pii: jc-17- 00468http://dx.doi.org/10.5664/jcsm.

6942

S CI E NT IF IC IN VES TIGATIONS

Evaluating DSM-5 Insomnia Disorder and the Treatment of Sleep Problems in a

Psychiatric Population
Lee Seng Esmond Seow, BA1; Swapna Kamal Verma, MBBS, MD2; Yee Ming Mok, MB BCh BAO, DIP, MMed2; Sunita Kumar, MD, FCCP, FAASM3;
Sherilyn Chang, BSocSc1; Pratika Satghare, MSc, CRRA1; Aditi Hombali, MPT1; Janhavi Vaingankar, MSc1; Siow Ann Chong, MBBS, MMed, MD1;
Mythily Subramaniam, MBBS, MHSM, PhD1
Research Division, Institute of Mental Health, Singapore; 2Department of General Psychiatry, Institute of Mental Health, Singapore; 3Division of Pulmonary and Critical Care
1

Medicine, Loyola University, Chicago, Illinois

Study Objectives: With the introduction of insomnia disorder in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), greater
emphasis has been placed on the diagnosis and treatment of sleep disorder even in the presence of a coexisting mental disorder. The current study seeks to
explore the clinical picture of insomnia in the context of psychiatric disorders commonly associated with sleep complaints by assessing the prevalence and
correlates of DSM-5 insomnia disorder, and examining the extent to which insomnia symptoms have been addressed in this population.
Methods: Four hundred treatment-seeking outpatients suffering from depressive, bipolar affective, anxiety, and schizophrenia spectrum disorders were
recruited. DSM-5 insomnia was established using the modified Brief Insomnia Questionnaire. Differences in sociodemographic factors, clinical status,
impairment outcomes, and mental health services utilization were compared. Information on patients’ help-seeking experiences for insomnia-related
symptoms was collected to determine the treatment received and treatment effectiveness.
Results: Almost one-third of our sample (31.8%) had DSM-5 insomnia disorder. Those with insomnia disorder had significantly higher impairment outcomes
than their counterparts but no group difference was observed for mental health services utilization. Findings based on past treatment contact for sleep
problems suggest that diagnosis and treatment of insomnia is lacking in this population.
Conclusions: With the new calling from DSM-5, clinicians treating psychiatric patients should view insomnia less as a symptom of their mental illnesses and
treat clinical insomnia as a primary disorder. Patients should also be educated on the importance of reporting and treating their sleep complaints. Nonmedical
(cognitive and behavioral) interventions for insomnia need to be further explored given their proven clinical effectiveness.
Keywords: diagnosis and treatment, DSM-5 insomnia disorder, psychiatric population
Citation: Seow LSE, Verma SK, Mok YM, Kumar S, Chang S, Satghare P, Hombali A, Vaingankar J, Chong SA, Subramaniam M. Evaluating DSM-5
insomnia disorder and the treatment of sleep problems in a psychiatric population. J Clin Sleep Med. 2018;14(2):237–244.

BRIEF SUMMARY
Current Knowledge/Study Rationale: The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition distinction into primary and
secondary insomnia has been replaced with a unitary diagnosis of insomnia disorder in Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5), an advocate for its detection and treatment even in the presence of comorbid mental disorders. In view of these changes, the current
study aimed to determine the prevalence and correlates of DSM-5 insomnia disorder, and the extent of insomnia management and treatment in a
psychiatric population.
Study Impact: Beyond mere symptoms of mental illnesses, our study illustrates that a high proportion of psychiatric patients also suffer from clinically
significant insomnia disorder. Evidence from our study is indicative of the need for both clinicians and patients to place greater emphasis on addressing
insomnia symptoms in this population.

I N T RO D U C T I O N with psychiatric disorders and it can be primary or secondary

