Archival Report| Volume 69, ISSUE 6, P592-600, March 15, 2011

Prevalence and Perceived Health Associated with Insomnia Based on DSM-IV-TR; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision; and Research Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition Criteria: Results from the America Insomnia Survey


      Although several diagnostic systems define insomnia, little is known about the implications of using one versus another of them.


      The America Insomnia Survey, an epidemiological survey of managed health care plan subscribers (n = 10,094), assessed insomnia with the Brief Insomnia Questionnaire, a clinically validated scale generating diagnoses according to DSM-IV-TR; International Statistical Classification of Diseases, Tenth Revision (ICD-10); and Research Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition (RDC/ICSD-2) criteria. Regression analysis examines associations of insomnia according to the different systems with summary 12-item Short-Form Health Survey scales of perceived health and health utility.


      Insomnia prevalence estimates varied widely, from 22.1% for DSM-IV-TR to 3.9% for ICD-10 criteria. Although ICD insomnia was associated with significantly worse perceived health than DSM or RDC/ICSD insomnia, DSM-only cases also had significant decrements in perceived health. Because of its low prevalence, 66% of the population-level health disutility associated with overall insomnia and 84% of clinically relevant cases of overall insomnia were missed by ICD criteria.


      Insomnia is highly prevalent and associated with substantial decrements in perceived health. Although ICD criteria define a narrower and more severe subset of cases than DSM criteria, the fact that most health disutility associated with insomnia is missed by ICD criteria, while RDC/ICSD-only cases do not have significant decrements in perceived health, supports use of the broader DSM criteria.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Biological Psychiatry
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • LeBlanc M.
        • Merette C.
        • Savard J.
        • Ivers H.
        • Baillargeon L.
        • Morin C.M.
        Incidence and risk factors of insomnia in a population-based sample.
        Sleep. 2009; 32: 1027-1037
        • Morphy H.
        • Dunn K.M.
        • Lewis M.
        • Boardman H.F.
        • Croft P.R.
        Epidemiology of insomnia: A longitudinal study in a UK population.
        Sleep. 2007; 30: 274-280
        • Stein M.B.
        • Belik S.L.
        • Jacobi F.
        • Sareen J.
        Impairment associated with sleep problems in the community: Relationship to physical and mental health comorbidity.
        Psychosom Med. 2008; 70: 913-919
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).
        4th ed., Text Revision. American Psychiatric Association, Washington, DC2000
        • World Health Organization
        International Classification of Diseases (ICD-10).
        World Health Organization, Geneva1991
        • American Academy of Sleep Medicine
        International Classification of Sleep Disorders: Diagnostic and Coding Manual.
        2nd ed. Sleep Disorders Association, Rochester, MN2005 (ICSD-2)
        • Edinger J.D.
        • Bonnet M.H.
        • Bootzin R.R.
        • Doghramji K.
        • Dorsey C.M.
        • Espie C.A.
        • et al.
        Derivation of research diagnostic criteria for insomnia: Report of an American Academy of Sleep Medicine Work Group.
        Sleep. 2004; 27: 1567-1596
        • Buysse D.J.
        • Angst J.
        • Gamma A.
        • Ajdacic V.
        • Eich D.
        • Rossler W.
        Prevalence, course, and comorbidity of insomnia and depression in young adults.
        Sleep. 2008; 31: 473-480
        • Ram S.
        • Seirawan H.
        • Kumar S.K.
        • Clark G.T.
        Prevalence and impact of sleep disorders and sleep habits in the United States.
        Sleep Breath. 2010; 14: 63-70
        • Buysse D.J.
        • Reynolds 3rd, C.F.
        • Hauri P.J.
        • Roth T.
        • Stepanski E.J.
        • Thorpy M.J.
        • et al.
        Diagnostic concordance for DSM-IV sleep disorders: A report from the APA/NIMH DSM-IV field trial.
        Am J Psychiatry. 1994; 151: 1351-1360
        • Summers M.O.
        • Crisostomo M.I.
        • Stepanski E.J.
        Recent developments in the classification, evaluation, and treatment of insomnia.
        Chest. 2006; 130: 276-286
        • Buysse D.J.
        • Reynolds 3rd, C.F.
        • Monk T.H.
        • Berman S.R.
        • Kupfer D.J.
        The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research.
