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Self-report measures of insomnia in adults: rationales, choices, and needs
Douglas E. Moul*, Martica Hall, Paul A. Pilkonis, Daniel J. Buysse
Department of Psychiatry, Western Psychiatric Institute and Clinic, Sleep and Chronobiology Center, University of Pittsburgh, Room E-1119, 3811 O’Hara Street, Pittsburgh, PA 15213, USA
Insomnia; Methodology; Questionnaires; Literature review; Adults; Priorities; Criteria
Summary Self-report measures continue to provide key information in the evaluation and treatment of insomnia. While knowledge development about insomnia continues to require multi-trait, multi-method studies, self-report measures remain central in most study designs. The available stock of insomnia-related questionnaires has a substantial heterogeneity in their formats, foci, scopes, and other attributes. While there may be beneﬁts from using specially tailored questionnaires in particular circumstances, in other cases the information quality of a study will be downgraded by poor choice of questionnaires. To assist clinicians and investigators in selecting questionnaires wisely, the present paper reviews questionnaire criteria and attribute priorities for clinical trials, theory tests, observational studies, and aging studies concerning insomnia. An extensive table of currently available questionnaires is provided, and some needs for future questionnaire development are also identiﬁed. q 2003 Elsevier Ltd. All rights reserved.
Insomnia has become a topic of increasing interest as more becomes known about the impact of insomnia on psychological functioning and physical health. Many kinds of studies are important for researching insomnia, and many kinds of self-report instruments will be needed to investigate it fully. The selection of instrument(s) for a particular study depends partly upon the deﬁnition of insomnia an investigator selects. Kleitman made the point that ‘hyposomnia’ might be a better term to describe the problem that most people experience. In the historical past, ‘insomnia’ denoted any poor sleeping (including sleep apnea). However, insomnia now has more constrained deﬁnitions, all without welldeﬁned polysomnographic (PSG) criteria. 1
*Corresponding author. Tel.: þ1-412-624-5281; fax: þ1-412624-2841. E-mail address: firstname.lastname@example.org (D.E. Moul).
The International Classiﬁcation of Sleep Disorders (ICSD) deﬁnes mild insomnia as ‘an almost nightly complaint of an insufﬁcient amount of sleep or not feeling rested after the habitual sleep episode’2 The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) deﬁnes Primary Insomnia as ‘a complaint of difﬁculty initiating or maintaining sleep or of non-restorative sleep that lasts for at least 1 month,’ along with the presence of functional impairment or signiﬁcant distress.3 These differing deﬁnitions reﬂect the lack of consensus in deﬁning insomnia as a syndrome. As a symptom, insomnia is also understood to be integral to well-deﬁned medical conditions (e.g. depression, pain, head trauma) that, when present, disqualify an experienced insomnia as being psychophysiologic or primary. Stated differently, the general construct validity of insomnia as a clinical problem is generally acknowledged, yet as a speciﬁc
1087-0792/$ - see front matter q 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1087-0792(03)00060-1
178 syndrome, its construct validity remains problematic. Both the ICSD and DSM deﬁnitions refer to insomnia as a collection of symptoms (i.e. complaints) rather than as a collection of clinical signs. Broadly speaking, insomnia research makes use of various approaches in attempting to understand the causes and consequences of poor sleeping. Selfreport questionnaires have remained a mainstay of insomnia research for several reasons. First, selfreports remain the primary metric for clinicians who treat insomnia patients. Second, obtaining self-reports is comparatively inexpensive. Third, in the absence of biomarkers of insomnia, and in the presence of competing deﬁnitions of insomnia, selfreport questionnaires provide key data through which one study may be compared to another. In contrast to many other syndromes, unique methodological problems may arise when studying insomnia because some of the subjective and objective data represent the same phenomena (e.g. sleep latency). The resulting subjective – objective contrasts may challenge the validity of self-reports of sleep beyond the usual difﬁculty of establishing the semantic validity of self-reports.4,5 The clinical deﬁnition of chronic insomnia probably cannot be based only on self-reports or only on PSG or other objective measures of sleeping. For this reason, it is highly important to be conceptually precise about the relation of selfreports to PSG data. A clear reference point is that the validity of PSG data cannot be regarded as an absolute, monolithic measure of sleep. PSG leads (e.g. C4) report on only a small fraction of the brain’s activity during sleep, and illuminate little about brain activity during waking to correlate with daytime symptoms of insomnia. Self-reports remain a part of any syndromal deﬁnition of chronic insomnia, and because of this also have validity, albeit a validity different from that of PSG data. While self-reports have this generalized validity, a separate question asks what relation exists between self-reports having different periods of recall (e.g. past-night versus past-week). At ﬁrst glance, this relation between recall periods appears to concern validity, or truthfulness, in reporting. However, because self-reporting is inherently experiential rather than strictly ‘factual’, it is clear that these relations are merely phenomenological rather than subject to strict tests of contradiction. (Interestingly, the same might be said for comparisons between objective measures. For example, it would make no sense to say that PSG data from the C4 lead was the ‘objective’ measure of sleep state, whereas the data from the F3 lead was not valid because it may not be in strict
