, Steel Z (2020) Obesity, physical activity and sleep quality in patients admitted to a posttraumatic stress inpatient ward. Australas Psychiatry 28(3):270–273.

    Article  PubMed  Google Scholar 

  32. 32.

    Theal R et al (2019) Comparison of sleep patterns in Vietnam veterans with and without posttraumatic stress disorder using wrist actigraphy. J Clin Sleep Med 15(5):725–732.

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Ancoli-Israel S, Cole R, Alessi C, Chambers M, Moorcroft W, Pollak CP (2003) The role of actigraphy in the study of sleep and circadian rhythms. Sleep 26(3):342–392.

    Article  PubMed  Google Scholar 

  34. 34.

    Calogiuri G, Weydahl A, Carandente F (2013) Methodological issues for studying the rest–activity cycle and sleep disturbances: a chronobiological approach using actigraphy data. Biol Res Nurs 15(1):5–12.

    Article  PubMed  Google Scholar 

  35. 35.

    Straus LD, Drummond SPA, Nappi CM, Jenkins MM, Norman SB (2015) Sleep variability in military-related PTSD: A comparison to primary insomnia and healthy controls. J Trauma Stress 28(1):8–16.

    Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Van Someren EJW, Swaab DF, Colenda CC, Cohen W, McCall WV, Rosenquist PB (1999) Bright light therapy: Improved sensitivity to its effects on rest- activity rhythms in Alzheimer patients by application of nonparametric methods. Chronobiol Int 16(4):505–518.

    Article  PubMed  Google Scholar 

  37. 37.

    Gonçalves BSB, Adamowicz T, Louzada FM, Moreno CR, Araujo JF (2015) A fresh look at the use of nonparametric analysis in actimetry. Sleep Medicine Reviews 20:84–91.

    Article  PubMed  Google Scholar 

  38. 38.

    Khawaja S, I, A. Madeeh Hashmi, M. Awais Aftab, J. Westermeyer, and T. Hurwitz (2014) Actigraphy in post traumatic stress disorder. Pakistan J Med Sci 30(2):438

    Google Scholar 

  39. 39.

    Werner KB, Griffin MG, Galovski TE (2016) Objective and subjective measurement of sleep disturbance in female trauma survivors with posttraumatic stress disorder. Psychiatry Res 240:234–240.

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Zhang Y et al (2019) Sleep in posttraumatic stress disorder: a systematic review and meta-analysis of polysomnographic findings. Sleep Med. Rev 48:101210.

    Article  PubMed  Google Scholar 

  41. 41.

    Lewis C, Lewis K, Kitchiner N, Isaac S, Jones I, Bisson JI (2020) Sleep disturbance in post-traumatic stress disorder (PTSD): a systematic review and meta-analysis of actigraphy studies. Eur J Psychotraumatol 11(1):1767349.

    Article  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Sandahl H, Jennum P, Baandrup L, Poschmann IS, Carlsson J (2017) Treatment of sleep disturbances in trauma-affected refugees: study protocol for a randomised controlled trial. Trials.

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Hollifield M et al (2002) Measuring trauma and health status in refugees: a critical review. JAMA 288(5):611–621.

    Article  PubMed  Google Scholar 

  44. 44.

    Bech P, Kastrup M, Rafaelsen OJ (1986) Mini-compendium of rating scales for states of anxiety depression mania schizophrenia with corresponding DSM-III syndromes. Acta Psychiatr Scand 326:1–37

    CAS  Google Scholar 

  45. 45.

    Van Someren EJW (2007) Improving actigraphic sleep estimates in insomnia and dementia: How many nights? J Sleep Res.

    Article  PubMed  Google Scholar 

  46. 46.

    Mitchell JA et al (2017) Variation in actigraphy-estimated rest–activity patterns by demographic factors. Chronobiol Int 34(8):1042–1056.

    Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Galasso L et al (2019) The multidisciplinary therapy in binge eating disorder is able to influence the interdaily stability and sleep quality? Chronobiol Int.

    Article  PubMed  Google Scholar 

  48. 48.

    Sohail S, Yu L, Bennett DA, Buchman AS, Lim ASP (2015) Irregular 24-hour activity rhythms and the metabolic syndrome in older adults. Chronobiol Int.

    Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Quante M et al (2019) Zeitgebers and their association with rest–activity patterns. Chronobiol Int 36(2):203–213.

    Article  PubMed  Google Scholar 

  50. 50.

    Cespedes Feliciano EM et al (2017) Actigraphy-derived daily rest–activity patterns and body mass index in community-dwelling adults. Sleep.

