Mediating effect of sleep quality on the relationship between competitive level and depressive symptoms in elite para-athletes

This study aimed to examine whether sleep quality mediates the association between competitive level and depressive symptoms among elite para-athletes in South Korea. A total of 104 elite para-athletes registered with the Korea Paralympic Committee were included in the analysis. Competitive level was classified as national-level or Paralympic-level based on participation in the Paralympic Games. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), and sleep quality was evaluated using the Korean version of the Pittsburgh Sleep Quality Index (PSQI-K). Participants with depressive symptoms exhibited significantly higher global PSQI scores (9.0 ± 4.1 vs. 5.3 ± 3.0, p < 0.001) and a higher prevalence of poor sleepers compared with those without depressive symptoms (70.3% vs. 37.3%, p = 0.001). Paralympic-level athletes showed significantly higher odds of depressive symptoms compared with national-level athletes (odds ratio [OR] = 6.258, 95% confidence interval [CI]: 2.155–18.177, p <0.001). Higher global PSQI scores were significantly associated with higher odds of depressive symptoms compared with those reporting better sleep quality (OR = 5.442, 95% CI: 2.024–14.631, p <0.001). Mediation analysis revealed that the global PSQI score (95% CI: 0.416–2.912) and its subjective sleep quality (95% CI: 0.367–3.268) and sleep disturbances (95% CI: 0.004–1.567) fully mediated the association between competitive level and depressive symptoms. Sleep quality may be an important factor associated with the relationship between competitive level and depressive symptoms among elite para-athletes. These findings suggest that sleep quality should be considered as part of the mental health assessment of elite para-athletes.