INSOMNIA
Sleep Hygiene Practices in a Population-Based Sample of Insomniacs
Catherine D. Jefferson, BS;1 Christopher L. Drake, PhD;1,2 Holly M. Scoﬁeld, BA;1 Eric Myers, BS;1 Tara McClure, BA;1 Timothy Roehrs, PhD;1,2 Thomas Roth, PhD1,2
¹Henry Ford Hospital Sleep Disorders and Research Center and ²Wayne State University Department of Psychiatry & Neurosciences, Detroit, MI
Measurements and Results: Insomniacs reported poorer sleep hygiene,
as evidenced by an increase in prevalence of smoking close to bedtime
and increased use of alcohol. They also reported more naps per week
and sleeping in on days not worked. Caffeine use did not differ between
groups. Time in bed was also comparable between insomniacs and controls.
Conclusion: Insomniacs do engage in speciﬁc poor sleep hygiene practices, such as smoking and drinking alcohol just before bedtime. These
particular aspects of sleep hygiene may be important components that
exacerbate or perpetuate insomnia.
Key Words: Insomnia, sleep hygiene, alcohol
Citation: Jefferson CD; Drake CL; Scoﬁeld HM et al. Sleep hygiene practices in a population-based sample of insomniacs. SLEEP 2005;28(5):611615.
Study Objectives: The present study was designed to assess selected
aspects of sleep hygiene from a population-based sample of individuals
with insomnia compared to age- and sex-matched controls.
Design: A random-sample phone survey of 258 individuals meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-based
criteria for insomnia was compared to age- and sex-matched normal
sleepers on speciﬁc measures of sleep hygiene. Sleep hygiene practices
measured included cigarette smoking, smoking near bedtime, alcohol
use, caffeine use, napping, time in bed, and reported likelihood of sleeping in on weekends.
Setting: Detroit tricounty population.
Participants: 258 individuals 18 to 65 years old with insomnia and 258
age- and sex-matched controls.
Interventions: N/A.
as a therapy is contingent upon poor basal sleep hygiene. There
are few representative community-based data evaluating speciﬁc sleep hygiene practices in individuals with insomnia. Thus,
within the multiple components of sleep hygiene, it is not known
which, if any, speciﬁc behaviors should be targeted in insomnia
treatment programs.
Sleep hygiene involves behavioral practices based on our understanding of sleep physiology and pharmacology, which have
been identiﬁed to promote good sleep. First introduced by Peter Hauri8 in 1977, sleep hygiene has become a common tool
of clinicians in the treatment of insomnia. Most insomnia treatment programs have incorporated sleep hygiene as 1 facet of a
multicomponent approach.9 There have been several studies that
have tested the effectiveness of general sleep hygiene practices
as a single component in comparison to other speciﬁc sleep treatments; however, these studies have produced inconsistent results.
One study evaluated meditation, stimulus control, and sleep hygiene treatments for sleep-maintenance insomnia. They found
that sleep hygiene was effective, as were the other treatments,
although this study had no control group for comparison.10 Harvey et al used a cognitive behavioral treatment intervention over
6 sessions. These sessions included information on sleep education, sleep hygiene, stimulus control, and sleep restriction.11 The
results showed that sleep scheduling and cognitive restructuring
methods were more likely to produce signiﬁcant improvements in
sleep latency and nighttime wakefulness than was a combination
of broad education techniques such as sleep hygiene, relaxation,
or thought-blocking methods. However, the study did not examine sleep hygiene as a single component.
