Arthritis & Rheumatism (Arthritis Care & Research)

Vol. 49, No. 5S, October 15, 2003, pp S184 –S196

DOI 10.1002/art.11409
© 2003, American College of Rheumatology
MEASURES OF FATIGUE AND SLEEP

Measures of Sleep
The Insomnia Severity Index, Medical Outcomes Study (MOS) Sleep Scale,
Pittsburgh Sleep Diary (PSD), and Pittsburgh Sleep Quality Index (PSQI)

Michael T. Smith and Stephen T. Wegener

INSOMNIA SEVERITY INDEX a sample of adults (ages 17– 84 years) with

General Description
Purpose. The Insomnia Severity Index (ISI) is
designed to be both a brief screening measure of
insomnia and an outcomes measure for use in
treatment research (1,2).
Content. Scale content corresponds in part to
DSM-IV criteria for insomnia, and measures the
subject’s current (within the past 2 weeks)
perception of symptom severity, distress, and
daytime impairment. Items include: the severity of
sleep onset and maintenance (middle and early
morning awakening) difficulties, satisfaction with
current sleep pattern, interference with daily
functioning, appearance of impairment attributed
to the sleep problem, and the degree of concern
caused by insomnia.
Developer/contact information. Charles M.
Morin, PhD. E-mail: cmorin@psy.ulaval.ca.
Versions. Primary version is self-administered;
clinician-administered, significant other, and
French language versions are available.
Number of items in scale. There are 7 items.
Subscales. None.
Population. Developmental/target. The
psychometric properties of ISI were reported from
Supported by NIH/NIDCR grant DE-13906 (MTS).
Michael T. Smith, PhD, Stephen T. Wegener, PhD: Johns
Hopkins University School of Medicine, Baltimore, Mary-
land.
Address correspondence to Michael T. Smith, PhD, De-
partment of Psychiatry and Behavioral Sciences, Behavioral
Medicine Research Laboratory and Clinic, 600 N. Wolfe
Street, Meyer 101, Baltimore, MD 21287. E-mail:
Msmith62@jhmi.edu.
Submitted for publication April 23, 2003; accepted in
revised form April 24, 2003.
insomnia complaints (primary and secondary to
medical, psychiatric, or other sleep disorders) (2).
Other uses. The ISI has also been validated on
samples of young adults (mean age 20 years) (3),
and older adults (mean age 65 years) with primary
insomnia (2).
WHO ICF Components. Body function,
Impairment, Activity limitation, Participation
restriction, Environmental factor.
Administration
Method. Self-administration; paper and pencil.
Training. Minimal.
Time to administer/complete. Five minutes or
less.
Equipment needed. None.
Cost/availability. No cost; available from
authors. Copy available at the Arthritis Care &
Research Web site at
http://www.interscience.wiley.com/jpages/0004-
3591:1/suppmat/index.html.
Scoring
Responses. Scale. Five-point Likert scale (0 ⫽
not at all, 4 ⫽ extremely).
Score range. Range is 0 –28.
Interpretation of scores. Suggested guidelines
for interpretation: 0 –7 ⫽ no clinically significant
insomnia; 8 –14 ⫽ subthreshold insomnia; 15–21 ⫽
clinical insomnia of moderate severity; 21–28 ⫽
severe clinical insomnia. Guidelines require
additional validation. Smith and Trinder (3) found
a cutoff score of 14 distinguished subjects with

