Salud Mental

Sleep hygiene practices in patients with major depression with comorbid insomnia, primary insomnia, and good sleepers


Maritza Sandoval-Rincón
José Carlos Sánchez-Ferrer
Jairo Muñoz-Delgado
R. Krisel Saldívar-Hernández
Alejandro Jiménez-Genchi


Introduction. Inadequate sleep hygiene (SH) is considered factor contributing to insomnia. However, the practice of SH by depressed patients with comorbid insomnia has not been explored.

Objective. We aimed to compare the practice of SH between patients with major depression, comorbid insomnia, primary insomnia, and good sleepers.

Method. One hundred and eighty-two adult individuals participated: 62 outpatients with major depressive disorder with comorbid insomnia (MDD), 56 outpatients with primary insomnia (PI), and 64 good sleepers (GS). All participants were assessed with a structured psychiatric interview, an insomnia interview, the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, and the Sleep Hygiene Practice Scale. We compared the practice of SH as a whole and by domains between the groups and the relation between SH practice, insomnia, and sleep quality.

Results. Patients with PI and MDD showed a significantly worse practice of global SH. In the comparison by SH domains, MDD and PI groups had significantly worse scores than GS in all domains. Individuals with MDD showed a significantly worse practice of sleep schedule and arousal related behaviors than PI group. Although, SH practice was significantly related with insomnia and sleep quality in the whole sample, this association remained significant only in the PI. The arousal-related behaviors domain was the main predictor of insomnia and sleep quality.

Discussion and conclusion. Although patients with insomnia comorbid with MDD or with PI have a worse SH practice than GS, only arousal-related behaviors and drinking/eating habits contribute significantly to insomnia severity and sleep quality.
Sleep hygiene, insomnia, comorbid insomnia, major depression


Download data is not yet available.


American Academy of Sleep Medicine. (2005). International Classification of Sleep Disorders, 2nd. ed: Diagnostic and Coding Manual. Westchester, IL: Author.

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author.

Bastien, C. H., Vallières, A., & Morin, C. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2(4), 297-307. doi: 10.1016/s1389-9457(00)00065-4

Brown, F. C., Buboltz, W. C., & Soper, B. (2002). Relationship of sleep hygiene awareness, sleep hygiene practices, and sleep quality in university students. Behavioral Medicine, 28(1), 33-38. doi: 10.1080/08964280209596396

Buysse, D. J., Reynolds, C. F., 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(2), 193-213. doi: 10.1016/0165-1781(89)90047-4

Chung, K. F., Lee, C. T., Yeung, W. F., Chan, M. S., Chung, E. W., & Lin, W. L. (2017). Sleep hygiene education as a treatment of insomnia: a systematic review and meta-analysis. Family Practice, 35(4), 365-375. doi: 10.1093/fampra/cmx122

Engle-Friedman, M., Bootzin, R., Hazlewood, L., & Tsao, C. (1992). An evaluation of behavioral treatments for insomnia in the older adult. Journal of Clinical Psychology, 48(1), 77-90. doi: 10.1002/1097-4679(199201);2-j

Friedman, L., Benson, K., Noda, A., Zarcone, V., Wicks, D., O´Connell, K., … Yesavage, J. A. (2000). An actigraphic comparison of sleep restriction and sleep hygiene treatments for insomnia in older adults. Journal of Geriatric Psychiatry and Neurology, 13(1), 17-27. doi: 10.1177/089198870001300103

Gellis, L. A., & Lichstein, K. L. (2009). Sleep hygiene practices of good and poor sleepers in the United States: an internet-based study. Behavior Therapy, 40(1), 1-9. doi: 10.1016/j.beth.2008.02.001

Gellis, L. A., Park, A., Stotsky, M. T., & Taylor, D. J. (2014). Associations between sleep hygiene and insomnia severity in college students: Cross-sectional and prospective analyses. Behavior Therapy, 45(6), 806-816. doi: 10.1016/j.beth.2014.05.002

Harvey, A. (2000). Sleep hygiene and sleep-onset insomnia. Journal of Nervous and Mental Disease, 188(1), 53-55. doi: 10.1097/00005053-200001000-00011

Hauri, P. (1977). Current Concepts: The Sleep Disorders. Kalamazoo, MI: The Upjohn Company.

