See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/239943166

Epidemiology of Insomnia in College Students: Relationship With Mental

Health, Quality of Life, and Substance Use Difficulties

Article in Behavior Therapy · September 2013

DOI: 10.1016/j.beth.2012.12.001 · Source: PubMed

CITATIONS READS

266 6,779

5 authors, including:

Daniel J Taylor Adam D Bramoweth

The University of Arizona VA Pittsburgh Healthcare System
229 PUBLICATIONS 8,899 CITATIONS 48 PUBLICATIONS 1,748 CITATIONS

SEE PROFILE SEE PROFILE

Brandy M Roane
University of North Texas HSC at Fort Worth
45 PUBLICATIONS 1,711 CITATIONS

SEE PROFILE

All content following this page was uploaded by Daniel J Taylor on 25 October 2017.

The user has requested enhancement of the downloaded file.

This article appeared in a journal published by Elsevier. The attached
copy is furnished to the author for internal non-commercial research
and education use, including for instruction at the authors institution
and sharing with colleagues.
Other uses, including reproduction and distribution, or selling or
licensing copies, or posting to personal, institutional or third party
websites are prohibited.
In most cases authors are permitted to post their version of the
article (e.g. in Word or Tex form) to their personal website or
institutional repository. Authors requiring further information
regarding Elsevier’s archiving and manuscript policies are
encouraged to visit:
http://www.elsevier.com/authorsrights
 Author's personal copy

Behavior Therapy 44 (2013) 339 – 348

www.elsevier.com/locate/bt

Epidemiology of Insomnia in College Students: Relationship With

Mental Health, Quality of Life, and Substance Use Difficulties
Daniel J. Taylor
University of North Texas

Adam D. Bramoweth
VISN 4 Mental Illness Research, Education and Clinical Center and VA Pittsburgh Healthcare System