S184
Sleep
insomnia from normal controls with a sensitivity ⫽
94% and specificity ⫽ 94%.
Method of scoring. Individual items are summed
by hand.
Time to score. Less than one minute.
Training to score. Minimal.
Training to interpret. Minimal.
Norms available. Traditional norms are not
available. Mean (SD) for insomnia patients (n ⫽
145) is 19.7 (4.1). Mean (SD) older adults with
DSM-IV diagnosis of primary insomnia is 15.4
(4.2). ISI scores for the 5 insomnia subgroups in
the original sample were pain conditions (20.2);
psychophysiological (19.5); psychiatric (21.0);
idiopathic (19.7); alcohol/substance abuse (19.8);
and other (19.5) (2).
Psychometric Information
Reliability. Internal consistency. Cronbach’s
alpha ⫽ 0.74 to 0.78. Individual item correlations
to the total score ranged from 0.36 (difficulty
falling asleep) to 0.67 (interference with daily
functioning), with a mean of 0.54. Internal
reliability coefficients of individual items to total
score demonstrated increased stability following
treatment with means of 0.69 at post-treatment and
0.72 at followup (2).
Validity. Content. The ISI has good face validity
with the concept of insomnia as defined by DSM-
IV. Formal evaluation of content validity was
demonstrated via principal component analysis,
which yielded 3 components (impact, severity, and
satisfaction). These components are consistent with
the diagnostic criteria of insomnia and captured
72% of the variance (2).
Criterion. A cutoff score of 14 demonstrated a
sensitivity of 94% and a specificity of 94% in
distinguishing individuals diagnosed with primary
insomnia from good sleeper controls. Diagnoses
were established based on integration of expert
clinical interview, polysomnography, and
psychometric testing (3).
Concurrent. Bastien and colleagues reported
significant correlations of select ISI items and Total
Score with relevant polysomnography (PSG)
variables before and after treatment (2). The ISI
Sleep Onset item was the only significant
pretreatment correlation (r ⫽ 0.45; P ⬍ 0.05, PSG
S185
Sleep Latency). At posttreatment, ISI Total Score
correlated with PSG Sleep Efficiency (⫺0.35; P ⬍
0.05). ISI Sleep Onset and middle insomnia items
correlated with PSG Sleep Latency and Wake After
Sleep Onset (0.39 and 0.45; P ⬍ 0.05, respectively).
In regards to sleep diatries, Bastien and
colleagues (2) reported significant correlations of
select ISI items with corresponding daily sleep
diary parameters in 2 separate samples, one of
which included correlations between measures
both before and after treatment. Pretreatment
correlations were weak to moderate (0.32– 0.55)
and posttreatment correlations were moderate to
strong (0.55– 0.99). The ISI Total Score correlated
weakly to moderately with diary measures of Sleep
Efficiency (Pearson’s r values ranging between
⫺0.19 and ⫺0.61).
Correlation coefficients between clinician ISI
ratings and the patient version for ISI total score
ranged between 0.57 and 0.71, P ⬍ 0.01. Individual
item correlations between the 2 versions ranged
between 0.50 (difficulty staying asleep) and 0.69
(problem waking up too early).
Predictive. Clinician ratings of insomnia severity
predicted ISI Total Score. R2 ranged from 0.37
(pretreatment) to 0.61 (post-treatment) P ⬍ 0.05)
(2).
Sensitivity/responsiveness to change. Morin and
colleagues demonstrated sensitivity to change
following pharmacologic and/or behavioral
intervention for primary insomnia in older adults (4).
Comments and Critique
The ISI is a face valid index of insomnia
severity demonstrating criterion validity and other
adequate psychometric properties. It has been
validated against both polysomnographic and
prospective sleep diary measures and demonstrates
convergence with clinical interview criteria. It may
be particularly useful for treatment outcome
research in which insomnia is a secondary
endpoint, and a brief, low subject burden
instrument is needed. It may also be useful for
diagnosis and treatment planning. The cutoff score
may be useful as a guideline for clinicians in
evaluating the clinical significance of the insomnia
complaint. While not specifically developed for
rheumatology patients, scale development included
a heterogenous group of patients with insomnia
secondary to pain conditions.
Due to its brevity and Likert scale data, this
instrument would not be an appropriate stand-
alone measure of sleep disturbance. The scale is
limited to questions pertaining to insomnia
S186
severity/impact and does not assess frequency of
symptoms. It also does not include items relevant
to other sleep disorders, which may occur more
frequently in chronic pain populations (e.g.,
periodic limb movements, restless legs syndrome,
or sleep apnea). More research demonstrating the
psychometric properties of the ISI, and establishing
cutoff scores and sensitivity to change in
rheumatologic populations is needed.
References
1. (Original) Morin CM. Insomnia: psychological
assessment and management. New York: Guilford
Press; 1993.
2. Bastien CH, Vallie’res A, Morin CM. Validation of the
Insomnia Severity Index as an outcome measure for
insomnia research. Sleep Med 2000;2:297–307.
3. Smith S, Trinder J. Detecting insomnia: comparison of
four self-report measures of sleep in a young adult
population. J Sleep Res 2001;10:229 –35.
4. Morin CM, Colecchi C, Stone J, Sood R, Brink D.
Behavioral and pharmacological therapies for late-life
insomnia: a randomized controlled trial. JAMA 1999;
281:991–9.
MEDICAL OUTCOMES STUDY (MOS)
SLEEP SCALE
General Description
Purpose. Measure 6 sleep dimensions. The sleep
scale is one subscale of the Medical Outcomes
Study (MOS) health status measure (1).
Content. Consists of 12 items to measure 6 sleep
dimensions: initiation (time to fall asleep), quantity
(hours of sleep each night), maintenance ,
respiratory problems, perceived adequacy,
somnolence (the last 4 items reported using a 6-
item Likert scale ranging from “All of the time” to
“None of the time”). The time frame for the
responses is “the past 4 weeks.”
Developer/contact information. RD Hays and AL
Stewart, Medical Outcomes Trust, 198 Tremont
Street #503, Boston, MA 02166. Available at http://
www.outcomes-trust.org/instruments.htm.
Versions. A 6-item Likert-scale short form is
available that measures initiation, maintenance,
respiratory problems, adequacy, and somnolence.
A correlation of 0.97 indicates the short version is
nearly equivalent to the long version.
Number of items in scale. There are 12 items.
Subscales. Two indexes can be derived: Sleep
Problems Index I (short form) and Sleep Problems
Smith and Wegener
Index II (long form). Additional subscales can be
derived: sleep disturbance, snoring, sleep shortness
of breath or headache, sleep adequacy, sleep
somnolence, sleep quantity, and optimal sleep.
Populations. Developmental/target. Patients
served in primary care and multi-specialty
practices.
Other uses. Has been used with congestive heart
failure, patients with depression, diabetes, recent
myocardial infarction, hypertension, asthma, back
problems, arthritis samples.
WHO ICF Components. Body function,
Impairment, Activity limitation, Participation
restriction.
Administration
Method. Self-report instrument that may be
administered in person, by mail, or telephone.
Training. No training needed.
Time to administer/complete. Not reported.
Estimated to be 2–3 minutes for 12 items.
Equipment needed. None, other than instrument
and writing implement.
Cost/availability. No cost. Available through
source listed above and references listed below.
Scoring
Responses. Scale. Sleep Initiation (0 –15
minutes, 16 –30 minutes, 31– 45 minutes, 46 – 60
minutes, 60⫹ minutes); Sleep Quantity (number of
hours), 10 items about other sleep activities (All of
the Time, Most of the Time, A Good Bit of the
Time, Some of the Time, A Little of the Time,
None of the Time).
Score range. The range for the 12-item version is
12–71.
Interpretation of scores. No formal cutoff scores
are provided. Data from original scale development
samples are available for comparison.
Method of scoring. Scoring is done by hand,
requires reverse scoring of selected items and only
requires simple arithmetic.
Time to score. Less than 5 minutes.
Training to score. Training is minimal.
Sleep
Training to interpret. Training is minimal.
Norms available. No formal norms have been
published. Data from original scale development
samples are available for comparison.
Psychometric Information
Reliability. Internal consistency. Cronbach alpha
ranged from 0.75 to 0.86 for item to subscales.
Item-total correlations were 0.03– 0.64, which is
not surprising given the multiple dimensions of
sleep assessed. Intercorrelations among subscales
ranged from 0.05 to 0.88.
Test-retest. Not available.
Intra/interrater. Not formally reported or
applicable; self-report data with objective, simple
scoring.
Variability. Full range of scores observed with
fairly normal distribution (skewness ranging from
-0.055 to 1.81 for items).
Validity. Content. The MOS has good face
validity covering multiple dimensions of sleep that
are represented in prior sleep measures.
Criterion. The MOS has not been formally
compared to sleep laboratory observations.
Concurrent/predictive. Not available.
Construct/discriminant. Comparison of the MOS
Sleep scale with other dimensions of the MOS
indicated correlations in the expected directions
(Effects of pain 0.53, Pain severity 0.44, Physical
symptoms 0.57, Energy/fatigue ⫺0.60, Physical
functioning ⫺0.36, Cognitive functioning ⫺0.53,
Depression/behavioral-emotional control 0.57,
Anxiety 0.57, Positive affect ⫺0.55).
Sensitivity/responsiveness to change. Not
established.
Comments and Critique
The MOS is a face valid index of sleep disturbance
with adequate established reliability but no
established validity with objective sleep measures.
It should be noted that the subscales do not
necessarily reflect DSM criteria for insomnia
diagnosis. Criterion validity remains to be
established and comparison with other sleep
measures is unknown. The lack of a cutoff score
undermines its utility as a clinical tool. Other
sleep measures have more established validity and
S187
would be more appropriate for research focused on
sleep parameters. While not specifically normed on
a rheumatology sample, as it was developed using
a large number of patients served in primary care
and specialty practice settings, the MOS is one of
the few health status measures that has a sleep
subscale. The MOS scale may be more useful in
studies where the focus is general health status
assessment but information on sleep parameters is
of interest. The short 6-item version is nearly
equivalent to the 12-item version and reduces
subject burden. It should be noted there is no item
assessing use of sleep medication or assessment of
leg movements, if these are variables of interest.
The sleep somnolence subscale actually measures
daytime sleepiness. The utility in treatment
outcome studies remains to be established. It
should be noted, while the Short Form-36 is a brief
version of the MOS it does not contain items on
sleep behavior.
Reference
1. (Original) Stewart AL, Ware JE, Brook RH, Davies AR.
Conceptualization and measurement of health for
adults in the Health Insurance Study. Vol II. Physical
health in terms of functioning. Santa Monica (CA):
The RAND Corporation; 1978. p. 236 –359.
Additional References
Hays RD, Stewart AL. Sleep measures. In: Stewart AL,
Ware JE, editors. Measuring functioning and well-
being: the Medical Outcomes Study Approach.
Durham (NC): Duke University Press; 1992. p. 235–
59.
Stewart AL, Hays RD, Ware JE. The MOS Short-Form
General Health Survey: reliability and validity in a
patient population. Med Care 1988;26:724 –732.
PITTSBURGH SLEEP DIARY
General Description
Purpose. The Pittsburgh Sleep Diary (PSD) is
designed to quantify subjectively reported sleep
and waking behaviors for use in research and
practice (1).
Content. The PSD is organized into 2 daily
questionnaires completed at “bedtime” and
“waketime.” The bedtime questionnaire gathers
data on 1) the timing of meals; 2) consumption of
caffeine, alcohol, and tobacco products; 3)
medication use; and 4) and the timing and
duration of exercise and nap periods. The
waketime questionnaire gathers data on 1) bedtime;
2) “lights out time;” 3) sleep latency (SL); 4) final
waketime; 5) method of final awakening; 6)
frequency of nightly awakenings (FNA); 7) wake
S188
after sleep onset time (WASO); 8) reason for
nightly awakenings, 9) sleep quality; and 10) mood
on final wakening, and alertness on final wakening.
Developer/contact information. Timothy H.
Monk, PhD, Sleep and Chronobiology Center
Western Psychiatric Institute and Clinic, University
of Pittsburgh School of Medicine, 3811 O’Hara
Street, Pittsburgh, PA 15213. Fax: 1-412-624-2841.
Versions. Multiple versions of sleep diaries have
been developed (2– 4). The PSD was selected for
review because it is the most comprehensive
published diary with psychometric data.
Number of items in scale. The bedtime
questionnaire is comprised of 6 general items. The
waketime questionnaire is comprised of 11 general
items.
Subscales. None.
Populations. Developmental/target. The PSD
was developed from 3 investigations including
samples of sleep disorder patients (n ⫽ 28) and
healthy adult controls (young [n ⫽ 29], middle-
aged [n ⫽ 96], and older adult [n ⫽ 81]). Sleep
disorder patients included patients with insomnia
or hypersomnia.
Other uses. Similar sleep diaries have been used
to assess sleep parameters in heterogeneous
chronic pain patients (3,5,6) and fibromyalgia (7).
Sleep diaries are extensively used in the clinical
trials literature of insomnia (8 –10). Diaries have
also been found to be useful in evaluating
circadian rhythm disorders (11).
WHO ICF Components. Body function,
Impairment, Environmental factor.
Administration
Method. Questionnaire, paper and pencil
(electronic and mail versions have been
developed). Standard assessment periods of 1
week, and more preferably 2 weeks, are
recommended to account for night-to-night
variability in sleep disorder populations.
Compliance problems need to be considered (12).
Electronic versions can be adopted for use with
PDA handheld devices. Electronic delivery
enhances data integrity with audible reminder
features, and time and date stamping of entries (7).
Training. Brief training of subjects is required to
avoid missing values and erroneous data. Subjects
Smith and Wegener
should be instructed to keep the diary on their
nightstand with a pen or pencil available. The
nighttime questionnaire is to be completed
immediately before retiring to bed. The morning
questionnaire is to be completed shortly after
waking. Instruction is required on properly
estimating wake after sleep onset time and the use
of visual analog scales. Individuals complete both
questionnaires each day for a period of 1 to 2
weeks or longer.
Time to administer/complete. Ten minutes a day
(5 minutes for the bedtime questionnaire and 5
minutes for the waketime questionnaire).
Equipment needed. None.
Cost, availability. No cost; available from
authors. Copy available at the Arthritis Care &
Research Web site at
http://www.interscience.wiley.com/jpages/0004-
3591:1/suppmat/index.html.
Scoring
Responses. Scale. The timing (hour:minutes)
and duration (minutes) of various daytime and
sleep-wake parameters and activities are hand
entered. For the nighttime questionnaire, the
frequency of servings of caffeine, alcohol, and
tobacco products are indicated for 4 time periods:
1) before or with breakfast; 2) after breakfast,
before/with lunch; 3) after lunch before/with
dinner; and 4) after dinner. Name, timing, and
dosage of medications are hand entered. For the
waketime questionnaire, subjects indicate the
timing of bedtime and final waketime, and the
duration of sleep latency and wake after sleep
onset time. Subjects also check on a categorical
scale the method of final awakening: “alarm/clock
radio,” “someone whom I asked to wake me,”
“noises,” or “just woke.” Frequency of nightly
awakenings is indicated using a 6-point Likert
scale: 0 –5 or more. Frequency of awakenings to
use the bathroom, awakenings by noise/bedpartner,
awakenings due to physical discomfort, and
spontaneous awakenings are indicated on the same
6-point Likert scale. Ratings of sleep quality, mood
on final wakening, and alertness are made on 100-
mm visual analog scales.
Score range. In addition to categorical and
frequency data generated by the nighttime
questionnaire, the waketime questionnaire permits
the calculation of standard continuity parameters
as follows: 1) Sleep latency (SL), minutes; ranges
from 0 to total time in bed (TIB); 2) frequency of
Sleep S189