Another study surveyed university students using the Sleep
Hygiene Awareness and Practice Scale and the Pittsburg Sleep
Quality Index and showed that the practice of proper sleep habits was related positively to good sleep quality.12 Thus, although
sleep hygiene as a single component has produced mixed results,
there are some data to indicate a relationship between sleep hygiene and sleep quality in normal sleepers. The question remains
as to whether speciﬁc aspects of sleep hygiene are differentially
INTRODUCTION
INSOMNIA IS AMONG THE MOST PREVALENT SYMPTOMS ASSOCIATED WITH SLEEP-WAKE DYSFUNCTION,
AFFECTING MORE THAN 10% OF THE GENERAL POPULATION.1 Studies have shown that insomnia can have a signiﬁcant negative impact on an individual’s work, physical, and social
performance, as well as overall quality of life.2,3 The economic
costs of insomnia have been estimated to be more than $77 billion per year;4,5 this is likely due in part to the chronic nature of
the disorder. Severe insomnia has been shown to last for a median
of 4 years,6 with 44% of insomniacs continuing to report severe
sleep disturbance ten years later.7
There has been debate over the efﬁcacy of sleep hygiene for
the treatment of chronic insomnia. The efﬁcacy of sleep hygiene
Disclosure Statement
This was not an industry funded project. Dr. Drake has received research
support from Cephalon, Pﬁzer, and Neurocrine; has participated in speaking engagements supported by Sepracor, Sanoﬁ-Aventis; and has received
equipment from Vivometrics. Dr. Roehrs has received research support
from Sanoﬁ-Aventis, Sepracor, Xenoport, Cephalon, Neurocrine, and Pﬁzer;
and has participated in speaking engagements supported by Sanoﬁ-Aventis and Sepracor. Dr. Roth has received research support from Cephalon,
Pﬁzer, Neurocrine, Sanoﬁ, Syrex, Takeda, GlaxoSmithKline, and Sepracor;
has received consulting fees from Cephalon, Pﬁzer, Neurocrine, Sanoﬁ,
Somaxon, Syrex, Takeda, GlaxoSmithKline, Aventis, Sepracor, Transoral,
Merck, Vivometrics, Eli Lilly, Wyeth, Roche, Organanon, AstraZeneca, McNeil, Lundbeck, Hypnion, and King Pharmaceutical; and has participated in
speaking engagements supported by Sanoﬁ. Jefferson, Scoﬁeld, Myers,
and McClure have indicated no ﬁnancial conﬂicts of interest.
Submitted for publication October 2004
Accepted for publication January 2005
Address correspondence to: Catherine Jefferson, BS, 2799 West Grand
Blvd. CFP-3, Detroit, MI 48202; Tel: (313) 916-2265; Fax: (313) 916-5167;
E-mail: [email protected]
SLEEP, Vol. 28, No. 5, 2005
611
Sleep Hygiene and Insomnia—Jefferson et al
practiced in insomniacs relative to noninsomniacs. If differences
are identiﬁed, they may help explain some of the discrepant ﬁndings related to sleep hygiene as an independent component in the
behavioral treatment of insomnia. The current study was designed
to assess selected aspects of sleep hygiene practices in a population-based sample of insomniacs and age- and sex-matched controls in order to determine if speciﬁc practices are encountered
more frequently in insomniacs than in controls. The sleep hygiene
practices assayed were only those related to commonly used substances and sleep habits, as these components are frequently engaged-in behaviors and often cited as potential targets for sleep
hygiene targets.13
ten experiencing difﬁculty getting to sleep, staying asleep, or having nonrefreshing sleep for at least 1 month during their lifetime.
In addition, an insomnia severity of more than 6 (scale = 0 [not at
all severe] through 10 [severe as possible]) over the past 3 months
was required. Each insomniac was paired with an age- and sexmatched control who did not meet insomnia criteria. Shift workers were excluded from the study. Demographic characteristics
were similar between groups (Table 2). Selected aspects of sleep
hygiene were measured by several questions eliciting information
on typical cigarette use. Regular smokers were deﬁned as those
individuals who reported smoking over the past year. Aspects of
sleep hygiene were measured by several questions eliciting information on cigarette use, regular smokers (deﬁned as those individuals who reported smoking over the past year), alcohol, caffeine use, napping, time in bed, and total sleep time (Appendix).
METHODS
A representative sample of 516 individuals was selected from
the Detroit tricounty population based on answers provided during a 20-minute phone interview. Subjects were paid 25 dollars
for participation. The protocol was approved by the institutional
review board of Henry Ford Hospital. Individuals participating
in this study were assessed in conjunction with a larger ongoing epidemiologic study investigating the prevalence of daytime
sleepiness. Participants were drawn from the general population
of tricounty metropolitan Detroit using random-digit dialing techniques. For eligibility, the calling address had to be a residence,
and the participant an adult between the ages of 18 and 65 years.