Insomnia is a common sleep problem and is marked by the
difficulty in initiating or maintaining sleep or when the sleep
that is obtained is nonrefreshing or of poor quality.1 Research
in insomnia has been undertaken in different populations and
settings, including primary care, outpatient clinics, and the
general population. Of these, chronic sleep problems have been
most commonly reported among those with psychiatric disor-
ders. Approximately 50% to 80% of adult patients with mental
illnesses had difficulty with falling or staying asleep in a typical
year.2 Research has shown that insomnia is strongly associated
to a mental disorder. The relationship between sleep and mental
disorders has been described as complex and is possibly marked
by bidirectional causality.3 Data from the large-scale Epidemio-
logic Catchment Area project revealed that 40% of insomnia
sufferers meet criteria for at least one psychiatric disorder, with
23% of them also receiving a diagnosis of major depression or
dysthymia; 24%, anxiety disorders; 7%, alcohol abuse; and 4%,
drug abuse.4 Evidence supporting this interrelationship has
found that treating certain psychiatric conditions may help to
improve sleep and treating sleep disturbances can have a ben-
eficial effect on their psychiatric treatment.3

Journal of Clinical Sleep Medicine, Vol. 14, No. 2 237 February 15, 2018
LSE Seow, SK Verma, YM Mok, et al.
Few psychiatric disorders have been consistently identi-
fied in the sleep literature due to their strong associations
with insomnia—major depressive disorder (MDD), bipolar
disorder, anxiety disorders, and schizophrenia spectrum dis-
order.3,5–8 Depression is by far the most extensively studied
in terms of sleep disturbance with more than 90% of indi-
viduals with MDD having reported insomnia-related sleep
disturbance.9,10 Insomnia has been recognized as a core
symptom of depression.11 In bipolar disorder, the diagnos-
tic criteria indicate that there may be a decreased need for
sleep during the manic phase and a decreased inability to
sleep during the depression phase with about 69% to 99%
of the patients being affected.12 Insomnia is also prevalent
among those with anxiety disorders, particularly among
those with generalized anxiety disorder and posttraumatic
stress disorder given that sleep disturbance has been identi-
fied as a diagnostic criterion for these disorders.13,14 Lastly,
sleep difficulties have been frequently reported among those
with schizophrenia, possibly secondary to the hyperarousal
caused by positive psychotic symptoms,15 and approximately
40% of an outpatient sample was found to meet the criteria
for clinical insomnia.16 In Singapore, the lifetime prevalence
of MDD, bipolar disorders, and anxiety disorders was 5.8%,
1.2%, and 3.6%, respectively,17 whereas the lifetime preva-
lence of any psychotic experience was 3.8%18 based on find-
ings from the Singapore Mental Health Study.
The presence of insomnia symptoms can have adverse im-
plications on sufferers in terms of their emotional and mental
health and quality of life. Daytime consequences include in-
creased risks of accidents, decreased work productivity and
concentration, and impaired daily performance.19,20 Among
individuals with mental disorders, the presence of sleep dis-
turbance independent of the patients’ primary condition was
also associated with higher symptom severity, higher disor-
der severity, lower level of functioning, and fewer benefits
from treatment.21 The Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) calls for the inde-
pendent clinical importance of a sleep disorder regardless
of the presence of a coexisting mental or medical condi-
tion. As a result, the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition distinction into primary
and secondary insomnia has been removed in DSM-5 and
replaced with the diagnosis of insomnia disorder in favor
of unitary diagnosis of insomnia disorder with concurrent
specification of clinically comorbid conditions. This signifi-
cant change in the sleep-wake diagnostic criteria in recogni-
tion of the comorbid nature of insomnia also advocates for
the treatment of insomnia itself in addition to the medical or
psychiatric disorder.22
The current study therefore aims to provide an over-
view of the clinical picture of insomnia in view of the new
highlights in DSM-5 among a group of psychiatric pa-
tients with major depressive, bipolar affective, anxiety, and
schizophrenia spectrum disorders. Mainly, we intend to
establish the prevalence of clinical insomnia using DSM-5
diagnostic criteria along with its correlates, and to evalu-
ate the extent to which sleep problems were treated in this