Table 1. Sleep Diary Estimates of Sleep Continuity Parameters*

Groups SL FNA WASO TST SE%

Healthy young adults, 10.7 (7.0) 0.3 (0.5) 6.7 (11.7) NR NR

ages 20–30 years (n ⫽
29), 41% female (1)
Healthy older adult 24.3 (25.4) 1.2 (0.7) 23.4 (24.7) NR NR
females, ages ⱖ81
years (n ⫽ 44) (1)
Healthy older adult 15.7 (21.3) 1.5 (0.8) 21.8 (21.0) NR NR
males, ages ⱖ81 years
(n ⫽ 37) (1)
General sleep disorder NR NR 35.3 (33.2) NR NR
patients, (n ⫽ 28, 14
insomnia and 14
hypersomnia), 40%
female (1)
Mixed outpatient chronic 43.9 (22.3) 2.26 (1.2) 41.8 (40.9) 391.4 (74.3) 71.0 (14.0)
pain, mean age 43 (10),
67% female (5)
Chronic persistent 51.5 (29.1) 2.7 (1.9) 61.8 (39.0) 332.7 (46.6) NR
insomnia, adults age
range 18–80⫹, years,
Mean n ⫽ 217, 65%
female (8)†

* Values are mean (SD). SL ⫽ sleep latency; FNA ⫽ frequency of nightly awakenings; WASO ⫽ wake after sleep onset time; TST ⫽ total sleep time;
SE% ⫽ sleep efficiency percentage; NR ⫽ not rated.
† Based on meta-analysis of clinical trials literature of primary insomnia. Values are pretreatment means. Number of subjects included in averages
varied due to differential reporting of sleep parameters by study. Results are based on a total of 23 clinical trials.