A random-probability selection procedure was used to determine
the sex of the target adult. If 2 or 3 adults within a target sex were
present in a household, random-probability selection procedure
(oldest/second, oldest/youngest) was used to determine the treatment respondent. If 4 or more adults with the target sex were present in the household, last birthday method was used to determine
the target respondent. In order to maintain an unbiased sample,
only individuals who couldn’t answer the questionnaire due to
sensory or mental impairment were excluded from the sample.
From 4,682 eligible participants, 3,283 interviews were obtained
(response rate 70.1%). The demographic details of the sample,
including race status, is shown in Table 1 and are nearly identical
to the 2000 Census data for the area.
Criteria for insomnia included a response of sometimes or of-
RESULTS
Sleep Variables
Data regarding both the self-reported sleep habits and selected
sleep hygiene behaviors for the insomnia and control groups are
shown in Table 3. As expected, total sleep time was signiﬁcantly
lower for insomniacs than controls (P < .001). Number of hours
spent in bed did not differ between groups for either weekdays (P
> .6) or weekends (P > .3). Sleep efﬁciency was signiﬁcantly lower for insomniacs versus controls (P < .001). Despite comparable
times in bed, insomniacs were more likely to report sleeping in
on days not worked (P = .02). Insomniacs also reported a higher
frequency of naps per week (P < .02).
Substance Use
Insomniacs had an increased prevalence of regular smoking
compared to controls (P < .001). Within regular smokers, insomniacs more often smoked within 5 minutes of bedtime (P =
.004). Insomniacs engaged in more social drinking, as measured
by number of alcoholic drinks per week, (P = .003). More importantly, insomniacs used alcohol to induce sleep more frequently
(P < .001). Within those who reported drinking alcohol in the past
2 weeks, insomniacs consumed alcohol within 30 minutes of bedtime more often than did controls (P < .05). In contrast, caffeine
intake (drinks per day) did not differ between groups (P > .26).
A secondary analysis using multiple logistic regression was
undertaken to determine which sleep hygiene variables were independent predictors of insomnia. The use of alcohol for sleep
(P < .001, odds ratio [OR] = 2.99, 95% conﬁdence interval [CI]
= 1.74-5.14) and smoking within 5 minutes of bedtime (P < .05,
OR= 2.69, 95% CI = 1.2-2.03), sleeping in on days not worked (P
< .05, OR = 1.54, 95% CI = 1.03-2.28) were signiﬁcant independent predictors. Use of alcohol within 30 minutes of bedtime and
Table 1—2000 US Census data
Sociodemographic
Characteristics, %
Sex
Men
Women
Race/ethnicity
Caucasian
African American
Asian or Paciﬁc Islander
Native American
Other or refused
Age, y
18-24*
25-34
35-44
45-54
55-64
SLEEP, Vol. 28, No. 5, 2005
Population (No.)
Sample
(3,283)
Tricounty
US
(4,043,467) (281,421,906)
49.1
50.9
48.5
51.5
49.1
50.9
68.6
24.9
1.9
.9
3.5
68.9
25.0
2.5
0.3
3.3
75.1
12.3
3.7
0.9
7.9
10.7
21
25
24.7
18
18.7
22.5
25.0
21.0
12.7
21.0
21.4
24.3
20.2
13.0
Table 2—Study Sample Demographics
Mean age, y
Women, %
Race, %
Caucasian
African American
Other
612
Insomniacs
n = 258
43 ± 11
62
Controls
n = 258
43 ± 11
62
63.6
27.5
8.9
72.9
20.9
6.2
Sleep Hygiene and Insomnia—Jefferson et al
sleep hygiene variable. Treatment programs routinely include this
as a sleep hygiene target but do not quantify its effect or patient
adherence to speciﬁc behaviors. Previous studies have explored
the relationship between nicotine and sleep. One populationbased study found a relationship between cigarette smoking, difﬁculty initiating sleep, and symptoms associated with sleep fragmentation.16 Another study showed similar results; smokers were
signiﬁcantly more likely to report difﬁculty sleeping.17 In that
study, smokers also reported a high daily caffeine intake, suggesting an inclination for individuals who engage in one unhealthy
sleep behavior to also engage in others. This raises the question
as to whether these behaviors are speciﬁc disturbers of sleep or
simply reﬂective of a cognitive lifestyle that might be associated
with insomnia. A study on smokers and age, ethnicity, and sexmatched nonsmokers, recorded information on cigarette, alcohol,
and caffeine intake, as well as daily stress and sleep quality. The
results showed that smokers were more likely to report poor sleep
and use more alcohol than were nonsmokers.18 Results from the
present study are consistent with these data, as we found that insomniacs smoke more often and closer to bedtime than controls.