        Psychiatry Res. 1989; 28: 193-213
        • Ohayon M.M.
        • Guilleminault C.
        • Zulley J.
        • Palombini L.
        • Raab H.
        Validation of the sleep-EVAL system against clinical assessments of sleep disorders and polysomnographic data.
        Sleep. 1999; 22: 925-930
        • Okun M.L.
        • Kravitz H.M.
        • Sowers M.F.
        • Moul D.E.
        • Buysse D.J.
        • Hall M.
        Psychometric evaluation of the Insomnia Symptom Questionnaire: A self-report measure to identify chronic insomnia.
        J Clin Sleep Med. 2009; 5: 41-51
        • Roth T.
        • Zammit G.
        • Kushida C.
        • Doghramji K.
        • Mathias S.D.
        • Wong J.M.
        • Buysse D.J.
        A new questionnaire to detect sleep disorders.
        Sleep Med. 2002; 3: 99-108
        • Soldatos C.R.
        • Dikeos D.G.
        • Paparrigopoulos T.J.
        The diagnostic validity of the Athens Insomnia Scale.
        J Psychosom Res. 2003; 55: 263-267
        • Kohn L.
        • Espie C.A.
        Sensitivity and specificity of measures of the insomnia experience: A comparative study of psychophysiologic insomnia, insomnia associated with mental disorder and good sleepers.
        Sleep. 2005; 28: 104-112
        • Smith S.
        • Trinder J.
        Detecting insomnia: Comparison of four self-report measures of sleep in a young adult population.
        J Sleep Res. 2001; 10: 229-235
        • Violani C.
        • Devoto A.
        • Lucidi F.
        • Lombardo C.
        • Russo P.M.
        Validity of a short insomnia questionnaire: The SDQ.
        Brain Res Bull. 2004; 63: 415-421
        • Kessler R.C.
        • Coulouvrat C.
        • Hajak G.
        • Lakoma M.D.
        • Roth T.
        • Sampson N.A.
        • et al.
        Reliability and validity of the Brief Insomnia Questionnaire (BIQ) in the America Insomnia Survey (AIS).
        Sleep. 2010; 33: 1539-1549
        • Reynolds 3rd, C.F.
        • Redline S.
        The DSM-V sleep-wake disorders nosology: An update and an invitation to the sleep community.
        J Clin Sleep Med. 2010; 6: 9-10
        • National Institutes of Health
        NIH State-of-the-Science Conference statement on manifestations and management of chronic insomnia in adults.
        NIH Consens State Sci Statements. 2005; 22: 1-30
        • Buysse D.J.
        • Ancoli-Israel S.
        • Edinger J.D.
        • Lichstein K.L.
        • Morin C.M.
        Recommendations for a standard research assessment of insomnia.
        Sleep. 2006; 29: 1155-1173
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Ancoli-Israel S.
        • Cooke J.R.
        Prevalence and comorbidity of insomnia and effect on functioning in elderly populations.
        J Am Geriatr Soc. 2005; 53: S264-S271
        • Parish J.M.
        Sleep-related problems in common medical conditions.
        Chest. 2009; 135: 563-572
        • Riemann D.
        Insomnia and comorbid psychiatric disorders.
        Sleep Med. 2007; 8: S15-S20
        • Centers for Disease Control and Prevention
        Centers for Disease Control and Prevention, Atlanta, GA2004
        • Schoenborn C.A.
        • Adams P.F.
        • Schiller J.S.
        Summary health statistics for the U.S. population: National Health Interview Survey, 2000.
        Vital Health Stat 10. 2003; 214: 1-83
        • Baker M.
        • Stabile M.
        • Deri C.
        What do self-reported, objective, measures of health measure?.
        J Hum Resour. 2001; 39: 1067-1093
        • National Center for Health Statistics
        Evaluation of National Health Interview Survey Diagnostic reporting.
        Vital Health Stat 2. 1994; 120: 1-116
        • Knight M.
        • Stewart-Brown S.
        • Fletcher L.
        Estimating health needs: The impact of a checklist of conditions and quality of life measurement on health information derived from community surveys.
        J Public Health Med. 2001; 23: 179-186
        • Revicki D.A.
        • Rentz A.M.
        • Dubois D.
        • Kahrilas P.
        • Stanghellini V.
        • Talley N.J.
        • Tack J.
        Gastroparesis Cardinal Symptom Index (GCSI): Development and validation of a patient reported assessment of severity of gastroparesis symptoms.