nightly awakenings (FNA); ranges from 0 to 5⫹; 3)
wake after sleep onset time (WASO), minutes;
ranges from 0 to TIB – SL; 4) total sleep time
(TST), minutes calculated by the formula, TST⫽
[TIB – (SL⫹WASO)]; ranges from 0 to TIB; 5) Sleep
efficiency percentage (SE), calculated by formula,
SE ⫽ TST/TIB. Visual analog scales of sleep
quality, mood, and alertness on waking range from
0 to 100 mm.
Interpretation of scores. There are no formally
established research diagnostic criteria for sleep
diary estimates of sleep continuity. Commonly
used clinical and research criteria for symptom
severity are as follows: mean SL and/or WASO
⬎30 minutes, mean SE ⬍85% (2). Due to
individual variation in TST, researchers are less
inclined to establish TST criteria. Commonly used
criteria for problem frequency is: ⱖ3 nights per
week (2) for a 1-month period (13).
Method of scoring. Scoring is done by hand.
Calculation of previously described sleep
continuity parameters can be easily automated. A
ruler is required to measure the visual analog
scales. Typically, mean values for each sleep
parameter are obtained (averaged over 1 to 2
weeks).
Time to score. Scoring time depends on the
number of days data are collected. A week’s worth
of entries can usually be manually scored in 10 –15
minutes.
Training to score. Minimal.
Training to interpret. Minimal.
Norms available. Traditional norms are
unavailable. Table 1 shows diary-based means and
standard deviations that have been culled from the
literature for reference.
Psychometric Information
Reliability. Reliability and validity data are
primarily available for the waketime questionnaire
sleep continuity and quality items.
Test-retest reliability. Monk et al reported
significant (P ⬍ 0.001) long-term test-retest
correlation coefficients (r) for select waketime
questionnaire variables with a mean intertest
interval of 22 months (range 12–30 months):
FNA ⫽ 0.67; WASO ⫽ 0.56; Sleep Quality ⫽ 0.59;
Mood on waking ⫽ 0.61; Alertness on waking ⫽
0.65; bedtime ⫽ 0.81; Lights out ⫽ 0.80; and Final
waketime ⫽ 0.66 (1).
S190
Short-term test-retest reliability. Using a sleep
diary similar to the waketime PSD items, Coates et
al reported test-retest reliability coefficients
measured over 3 consecutive days for poor sleepers
of 0.93, 0.88, 0.84 for SL, FNA, and WASO,
respectively (Spearman-Brown Prophecy
coefficients) (14). For good sleepers, Coates et al
reported coefficients of 0.81, 0.84 and 0.64 for SL,
FNA, and WASO, respectively (14).
Inpatient chronic pain patients. Haythornthwaite
and colleagues used ordinally scaled diary items
over a 4-day period (3). They reported internal
consistency estimates for standard sleep
continuity/quality questions (average interitem
correlations using Fisher’s Z transformation
ranging from 0.41 (Sleep Quality) to 0.62 (TST).
Spearman’s Brown prophesy formula reliability
test-retest coefficients ranged from 0.74 (Sleep
Quality) to 0.87 (SL).
Validity. Criterion. Several investigations
comparing sleep diary data against traditionally
scored polysomnographic criteria have found
patients with insomnia to reliably overestimate SL
and WASO and underestimate TST compared with
PSG (14,15). Diary estimates, however, have
consistently been demonstrated to provide a valid
relative index of insomnia. In a study of 122 men
and women with chronic insomnia, Carskadon
reported significant correlation coefficients
between diary and PSG measures of SL (0.62) and
TST (0.47), (P ⬍ 0.001, WASO not reported).
Coates and colleagues reported a correlation
coefficient of 0.98 for SL and 0.88 for WASO for a
sample of 12 patients with insomnia, P ⬍ 0.01.
Diaries have not been shown to be a valid
indicator of Frequency of Nightly Awakenings
(FNA).
Monk and colleagues reported PSD to be
sensitive to significant age related differences in
sleep continuity that were simultaneously verified
by polysomnography (1). Specifically, the PSD
found older adults to report longer WASO
compared with young, good-sleeper control
subjects (P ⬍ 0.0001). Longer WASO for the adult
sample was confirmed via PSG. The authors did
not report correlation coefficients.
Comparison with actigraphy. Actigraphs are a
lightweight, watch-like accelerometer device worn
on the wrist, which are increasingly being used in
sleep research to provide objective estimates of
circadian rhythm (16), and sleep continuity
(17,18). Algorithms for scoring sleep continuity
parameters based on movement counts have been
developed and validated against PSG, although
Smith and Wegener
more validation studies particularly for sleep
disorder populations are needed (19). Monk et al
reported the PSD correlated significantly with
actigraphic measures of TST (r ⫽ 0.43, P ⬍ 0.0001)
(1). They also reported PSD estimates of sleep
disruption based on WASO were significantly
related to mean activity counts between bedtime
and waketime (t ⫽ 4.1, P ⬍ 0.0001).
Convergent. Monk reported convergent validity
with circadian type and personality measures.
With respect to circadian type, PSD correlated in
the expected direction on the morningness score of
the Horne-Osteberg morningness questionnaire (P
⬍ 0.05). Specific PSD correlations with the
morningness score were as follows: all PSD items
pertaining to the timing of the sleep episode, rho ⬎
0.6; ratings of alertness on awakening, rho ⫽ 0.35;
and mood upon wakening, rho ⫽ 0.22. With
respect to personality, elevated scores on
neuroticism as measured by the Eysenck
Personality Inventory were associated with PSD
estimates of WASO (rho ⫽ 0.28), FNA (rho ⫽
0.33), poorer sleep quality (rho ⫽ ⫺0.34), negative
mood (rho ⫽ ⫺0.35), and decreased morning
alertness (rho ⫽ ⫺0.23) (P ⬎ 0.03).
Haythornthwaite and colleagues also reported
convergent validity of a sleep diary in an inpatient
sample of chronic pain patients. Diary measures
correlated in the expected direction with standard
measures of pain severity, depression, and anxiety
(3).
Convergent validity with retrospective measures
of sleep quality. Monk et al reported small, but
significant correlation of PSD items with the
Pittsburgh Sleep Quality Index Global Score as
follows: FNA rho ⫽ 32, P ⬍ 0.002; WASO rho ⫽
0.27, P ⬍ 0.01; Sleep Quality rho ⫽ ⫺0.36, P ⬍
0.0005); Mood rho ⫽ ⫺0.37, P ⬍ 0.0005; Alertness
rho ⫽ ⫺0.37, P ⬍ 0.0005 (1).
In chronic pain patients, Haythornthwaite et
al. reported moderate correlations in the expected
direction with their sleep diary and retrospective
summary measures of sleep (coefficient ranged
from 0.31 to 0.48, P ⬍ 0.05) (3).
Sensitivity/responsiveness to change. Sleep
diaries are the most widely used outcome metric in
both the behavioral and pharmacologic clinical
trials literatures of insomnia (8). Numerous studies
and meta-analyses have demonstrated excellent
sensitivity to change (9,20 –22). Notably, sleep
diary measures have been shown to detect
treatment effects for cognitive-behavioral therapy
for insomnia secondary to chronic pain. These
Sleep
effects were concurrently validated via actigraphy
(23).
Comments and Critique
Sleep diaries are a valuable tool in sleep research
to quantify subjective sleep disturbance. In
rheumatology and pain research, however, sleep
diaries have been used infrequently. Most clinical
trials of chronic pain have relied on brief
retrospective ratings of sleep quality with dubious