The negative effect of alcohol on sleep and the use of alcohol to self-medicate in insomniacs have been extensively studied.
Johnson et al19 found that 13% of the general population use alcohol to promote sleep. Of these individuals, those with difﬁculty
falling asleep were more likely to use alcohol in order to improve
sleep. Approximately 30% of insomniacs self-medicate with alcohol or over-the counter medications.20 Furthermore, insomniacs
who use alcohol have greater levels of daytime sleepiness than do
insomniacs who do not use alcohol. The present results show that
13% of insomniacs consume their last alcoholic beverage within
30 minutes of bedtime. It has been shown that tolerance to the
sleep-inducing effects of alcohol develops within several nights.21
Consequently, individuals who use alcohol to promote sleep not
only increase their social use, but also increase their intake after
several nights of exposure.22 In the present study, insomniacs reported an average frequency of alcohol use of 5 days per week
in comparison to 2 days per week in controls. These lines of evidence suggest the possibility that individuals with insomnia who
self-medicate with alcohol may be at a higher risk for the development of alcohol dependence, but further research in this area is
clearly needed before such a conclusion can be made.
Since caffeine has been known to disturb sleep, we chose to
evaluate its use as a component of sleep hygiene.23,24 Though
caffeine consumption was found to be slightly increased for the
insomnia group compared to controls, the difference was not statistically signiﬁcant. While the present data do not provide support for caffeine consumption as a target for treatment, we did not
speciﬁcally differentiate the time of caffeine consumption. Thus,
it is difﬁcult to make a deﬁnitive conclusion in this regard. It is
possible that insomniacs consume caffeine in the morning in response to poor sleep the previous night. In contrast, because caffeine is widely used and known to adversely effect sleep, perhaps
insomniacs deliberately avoid such substances. Finally, individuals with insomnia may not consume more caffeine, but they may
be more sensitive to it than are other people. These questions need
to be addressed in future studies.
Daytime napping has also been associated with poor sleep hygiene, in so far as frequent naps may decrease the homeostatic
drive for nocturnal sleep. Generally, it has been accepted that
sleep need is approximately 8 hours per 24-hour period. As a re-
Table 3—Summary of Results
Sleep Hygiene Variable
Total sleep time, h
Time in bed, h
Weekdays
Weekends
Sleep efﬁciency, %
“Sleeping in,” %
Naps, no./wk
Regular smokers, %
Smoke within 5 minutes of
bedtime(regular smokers), %
Alcoholic beverages, no./wk
Use alcohol to sleep, %
Alcohol within 30 minutes of
bedtime (regular drinkers), %
Caffeine, no./d
Insomniac
n = 258
5.9 ± 1.7***
Control
n = 258
6.9 ± 1.2
7.3 ± 1.9
7.8 ± 2.0
79.9***
42.7*
3.5 ± 4.5*
40.7***
45.3**
7.4 ± 1.2
8.03 ± 1.4
90.8
32.4
2.7 ± 3.5
22.9
21.8
**4.7 ± 11.0
***29.1
*12.9
2.3 ± 4.8
11.2
5.6
3.0 ± 4.0
2.7± 3.3
Results are presented as mean ± SD for each variable in insomniacs
and controls. See text for deﬁnition of “regular” smokers and “regular” drinkers.
*P < .05
**P < .01
***P < .001
overall cigarette smoking approached signiﬁcance (P < .1), while
the remainder of the sleep hygiene variables were not independent
predictors of insomnia (P > .1).
DISCUSSION
The results of this study demonstrate that individuals with
insomnia engage in some inappropriate sleep practices, such as
smoking, alcohol use, and compensatory sleep (ie, naps and sleeping-in on weekends), more frequently than do normal sleepers.