Emily A. Grieser
United States Air Force

Jolyn I. Tatum
United States Air Force

Brandy M. Roane
University of North Texas Health Science Center

portion of this sample of college students met proposed

The purpose of this study was to evaluate the prevalence and
correlates of insomnia using rigorous diagnostic criteria and
a comprehensive assessment battery. In a large sample (N =
1,074) of college students (mean age 20.39 years), partic-
ipants were asked to complete a week-long sleep diary and
comprehensive questionnaire packet assessing recom-
mended daytime functioning domains (i.e., fatigue, quality
of life, depression, anxiety, stress, academic performance,
substance use) during the academic year. A significant
The work was performed at the University of North Texas and
was supported by grants to the first author from the University of
North Texas [G69250] and National Institute of Allergy and
Infectious Diseases [A1085558]. There was no other financial
support for this research nor are there any conflicts of interest for
any of the authors. No off-label or investigational drugs were used
in this study.
Address correspondence to Daniel J. Taylor, Ph.D., ABSM,
C.BSM, University of North Texas, Department of Psychology,
1155 Union Circle #311280, Denton, TX 76203-5017; e-mail:
djtaylor@unt.edu.
0005-7894/44/339–348/$1.00/0
© 2012 Association for Behavioral and Cognitive Therapies. Published by
Elsevier Ltd. All rights reserved.
DSM-5 criteria for chronic insomnia (9.5%). The chronic
insomnia group reported significantly worse sleep, fatigue,
depression, anxiety, stress, and quality of life, and greater
hypnotic and stimulant use for sleep problems. There were
no differences between groups on excessive daytime
sleepiness, academic performance, or substance use. This
was a rigorous and comprehensive assessment of the
prevalence and psychosocial correlates of insomnia. Insom-
nia is a significant problem in college students and should be
regularly assessed. More research is also needed to guide
treatment in this population.
Keywords: insomnia; college; psychosocial; hypnotic; stimulant
THE TRANSITION FROM HIGH SCHOOL to college
presents many challenges, including leaving home,
increased independence, changes in peer groups,
new social situations, maintenance of academic
responsibilities, and increased access to alcohol and
drugs. Some students may cope more effectively
 Author's personal copy
340 taylor et al.
with these stressors than others, and the latter may
be at increased risk for developing insomnia. While
recent research has helped to increase the public
understanding of the importance of good sleep
behaviors in young adults (Lund, Reider, Whiting,
& Prichard, 2010; Taylor & Bramoweth, 2010), a
thorough investigation of insomnia and correlates
in college students is still lacking.
The American Psychiatric Association's (APA)
Diagnostic and Statistical Manual of Mental
Disorders’ newly proposed criteria for chronic
insomnia (DSM-5; APA, 2012), which is now
closed to public comment, includes an insomnia
complaint (i.e., difficulty initiating or maintaining
sleep, early-morning awakenings, or nonrestorative
sleep in adults) accompanied by daytime impair-
ments, for at least 3 nights per week, for at least
3 months. Meeting any of these criteria might be
considered insomnia symptoms, whereas meeting
all of the criteria would be needed to diagnose
someone with chronic insomnia. This new defini-
tion approximates recommendations for quantita-
tive (Lichstein, Durrence, Taylor, Bush, & Riedel,
2003) and research diagnostic criteria (RDC)
for insomnia (Edinger et al., 2004), and should
result in “harmonizing criteria across diagnostic
nosologies” and across research studies. Not
surprisingly, no study, in either college students or
the general population, has examined the preva-
lence of insomnia using proposed DSM-5 criteria.
Inconsistent operational definitions of chronic
insomnia (for a review, see Edinger et al., 2004;
Lichstein et al., 2003; Ohayon, 2002) have
contributed to widely varying prevalence rates of
chronic insomnia in college students (i.e., 8.7% to
69%) in previous literature (Bramoweth & Taylor,
2012; Buboltz, Brown, & Soper, 2001; Sing &
Wong, 2011; Taylor et al., 2011). One study of
Hong Kong college students found that 68.6%
were “insomniacs” based on a score of greater than
5 on the Pittsburg Sleep Quality Index (PSQI;
Buysse, Reynolds, Monk, Berman, & Kupfer,
1989), which was not intended or useful for
generating such a diagnosis (Sing & Wong).
Buboltz et al. (2001) examined sleep habits and
patterns (i.e., insomnia symptoms) and found 15%
of students reported having poor sleep quality and
12% to 13% reported difficulty falling asleep,
waking during the night, or waking too early in the
morning at least three times per week. Taylor et al.
(2011) found 9.4% of American college students
reported difficulty falling asleep or staying asleep at
least 3 nights per week for at least 6 months. These
researchers did not assess for daytime complaints, a
requirement for most diagnostic systems, because
they were interested in determining the relationship
between insomnia and mental health symptoms, and
mental health symptoms are frequently used as a
marker of daytime complaints. Finally, Bramoweth
and Taylor (2012) found 8.7% of college students
reported difficulty falling asleep or staying asleep at
least 3 nights per week, with daytime impairment, for
at least 6 months (i.e., slightly more conservative
than DSM-5).
In addition, no study, in either college students or
the general population, has comprehensively
assessed the daytime impairments related to insom-
nia using measures deemed “essential” by experts in
the field (Buysse, Ancoli-Israel, Edinger, Lichstein, &
Morin, 2006). The primary reason for this is that
most studies either did not think to measure all of the
areas recommended by Buysse et al. (2006) or failed
to report on those constructs measured, instead
focusing on just the few variables of interest to the
researchers. This fails to provide a complete picture
of the difficulties associated with insomnia. That
said, researchers have shown that people with
insomnia symptoms in the general population report
greater fatigue, irritability, anxiety, depression,
difficulties completing tasks, impairments in cogni-
tive functioning, accidents, work absenteeism, and
poor quality of life, when compared to those without
insomnia (Kuppermann et al., 1995; Roth & Roehrs,
1988; Walsh, 2004). In addition, people with
insomnia symptoms in the general population are
also at a higher risk for developing depression,
anxiety, substance abuse or dependence, suicide,
impaired immune functioning, and cardiovascular
disease (Taylor et al., 2011; Taylor, Lichstein, &
Durrence, 2003).
We know less about daytime impairments in
college students with chronic insomnia. Research
does show that college students who have insomnia
symptoms (i.e., do not meet all insomnia diagnostic
criteria) have slower reaction times, lower grades,
higher levels of daytime sleepiness, fatigue, worry,
mental health complaints and a higher risk for
traffic accidents (Lindsay, Hanks, Hurley, & Dane,
1999; Means, Lichstein, Epperson, & Johnson,
2000; Taub, 1978; Taylor et al., 2011; Trockel,
Barnes, & Egget, 2000). Longitudinal studies have
also suggested that insomnia symptoms at young
ages predict problems later in life (Chang, Ford,
Mead, Cooper-Patrick, & Klag, 1997; Roane &
Taylor, 2008). For instance, adolescents with
insomnia symptoms are more likely to experience
depression or attempt suicide as young adults
(Roane & Taylor). One long-term study found
male medical students who reported difficulty
sleeping had a significantly higher risk of experienc-
ing depression more than 20 years later, independent
of other risk factors such as family history, age,
 Author's personal copy
insomnia in college students
temperament type, smoking, and alcohol use (Chang
et al., 1997).
The current study used proposed criteria for
chronic insomnia in the forthcoming DSM-5 to
compare students with and without chronic insom-
nia on a comprehensive group of potential daytime
impairments. Daytime impairment constructs deemed
“essential” or “recommended” were assessed using
measures recommended by experts in the field of
sleep research for standard assessments to be used in
insomnia research studies (see Buysse et al., 2006).
Those “essential” constructs measured included
insomnia criteria, psychiatric disorders, medical
disorders, current medications and substances.
Those “recommended” constructs that were also
measured included global sleep and insomnia symp-
toms, daily self-report of sleep, fatigue, mood,
anxiety, and quality of life.
Methods
participants
This study recruited undergraduate students from
the University of North Texas (UNT) during the
academic year, following approval from the Insti-
tutional Review Board. A survey was completed by
1,074 undergraduate students. Students were
recruited from classes, the majority of which were