validity. This is somewhat surprising given that
pain diaries have become an important instrument
in the assessment of chronic pain conditions.
Standard sleep continuity/quality items can easily
be added to pain diaries. Electronic diaries with
data integrity features and automatic scoring
capability will undoubtedly increase their use in
pain research.
Prospective diary monitoring has distinct
advantages over retrospective measures in its
sensitivity to variations in sleep parameters over
time and its diminished vulnerability to recall bias.
Compared to traditional PSG, they permit a
relatively unobtrusive, inexpensive assessment of
sleep quality in the natural environment.
Concern that sleep diaries overestimate
insomnia severity relative to objective measures of
sleep, should be considered by researchers
utilizing only one measure of sleep disturbance.
However, despite reliable deviations from
polysomnographic measures, diaries have been
found to yield a valid, relative index of insomnia,
which is sensitive to change. Furthermore, recent
studies analyzing sleep microstructure have found
that patients reporting the largest discrepancies
between sleep diary and PSG show a heightened
degree of fast-frequency electroencephalogram
activity during non-rapid eye movement sleep
(24,25). This research suggests that subjective
estimates of sleep quality may actually reflect a
combination of traditional sleep continuity
disturbance measures and sleep microstructure
abnormalities. The findings highlight the need for a
multi-method approach to sleep assessment that
combines, subjective ratings and objective
measures such as PSG and actigraphy. Finally,
although sleep diaries rarely have formal weekday
(work week) and weekend (days off) subscales,
these factors should be considered in the
interpretation of any sleep diary data.
References
1. (Original) Monk TH, Reynolds CF, Kupfer DJ, Buysse
DJ, Coble PA, Hayes AJ, et al. The Pittsburgh Sleep
Diary. J Sleep Res 1994;3:111–20.
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2. Morin CM. Insomnia: psychological assessment and
management. New York: Guilford Press; 1993.
3. Haythornthwaite JA, Hegel MT, Kerns RD.
Development of a sleep diary for chronic pain
patients. J Pain Symptom Manage 1991;6:65–72.
4. Akerstedt T, Hume K, Minors D, Waterhouse J. The
subjective meaning of good sleep, an intraindividual
approach using the Karolinska Sleep Diary. Percept
Mot Skills 1994;79:287–96.
5. Smith MT, Perlis ML, Smith MS, Giles DE. Pre-sleep
cognitions in patients with insomnia secondary to
chronic pain. J Behav Med 2001;24:93–-114.
6. Wilson KG, Watson ST, Currie SR. Daily diary and
ambulatory activity monitoring of sleep in patients
with insomnia associated with chronic
musculoskeletal pain. Pain 1998;75:75– 84.
7. Affleck G, Urrows S, Tennen H, Higgins P, Abeles M.
Sequential daily relations of sleep, pain intensity,
and attention to pain among women with
fibromyalgia. Pain 1996;68:363– 8.
8. Smith MT, Perlis ML, Park A, Smith MS, Pennington
JY, Giles DE, et al. Comparative meta-analysis of
pharmacotherapy and behavior therapy for persistent
insomnia. Am J Psychiatry 2002;159:5–11.
9. Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR,
Quillian RE. Cognitive behavioral therapy for
treatment of chronic primary insomnia: a
randomized controlled trial. JAMA 2001;285:1856 –
64.
10. Morin CM, Colecchi C, Stone J, Sood R, Brink D.
Behavioral and pharmacological therapies for late-
life insomnia: a randomized controlled trial. JAMA
1999;281:991–9.
11. Harma M, Sallinen M, Ranta R, Mutanen P, Muller
K. The effect of an irregular shift system on
sleepiness at work in train drivers and railway traffic
controllers. J Sleep Res 2002;11:141–51.
12. Stone AA, Shiffman S, Schwartz JE, Broderick JE,
Hufford MR. Patient non-compliance with paper
diaries. BMJ 2002;324:1193– 4.
13. American Psychiatric Association. Diagnositic and
Statistical Manual of Mental Disorders (DSM-IV). 4
ed. Washington (DC): American Psychiatric
Association; 1994.
14. Coates TJ, Killen J, George J, Marchini E, Hamilton
S, Thoresen C. Estimating sleep parameters: a
multitrait-multimethod analysis. J Consult Clin
Psychol 1982;50:345–52.
15. Carskadon M, Dement W, Mitler M, Guilleminault C,
Zarcone VP, Spiegel R. Self-reports versus sleep
laboratory findings in 122 drug-free subjects with
complaints of chronic insomnia. Am J Psychiatry
1976;133:1382– 8.
16. Mormont MC, De Prins J, Levi F. [Study of circadian
rhythms of activity by actometry: preliminary results
in 30 patients with metastatic colorectal cancer].
Pathol Biol (Paris) 1996;44:165–71.
17. Sadeh A, Hauri PJ, Kripke DF, Lavie P. The role of
actigraphy in the evaluation of sleep disorders. Sleep
1995;18:288 –302.
18. Jean-Louis G, von Gizycki H, Zizi F, Spielman A,
Hauri P, Taub H. The actigraph data analysis
S192
software. I. A novel approach to scoring and
interpreting sleep-wake activity. Percept Mot Skills
1997;85:207–16.
19. Sadeh A, Hauri PJ, Kripke DF, Lavie P. The role of
actigraphy in the evaluation of sleep disorders. Sleep
1995;18:288 –302.
20. Murtagh DR, Greenwood KM. Identifying effective
psychological treatments for insomnia: a meta-
analysis. J Consult Clin Psychol 1995;63:79 – 89.
21. Nowell PD, Mazumdar S, Buysse DJ, Dew MA,
Reynolds CF III, Kupfer DJ. Benzodiazepines and
zolpidem for chronic insomnia: a meta-analysis of
treatment efficacy. JAMA 1997;278:2170 –7.
22. Morin CM, Culbert JP, Schwartz SM.
Nonpharmacological interventions for insomnia: a
meta-analysis of treatment efficacy. Am J Psychiatry
1994;151:1172– 80.
23. Currie SR, Wilson KG, Pontefract AJ, deLaplante L.
Cognitive-behavioral treatment of insomnia
secondary to chronic pain. J Consult Clin Psychol
2000;68:407–16.
24. Krystal AD, Edinger JD, Wohlgemuth WK, Marsh GR.
NREM sleep EEG frequency spectral correlates of
sleep complaints in primary insomnia subtypes.
Sleep 2002;25:630 – 40.
25. Perlis ML, Smith MT, Orff HJ, Andrews PJ, Giles DE.
Beta/Gamma EEG activity in patients with primary
and secondary insomnia and good sleeper controls.
Sleep 2001;24:110 –7.
PITTSBURGH SLEEP QUALITY INDEX
(PSQI)
General Description
Purpose. The Pittsburgh Sleep Quality Index
(PSQI) measures retrospective sleep quality and
disturbances over a 1-month period for use in
clinical practice and research (1). The PSQI
discriminates between good and poor sleepers, and
provides a brief, clinically useful assessment of
multiple sleep disturbances.
Content. Individual self-report items assess a
broad range of domains associated with sleep
quality, including: usual sleep wake patterns,
duration of sleep, sleep latency, the frequency and
severity of specific sleep-related problems, and the
perceived impact of poor sleep on daytime
functioning. Specific problems contributing to poor
sleep that are assessed include: pain, urinary
frequency, breathing difficulty, snoring, dreams,
temperature, etc.
Developer/contact information. Daniel J. Buysse,
MD, Sleep and Chronobiology Center, Western
Psychiatric Institute and Clinic, University of
Pittsburgh School of Medicine, 3811 O’Hara Street,
Pittsburgh, PA 15213. Fax: 1-412-624-2841.
Smith and Wegener
Versions. Japanese (validated) (2), German (3),
and French (validated) (4).
Number of items in scale. The instrument
consists of 19 items. There are 5 additional