These sleep-related health practices could potentially exacerbate
or perpetuate an existing sleep disturbance. Our ﬁndings are similar to previous studies of sleep hygiene, which have demonstrated
an association between smoking, alcohol use, and compensatory
sleep. Our results are also consistent with existing behavioral
treatment regimens (e.g., cognitive behavioral treatments) that
frequently employ a general component addressing sleep hygiene
for insomnia patients.9
It is important to emphasize that while previous studies have
demonstrated the disruptive sleep effects of some of the poor
sleep practices assessed in the present study (e.g., caffeine consumption) the data do not provide information regarding causality.14 Although, these data provide useful information regarding
the population prevalence of these behaviors in insomniacs and
matched controls, the direction of any potential causality also
remains unknown. For example, the current data do not inform
whether a reduction in smoking prior to bedtime would improve
sleep or potentially disrupt sleep due to possible nicotine withdrawal effects close to sleep onset. While the behaviors assessed
are considered important aspects of sleep hygiene,12,15 continued
research is necessary to test the potential therapeutic effects of
alterations in each of these speciﬁc sleep hygiene components.
What the present data do suggest is that there are diverse and
highly relevant targets for sleep hygiene in the insomnia population.
There have been few studies that include smoking as a speciﬁc
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613
Sleep Hygiene and Insomnia—Jefferson et al
studies will need to determine where inappropriate sleep hygiene
ﬁts within the purposed multifactoral model of insomnia. Specifically, many individuals may unknowingly utilize inappropriate
sleep practices for the purpose of minimizing sleep disturbance.
For example, a person may smoke or have a drink just prior to
bedtime in order to relax and hence to facilitate sleep. Though
some individuals may believe these behaviors improve sleep,
they are likely to prolong sleep latency and exacerbate sleep disturbance over time.
Previous studies have shown that individuals will often engage in multiple unhealthy behaviors.17 In the multivariate
analysis, naps per week were not a signiﬁcant predictor, suggesting that other sleep hygiene behaviors covary with daytime
nap frequency. Indeed, a posthoc correlation matrix using all of
the sleep hygiene parameters measured shows that napping is
closely associated with sleeping-in on weekends (r = .14, P <
.005). Similarly, the fact that drinks per week were no longer
a signiﬁcant predicator of insomnia in the multivariate model
suggests that the differences found (increased drinks per week
in insomniacs) is likely mediated by alcohol use speciﬁc to sleep
near bedtime.
In conclusion, this population-based study demonstrated that
insomniacs exhibit poor sleep behaviors. Insomniacs are more
likely to smoke and drink alcohol and do so close to bedtime.
Furthermore, they are also more likely to “sleep in,” possibly
in an attempt to compensate for their disturbed sleep at night.
Finally, while some insomniacs may engage in these activities
with the aim of improving their sleep, such behaviors may be
exacerbating or perpetuating their sleep disturbance.
sult, any sleep accumulated during the day may decrease an individual’s sleep drive at night, thereby producing sleep disturbance.
The present data, demonstrating a greater frequency of naps per
week in insomniacs, are consistent with this notion. However, it
must be recognized that polysomnographic data on the napping
behavior of insomniacs are sparse and inconsistent.25-27 Because
the majority of literature regarding napping is based on the sleep
of normal individuals, controlled studies are needed to more systematically understand the potential impact of daytime naps on
nocturnal sleep in individuals with insomnia.
While individuals with insomnia in our study report less total
sleep time on both weekdays and weekends, there was no difference in nightly time in bed compared to controls. Interestingly,
insomniacs report more frequently sleeping in on nonwork days.