        Qual Life Res. 2004; 13: 833-844
        • Netzer N.C.
        • Stoohs R.A.
        • Netzer C.M.
        • Clark K.
        • Strohl K.P.
        Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.
        Ann Intern Med. 1999; 131: 485-491
        • Rush A.J.
        • Trivedi M.H.
        • Ibrahim H.M.
        • Carmody T.J.
        • Arnow B.
        • Klein D.N.
        • et al.
        The 16-Item Quick Inventory of Depressive symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): A psychometric evaluation in patients with chronic major depression.
        Biol Psychiatry. 2003; 54: 573-583
        • Sharma S.K.
        • Vasudev C.
        • Sinha S.
        • Banga A.
        • Pandey R.M.
        • Handa K.K.
        Validation of the modified Berlin questionnaire to identify patients at risk for the obstructive sleep apnoea syndrome.
        Indian J Med Res. 2006; 124: 281-290
        • Spitzer R.L.
        • Kroenke K.
        • Williams J.B.
        • Lowe B.
        A brief measure for assessing generalized anxiety disorder: The GAD-7.
        Arch Intern Med. 2006; 166: 1092-1097
        • Winkelman J.W.
        • Shahar E.
        • Sharief I.
        • Gottlieb D.J.
        Association of restless legs syndrome and cardiovascular disease in the Sleep Heart Health Study.
        Neurology. 2008; 70: 35-42
        • Ware Jr, J.
        • Kosinski M.
        • Keller S.D.
        A 12-Item Short-Form Health Survey: Construction of scales and preliminary tests of reliability and validity.
        Med Care. 1996; 34: 220-233
        • Brazier J.
        The Short-Form 36 (SF-36) Health Survey and its use in pharmacoeconomic evaluation.
        Pharmacoeconomics. 1995; 7: 403-415
        • Gandek B.
        • Ware J.E.
        • Aaronson N.K.
        • Apolone G.
        • Bjorner J.B.
        • Brazier J.E.
        • et al.
        Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: Results from the IQOLA Project.
        J Clin Epidemiol. 1998; 51: 1171-1178
        • Brazier J.E.
        • Roberts J.
        The estimation of a preference-based measure of health from the SF-12.
        Med Care. 2004; 42: 851-859
        • Gander P.H.
        • Marshall N.S.
        • Harris R.
        • Reid P.
        The Epworth Sleepiness Scale: Influence of age, ethnicity, and socioeconomic deprivation.
        Sleep. 2005; 28: 249-253
        • Gellis L.A.
        • Lichstein K.L.
        • Scarinci I.C.
        • Durrence H.H.
        • Taylor D.J.
        • Bush A.J.
        • Riedel B.W.
        Socioeconomic status and insomnia.
        J Abnorm Psychol. 2005; 114: 111-118
        • Paine S.J.
        • Gander P.H.
        • Harris R.
        • Reid P.
        Who reports insomnia?.
        Sleep. 2004; 27: 1163-1169
        • Sanford S.D.
        • Lichstein K.L.
        • Durrence H.H.
        • Riedel B.W.
        • Taylor D.J.
        • Bush A.J.
        The influence of age, gender, ethnicity, and insomnia on Epworth sleepiness scores: a normative US population.
        Sleep Med. 2006; 7: 319-326
        • Wolter K.M.
        Introduction to Variance Estimation.
        Springer-Verlag, New York1985
        • SAS Institute Inc.
        SAS/STAT®Software, Version 9.1 for Unix.
        SAS Institute Inc, Cary, NC2002
        • First M.B.
        • Spitzer R.L.
        • Gibbon M.
        • Williams J.B.W.
        Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version, Non-Patient Edition (SCID-I/NP).
        Biometrics Research, New York State Psychiatric Institute, New York2002
        • Cohen J.
        Statistical Power Analysis for the Behavioral Sciences.
        2nd ed. Lawrence Erlbaum Associates, Hillsdale, NJ1988
        • Ohayon M.M.
        Prevalence of DSM-IV diagnostic criteria of insomnia: Distinguishing insomnia related to mental disorders from sleep disorders.
        J Psychiatr Res. 1997; 31: 333-346
        • Ohayon M.M.
        Epidemiology of insomnia: What we know and what we still need to learn.
        Sleep Med Rev. 2002; 6: 97-111
        • Ohayon M.M.