part of the university's core curriculum; thus; a
variety of majors were represented. Data from 35
students were excluded from analysis for inade-
quately completing the questionnaires, resulting in
a final sample of 1,039 students. The sample was
72.0% female, 24.5% male, and 3.5% did not
specify gender (N = 1,039); the mean age was
20.39 years (SD = 3.93). A chi-square test of
independence indicated significantly more females
than males in the sample, χ 2 (1, N = 1003) =
242.32, p b .001. The ethnicity of the sample was
66.4% Caucasian, 12.9% African American,
10.4% Hispanic, 5.6% Asian/Pacific Islander,
4.5% other, and 0.2% missing; this breakdown
was similar to the ethnicity of UNT's student body.
The academic rank of the sample was 36.8%
freshmen, 25.1% sophomore, 17.2% junior,
13.7% senior, 0.9% other, and 6.5% missing.
power analysis
The program G*Power 3.1.2 (Faul, Erdfelder,
Lang, & Buchner, 2007) was used to calculate
necessary group sizes to find a Cohen's d effect size
of 0.5 with p b .05. Using a two-tailed design and a
group allocation ratio of 1:9 (based on 10%
prevalence of chronic insomnia in the population
(Ford & Kamerow, 1989), sample sizes of 35 and
317 were recommended for the chronic insomnia
and normal sleeper groups, respectively.
341
Procedure
Students in psychology courses earned extra credit
for completing a questionnaire packet and a
week-long sleep diary. Students accessed the
consent form and questionnaires online, through
the Department of Psychology's undergraduate
research participant pool website (SONA system).
Participants printed the survey, signed the consent
form, and then filled out all questionnaires and the
week-long sleep diary. During both fall and spring
semesters, data collection began 1 week after the
start of the semester and ended prior to the start of
finals week (so that sleep diaries were not influenced
by a change in sleep schedules during the final exam
period). Because of the variable nature of when tests
were offered during the semester (i.e., there is no
midterm period at this university), exams during the
semester could not be avoided during data collection.
When participants completed the questionnaire and
sleep diary they returned all materials to the Sleep
and Health Research Lab.
materials
Health Questionnaire (HQ)
Developed by the primary investigator, the HQ
assessed variables of interest that generally didn't
have a validated scale (e.g., demographics, major
medical disorders, medication use, exercise behav-
ior, substance and stimulant use). Of relevance to
the current study were self-reported measures of
alcohol (ETOH; “In the past 7 days, how many
alcoholic drinks did you have [12 oz beer, 1 oz
hard liquor, 5 oz wine]?”), cigarettes (“In the past
7 days, how many cigarettes did you smoke?”),
illicit drugs (“In past 7 days how often have you
used the following illicit drugs?” followed by a
checklist of cocaine, marijuana, steroids, ecstasy,
etc.).
Sleep Diaries
Sleep diaries are the most cost-effective, efficient,
and commonly used clinical and research measure
of subjective sleep. Participants were asked to
complete a sleep diary every morning for 1 week,
recording their sleep activity from the night before.
Information gathered by these sleep diaries included
estimates of bedtime, sleep onset latency (SOL),
number of awakenings during the night (NWAK),
total wake time after sleep onset (WASO), time spent
in bed after final awakening in the morning (TWAK),
total time spent in bed (TIB), total sleep time
(TST = TIB–SOL–WASO–TWAK), sleep efficiency
(SE = TST/TIB × 100), and time spent napping
during the day (Nap). Research has found that
 Author's personal copy
342 taylor et al.
sleep diaries are better than single-time-point
retrospective estimates of typical sleep (Coursey,
Frankel, Gaarder, & Mott, 1980), and there is
adequate agreement between sleep diaries and the
gold-standard objective measure of sleep, poly-
somnography, on WASO (r = .46), TST (r = .59)
and SE (r = .48) for people with insomnia (Lichstein
et al., 2006). Additionally, participants were asked
to rate the quality of their sleep on a scale of 1 to
10, where higher scores indicate better sleep
quality (SQ). This variable was assessed with the
question, “How was the quality of your sleep last
night?” on the sleep diary. All of the above values
reported for sleep diaries in this manuscript
represent weekly averages calculated according
to criteria set forth in Buysse et al. (2006). In
addition, the diary asked about daily use of
stimulants and hypnotics.
Pittsburgh Sleep Quality Index (PSQI; Buysse et al.,
1989)
The PSQI is a 19-item self-rated questionnaire
covering seven domains: subjective sleep quality,
sleep latency, sleep duration, habitual sleep effi-
ciency, sleep disturbances, use of sleep medications,
and daytime dysfunction. The 15 multiple-choice
items and 4 write-in items yield scores from 0 (no
difficulty) to 3 (severe difficulty) on these seven
domains. These domains produce a global score,
ranging from 0 to 21, where scores greater than 5
suggest significant sleep disturbance. The global
score for the PSQI demonstrated an internal
consistency Cronbach's alpha coefficient of 0.83
in the current study.
Insomnia Severity Index (ISI; Morin, 1993)
The ISI is a self-report measure designed to assess
perceived severity of insomnia. This measure
consists of 7 items on a 5-point Likert scale from
0 (not at all satisfied) to 4 (very much satisfied).
Total scores range from 0 to 28, with higher scores
indicating greater insomnia severity. The ISI yielded
a Cronbach's alpha ranging from .74 on the English
version to .88 on the French-Canadian version. The
ISI yielded a Cronbach's alpha of .86 for the current
study.
Epworth Sleepiness Scale (ESS; Johns, 1991)
The ESS is a self-report measure designed to assess
the overall level of daytime sleepiness. This measure
consists of 8 items on a 4-point Likert scale from
0 (would never) to 3 (high chance). Total scores
range from 0 to 24, where scores above 10 suggest
significant daytime sleepiness, and scores above 15
have been associated with pathological sleepiness that
may be due to conditions such as narcolepsy or
obstructive sleep apnea. The ESS yielded a Cronbach's
alpha of .68 in the current study.
Multidimensional Fatigue Inventory (MFI; Smets,
Garssen, Bonke, & De Haes, 1995)
The MFI is a self-report measure designed to assess
fatigue on the dimensions of general fatigue,
physical fatigue, mental fatigue, reduced motiva-
tion, and reduced activity. This measure consists of
20 items on a 5-point Likert scale ranging from
0 (yes, that is true) to 4 (no, that is not true), with
higher total scores equaling greater fatigue. The
internal consistency of the MFI ranges from .65 to
.80 (Smets et al., 1995). For the current study,
Cronbach's alpha for the subscales was .56 to .85.
Quick Inventory of Depressive Symptomatology
(QIDS; Rush et al., 2003)
The QIDS is a 16-item self-report questionnaire
that assesses nine symptom domains of depression:
sleep disturbance, psychomotor disturbance, changes in
weight, depressed mood, decreased interest, decreased
energy, worthlessness and guilt, concentration and
decision making, and suicidal ideation (Rush et al.,
2003). Each item is rated 0 to 3 and the total score has a
range of 0 to 27. Initial validation studies found the
QIDS has good internal consistency (Cronbach's
alpha=.81 – .90; Rush et al.). For this study, the
internal consistency coefficient was .71. A score N 11
indicated clinically significant depression (i.e., moderate
to severe depression symptoms; Rush et al.).
State-Trait Anxiety Inventory, Trait Scale (STAI;
Spielberger, Gorsuch, & Lushene, 1970)
The STAI consists of 20 statements, with every
statement being on a 4-point scale. The Trait scale is
composed of questions that ask people to describe how
they feel in general (e.g., pleasant, nervous, rested) and
has shown Cronbach's alphas from .72 to .96 (Barnes,
Harp, & Jung, 2002). The current study yielded a
Cronbach's alpha of .92. A score of N 59 (2 SDs above a
normative mean) indicated clinically significant anxiety.
Perceived Stress Scale (PSS; Cohen, 1988)
The PSS is a self-report questionnaire used to assess
the stress domains of unpredictability, lack of control,
burden overload, and stressful life circumstances.
This measure consists of 14 items on a 5-point Likert
scale from 0 (never) to 4 (very often). Total scores
range from 0 to 56, with higher scores reflecting
greater perceived stress. The internal consistency of
the PSS was shown in two college student samples
with Cronbach's alpha coefficients of .84 and .85.
The current study had a Cronbach's alpha of .88.
Quality of Life Enjoyment and Satisfaction
Questionnaire–Short Form (Q-LES-Q-SF; Endicott,
Nee, Harrison, & Blumenthal, 1993)
The Q-LES-Q-SF is a measure designed to assess the
degree of enjoyment and satisfaction experienced
by individuals in eight areas of daily functioning,
 Author's personal copy