Sleep efﬁciency was lower in the insomniacs than in control participants. Sleep efﬁciency in our data is consistent with previous
ﬁndings commonly of < 80% in both self-reported and polysomnograph data.28 One might speculate that such excess time in bed
may contribute to elevated arousal associated with the bedroom
environment, as has been suggested by previous investigators.29
This possibility is also supported by studies showing that sleep
restriction therapy, where time in bed is reduced to approximate
habitual total sleep time and then slowly extended as sleep efﬁciency improves, is an effective treatment for improving sleep in
patients with insomnia.30
There were several limitations to this study that should be acknowledged. Because this was a population-based sample, clinical evaluations were not used to assess insomnia; thus, our results
may not generalize to clinical populations. However, the criteria employed for identifying insomniacs in the current study was
based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and included a standardized and conservative measure of severity over the past 3 months. Therefore, the
current sample is not likely to be biased in the direction of milder
insomnia. In addition, the prevalence of insomnia using this criterion is consistent with other population-based studies.31,32 Caffeine use was measured only by the number of caffeinated beverages consumed and, as noted, was not assessed relative to time of
day or other types of caffeine consumption. Our sample included
persons with secondary as well as primary insomnia, and future
studies may beneﬁt by differentiating these subgroups. Both alcohol and smoking patterns can vary depending on psychological
make-up;33 however, speciﬁc psychiatric proﬁles were not assed
in our interview. Therefore, we are unable to make any statements
regarding the interaction between psychological disposition and
speciﬁc sleep hygiene practices. As this is not a longitudinal study,
we are unable to determine where in the evolutionary process of
chronic insomnia these practices began. Another important limitation of the present study is that only selected aspects of sleep hygiene practices were evaluated. The present research focused on
pharmacologic challenges to sleep and sleep habits. Other important aspects of sleep hygiene practices such as sleep environment
(eg, noise, temperature, mattress), as well as daytime activities
impacting sleep (exercise, bathing, wind down period, presleep
eating), were not evaluated. Clearly, these have been shown to be
important and warrant further research.
According to Spielman’s model of insomnia, predisposing, precipitating, and perpetuating factors all play a role in the manifestation of the disorder.34 The current results illustrate the potential
importance of sleep hygiene as a component of this model. Future
SLEEP, Vol. 28, No. 5, 2005
ACKNOWLEDGMENTS
This research was supported by the National Institute of Mental Health Grant K23-068372, 59338 to Drs. Drake and Roth
respectively.We would like to give a special thanks to Zoe Anne
Gibson.
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Appendix
1) Overall cigarette smoking: “during the 12 months, did you ever smoke tobacco regularly?”
1a)“During the last 2 weeks, how many cigarettes per day did you usually smoke?”
2) Smoking near bedtime: “in the last 2 weeks, how close to the time you went to bed did you usually ﬁnish your last cigarette?” (within 5, 630,31-60 minutes, or more than one hour before bed).
*3)Overall alcohol use: “during the last 12 months, about how often did you drink alcohol?” (every day, nearly every day, 3-4 days a week, 1 or 2
days a week, 2 or 3 a month, once per month, less than once a month, never/did not drink alcohol in last 12 months).
*4)Alcohol uses for sleep: “in the past year, did you ever drink alcohol to help you fall asleep?”
*4a)“When you drank an alcoholic beverage in the last 2 weeks, how close to the time you went to bed did you usually ﬁnish your last drink?”
(less than 30 minutes before bed, 30 to just under and hour, 1 to just under 2 hours, 2 to just under 4 hours, or 4 or more hours before bed).
**5)Caffeine use: “in the past two weeks, on average, how many cups of caffeinated coffee did you drink per day?”
**5a)“In the past two weeks, on average, how many cups of other caffeinated beverages did you drink per day, such as pop or tea?”
6) Napping: “How many days during the past two weeks did you nap?”
7) Time in bed: “Thinking about your average weekday, how many hours did you actually sleep, each day, during the past two weeks?”
7a)“Thinking about your average weekend, how many hours did you actually sleep, each day, in the past two weeks?”
8) Reported likelihood of sleeping in on weekends: “in the past two weeks, did you sleep in on days you didn’t work?” (often, sometimes, rarely,
or never true for you).
9) Time in bed: “At what time did you typically get up on weekdays (during the past two weeks)? And, at what time did you typically go to bed on
weekdays (during the past two weeks)?”
10)“Thinking about your average weekday, how many hours did you actually sleep, each day (during the past two weeks)?”
11)“At what time did you typically get up on weekends (during the past two weeks)?”
12)“And, at what time did you typically go to bed on weekends (during the past two weeks)?”
13)“Thinking about your average weekend, how many hours did you actually sleep, each day (during the past two weeks)?”
*Combined questions to get an assessment of the number of drinks per week.
**Combined the two questions to get a total caffeine use per day.
SLEEP, Vol. 28, No. 5, 2005
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Sleep Hygiene and Insomnia—Jefferson et al