    Article  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Kashyap S, Page AC, Joscelyne A (2019) Post-migration treatment targets associated with reductions in depression and PTSD among survivors of torture seeking asylum in the USA. Psychiatry Res 271:565–572.

    Article  PubMed  Google Scholar 

  52. 52.

    Haynes PL, Burger SB, Kelly M, Emert S, Perkins S, Shea MT (2020) Cognitive behavioral social rhythm group therapy versus present centered group therapy for veterans with posttraumatic stress disorder and major depressive disorder: a randomized controlled pilot trial. J Affect Disord 277:800–809.

    Article  PubMed  Google Scholar 

  53. 53.

    Haynes PL, Kelly M, Warner L, Quan SF, Krakow B, Bootzin RR (2016) Cognitive behavioral social rhythm group therapy for veterans with posttraumatic stress disorder, depression, and sleep disturbance: Results from an open trial. J Affect Disord 192:234–243.

    Article  PubMed  Google Scholar 

  54. 54.

    Geoffroy PA, Palagini L (2020) Biological rhythms and chronotherapeutics in depression. Prog Neuro-Psychopharmacol Biol Psychiatry 106:110158.

    Article  Google Scholar 

  55. 55.

    Dunker Svendsen S et al (2019) Circadian reinforcement therapy in combination with electronic self-monitoring to facilitate a safe post-discharge period of patients with depression by stabilizing sleep: protocol of a randomized controlled trial. BMC Psychiatry.

    Article  PubMed  PubMed Central  Google Scholar 

  56. 56.

    Miller KE, Brownlow JA, Gehrman PR (2020) Sleep in PTSD: treatment approaches and outcomes. Curr Opin Psychol 34:12–17.

    Article  PubMed  Google Scholar 

  57. 57.

    Colvonen PJ, Straus LD, Stepnowsky C, McCarthy MJ, Goldstein LA, Norman SB (2018) Recent advancements in treating sleep disorders in co-occurring PTSD. Curr Psychiatry Rep 20(7):48.

    Article  PubMed  PubMed Central  Google Scholar 

  58. 58.

    Ho FYY, Chan CS, Tang KNS (2016) Cognitive-behavioral therapy for sleep disturbances in treating posttraumatic stress disorder symptoms: A meta-analysis of randomized controlled trials. Clin. Psychol. Rev 43:90–102.

    Article  PubMed  Google Scholar 

  59. 59.

    Rosenbaum S, Vancampfort D, Steel Z, Newby J, Ward PB, Stubbs B (2015) Physical activity in the treatment of post-traumatic stress disorder: a systematic review and meta-analysis. Psychiatr Res.

    Article  Google Scholar 

  60. 60.

    Rosenbaum S, Tiedemann A, Sherrington C, Van Der Ploeg HP (2014) Assessing physical activity in people with posttraumatic stress disorder: Feasibility and concurrent validity of the International Physical Activity Questionnaire- short form and actigraph accelerometers. BMC Res.

    Article  Google Scholar 

Download references


The authors wish to thank the participants and staff at the Competence Centre for Transcultural Psychiatry. In particular, we are grateful to Henriette Laugesen and Joakim Friis for managing the data.


This work was supported by TrygFonden (Grant number 120354) and Fonden til Lægevidenskabens fremme (Foundation for Promotion of Medicine, Grant number 16–319). Treatment facilities were provided by the Mental Health Services of the Capital Region, Denmark. The design, management of the study and interpretation of the data were entirely independent of funding.

Author information




All authors contributed to the study conception and design. Material preparation, data collection and analyses were performed by Hinuga Sandahl and Jessica Carlsson. The first draft of the manuscript was written by Hinuga Sandahl and the other authors commented on subsequent versions. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Hinuga Sandahl.

Ethics declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethics approval

The authors assert that all procedures were carried out in accordance with the ethical standards of the National Research Committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study protocol and amendments were approved by the Ethics Committee of the Capital Region of Denmark (H-15014503), the Danish Medicines Agency (EudraCT: 2015–004153-40) and the Danish Data Protection Agency (2012–58-0004).

Consent to participate

All participants gave written informed consent prior to participation.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Sandahl, H., Baandrup, L., Vindbjerg, E. et al. Social zeitgebers and circadian dysrhythmia are associated with severity of symptoms of PTSD and depression in trauma-affected refugees. Eur Arch Psychiatry Clin Neurosci (2021).

Download citation


  • Circadian rhythm
  • Social zeitgebers
  • Physical activity
  • Sleep
  • Employment
  • Social relationships