insomnia in college students 343

Table 1
Means and Standard Deviations of Self-Reported Psychosocial and Sleep Variables for Chronic Insomnia and Normal Sleepers
Normal Sleepers Chronic Insomnia ANOVA
n M (SD) n M (SD) F P η2
Sleep Diary
TST 593 451.58 (62.16) 99 437.75 (63.31) 4.18 .041 .006
SE 93.68 (3.25) 84.55 (7.00) 441.63 b .001 .390
Sleep Quality 7.36 (1.42) 6.01 (1.52) 75.16 b .001 .098
SOL 12.65 (8.53) 42.51 (33.49) 340.97 b .001 .331
WASO 3.52 (4.47) 15.83 (17.16) 218.04 b .001 .240
TWAK 13.09 (10.00) 19.97 (15.23) 33.85 b .001 .047
NWAK .67 (.69) 1.31 (0.96) 63.63 b .001 .084
Nap 25.37 (35.60) 33.28 (37.30) 4.13 .042 .006
Bedtime 0057 (1.17 h) 0059 (1.34 h) .061 .805 b .001
Wake Time 0844 (1.20 h) 0915 (1.38 h) 14.48 b .001 .021
Rise Time 0858 (1.21 h) 0935 (1.40 h) 21.34 b .001 .030
Self-Report Sleep Questionnaires
ESS 559 8.74 (3.50) 92 8.86 (4.17) .084 .772 .000
ISI 5.62 (4.10) 13.07 (4.51) 252.37 b .001 .280
PSQI 4.52 (2.08) 8.48 (2.93) 251.75 b .001 .279
Daytime Functioning
General Fatigue 538 11.17 (3.37) 92 14.10 (3.13) 60.19 b .001 .087
Physical Fatigue 8.96 (3.57) 10.95 (3.74) 24.00 b .001 .037
Reduced Activity 8.43 (3.24) 10.57 (3.96) 31.70 b .001 .048
Motivation 8.67 (2.81) 10.30 (2.72) 26.67 b .001 .041
Mental Fatigue 10.30 (3.83) 13.09 (4.04) 40.85 b .001 .061
QoL 3.86 (.86) 3.39 (.73) 24.92 b .001 .038
QIDS 5.77 (3.51) 9.70 (3.74) 96.32 b .001 .133
STAI 38.27 (10.10) 45.78 (10.46) 43.02 b .001 .064
PSS 17.60 (7.17) 21.21 (6.92) 20.13 b .001 .031
Cumulative GPA 2.92 (.73) 2.83 (.72) 1.17 .280 .002
Risky Health Behaviors
ETOH 547 2.98 (6.56) 91 1.99 (3.77) 1.96 .162 .003
Cigarettes 3.70 (15.99) 4.77 (23.45) .30 .586 .000
Caffeine Drinks 5.86 (6.92) 6.36 (9.20) .37 .544 .001
AUDIT 4.32 (4.75) 3.25 (4.01) 4.11 .043 .006
MPS .90 (2.73) .69 (2.18) .46 .499 .001
η2 = effect size: small = 0.01, medium = 0.09, large = 0.25.
Note. TST = total sleep time; SE = sleep efficiency; SOL = sleep onset latency; WASO = wake time after sleep onset; TWAK = time awake after
arising; Nap = naptime; ESS = Epworth Sleepiness Scale; ISI = Insomnia Severity Index; PSQI = Pittsburg Sleep Quality Index; QoL = Quality of
Life; QIDS = Quick Inventory of Depressive Symptomatology; STAI = State-Trait Anxiety Inventory; PSS = Perceived Stress Scale; ETOH =
Alcohol Consumption; AUDIT = Alcohol Use Disorders Identification Test; MPS = Marijuana Problem Scale. Bedtime, Wake Time and Rise
Times are all given in military time.
N changes for different analyses based on pairwise exclusion in MANOVA analyses.