questions rated by the bed partner/roommate that
are not included in the total score, but may be
useful for clinical purposes.
Subscales. The 19-items are grouped into 7
equally-weighted component scores: 1) Subjective
Sleep Quality (1 item); 2) Sleep Latency (2 items);
3) Sleep Duration (1 item); 4) Habitual Sleep
Efficiency (3 items); 5) Sleep Disturbances (9
items); 6) Use of Sleeping Medication (1 item); and
7) Daytime Dysfunction (2 items).
Populations. Developmental/target. The PSQI
was originally developed on 2 distinct groups of
poor sleepers, patients with major depression and
sleep disorder patients. A sample of good sleeper
controls was also used in the original development
(1). The sleep disorder sample consisted of patients
referred to a sleep disorders center who presented
with trouble initiating or maintaining sleep and/or
disorders of excessive daytime somnolence.
Other uses. The PSQI has been subsequently
used and, in some cases, validated in a variety of
clinical populations including: heterogeneous
samples of chronic pain patients (5–7),
fibromyalgia (8), temporomandibular joint disorder
(9), post acute traumatic brain injury (validated)
(10), bone marrow transplant (validated) (11), renal
transplant (validated) (11), women with breast
cancer (validated) (11), human immunodeficiency
virus infection (12), irritable bowel syndrome (13),
Parkinson’s disease (14), older adults (15), primary
insomnia (validated) (3), panic disorders (16),
posttraumatic stress disorder (17), and sheltered
battered women (18).
WHO ICF Components. Body function,
Impairment, Activity liimitation, Participation
restriction, Environmental factor.
Administration
Method. Self-report, paper and pencil.
Training. Minimal.
Time to administer/complete. Five to ten
minutes.
Equipment needed. None.
Sleep
Cost, availability. No cost; available from
authors.
Scoring
Responses. Scale. Items 1– 4 are free entry of:
usual bed and wake times, minutes of total sleep
time, and sleep latency (minutes). Items 5–18 are
4-point Likert scale responses pertaining to
problem frequency: “not during the past month
(0)”; “less than once a week (1)”; “once or twice a
week (2)”; and “three or more times a week (3).”
Item 19 is a 4-point Likert scale rating of overall
sleep quality: “Very good (0)”; “Fairly Good (1)”;
“Fairly Bad (2)”; “Very Bad (3).”
Score range. The Global Score ranges from 0 to
21. All component scores range from 0 to 3.
Interpretation of scores. Higher Global Scores
indicate poorer sleep quality. An empirically
derived cutoff score of ⬎ 5 distinguishes poor
sleepers from good sleepers. A Global Score ⬎5
indicates that a subject reports severe difficulties in
at least 2 domains, or moderate difficulties in more
than 3 areas.
Method of scoring. The PSQI is hand-scored by
assigning ordinal values to quantitative and
qualitative items in order to generate seven
equally-weighted component scores. The 7
component scores are summed to yield a single
Global Score. Scoring instructions are provided in
the original publication.
Time to score. Five minutes.
Training to score. Minimal.
Training to interpret. Minimal.
Norms available. Traditional norms are
unavailable. Mean ⫾ SD Global Score values for
good sleeper controls (n ⫽ 52, 2.67 ⫾ 1.70; Major
depression (n ⫽ 34, 11.09 ⫾ 4.31); Disorders of
Initiating and Maintaining Sleep (n ⫽ 45, 10.38 ⫾
4.57); Disorders of Excessive Daytime Somnolence
(n ⫽ 17, 6.53 ⫾ 2.98) (1). Mean Global Score ⫾ SD
for healthy older adults, ⬎80 years of age (n ⫽ 44,
age ⫽ 4.75 ⫾ 3) (15). Mean Global Score ⫾ SD for
heterogeneous outpatient chronic pain (n ⫽ 51,
11.57 ⫾ 4.36) (5). Mean Global Score for Primary
Insomnia (n ⫽ 80, 12.5 ⫾ 3.8) (3).
Psychometric Information
Reliability. Internal consistency. In the original
report (1), the 7 component scores had an overall
S193
Cronbach’s alpha coefficient of 0.83, indicating
high internal consistency. Component to Global
Score correlation coefficients ranged from 0.35
(Sleep Disturbance) to 0.76 (Habitual Sleep
Efficiency and Subjective Sleep Quality), with a
mean component to global score Pearson’s r
correlation ⫽ 0.58. Individual items were also
strongly intercorrelated with an internal reliability
coefficient (Cronbach’s alpha) ⫽ 0.83. Item to total
correlation coefficients ranged from 0.20 (item #8;
difficulty staying awake) to 0.66 (item #9,
enthusiasm to get things done).
Test-retest. The PSQI global score and
component scores demonstrate adequate stability.
Paired t-tests indicated no significant differences
between global and component scores measured at
T1 and T2 (mean of 28.2 days later). The Global
Score Pearson product-moment correlation
between T1 and T2 ⫽ 0.85 (P ⬍0.001). Component
score test-retest correlation coefficients ranged from
0.65 (Medication Usage) to 0.84 (Sleep Latency, P
⬍0.001) (1).
Validity. Criterion. Criterion validity was
originally established by evaluating the PSQI’s
ability to distinguish “good sleepers” from “poor
sleepers” as defined by diagnoses based on the
integration of expert structured clinical interviews,
physical exam, and polysomnographic testing (1).
The Global Score and all component scores
differentiated poor sleeper groups from controls (P
⬍ 0.001). A post hoc Global Score cutoff ⬎ 5
correctly identified 88.5% of all patients and
controls (kappa ⫽ 0.75, P ⬍ 0.001) with a
sensitivity of 89.6% and a specificity of 86.5%.
Convergent validity with polysomnographic
indices. The individual PSQI estimate of sleep
latency for the previous month was not found to be
different from polysomnographically defined sleep
latency (Pearson’s r ⫽ 0.33, P ⬍ 0.001) (1). PSQI
estimates of usual sleep duration and sleep
efficiency were significantly greater than
polysomnographic estimates, however (P ⬍ 0.001).
The PSQI Global Score correlated weakly with PSG
defined sleep latency (r ⫽ 0.20, P ⬍ 0.01). It
should be noted that PSG data (2-night laboratory
evaluation) and PSQI data (self-report of previous 1
month period) were based on different time frames.
In a study of primary insomnia (n ⫽ 80), PSQI
Global Score correlated significantly (P ⬍ 0.05)
with PSG measures of Total Sleep Time (without
stage 1) (r ⫽ ⫺0.32), sleep efficiency (r ⫽ ⫺0.32),
and % of stage 2 sleep (⫺0.33) (3).
S194
Convergent validity with daily sleep diaries. In a
sample of patients diagnosed with primary
insomnia, PSQI estimates of sleep duration and
sleep latency correlated strongly with daily sleep
diary estimates (r ⫽ 0.81 and 0.71, P ⬍ 0.000,
respectively) (3). Notably, the PSQI yielded reliably
longer sleep latency times and shorter sleep
duration times relative to diary estimates.
Convergent validity with other retrospective
measures of sleep quality. In medical patients
(bone marrow transplant, renal transplant, breast
cancer, and women with benign breast problems),
PSQI Global Scores were found to be moderately to
highly correlated with single and multiple item
scales of sleep quality/problems (11). Specifically
the PSQI global score correlated highly with sleep
problems on the Symptom Experience Report (11),
the Sleep Restedness item from the CES-D (19),
and Sleep Quality from the Sleep Energy, and
Appetite Scale (11) (correlation coefficients ⬎0.69).
Divergent validity. In medical populations, the
PSQI global score was poorly correlated with
measures unrelated to sleep quality such as
