High-altitude hypoxia differentially increases risk of poor sleep and depression in males rather than protecting females, with males showing marked vulnerability and females demonstrating resilience to high-altitude-associated sleep and mood impairments.
Key Findings
Results
High-altitude residents exhibited significantly higher prevalence of poor sleep, depression, and their co-occurrence compared to low-altitude controls.
Poor sleep prevalence: 24.2% (high-altitude) vs. 18.7% (low-altitude), P < 0.001
Depression prevalence: 23.6% (high-altitude) vs. 15.3% (low-altitude), P < 0.001
Co-occurrence of poor sleep and depression: 12.6% (high-altitude) vs. 8.6% (low-altitude), P < 0.001
High-altitude group: 1,345 long-term residents of Shannan Tibet Autonomous Prefecture (altitude: 3,650–4,800 m); low-altitude controls: 2,909 age-matched participants from Anhui Province, China
Cross-sectional study conducted March–May 2024
Results
Sex significantly modified the association between high-altitude residence and poor sleep quality, as indicated by a significant negative additive interaction.
RERI = -0.78, 95% CI: -1.35 to -0.30; P < 0.001
High-altitude residence significantly increased poor sleep risk in males (OR = 1.60, 95% CI: 1.26–2.03) but not in females (OR = 1.39, 95% CI: 1.07–1.79)
The expected female predominance in poor sleep observed in the plain region (OR = 1.452, 95% CI: 1.191–1.769) disappeared in the plateau region (OR = 0.865, 95% CI: 0.667–1.121)
Sex-stratified analyses and interaction metrics (RERI/AP/SI) were employed to evaluate additive and multiplicative effects
Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI)
Results
Similar sex-modifying patterns observed for poor sleep were independently replicated for depressive symptoms at high altitude.
The female predominance in depressive symptoms seen at low altitude disappeared at high altitude, mirroring the pattern found for sleep quality
Depression was assessed using the Montgomery-Asberg Depression Rating Scale (MADRS)
Males showed marked vulnerability to high-altitude-associated mood impairments, while females demonstrated resilience
The pattern of interaction for depression was described as independently replicated, consistent with findings for poor sleep
Results
The typical female predominance in poor sleep and depressive symptoms observed at low altitude was attenuated or eliminated at high altitude.
At low altitude, females had significantly higher odds of poor sleep than males (OR = 1.452, 95% CI: 1.191–1.769)
At high altitude, this female predominance disappeared (OR = 0.865, 95% CI: 0.667–1.121)
High-altitude exposure differentially increased risk in males rather than protecting females, according to the authors' interpretation
The finding suggests that high-altitude hypoxia narrows or reverses the typical sex gap in sleep and mood outcomes
Methods
The study design enrolled school-age children and adolescents as long-term high-altitude residents assessed during a specific seasonal window.
1,345 participants from Shannan Tibet Autonomous Prefecture (altitude: 3,650–4,800 m) and 2,909 age-matched controls from Anhui Province, China
Data collection occurred March–May 2024
Participants were described as long-term residents, indicating chronic rather than acute high-altitude exposure
Population comprised school-age children and adolescents
What This Means
This research suggests that living at high altitude — where oxygen levels are lower — is associated with higher rates of poor sleep and depression in children and adolescents compared to those living at lower altitudes. The study compared over 1,300 young people living in Tibet (at altitudes between 3,650 and 4,800 meters) to nearly 3,000 age-matched peers living at low altitude in Anhui Province, China. Rates of poor sleep, depression, and having both conditions together were all notably higher among the high-altitude group.
A particularly important finding is that the relationship between high altitude and these outcomes differed meaningfully by sex. At low altitudes, girls were more likely than boys to have poor sleep and depressive symptoms — a pattern commonly observed in research on adolescent mental health. However, at high altitude, this female-predominant pattern disappeared. Boys living at high altitude showed a substantially increased risk of poor sleep and depression, while girls appeared comparatively more resilient to the effects of altitude-related low oxygen. This sex-modifying effect was found for both sleep quality and depressive symptoms independently.
This research suggests that boys may be particularly vulnerable to the sleep and mood effects of chronic high-altitude living, while girls may have some biological or other resilience to these effects in low-oxygen environments. The findings highlight that health interventions for children and adolescents in high-altitude communities may need to be tailored by sex, with particular attention to the mental health and sleep needs of male adolescents in these regions.
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Mei J, Pan P, Wei G, Wang X, Xu X, Baima Y, et al.. (2026). Sex modifies the association of high-altitude hypoxia with poor sleep quality and depression in school-age children and adolescents.. Sleep & breathing = Schlaf & Atmung. https://doi.org/10.1007/s11325-026-03791-z