including physical health, subjective feelings, leisure
time activities, social relationships, general activities,
work, household duties, and school/course work.
This measure consists of 14 items that are scored on a
5-point scale indicating the degree of enjoyment or
satisfaction achieved during the past week. The
current study yielded a Cronbach's alpha of .89.
Alcohol Use Disorders Identification Test (AUDIT;
Saunders et al., 1993)
The AUDIT is a screening instrument used to detect
alcohol consumption that has become harmful to
health, rather than alcoholism (Saunders et al.,
1993). This measure consists of 10 yes/no and
multiple choice items on a 5-point Likert scale
ranging from 0 to 4. The internal consistency of the
AUDIT was shown on a sample of undergraduate
students to be a Cronbach's alpha coefficient of .80.
This study yielded an alpha coefficient of .83. A
score of ≥ 8 indicated problematic alcohol use.
Marijuana Problem Scale (MPS; Stephens, Roffman,
& Curtin, 2000; Stephens, Wertz, & Roffman, 1993)
The MPS is a 20-item self-report instrument that
assesses negative social, occupational, physical, and
personal consequences of excessive marijuana use
 Author's personal copy
344 taylor et al.
(Stephens et al., 2000; Stephens et al., 1993).
Participants specify the incidence and intensity of
each item (0 = no problem, 1 = minor problem, 2 =
serious problem) in the previous 90 days. Items were
totaled to provide an index of the severity of
marijuana-related consequences. The MPS has a
Cronbach's alpha coefficient of .85 in a normative
sample (Stephens et al., 2004). This study had an
alpha coefficient of .90.
Academic Performance
Academic performance was measured by cumula-
tive grade point average (GPA; 0.0–4.0 scale),
obtained from academic transcripts with the
participants’ consent.
operational definitions
The operational definition of “chronic insomnia”
used in this study was based on proposed DSM-5
criteria (APA, 2012), which appears to be a
combination of both the quantitative criteria and
RDC (Edinger et al., 2004; Lichstein et al., 2003).
First, a participant had to have an insomnia
complaint that has lasted at least 3 months on the
HQ (RDC = 1 month vs. quantitative criteria =
6 months). Second, using sleep diary data, a
participant must report SOL and/or WASO of at
least 30 minutes, at least 3 nights per week (matches
quantitative criteria; RDC does not have this
criteria). Finally, participants must report daytime
dysfunction due to the sleep problem (matches both
RDC and quantitative criteria). For the current study,
the daytime dysfunction criteria was met by a report of
moderate to severe interference on daily functioning
on the ISI, an ESS score ≥ 7.4 (i.e., one SD above the
normative ESS mean), or a score one SD above the
sample mean on any MFI subscale, which are similar
to those used in the quantitative criteria. For a more
thorough review and comparison of these two criteria,
see Bramoweth and Taylor (2012). Participants were
considered “normal sleepers” if they did not have an
insomnia complaint and did not meet frequency,
severity, and duration criteria for chronic insomnia.
Results
missing data
Missing data was minimal (b 5%), and since the
sample size was large and missing data appeared to
be missing at random, missing data was excluded
from analyses using pairwise deletion as recom-
mended by Tabachnick and Fidell (2007). Statisti-
cal analyses were performed using the Statistical
Package for Social Sciences (SPSS 18.0). We utilized
Multivariate Analysis of Variance (MANOVA)
when possible to compare groups on similar vari-
ables (e.g., sleep, daytime functioning, and sub-
stance use), in an effort to control experiment-wise
Type I error that would have occurred had we
performed pairwise comparisons for each variable.
prevalence of insomnia
Of the sample of 1,039 students, 57.1% were
normal sleepers, 9.5% had chronic insomnia, 6.5%
reported an insomnia complaint but did not meet
severity, frequency, and duration criteria, and
26.9% met severity, frequency, and duration
criteria but did not report an insomnia complaint.
The average duration of the insomnia complaint
was 41.17 months (3.43 years), with a maximum
of 252 months (21 years). There was a trend (p =
.062) for more women (15.7%) than men (9.9%) to
meet criteria for chronic insomnia. There were no
ethnicity differences found (White = 9.0%; Black =
11.2%; Asian/Pacific Islander = 8.6%; Hispanic =
10.2%; Native American = 16.7% [cell size = 1]).
sleep
Not surprisingly, a MANOVA found significant
differences between the chronic insomnia and normal
sleeper groups on overall sleep diary estimates of sleep
(i.e., TST, SE [TST/TIB], Sleep quality), Wilks’ Λ =
.575, F(3, 688) = 169.78, p b .001, η 2 = .43. Follow-up
one-way Analyses of Variance (ANOVAs) found the
chronic insomnia group was significantly worse on all
three variables (ps b .05; Table 1).
Because SE is calculated by subtracting SOL,
WASO, and TWAK from TIB to arrive at TST, a
separate MANOVA was performed on these variables
as well as NWAK and Nap, to avoid circularity.
Results indicated that the chronic insomnia group was
again significantly different from the normal sleepers,
Wilks’ Λ = .519, F(5, 686) = 127.25, p b .001, η 2 = .48,
with the chronic insomnia group being significantly
worse on all variables (ps b .05; Table 1).
Finally, in an attempt to determine differences in
sleep schedules, a MANOVA was performed com-
paring groups on average bedtimes, wake times,
and rise times. These results too were significant,
Wilks’ Λ = .922, F(3, 688) = 19.43, p b .001, η 2 = .078.
Follow-up one-way ANOVAs found the chronic
insomnia group was no different on bedtime, but
woke up and got out of bed significantly later
(ps b .05; Table 1).
A MANOVA of the self-report questionnaires
was also significant, Wilks’ Λ = .639, F(3, 647) =
121.83, p b .001, η 2 = .36, with the chronic insom-
nia group being significantly worse on the ISI and
PSQI (ps b .01; Table 1) but not the ESS.
daytime functioning
A MANOVA was performed comparing groups on
measures of daytime functioning (i.e., MFI,
 Author's personal copy
insomnia in college students
Q-LES-Q-SF, QIDS, STAI, PSS, cumulative GPA),
and again significant differences were found,
Wilks’ Λ = .187, F(10, 619) = 11.60, p b .001, η 2 =
.158. Follow-up ANOVAs found the chronic insom-
nia group had significantly worse fatigue as well as
significantly increased levels of depression, anxiety,
