Pathways to better sleep: Depression, anxiety, and stress as mediators in the relationship between social support and insomnia severity in Appalachian adults

Background: Rural Appalachia has some the highest rates of sleep and health disparities in the United States. This study investigates the relationship between social support and insomnia severity in rural Appalachian adults, with specific attention to the potential mediating roles of depression, anxiety, and stress. Methods: Participants from 12 rural Eastern Kentucky counties completed validated measures of insomnia severity, social support, depression, anxiety, and perceived stress. Using R, we calculated descriptive statistics and fit mediation models for depressive symptoms, anxiety symptoms, and stress, with social support as the exposure and insomnia severity as the outcome. Results: Aligning with regional demographics, nearly all participants identified as Caucasian/White (97.4 %) and non-Hispanic/non-Latin (a/o)/non-Latinx (96.8 %). Of 270 participants (mean age: 46 [SD = 13.2], 79.9 % women) 30 % had clinically significant insomnia. Greater social support was associated with lower insomnia severity (r = −0.30, p < 0.001) in unadjusted analyses. Mediation analyses revealed that this relationship was significantly mediated by depressive symptoms (69 %), anxiety symptoms (64 %), and perceived stress (78 %). After accounting for these psychological mediators, the direct effect of social support on insomnia was no longer significant. Conclusions: Our findings provide valuable insight into the psychological mechanisms linking social support and sleep health in rural Appalachian adults, though generalizability may be limited to similar racially homogeneous, rural populations. Social support influences insomnia symptoms in rural Appalachian adults primarily through psychological pathways, particularly by buffering against stress. Interventions addressing sleep problems in this population should target psychological factors while leveraging existing social resources within the cultural context of Appalachia.