nausea, vomiting, and taste changes (correlations
⬍0.37) (11).
Sensitivity/responsiveness to change. Although
not designed as a treatment outcome measure, the
PSQI has been shown to be sensitive to change in
clinical trials of insomnia (20,21). Notably, Currie
and colleagues found the PSQI to be sensitive to
improvements in sleep quality after cognitive
behavior treatment for insomnia secondary to
chronic pain (22).
Comments and Critique
The PSQI is perhaps the most widely used
general measure of sleep quality available. The
strengths of this instrument are its range of
coverage of multiple dimensions of sleep quality,
its flexibility as a brief clinical tool, and its
demonstrated utility in chronic pain research. Two
primary limitations include the retrospective
design, and omission of items pertaining to
periodic limb movement/restless legs disorders
(PLMS/RLS) in the global score. PLMS/RLS are
important factors associated with sleep quality,
especially in older adult populations with chronic
pain. With regard to the retrospective nature of the
instrument, the PSQI may be subject to forms of
recall bias, such as recency effects and/or the
tendency to differentially weight the most extreme
nights of poor sleep in forming global impressions.
Because PSQI items refer to ratings of sleep for the
Smith and Wegener
previous 1-month period, this measure may be less
sensitive to estimating significant changes over
time or with brief intervention periods. Combining
the PSQI with prospective monitoring such as
daily sleep diaries or actigraphy is recommended.
It should also be noted that the cutoff score of 5
has been questioned and a score of 8 may be more
sensitive and specific for certain populations (11).
Another weakness is that the daytime
dysfunction component is comprised of only 2
items, enthusiasm and daytime sleepiness, and
does not include an item related to fatigue. Fatigue
is considered a hallmark symptom of insomnia,
whereas daytime sleepiness is often a primary
feature of other intrinsic sleep disorders. It should
be noted, however, that the PSQI is one of the few
measures of sleep that incorporate questions
pertaining to daytime sleepiness. Supplementing
an assessment of sleep in rheumatology patients
with measures of fatigue (see review in this series)
and one of the two most widely used measures of
excessive daytime sleepiness (23,24) is strongly
recommended. The Stanford Sleepiness Scale (SSI)
(24) is a 7-item measure, designed to evaluate
subjective changes in sleepiness using a 7-point
scale. Items range from 1 ⫽ feeling active, vital,
alert, or wide awake, to 7 ⫽ no longer fighting
sleep, sleep onset soon; having dream-like
thoughts. Strengths of the SSI are that it can be
repeatedly administered within a 24-hour period
and it is highly sensitive to change. The Epworth
Sleepiness Scale (ESS) (23) is an 8-item index
designed to measure the likelihood of falling
asleep in certain situations, such as sitting and
reading or in a car, while stopped at a traffic light,
etc. Items are ranked on a 4-point scale, from 0 ⫽
would never doze, to 3 ⫽ high chance of dozing.
The ESS is a reliable, well-validated measure of
“usual” sleepiness and may be of particular value
in the clinical assessment of sleep disorders such
as sleep apnea in individuals with a variety of
rheumatologic conditions.
References
1. (Original) Buysse DJ, Reynolds CF, Monk TH,
Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality
Index: a new instrument for psychiatric practice and
research. Psychiatry Res 1989;28:193–213.
2. Doi Y, Minowa M, Uchiyama M, Okawa M, Kim K,
Shibui K, et al. Psychometric assessment of
subjective sleep quality using the Japanese version of
the Pittsburgh Sleep Quality Index (PSQI-J) in
psychiatric disordered and control subjects.
Psychiatry Res 2000;97:165–172.
3. Backhaus J, Junghanns K, Broocks A, Riemann D,
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4. Blais FC, Gendron L, Mimeault V, Morin CM.
[Evaluation of insomnia: validity of 3
questionnaires]. Encephale 1997;23:447–53.
5. Smith MT, Perlis ML, Smith MS, Giles DE, Carmody
TP. Sleep quality and presleep arousal in chronic
pain. J Behav Med 2000;23:1–13.
6. Currie SR, Wilson KG, Curran D. Clinical
significance and predictors of treatment response to
cognitive-behavior therapy for insomnia secondary to
chronic pain. J Behav Med 2002;25:135–53.
7. Menefee LA, Frank ED, Doghramji K, Picarello K,
Park JJ, Jalali S, et al. Self-reported sleep quality and
quality of life for individuals with chronic pain
conditions. Clin J Pain 2000;16:290 –7.
8. Agargun MY, Tekeoglu I, Gunes A, Adak B, Kara H,
Ercan M. Sleep quality and pain threshold in
patients with fibromyalgia. Compr Psychiatry 1999;
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9. Yatani H, Studts J, Cordova M, Carlson CR, Okeson
JP. Comparison of sleep quality and clinical and
psychologic characteristics in patients with
temporomandibular disorders. J Orofac Pain 2002;16:
221– 8.
10. Fictenberg NL, Putnam SH, Mann NR, Zafonte RD,
Millard AE. Insomnia screening in postacute
traumatic brain injury: utility and validity of the
Pittsburgh Sleep Quality Index. Am J Phys Med
Rehabil 2001;80:339 – 45.
11. Carpenter JS, Andrykowski MA. Psychometric
evaluation of the Pittsburgh Sleep Quality Index.
J Psychosom Res 1998;45:5–13.
12. Nokes KM, Kendrew J. Sleep quality in people with
HIV disease. J Assoc Nurses AIDS Care 1996;7:43–50.
13. Elsenbruch S, Harnish MJ, Orr WC. Subjective and
objective sleep quality in irritable bowel syndrome.
Am J Gastroenterol 1999;94:2447–52.
14. Shulman LM, Taback RL, Bean J, Weiner
WJ. Comorbidity of the nonmotor symptoms of
Parkinson’s disease. Mov Disord 2001;16:507–10.
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15. Buysse DJ, Reynolds C, Monk T. Quantification of
subjective sleep quality in healthy elderly men and
women using the Pittsburgh Sleep Quality Index.
Sleep 1991;14:331– 8.
16. Stein MB, Chartier M, Walker JR. Sleep in
nondepressed patients with panic disorder: I.
Systematic assessment of subjective sleep quality
and sleep disturbance. Sleep 1993;16:724 – 6.
17. Krakow B, Germain A, Warner TD, Schrader R, Koss
M, Hollifield M, et al. The relationship of sleep
quality and posttraumatic stress to potential sleep
disorders in sexual assault survivors with
nightmares, insomnia, and PTSD. J Trauma Stress
2001;14:647– 65.
18. Humphreys JC, Lee KA, Neylan TC, Marmar CR.
Sleep patterns of sheltered battered women. Image J
Nurs Sch 1999;31:139 – 43.
19. Radloff LS. The CES-D scale: a self-report depression
scale for research in the general population. Appl
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20. Backhaus J, Hohagen F, Voderholzer U, Riemann D.
Long-term effectiveness of a short-term cognitive-
behavioral roup treatment for primary insomnia. Eur
Arch Psychiatry Clin Neurosci 2001;251:35– 41.
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effectiveness of cognitive behaviour therapy for
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Ther 2001;39:45– 60.
22. Currie SR, Wilson KG, Pontefract AJ, deLaplante L.
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secondary to chronic pain. J Consult Clin Psychol
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Psychophysiology 1973;10:431– 6.
 S196