and stress, and lower quality of life (ps b .05;
Table 1). Although the insomnia group had slightly
lower GPAs than the good sleeper group, the
difference was not significant (Table 1). In addition,
the chronic insomnia group had significantly higher
rates of clinically significant depression (26.3% vs.
8.6%, OR = 3.05: 95% CI 2.00–4.66) and anxiety
(15.2% vs. 5.4%; OR 2.81: 95% CI 1.58–4.99).
substance use
A MANOVA comparing groups on self-report
substance use or problems (i.e., ETOH, cigarettes
per day, illicit drug use, AUDIT, MPS) found no
significant differences between groups. This was
confirmed with exploratory ANOVAs (Table 1),
although the normal sleeper group reported more
alcohol problems as measured by the AUDIT (p =
.043). When groups were dichotomized based on
meeting AUDIT problematic alcohol use criteria
(i.e., score of ≥ 8), group differences were not
significant (16.2% insomnia vs. 23.6% no insom-
nia).
A χ 2 test of independence analysis found the
chronic insomnia group reported higher rates of
hypnotic (10.1% vs. 1.9%), χ 2(2, N = 692) = 20.04,
p b .001, and stimulant use (2.0% vs. 0.0%), χ 2 (2,
N = 692) = 12.02, p = .001, than the normal sleeper
group.
medical problems
Participants were also asked to indicate if they had
any of a number of medical problems using a checklist
format similar to previous studies (Bramoweth &
Taylor, 2012; Taylor et al., 2007). A significantly
(p b .001) higher percentage of insomnia group
(44.4%) reported medical problems than did the
normal sleeper group (24.8%). Therefore, presence of
a medical problem was entered in as a covariate and
the analyses above were repeated. All results remained
significant except the Nap (p = .065).
Discussion
A significant portion (9.5%) of this sample of
college students met proposed DSM-5 criteria
for chronic insomnia. As expected, the chronic
insomnia group reported significantly worse sleep
across all domains, including prospective sleep
diaries and retrospective self-reports, when com-
pared to normal sleepers. In addition, the chronic
insomnia group reported increased levels of depres-
345
sion, anxiety, stress, and fatigue across multiple
dimensions, and decreased quality of life. A signif-
icantly greater proportion of students with chronic
insomnia reported clinically significant depression
(26.3% vs. 8.6%) and anxiety (15.2% vs. 5.4%).
There were no differences between groups on
excessive daytime sleepiness, academic performance,
or substance use; there was a trend for alcohol abuse
in the normal sleeper group. These results were in
general agreement with the majority of research done in
the general population comparing people with and
without chronic insomnia. This was, however, the most
comprehensive assessment of the prevalence and
correlates of chronic insomnia in college students to date.
The 9.5% prevalence estimate appears to be
consistent with the more rigorous general popula-
tion studies. For example, one of the largest and
most rigorous epidemiology studies of insomnia
using self-report of sleep problems found 16.8%
reported the symptoms of difficulty falling or
staying asleep or nor restorative sleep ≥ 3 nights
per week, of whom 15.8% said symptoms lasted ≥
1 month (i.e., DSM-IV criteria), of whom only
9.3% reported significant daytime complaints and
did not have a different DSM-IV sleep disorder
(Ohayon & Roth, 2001). In another rigorous
epidemiological study, which also incorporated
sleep diaries, Lichstein et al. (2004) found a
prevalence rate of 9.1% in young adults aged 20
to 29, using similar criteria as ours, albeit with a
slightly more restrictive duration component
of ≥ 6 months. Overall, the criteria in these two
studies closely match those used in the current study,
as do the prevalence data. These results suggest that
the prevalence of insomnia in college students
approximates those in the general population,
making it equally important to address in this group.
The nonsignificant results within this study
deserve some discussion. It was not surprising that
the groups did not differ on excessive daytime
sleepiness, as many studies have shown that people
with insomnia do not have more daytime sleepiness
than people without (for a review see Riedel &
Lichstein, 2000). The academic differences were a
bit unexpected. One would assume that college
students with insomnia, as well as a myriad of other
psychosocial difficulties as demonstrated here,
would have greater difficulty keeping up with
academic demands. However, research has shown
that people with insomnia are more perfectionistic
(Vincent, Oakley, Pohl, & Walker, 2000) and
mobilize more effort to cope with cognitive tasks
(Schmidt, Richter, Gendolla, & Van der Linden,
2010), both of which likely compensate for the
effects of poor sleep. One might argue that students
with insomnia use their extra time awake to do
 Author's personal copy
346 taylor et al.
homework or study, but they only slept an average
of 13.83 minutes less than normal sleepers. Finally,
it was expected that the insomnia group would
report greater substance use. It was quite surprising
that this difference was not found given that
insomnia is such a strong risk factor for these
difficulties (Taylor et al., 2003). It is possible over
time that the insomnia group gradually transitions
into using substances to cope with their insomnia
(e.g., as sleep or stress aid), where the people
without insomnia gradually reduce their usage after
college. Future prospective studies are needed to
help determine when social usage turns into
problem usage for people with insomnia.
The primary limitations of the current study are
(a) the cross-sectional nature of the data collection,
(b) the lack of objective measurement of sleep, and
(c) use of self-report instruments rather than clinical
interviews to diagnose insomnia. Future studies
might overcome these limitations by following
students from enrollment until graduation, to
determine the onset and course of insomnia, as
well as determine the intercorrelation with other
difficulties, to help further clarify the bidirectional
relationship of insomnia and psychosocial func-
tioning. These studies could also incorporate
clinical interviews and objective measurement of
sleep using actigraphy, which can collect data for as
many as 365 days without download, and smart
phone technology which could also allow for the
inclusion of ecological momentary assessment and
daily, or more frequent, downloads of data.