patient population.
Journal of Clinical Sleep Medicine, Vol. 14, No. 2
Insomnia Diagnosis and Treatment in a Psychiatric Population
METHODS
Study Participants
This cross-sectional study recruited adult patients who were
seeking treatment at the outpatient and community-based
clinics of the Institute of Mental Health, the main psychiatric
hospital in Singapore. Inclusion criteria included age of 21 to
65 years and the ability to complete self-administered study
questionnaires; exclusion criteria included history of intellec-
tual disability or dementia. Study subjects were recruited us-
ing multiple methods (posters and flyers) and referral sources
(psychiatrists, other health care professionals, or self-referral).
A total of 400 psychiatric outpatients were recruited based on
their primary diagnosis—100 with major depressive disorder,
80 with bipolar affective disorder, 100 with anxiety disorders,
and 120 with schizophrenia spectrum disorder (schizophrenia
or schizoaffective disorder). All psychiatric diagnoses were
made by the attending psychiatrists based on International
Classification of Diseases, 9th Revision criteria. Written in-
formed consent was obtained from all participants. The study
was approved by the ethics committee of the Domain Specific
Review Board of the National Healthcare Group, Singapore
and participants were reimbursed upon completion of the
questionnaires.
Data Collection
Participants were asked to complete a questionnaire set
comprising sociodemographic (age, sex, ethnicity, marital
status, education, and employment) and lifestyle informa-
tion (smoking, drinking, and physical activity statuses).
For physical activity level, participants were first asked to
recall the number of days in an average week and for how
long each day they had engaged in activities that increased
their heart rate and/or made them breathe hard before pro-
viding an overall rating. All clinical information including
psychiatric and medical diagnoses, psychiatric illness dura-
tion and onset, use of sleep medication, and mental health
services utilization (hospitalization, outpatient, emergency,
and psychologist visits) in the past year was obtained from
the patients’ medical records. For the purpose of this study,
medications for sleep problems included diazepam, loraz-
epam, alprazolam (Xanax), zolpidem tartrate, zopiclone and
hydroxyzine (Atarax). The participants were also required to
self-complete a set of questionnaires (described in the fol-
lowing paragraphs) to measure their impairment outcomes
due to sleep, followed by a structured interview—the modi-
fied Brief Insomnia Questionnaire (BIQ) to determine their
status for DSM-5 insomnia disorder.
Instruments
Brief Insomnia Questionnaire
The BIQ is a fully structured questionnaire first developed
to diagnose insomnia according to hierarchy-free Diagnos-
tic and Statistical Manual, Fourth Edition, Text Revision,
International Classification of Diseases, Tenth Revision,
and research diagnostic criteria/International Classification
of Sleep Disorders, Second Edition general criteria without
238 February 15, 2018
LSE Seow, SK Verma, YM Mok, et al.
organic exclusions.23 Additional items were later added and
validated in the Hong Kong population to generate insom-
nia diagnosis according to the DSM-5.24 The current study
adopted the Hong Kong-modified BIQ and a diagnosis of
DSM-5 insomnia disorder was given if all the following
criteria were met: (1) dissatisfaction with sleep quality or
quantity; (2) complaint of one or more of the following sleep
difficulties: difficulty initiating sleep, difficulty maintaining
sleep, early morning awakening, or a nonrestorative sleep; (3)
significant distress or interference with personal functioning
in daily living caused by the sleep difficulty; (4) the sleep
difficulty occurs at least three times a week; (5) the sleep dif-
ficulty is present for at least 3 months; and (6) the sleep diffi-
culty occurs despite adequate opportunity and circumstances
for sleep.
Functional Outcomes of Sleep Questionnaire
The Functional Outcomes of Sleep Questionnaire consists of
30 items that can be used to profile functional status due to
sleep loss or excessive daytime sleepiness by probing the ex-
tent to which sleepiness or sleep disruption impairs five aspects
of daily activities: general productivity, social outcomes, activ-
ity levels, vigilance, and sexual relationships.25 Respondents
are asked to rate the difficulty of these activities on a four-
point (extreme difficulty to no difficulty) Likert scale. Potential
scores range from 5 to 20, with higher score indicating better
functional status.