        • Caulet M.
        • Guilleminault C.
        How a general population perceives its sleep and how this relates to the complaint of insomnia.
        Sleep. 1997; 20: 715-723
        • Ohayon M.M.
        • Partinen M.
        Insomnia and global sleep dissatisfaction in Finland.
        J Sleep Res. 2002; 11: 339-346
        • Ohayon M.M.
        • Reynolds 3rd, C.F.
        Epidemiological and clinical relevance of insomnia diagnosis algorithms according to the DSM-IV and the International Classification of Sleep Disorders (ICSD).
        Sleep Med. 2009; 10: 952-960
        • Ohayon M.M.
        • Roth T.
        What are the contributing factors for insomnia in the general population?.
        J Psychosom Res. 2001; 51: 745-755
        • Ohayon M.M.
        • Caulet M.
        • Priest R.G.
        • Guilleminault C.
        DSM-IV and ICSD-90 insomnia symptoms and sleep dissatisfaction.
        Br J Psychiatry. 1997; 171: 382-388
        • Ohayon M.M.
        • Smirne S.
        Prevalence and consequences of insomnia disorders in the general population of Italy.
        Sleep Med. 2002; 3: 115-120
        • Ohayon M.M.
        • Vecchierini M.F.
        Daytime sleepiness and cognitive impairment in the elderly population.
        Arch Intern Med. 2002; 162: 201-208
        • Ohayon M.M.
        • Zulley J.
        Correlates of global sleep dissatisfaction in the German population.
        Sleep. 2001; 24: 780-787
        • Ohayon M.M.
        • Guilleminault C.
        Epidemiology of sleep disorders.
        in: Chokroverty S. Sleep Disorders Medicine: Basic Science, Technical Considerations, and Clinical Aspects. 3rd ed. Saunders, Philadelphia2009: 284-294
        • Leger D.
        • Guilleminault C.
        • Dreyfus J.P.
        • Delahaye C.
        • Paillard M.
        Prevalence of insomnia in a survey of 12,778 adults in France.
        J Sleep Res. 2000; 9: 35-42
        • Hajak G.
        Epidemiology of severe insomnia and its consequences in Germany.
        Eur Arch Psychiatry Clin Neurosci. 2001; 251: 49-56
        • Katz D.A.
        • McHorney C.A.
        The relationship between insomnia and health-related quality of life in patients with chronic illness.
        J Fam Pract. 2002; 51: 229-235
        • Ohayon M.M.
        Difficulty in resuming or inability to resume sleep and the links to daytime impairment: Definition, prevalence and comorbidity.
        J Psychiatr Res. 2009; 43: 934-940
        • Sivertsen B.
        • Krokstad S.
        • Overland S.
        • Mykletun A.
        The epidemiology of insomnia: Associations with physical and mental health.
        J Psychosom Res. 2009; 67: 109-116
        • Ursin R.
        • Baste V.
        • Moen B.E.
        Sleep duration and sleep-related problems in different occupations in the Hordaland Health Study.
        Scand J Work Environ Health. 2009; 35: 193-202
        • Waage S.
        • Moen B.E.
        • Pallesen S.
        • Eriksen H.R.
        • Ursin H.
        • Akerstedt T.
        • Bjorvatn B.
        Shift work disorder among oil rig workers in the North Sea.
        Sleep. 2009; 32: 558-565
        • Klink M.
        • Quan S.F.
        Prevalence of reported sleep disturbances in a general adult population and their relationship to obstructive airways diseases.
        Chest. 1987; 91: 540-546
        • Ohayon M.
        Epidemiological study on insomnia in the general population.
        Sleep. 1996; 19: S7-S15
        • Troxel W.M.
        • Buysse D.J.
        • Hall M.
        • Matthews K.A.
        Marital happiness and sleep disturbances in a multi-ethnic sample of middle-aged women.
        Behav Sleep Med. 2009; 7: 2-19
        • Weyerer S.
        • Dilling H.
        Prevalence and treatment of insomnia in the community: Results from the upper Bavarian Field Study.
        Sleep. 1991; 14: 392-398
        • Liljenberg B.
        • Almqvist M.
        • Hetta J.
        • Roos B.E.
        • Agren H.
        The prevalence of insomnia: The importance of operationally defined criteria.
        Ann Clin Res. 1988; 20: 393-398