While the study found almost 10% of a large
college student sample met criteria for chronic
insomnia, it also found 27% with the severity,
frequency, and duration of chronic insomnia, but
without a complaint. This begs the questions, “Do
college students know when they have insomnia?”
The college environment is generally not the ideal
environment to promote good sleep and good sleep
habits. Students living in dorms on campus might
have poorer sleep due to social life and lack of
privacy, while students living off campus may find
it easier to keep more consistent sleep habits. It is
possible that a high percentage of college students
are struggling to get good-quality sleep and
suffering the daytime consequences, but assume
what they are experiencing is just “part of the
college experience.” This was borne out some in the
fact that there was only a 14 minute difference in
TST between students with and without insomnia.
However, these data are remarkably consistent
with other studies that reported sleep diary data
from college students with and without insomnia
(Lichstein et al., 2004; Means et al., 2000). As can
be seen in the data on bedtimes and wake times, it
appears that both groups are going to bed at the
same time (~ 1:00 A.M.), but the insomnia group
appears to sleep in to make up for the sleep lost
during the night. These are exactly the type of
perpetuating factors discussed in the behavioral
model of chronic insomnia (Spielman, Caruso, &
Glovinsky, 1987).
Similar to other common mental health disorders
that may be commonly screened for at college
student health centers (e.g., anxiety, depression,
stress), sleep is an important aspect of health
that should be regularly assessed among college
students, especially considering that insomnia is
often a symptom of and a risk factor for depression
and anxiety (Taylor et al., 2003). Also, general
education about healthy sleep should be provided
to all college students. If students don't know they
have a problem, they can't ask for help. Luckily,
effective, nonpharmacological treatments exist for
insomnia, such as cognitive behavioral therapy for
insomnia (CBTi), but to date, no study has
determined if CBTi would be as beneficial in college
students as it has been shown to be in the general
population (Morin et al., 2006). It would also be
important to demonstrate if treatment of insomnia
results in significant improvement in psychosocial
functioning. Qualitative studies of college students
could also help shed light on what sleep behaviors
are considered “normal” and what is deemed
“problematic.” Results could help inform what
information regarding healthy sleep and available
interventions is disseminated and what format
would be most beneficial.
In addition to the health and quality-of-life
consequences of insomnia, another consequence of
insomnia is increased health-care utilization and
costs. A large body of research already exists for the
economic burden of insomnia and the high costs of
health care related to insomnia—primarily indirect
costs such as workplace absenteeism (Daley, Morin,
LeBlanc, Gregoire, & Savard, 2009; Ozminkowski,
Wang, & Walsh, 2007; Walsh, 2004). Even in
college students, a relatively healthy population,
chronic insomnia is associated with increased use of
health-care services and increased health-care costs
(Bramoweth & Taylor, 2012). As noted in this study,
students with insomnia, on average, have the
disorder for over 3 years and there is no indication
that it subsides on its own. As more young adults are
attending and graduating from college and entering
the work force, insomnia, a highly treatable disorder
when correctly identified, may be contributing to
increased costs to the individual, the health-care
system, and the employer, in addition to increasing
risk of depression, anxiety, and decreased quality of
life.
 Author's personal copy
insomnia in college students
References
American Psychiatric Association (2012). DSM-5 development.
Retrieved December 18, 2012, from http://www.dsm5.org/
Pages/Default.aspx.
Barnes, L. L. B., Harp, D., & Jung, W. S. (2002). Reliability
generalization of scores on the Spielberger State-Trait Anxiety
Inventory. Educational and Psychological Measurement, 62,
603–618.
Bramoweth, A. D., & Taylor, D. J. (2012). Healthcare
utilization and chronic insomnia in young adults. Behavioral
Sleep Medicine, 10, 106–121.
BuboltzII, W. C., Brown, F., & Soper, B. (2001). Sleep habits
and patterns of college students: A preliminary study.
Journal of American College Health, 50, 131–135.
Buysse, D. J., Ancoli-Israel, S., Edinger, J. D., Lichstein, K. L., &
Morin, C. M. (2006). Recommendations for a Standard
Research Assessment of Insomnia. Sleep, 29, 1155–1173.
Buysse, D. J., Reynolds, C. F., III, Monk, T. H., Berman, S. R.,
& Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index:
A new instrument for psychiatric practice and research.
Psychiatry Research, 28, 193–213.
Chang, P. P., Ford, D. E., Mead, L. A., Cooper-Patrick, L., &
Klag, M. J. (1997). Insomnia in young men and subsequent
depression. The Johns Hopkins Precursors Study. American
Journal of Epidemiology, 146, 105–114.
Cohen, S. (1988). Perceived stress in a probability sample of the
United States. In S. Spacapan & S. Oskamp (Eds.), The
social psychology of health. (pp. 31–67). Thousand Oaks,
CA: Sage.
Coursey, R. D., Frankel, B. L., Gaarder, K. R., & Mott, D. E.
(1980). A comparison of relaxation techniques with electro-
sleep therapy for chronic, sleep-onset insomnia a sleep-EEG
study. Biofeedback and Self-Regulation, 5, 57–73.
Daley, M., Morin, C. M., LeBlanc, M., Gregoire, J. P., &
Savard, J. (2009). The economic burden of insomnia: Direct
and indirect costs for individuals with insomnia syndrome,
insomnia symptoms, and good sleepers. Sleep, 32, 55–64.
Edinger, J. D., Bonnet, M. H., Bootzin, R. R., Doghramji, K.,
Dorsey, C. M., Espie, C. A., … Stepanski, E. J. (2004).
Derivation of research diagnostic criteria for insomnia:
Report of an American Academy of Sleep Medicine Work
Group. Sleep, 27, 1567–1596.
Endicott, J., Nee, J., Harrison, W., & Blumenthal, R. (1993).
Quality of life enjoyment and satisfaction questionnaire:
A new measure. Psychopharmacology Bulletin, 29, 321.
Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007).
G*Power 3: A flexible statistical power analysis program for
the social, behavioral, and biomedical sciences. Behavior
Research Methods, 39, 175–191.