Summary Table for Sleep Measures*

Psychometric properties
Measure/ Method of Time for
scale Content Item formats Response format administration administration Primary scale outputs Validated populations Reliability Validity Responsiveness

ISI Severity of Sleep 7-items. Severity 5-point Likert Self, clinician 5 minutes or less Overall severity index with Primary insomnia and Good Good Good
onset, maintenance ratings of scale interview, and established cut offs medical/psychiatric
and early morning insomnia significant other insomnia, chronic pain
awakening symptoms report
insomnia, sleep
satisfaction,
insomnia-related
distress, daytime
impairment
MOS Sleep initiation, 12 items: sleep Free response and Self, clinician 5 minutes or less Overall sleep problem Primary care and multi- Good Poor Insufficientdata
quantity, continuity, and 6-point Likert interview severity index specialty care patients,
maintenance, graded severity scale Arthritis samples, back
respiratory, of common sleep problems
problems, disturbances
perceived adequacy
of sleep,
somnolence
PSD Timing of meals, 17 items. Diary Free response to Self 10 minutes sleep latency, # of Sleep disorders, Similar Good Good Good
stimulants, entries made standard awakenings, wake after diaries used in chronic
medications, twice a day questions, sleep onset time, total pain and fibromyalgia
exercise, napping, (Morning and some sleep time, sleep
bed and wake Night) categorical and efficiency
times, sleep 6-point Likert
continuity scale items
parameters, sleep
quality, mood and
alertness on waking
PSQI Sleep-wake patterns, 19-items. Questions Some free entry Self 5–10 minutes Global Sleep Quality Score General sleep disorders; Good Good Insufficientdata
sleep duration, pertaining sleep and 4-point with established cut-offs; Insomnia; breast
sleep latency, continuity Likert scale 7 subscales cancer; transplant
frequency and parameters and items patients, chronic pain;
severity of sleep graded severity fibromyalgia; TMD
disturbances, use of and frequency of
sleep medications, common sleep
daytime disturbances and
consequences, behaviors
overall/global sleep
quality

* ISI ⫽ Insomnia severity index; MOS ⫽ Medical Outcomes Study; PSD ⫽ Pittsburgh Sleep Diary; PSQI ⫽ Pittsburgh Sleep Quality Index; TMD ⫽ temporomandibular disorder.
Smith and Wegener