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Psychoneuroendocrinology. 2017 Sep;83:25-41. doi: 10.1016/j.psyneuen.2017.05.018. Epub 2017 May 24.

Diurnal cortisol slopes and mental and physical health outcomes: A systematic review and meta-analysis.

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School of Education and Social Policy and Institute for Policy Research, Northwestern University, 2120 Campus Drive, Evanston, IL, 60208, USA. Electronic address:
Department of Psychology, Northwestern University, 2029 Sheridan Rd., Evanston, IL 60208, USA; Department of Psychiatry, University of Illinois at Chicago, 912 S. Wood St., Chicago, IL, 60612, USA. Electronic address:
Department of Psychology, Wesleyan University, 207 High Street, Middletown, CT, 06459, USA. Electronic address:
School of Education and Social Policy and Institute for Policy Research, Northwestern University, 2120 Campus Drive, Evanston, IL, 60208, USA,. Electronic address:
American Institutes for Research, 1120 E. Diehl Road, Suite 200, Naperville, IL, 60563, USA. Electronic address:
Department of Psychiatry, Washington University in St. Louis, 4444 Forest Park Parkway, Suite 2100, St. Louis, MO, USA. Electronic address:


Changes in levels of the stress-sensitive hormone cortisol from morning to evening are referred to as diurnal cortisol slopes. Flatter diurnal cortisol slopes have been proposed as a mediator between chronic psychosocial stress and poor mental and physical health outcomes in past theory and research. Surprisingly, neither a systematic nor a meta-analytic review of associations between diurnal cortisol slopes and health has been conducted to date, despite extensive literature on the topic. The current systematic review and meta-analysis examined associations between diurnal cortisol slopes and physical and mental health outcomes. Analyses were based on 179 associations from 80 studies for the time period up to January 31, 2015. Results indicated a significant association between flatter diurnal cortisol slopes and poorer health across all studies (average effect size, r=0.147). Further, flatter diurnal cortisol slopes were associated with poorer health in 10 out of 12 subtypes of emotional and physical health outcomes examined. Among these subtypes, the effect size was largest for immune/inflammation outcomes (r=0.288). Potential moderators of the associations between diurnal cortisol slopes and health outcomes were examined, including type of slope measure and study quality indices. The possible roles of flatter slopes as either a marker or a mechanism for disease etiology are discussed. We argue that flatter diurnal cortisol slopes may both reflect and contribute to stress-related dysregulation of central and peripheral circadian mechanisms, with corresponding downstream effects on multiple aspects of biology, behavior, and health.


Circadian rhythms; Diurnal cortisol slopes; Hypothalamic pituitary adrenal (HPA) axis; Mental health; Physical health

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