Ford, D. E., & Kamerow, D. B. (1989). Epidemiologic study of
sleep disturbances and psychiatric disorders. An opportunity
for prevention? Journal of the American Medical Association,
262, 1479–1484.
Johns, M. W. (1991). A new method for measuring
daytime sleepiness: The Epworth Sleepiness Scale. Sleep, 14,
540–545.
Kuppermann, M., Lubeck, D. P., Mazonson, P. D., Patrick, D. L.,
Stewart, A. L., Buesching, D. P., & Fifer, S. K. (1995). Sleep
problems and their correlates in a working population.
Journal of General Internal Medicine, 10, 25–32.
Lichstein, K. L., Durrence, H. H., Riedel, B. W., Taylor, D. J., &
Bush, A. J. (2004). Epidemiology of sleep: Age, gender, and
ethnicity. Mahwah, NJ: Erlbaum.
Lichstein, K. L., Durrence, H. H., Taylor, D. J., Bush, A. J., &
Riedel, B. W. (2003). Quantitative criteria for insomnia.
Behavior Research and Therapy, 41, 427–445.
347
Lichstein, K. L., Stone, K. C., Donaldson, J., Nau, S. D., Soeffing,
J. P., Murray, D., Lester, K. W., & Aguillard, R. N. (2006).
Actigraphy validation with insomnia. Sleep, 29, 232–239.
Lindsay, G. A., Hanks, W. A., Hurley, R. D., & Dane, S.
(1999). Descriptive epidemiology of dozing and driving in a
college student population. Journal of American College
Health, 47, 157–162.
Lund, H. G., Reider, B. D., Whiting, A. B., & Prichard, J. R.
(2010). Sleep patterns and predictors of disturbed sleep in a
large population of college students. Journal of Adolescent
Health, 46, 124–132.
Means, M. K., Lichstein, K. L., Epperson, M. T., & Johnson, C. T.
(2000). Relaxation therapy for insomnia: Nighttime and day
time effects. Behaviour Research and Therapy, 38, 665–678.
Morin, C. M. (1993). Insomnia: Psychological assessment and
management. New York, NY: The Guilford Press.
Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D.,
Espie, C. A., & Lichstein, K. L. (2006). Psychological and
behavioral treatment of insomnia:update of the recent
evidence (1998-2004). Sleep, 29, 1398–1414.
Ohayon, M. M. (2002). Epidemiology of insomnia: What
we know and what we still need to learn. Sleep Medicine
Reviews, 6, 97–111.
Ohayon, M. M., & Roth, T. (2001). What are the contributing
factors for insomnia in the general population? Journal of
Psychosomatic Research, 745–755.
Ozminkowski, R. J., Wang, S., & Walsh, J. K. (2007). The
direct and indirect costs of untreated insomnia in adults in
the United States. Sleep, 30, 263–273.
Riedel, B. W., & Lichstein, K. L. (2000). Insomnia and daytime
functioning. Sleep Medicine Reviews, 4(3), 277–298.
Roane, B. M., & Taylor, D. J. (2008). Adolescent insomnia as a
risk factor for early adult depression and substance abuse.
Sleep, 31, 1351–1356.
Roth, T., & Roehrs, T. (1988). Sleepiness and motor vehicle
accidents. International Clinical Psychopharmacology, 3,
111–116.
Rush, A. J., Trivedi, M. H., Ibrahim, H. M., Carmody, T. J.,
Arnow, B., Klein, D. N., … Keller, M. B. (2003). The 16-item
Quick Inventory of Depressive Symptomatology (QUIDS)
Clinician Rating (QIDS-C) and Self-Report (QIDS-SR): A
psychometric evaluation in patients with chronic major
depression. Biological Psychiatry, 54, 573–583.
Saunders, J. B., Aasland, O. G., Babor, T. F., & Grant, M.
(1993). Development of the Alcohol Use Disorders Identi-
fication Test (Audit): WHO collaborative project on early
detection of persons with harmful alcohol consumption: II.
Addiction, 88, 791–804.
Schmidt, R. E., Richter, M., Gendolla, G. H., & Van der
Linden, M. (2010). Young poor sleepers mobilize extra
effort in an easy memory task: Evidence from cardiovascular
measures. Journal of Sleep Research, 19, 487–495.
Sing, C. Y., & Wong, W. S. (2011). Prevalence of insomnia and its
psychosocial correlates among college students in Hong Kong.
Journal of American College Health, 59, 174–182.
Smets, E. M., Garssen, B., Bonke, B., & De Haes, J. C. (1995).
The Multidimensional Fatigue Inventory (MFI) psychometric
qualities of an instrument to assess fatigue. Journal of
Psychosomatic Research, 39, 315–325.
Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970).
State-Trait Anxiety Inventory. Palo Alto, CA: Consulting
Psychologists Press.
Spielman, A. J., Caruso, L. S., & Glovinsky, P. B. (1987).
A behavioral perspective on insomnia treatment. The Psychi-
atric Clinics Of North America, 10, 541–553.
Stephens, R. S., Roffman, R. A., & Curtin, L. (2000).
Comparison of extended versus brief treatments for marijuana
 Author's personal copy
348 taylor et al.
use. Journal of Consulting and Clinical Psychology, 68,
898–908.
Stephens, R. S., Roffman, R. A., Fearer, S. A., Williams, C.,
Picciano, J. F., & Burke, R. S. (2004). The Marijuana
Check-up: Reaching users who are ambivalent about
change. Addiction, 99, 1323–1332.
Stephens, R. S., Wertz, J. S., & Roffman, R. A. (1993).
Predictors of marijuana treatment outcomes: The role of
self-efficacy. Journal of Substance Abuse, 5, 341–353.
Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate
statistics (5th ed.). Boston, MA: Pearson/Allyn & Bacon.
Taub, J. M. (1978). Behavioral and psychophysiological
correlates of irregularity in chronic sleep routines. Biological
Psychology, 7, 37–53.
Taylor, D. J., & Bramoweth, A. D. (2010). Patterns and
consequences of inadequate sleep in college students: Substance
use and motor vehicle accidents. Journal of Adolescent Health,
46, 610–612.
Taylor, D. J., Gardner, C. E., Bramoweth, A. D., Williams, J. M.,
Roane, B. M., Grieser, E. A., & Tatum, J. I. (2011). Insomnia
and mental health in college students. Behavioral Sleep
Medicine, 9, 107–116.
View publication stats
Taylor, D. J., Lichstein, K. L., & Durrence, H. H. (2003).
Insomnia as a health risk factor. Behavioral Sleep Medicine,
1, 227.
Taylor, D. J., Mallory, L. J., Lichstein, K. L., Durrence, H. H.,
Riedel, B. W., & Bush, A. J. (2007). Comorbidity of chronic
insomnia with medical problems. Sleep, 30, 213–218.
Trockel, M. T., Barnes, M. D., & Egget, D. L. (2000).
Health-related variables and academic performance among
first-year college students: Implications for sleep and other
behaviors. Journal of American College Health, 49, 125–131.
Vincent, D., Oakley, D., Pohl, J., & Walker, D. S. (2000).
Survival of nurse-managed centers: The importance of cost
analysis. Outcomes Management for Nursing Practice, 4,
124–128.
Walsh, J. K. (2004). Clinical and socioeconomic correlates of
insomnia. The Journal of Clinical Psychiatry, 65(Suppl. 8),
13–19.
R E C E I V E D : June 20, 2012
A C C E P T E D : December 6, 2012
Available online 19 December 2012