World Health Organization Well Being Index
The World Health Organization Well Being Index is a five-item
scale that assesses the degree of subjective psychological well-
being during the past 2 weeks based on positive mood (good
spirits, relaxation), vitality (being active and waking up fresh
and rested), and general interest (being interested in things).26
The total raw scores range from 0 (worst possible quality of
life) to 25 (best possible quality of life).
Epworth Sleepiness Scale
The Epworth Sleepiness Scale consists of eight items on a four-
point Likert scale from 0 (would never) to 3 (high chance) and
is a self-report measure designed to assess the overall level of
daytime sleepiness while engaged in eight different activities.27
Total scores range from 0 to 24, where higher score indicates
greater propensity to fall asleep or “daytime sleepiness.”
Flinders Fatigue Scale
The Flinders Fatigue Scale is a brief seven-item assessment for
measuring daytime fatigue over the previous two weeks.28 Six
of the seven items are presented in Likert format and responses
range from 0 (not at all) to 4 (extremely). Using a multiple item
checklist to indicate more than one response, the fifth item
measures the time of day when fatigue is experienced and the
sum of this response is reported. Total scores range from 0 to
31 and higher score indicates greater fatigue.
Treatment History
A semistructured questionnaire was used to collect informa-
tion on patients’ past help-seeking experience for any lifetime
Journal of Clinical Sleep Medicine, Vol. 14, No. 2
Insomnia Diagnosis and Treatment in a Psychiatric Population
insomnia-related sleep problems with a health care profes-
sional. This could be either a mental health care professional
such as the patients’ consulting psychiatrist and psychologist
for their psychiatric treatment, or other non-mental health care
professional including a sleep specialist, polyclinic doctor,
general practitioner, or family doctor. Participants were first
asked if they have ever consulted a professional for sleep prob-
lems and if yes, whether they have received a diagnosis of any
specific sleep disorder(s) by the consulting professional. The
type of interventions (medications, counseling/therapies, or
others) received for their sleep problems were recorded and the
effectiveness of the pharmacological intervention(s) received
was also rated.
Statistical Analyses
Statistical analyses were performed using IBM SPSS, version
23 (IBM Corp, Armonk, New York, United States). Descrip-
tive statistics were tabulated for the overall sample, along
with their insomnia disorder status. Frequencies and percent-
ages were calculated for categorical variables, whereas mean
and standard deviation were calculated for all other continu-
ous variables. Chi-square tests and independent t tests were
performed to analyze differences for categorical and continu-
ous variables, respectively. Statistical significance was set at
P < .05.
R ES U LT S
Patient Characteristics
The profile of the sample is shown in Table 1. The sample was
composed of mostly males (52.5%), in the younger age group of
21 to 39 years (55.0%), Chinese (37.8%), never married (58.3%),
completed postsecondary/pretertiary education (41.0%), and
employed (54.8%). The majority of them had illness duration
of more than 5 years (65.8%) and diagnosis made between the
age of 21 to 39 years (56.8%). In terms of comorbidities, 47.0%
had a secondary psychiatric diagnosis and 59.5% had a chronic
medical condition.
Insomnia Prevalence
The prevalence of DSM-5 insomnia disorder in the current
sample was 31.8% (n = 127) based on the modified BIQ.
Bivariate analyses (Table 1) revealed those with DSM-5
insomnia disorder differed from those without the disorder
in terms of age group, employment, level of physical activity,
their use of sleeping pills and the presence of a secondary psy-
chiatric diagnosis. It was more prevalent among the younger
age group (21 to 39 years), the unemployed, those who had low
physical activity level, those who had a secondary psychiatric
diagnosis, and those who were on sleep medications.
The prevalence of DSM-5 insomnia was highest among
those with depressive disorder (45.0%), followed by anxiety
disorder (33.0%), schizophrenia spectrum disorder (25.0%),
and bipolar disorder (23.8%). Chi-square analysis (Table 2) re-
vealed a significant difference in the rates of DSM-5 insomnia
among the different psychiatric disorders (P = .005). In terms
of the nature of sleep difficulties, chi-square analyses revealed
239 February 15, 2018
LSE Seow, SK Verma, YM Mok, et al. Insomnia Diagnosis and Treatment in a Psychiatric Population