Hauri, P. (1992). Sleep hygiene, relaxation therapy, and cognitive interventions. In P. J. Hauri (Ed.), Case studies in insomnia (pp. 65-84). New York, NY: Plenum.

Jefferson, C. D., Drake, C. L., Scofield, H. M., Myers, E., McClure, T., Rohers, T., & Roth, T. (2005). Sleep hygiene practices in a population-based sample of insomniacs. Sleep, 28(5), 611-615. doi: 10.1093/sleep/28.5.611

Johnson, E. O., Rohers, T., Roth, T., & Breslau, N. (1998). Epidemiology of alcohol and medication as aids to sleep in early adulthood. Sleep, 21(2), 178-186. doi: 10.1093/sleep/21.2.178

Kohn, L., & Espie, C. A. (2005). Sensitivity and specificity of measures of the insomnia experience: a comparative study of psychophysiologic insomnia, insomnia associated with mental disorder and good sleepers. Sleep, 28(1), 104-112. doi: 10.1093/sleep/28.1.104

Lacks, P., & Rotert, M. (1986). Knowledge and practice of sleep hygiene techniques in insomniacs and poor sleepers. Behaviour Research and Therapy, 24(3), 365-368. doi: 10.1016/0005-7967(86)90197-x

Manber, R., Edinger, J. D., Gress, J. L., San Pedro-Salcedo M. G., Kuo, T. F., & Kalista T. (2008) Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep, 31(4), 489-495. doi: 10.1093/sleep/31.4.489

Morin, C. M., Belleville, G., Bélanger, L., & Ivers., H. (2011) The insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep, 34(5), 601-608. doi: 10.1093/sleep/34.5.601

Nowell, P. D., Buysse, D. J., Reynolds, C. F., Hauri, P. J., Roth, T., Stepanski, E. J., … Kupfer, D. J. (1997). Clinical factors contributing to the differential diagnosis of primary insomnia and insomnia related to mental disorders. American Journal of Psychiatry, 154(10), 1412-1416. doi: 10.1176/ajp.154.10.1412

Royuela Rico, A., & Macias Fernández, J. A. (1997). Propiedades clinimétricas de la versión castellana del cuestionario de Pittsburgh. Vigilia-Sueño, 9(2), 81-94.

Schoicket, S., Bertelson, A., & Lacks, P. (1988). Is sleep hygiene a sufficient treatment for sleep-maintenance insomnia? Behavior Therapy, 19(2), 183-190. doi: 10.1016/S0005-7894(88)80041-8

Sheehan, D. V., Lecrubier, Y., Harnett-Sheehan, K., Amorin, P., Janavs, J., Weiller, E., … Dunbar, G. (1998). The MINI International Neuropsychiatric Interview (M. I. N. I.). The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl 20), 22-23.

Spielman, A. J., Caruso, L., & Glovinsky, P. (1987). A behavioral perspective on insomnia treatment. The Psychiatric Clinics of North America, 10(4), 541-553.

Stepanski, E. J., & Wyatt, J. K. (2003). Use of sleep hygiene in the treatment of insomnia. Sleep Medicine Reviews, 7(3), 215-225. doi: 10.1053/smrv.2001.0246

Vincent, N., & Lionberg, C. (2001). Treatment preference and patient satisfaction in chronic insomnia. Sleep, 24(4), 411-417. doi: 10.1093/sleep/24.4.411

Yang, C.-M., Lin, S.-C., Hsu, S.-C., & Cheng, C.-P. (2010). Maladaptive sleep hygiene practices in good sleepers and patients with insomnia. Journal of Health Psychology, 15(1), 147-155. doi: 10.1177/1359105309346342