Table 1—Characteristics of participants based on total sample and by DSM-5 insomnia disorder status.
DSM-5 Insomnia Disorder Test of
Total (n = 400)
No (n = 273) Yes (n = 127) Significance *

Sociodemographic
Male 210 (52.5) 145 (69.0) 65 (31.0)
Sex .719
Female 190 (47.5) 128 (67.4) 62 (32.6)
21–39 220 (55.0) 141 (64.1) 79 (35.9)
Age group .048 †
40–65 180 (45.0) 132 (73.3) 48 (26.7)
Chinese 151 (37.8) 101 (66.9) 50 (33.1)
Ethnicity Malay 105 (26.3) 71 (67.6) 34 (32.4) .825
Indian & Others 144 (36.0) 101 (70.1) 43 (29.9)
Not-married 233 (58.3) 162 (69.5) 71 (30.5)
Marital status .517
Married 167 (41.8) 111 (66.5) 56 (33.5)
Primary or below 28 (7.0) 19 (67.9) 9 (32.1)

Highest education Secondary 154 (38.5) 102 (66.2) 52 (33.8)

.845
attainment Post-secondary 164 (41.0) 116 (70.7) 48 (29.3)
Tertiary or above 54 (13.5) 36 (66.7) 18 (33.3)
Employed 219 (54.8) 162 (74.0) 57 (26.0)
Employment .007 ‡
Unemployed 181 (45.3) 111 (61.3) 70 (38.7)
Yes 118 (29.5) 76 (64.4) 42 (35.6)
Smoking status .285
No 282 (70.5) 197 (69.9) 85 (30.1)
Yes 127 (31.8) 85 (66.9) 42 (33.1)
Drinking status .699
No 273 (68.3) 188 (68.9) 85 (31.1)

Physical activity Low 185 (46.3) 112 (60.5) 73 (39.5)

.002 ‡
status High 215 (53.8) 161 (74.9) 54 (25.1)
Clinical
< 2 years 61 (15.3) 37 (60.7) 24 (39.3)
Illness duration 2–5 years 76 (19.0) 49 (64.5) 27 (35.5) .211
> 5 years 263 (65.8) 187 (71.1) 76 (28.9)
Below 21 93 (23.3) 56 (60.2) 37 (39.8)
Age at diagnosis 21–39 227 (56.8) 161 (70.9) 66 (29.1) .163
40–65 80 (20.0) 56 (70.0) 24 (30.0)

Secondary psychiatric Yes 188 (47.0) 117 (62.2) 71 (37.8)

.015 †
comorbidity No 212 (53.0) 156 (73.6) 56 (26.4)

Chronic physical Yes 238 (59.5) 164 (68.9) 74 (31.1)

.732
comorbidity No 162 (40.5) 109 (67.3) 53 (32.7)
Yes 140 (35.0) 80 (57.1) 60 (42.9)
Sleeping pills usage < .001 ‡
No 260 (65.0) 193 (74.2) 67 (25.8)

Values presented as n (%). * = chi-square analyses: † = P < .05, ‡ = P < .01. DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

only significant differences (P < .001) for both difficulty initi- Impairment Outcomes and Mental Health Services
ating and maintaining sleep across the four psychiatric disor- Utilization in the Past Year
ders. No significant difference was reported for early morning Table 3 shows that those with insomnia disorder had signifi-
awakening and nonrestorative sleep. cantly higher impairment outcomes in areas of functioning,

Journal of Clinical Sleep Medicine, Vol. 14, No. 2 240 February 15, 2018
LSE Seow, SK Verma, YM Mok, et al. Insomnia Diagnosis and Treatment in a Psychiatric Population

Table 2—Insomnia and its related symptoms across four primary diagnoses.
Schizophrenia Major Bipolar Test of
Spectrum Depression Affective Anxiety Significance *
DSM-5 insomnia disorder 30 (25.0) 45 (45.0) 19 (23.8) 33 (33.0) .005 ‡
Difficulty initiating sleep 34 (28.3) 68 (68.0) 31 (38.8) 41 (41.0) < .001 ‡
Difficulty maintaining sleep 22 (18.3) 43 (43.0) 14 (17.5) 32 (32.0) < .001 ‡
Early morning awakening 8 (6.7) 13 (13.1) 7 (8.8) 5 (5.0) .177
Non-restorative sleep 3 (2.5) 5 (5.0) 2 (2.5) 3 (3.0) .717

Values presented as n (%). * = chi-square analyses: ‡ = P < .01. DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Table 3—Differences in impairment outcomes and mental health services utilization between those with and without DSM-5
insomnia disorder.
No Insomnia Disorder Insomnia Disorder
Mean SD Mean SD P*
Impairment Outcomes
FOSQ score 15.4 3.5 14.3 3.5 .005 ‡
WHO-5 score 14.2 6.4 8.8 4.7 < .001 ‡
ESS score 7.7 5.1 8.1 5.2 .423
FFS score 11.4 6.5 16.0 6.0 < .001 ‡
Mental Health Services Utilization
No. of outpatient visits 6.4 4.1 6.7 4.6 .488
No. of emergency visits 0.6 1.5 1.0 2.0 .058
No. of psychotherapy 1.4 3.7 2.3 5.1 .067
No. of hospitalization 0.3 0.7 0.4 1.2 .274
Hospitalization duration (days) 7.7 25.8 11.3 43.7 .301

* = independent t tests: ‡ = P < .01. DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, ESS = Epworth Sleepiness Scale,
FFS = Flinders Fatigue Scale, FOSQ = Functional Outcomes of Sleep Questionnaire, SD = standard deviation, WHO-5 = World Health Organization Well
Being Index.

well-being, and daytime fatigue compared to those with- D I SCUS S I O N

out. However, no group difference was observed for daytime
sleepiness, as well as any mental health services utilization
including outpatients, emergency services, psychotherapy, and
hospitalization visits in the past year. Despite being nonsignifi-
cant, those with insomnia disorder had higher mental health
services utilization than those without.
Self-Reported Help-Seeking Experience for Sleep
Disturbance
Of the 400 psychiatric patients interviewed, 50.0% (n = 200)
reported having sought help from a health care professional for
any insomnia-related sleep difficulties. Of these 200 patients,
7.0% (n = 14) were not recommended any treatment specific to
their sleep problems. Only 12.5% of patients (n = 25) recalled
being informed of their insomnia diagnosis by their doctors
and only 12.0% of patients (n = 24) recounted being educated
on sleep hygiene or receiving any form of psychotherapy for
their sleep problems. A total of 91.0% of patients (n = 182)
were prescribed psychotropic medications or sleeping pills to
aid them in their sleep, of which 74.2% (n = 135) found the
drug treatment to be helpful but to varying extent. Common
concerns were, however, daytime drowsiness (n = 23), nonsus-
tained effectiveness (n = 21), and drug dependence (n = 18).
The current study focused on insomnia in the context of a
group of psychiatric patients at risk of sleep disturbance by
examining the prevalence and factors of DSM-5 insomnia
disorder among them, as well as their treatment history for
insomnia-related problems. Together with the International
Classification of Sleep Disorders, Third Edition, the contrast
between primary and secondary insomnia has been removed
due to the difficulty in establishing the cause/effect relationship
between insomnia and other psychiatric or medical conditions
with certainty.29 This major revision was a move consistent
with the recommendations of the 2005 National Institutes of
Health State of the Science position on the classification of in-
somnia disorders.30 The DSM-5 Sleep-Wake Disorders Work
Group took into consideration the pathological and etiologi-
cal factors associated with sleep-wake disorders, and thus in-
corporated these changes with the aim to increase uniformity
and consistency among health care professionals when they are
assessing and treating patients with various sleep disorders.31
Consequently, the examination of DSM-5 insomnia disorder
among individuals with psychiatric disorders becomes more
meaningful without having to differentiate primary and sec-
ondary insomnia and allows for useful comparison with other

Journal of Clinical Sleep Medicine, Vol. 14, No. 2 241 February 15, 2018
LSE Seow, SK Verma, YM Mok, et al.
populations. Furthermore, DSM-5 has been recognized as a
widely adopted psychiatric taxonomy for mental disorders in
its latest edition, and is therefore familiar to psychiatrists and
mental health care professionals.
DSM-5 Insomnia Disorder
In view of the aforementioned details, our study adopted the
modified BIQ to estimate insomnia prevalence in accordance
with the DSM-5 criteria. Our study revealed almost one-third
of our psychiatric sample (31.8%) to be suffering from a clini-
cally significant sleep disorder (ie, insomnia disorder). To the
best of our knowledge, only one study has reported on insom-
nia prevalence using diagnostic criteria of the International
Classification of Diseases, one of the three main classifications
for sleep disorders in a psychiatric population. The prevalence
of International Classification of Diseases, Tenth Revision in-
somnia was found to be 20.1% in a group of psychiatric outpa-
tients with diversified diagnoses.32 Despite the requirement of a
longer duration of 3 months for the experienced sleep difficulty
in DSM-5 compared to 1 month in International Classifica-
tion of Diseases, Tenth Revision, the higher prevalence in our
study may be attributed to the use of a psychiatric sample with
only four diagnoses that are at higher risk of insomnia. Stud-
ies reporting prevalence of DSM-5 insomnia in other popula-
tions have been limited. The Nord-Trøndelag Health Study has
established an adjusted DSM-5 insomnia prevalence of 7.9%
among a general adult population in Norway,33 whereas the
weighted prevalence in Hong Kong population was found to
be 10.8%,34 both of which were lower than our reported preva-
lence of 31.8% in a psychiatric outpatient sample. The need to
screen for clinical insomnia among psychiatric patients using
an appropriate and easy-to-administer tool has therefore be-
come important.35
The lack of studies using a standardized diagnostic instru-
ment to estimate prevalence of clinical insomnia among psy-
chiatric populations in a single study makes the comparison of
insomnia prevalence across differential psychiatric disorders
less reliable and consistent. Our findings revealed decreasing
DSM-5 insomnia disorder prevalence across major depres-
sive disorder (45.0%), followed by anxiety disorders (33.0%),
schizophrenia spectrum disorder (25.0%), and bipolar affective
disorder (23.8%). Ogbolu et al.,32 however, found International
Classification of Diseases, Tenth Revision nonorganic insom-
nia to be more prevalent among those with major depression
(n = 15, 33.3%), followed by bipolar affective disorder (n = 6,
24.0%), anxiety and other neurotic disorders (n = 3, 18.8%),
and schizophrenia (n = 7, 10.6%) using diagnostic groups of
smaller sample size. Nonetheless, the literature does seem to
suggest the close relationship of insomnia with depression and
anxiety disorders.36,37 Studies in community-based and non-
psychiatric clinical samples have also found a high proportion
of 40% to 60% of individuals with insomnia to suffer from
mainly depression or anxiety disorder, among other mental
disorders.4,38–42
Insomnia Treatment in Psychiatric Patients
In the current study, those with current DSM-5 insomnia
disorder were found to have significantly higher impairment
Journal of Clinical Sleep Medicine, Vol. 14, No. 2
Insomnia Diagnosis and Treatment in a Psychiatric Population
outcomes in terms of functioning, well-being, and daytime
fatigue than those without. Yet, the mental health services
utilization in the past year among them was higher but not
significantly higher, compared to their counterparts. This may
imply that the psychiatric patients in our sample were not re-
ceiving adequate treatment that corresponds to the level of im-
pairment due to their clinical insomnia. Nonetheless, further
research would need to be done to explain this lack of service
utilization among those with insomnia disorder despite suffer-
ing from significantly worse daytime consequences and quality
of life. One study exploring the lack of help-seeking for insom-
nia among primary care patients has proposed that the problem
may not be due to the clinician’s failure to identify and treat
sleep problems but because patients with syndrome-defined
insomnia do not view it as a clinically significant disorder that
warrants medical attention.43 Although studies generally sup-
ported that perceived greater daytime impairment would better
prompt patients to seek treatment,43,44 it has been suggested that
patients’ sleep and treatment beliefs, as well as the ease of ac-
cessing specialized care (including level of awareness, referral
mechanisms, availability of service providers and cost of treat-
ment), may also play a role in their help-seeking behaviors for
sleep problems.44 Supported in an earlier study, 28.4% denied
having any sleep problem and 39.8% did not seek help among
those who reported poor sleep quality based on the Pittsburgh
Sleep Quality Index in our sample.45
The current study also revealed that only 12.5% among those
who sought treatment for their sleep difficulties (n = 25) re-
called being told by their doctors that they had insomnia. This
low rate of diagnosis for insomnia may be due to clinicians’
attribution of the patients’ sleep problems to be secondary to
their psychiatric or other medical disorders and possible recall
bias. Because the clinical manifestations are similar, sleep dis-
orders may often be mistakenly attributed to the patient’s pri-
mary psychiatric condition.46 In addition, our data showed that
those who were currently on sleep medications had a higher
rate of DSM-5 insomnia disorder compared to those without,
hence suggesting that medications alone may not be the best
treatment for their insomnia symptoms. Although most of
those who sought help and were given psychotropic medica-
tions to aid in their sleep did find the pharmacological treat-
ment improved their sleep, the prevalence of DSM-5 insomnia
disorder based on the BIQ among them remains high at 31.8%.
The use of psychological and behavioral therapies such as cog-
nitive behavioral therapy or combined treatment with drug
intervention to treat chronic insomnia has been strongly advo-
cated in medical practice.1,47 However, only 12.0% (n = 24) of
patients who sought help reported having received psychoedu-
cation or psychotherapy for their sleep problems from a health
care professional. This findings, when taken together, seem to
suggest there is a lack of emphasis given to the treatment of
insomnia among psychiatric patients.
Strengths and Limitations
The study of insomnia in psychiatric patients may not be novel.
However, existing studies have mainly looked at insomnia
symptoms or disturbance and only one study seems to have
applied the diagnostic criteria for insomnia from existing
242 February 15, 2018
LSE Seow, SK Verma, YM Mok, et al.
classification systems.32 Most epidemiological studies that
examined the associations between psychiatric disorders and
insomnia were studied in population-based samples,4,36–39,48
which generally reported lower prevalence that is not surpris-
ing. Studying the relationship of sleep and mental disorders
from the perspective of treatment-seeking psychiatric patients
is equally important. Our study may also be unique in that we
shed some light on the management and treatment of insom-
nia in this population in view of the recommendations by the
DSM-5 Sleep-Wake Disorders Work Group by looking at their
treatment contact for sleep disturbance and evaluating the ex-
tent to which their sleep problems have been addressed.
Our study is not without its limitations. The current study
was conducted in a single clinical setting within Singapore
and has adopted a convenient sampling strategy that recruited
only patients with specific mental diagnoses, thus limiting the
generalizability of our findings to a larger population of psy-
chiatric patients. The endorsement of DSM-5 insomnia dis-
order requires the sleep disturbance not to occur exclusively
during the course of narcolepsy, sleep-related breathing dis-
order, circadian rhythm sleep disorder, or parasomnia but this
criterion was not operationalized within the BIQ. We did not
assess these sleep disorders other than insomnia, which may
have influenced some of the variables studied, such as daytime
sleepiness and functioning. Last, the cross-sectional design of
the study does not allow us to establish a causal relationship
between insomnia disorder and psychiatric disorders.
CO N CLUS I O N S
The current study suggests that almost one-third of our psy-
chiatric outpatients may be suffering from comorbid DSM-5
insomnia disorder, a sleep disorder that warrants further medi-
cal attention. Consistent with the literature, our study provides
further support through a single empirical study on the higher
rate of insomnia among those with affective disorders com-
pared to schizophrenia spectrum disorders. Evidence from our
study also is indicative of the undermining of sleep symptoms
as a clinically significant problem in this population, both from
the patients’ and/or the clinicians’ perspective. As a result,
there is a lower priority given to treat these sleep symptoms
compared to their psychiatric disorder. With the new calling
from DSM-5, clinicians treating psychiatric patients should
view insomnia less as a symptom of their mental illnesses
and place more focus on treating insomnia as a disorder itself,
which has been shown to help alleviate concurrent psychiatric
symptoms. In addition, the presence of a mental illness should
not be a distraction from a holistic evaluation of insomnia as
a presenting problem. Nonmedical (cognitive and behavioral)
interventions for insomnia need to be further explored among
psychiatric patients given their proven clinical effectiveness.
Greater awareness on the consequences of poor sleep and the
importance of treating insomnia should also be raised among
the patient group. As other sleep disorders such as obstructive
sleep apnea may also be responsible for poor sleep, referral to
a sleep specialist for further evaluation should be considered.
Journal of Clinical Sleep Medicine, Vol. 14, No. 2
Insomnia Diagnosis and Treatment in a Psychiatric Population
A B B R E V I AT I O N S
MDD, major depressive disorder
DSM, Diagnostic and Statistical Manual of Mental Disorders
ICD, International Classification of Diseases
ICSD, International Classification of Sleep Disorders
BIQ, Brief Insomnia Questionnaire
FOSQ, Functional Outcomes of Sleep Questionnaire
WHO, World Health Organization
ESS, Epworth Sleepiness Scale
FFS, Flinders Fatigue Scale
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SUBMISSION & CORRESPONDENCE INFORMATION
Submitted for publication September 10, 2017
Submitted in final revised form October 18, 2017
Accepted for publication October 25, 2017
Address correspondence to: Seow Lee Seng, Esmond, Research Division, Institute
of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore
539747; Email: esmond_LS_SEOW@imh.com.sg
D I SCLO S U R E S TAT E M E N T
Work for this study was performed at the Institute of Mental Health, Singapore.
This research is supported by the Singapore Ministry of Health’s National Medical
Research Council under the Centre Grant Programme (Grant No.: NMRC/
CG/004/2013). The authors report no conflicts of interest. All authors have seen and
approved the manuscript.
244 February 15, 2018