D.E. Moul et al. synchrony with the C4 lead or present the same data.) Self-report data and PSG data can certainly be examined for their validity in relation to one another where they concern the same phenomena, for example, sleep latency. However, self-report data may report on sleep-related phenomena that are currently impossible to measure objectively with current technologies. In any case, conceptual difﬁculties persist regarding what is actually being measured in current measurement systems. While this conceptual difﬁculty inhibits conﬁdence in current theories about insomnia, it also means that there still are many opportunities for researching how candidate objective and subjective measures are related to one another. By implication, these difﬁculties indicate the need for multi-trait, multi-method programs of research using various measures associated with subjective and objective poor sleeping. For example, a trait such as a person’s habitual sleep latency may be researched with multiple methods of objective and subjective measurement. Similarly, various traits (e.g. sleep latency, number of awakenings, sleep efﬁciency) may be investigated with cross-correlational methods. In the future, new traits to study may be identiﬁed, and new methods of measurement may be developed. Self-report measures are not the sole data for studying insomnia, and should be correlated with data derived from the PSG and other physiological measures. On the other hand, even if biomarkers of chronic insomnia become well established, selfreport data will remain a vital source of information. Just as with any other syndrome in clinical medicine, a complete explanation of chronic insomnia will require precise and detailed conceptual linkages between objective physiological abnormalities in insomnia patients and patients’ symptoms, as expressed in self-reports. To assist researchers in selecting instruments, this paper has the following aims: (1) To review some criteria by which insomnia self-report instruments may be evaluated, (2) to prioritize different criteria for different classes of insomnia research, (3) to review current insomnia-related self-report instruments, and (4) to identify self-report instruments that are needed.
Measurement domains and criteria
Testing self-report instruments psychometrically is important because the average research subject might provide imprecise or biased responses in
Designing one’s own instrument gives one ﬂexibility. several stubborn problems present themselves when one wants to generalize across these studies.Self-report measures of insomnia in adults: rationales. However. subjects were diagnosed using the different deﬁnitions and procedures. However. particularly if one is venturing into a new and unique area. theory relevance. Pioneers of new areas need to invent new questions and instruments.8 Table 1 presents an assessment of priorities for selected general measurement domains and criteria within several research contexts. C: low priority. how variables relate to one another becomes an analytic problem. relation to a questionnaire’s measurement objectives. B: intermediate priority.7 In addition.6. Second. Furthermore. choices. sleep quality.9 . This makes comparisons between studies difﬁcult. and impairs the extrapolation of ﬁndings to other research or clinical settings. and of studies in general. and other qualities is also important. double-blind studies of longer-term hypnotic use in patients with chronic insomnia shows that they used a wide variety of study-speciﬁc measures. and needs 179 Table 1 Priorities for characteristics in various study types. as needed? In some cases this is a good strategy. the measures of outcome were not uniform. when variables or instruments have different scopes of reference (e. sleepiness) that the instrument proposes to measure. when similar studies already exist.g. Where one investigator chose self-reported sleep latency as a critical variable. An example illustrates what happened over time in a collection of studies conducted without standardized instruments. overuse of studyspeciﬁc measures generally lowers the scientiﬁc value of a particular study. Pro and Con: making your own instrument. particular symptom versus quality of life). or using an established one Why not just make up ad hoc questions for one’s study. usual sleep length. These problematic responses impair accurate scaling of the latent dimensions (e. since new topics require new measures. Domain Characteristics Study type Clinical Theory Epidemiological Genetics Services Economic trials test cross-section research Scaling and scoring Continuous measurement scaling Transparency of scoring Item-response characteristics Nighttime and daytime symptoms Cognitive domains Functional impairment and quality of life Short time-frame for self-report Treatment responsivity Predictive validity A A B A B A B A C C C C B C C B C C C C A B A B A C A B A C C C C B A A A C C C C C C B B B A C A A C B B A A A A C A C A B B A A C C C C B C C B C B C A C C C C A B C C B C C C B A B B B A B A A A B A A A B B B A A A A A A A C B C C A B A A A B A B A C B C A A B A A A Symptoms and impacts Time and prediction Sensitivity and speciﬁcity Sensitivity for caseness Speciﬁcity for caseness Positive predictive value Instrument burden Theories and causes Brevity of instrument Low costs Construct validity Measures potential confounders Measures causal intermediates Ease of implementation Linkages to service use Acceptability to end users Aspects of care Costs and utility Direct cost estimates of care A Indirect cost estimates of syndrome C Utility assessments A A: high priority. First. Several authors discuss general methods of assessing instruments.g. assessment of an instrument’s feasibility. A review of randomized.
the time frame of reporting should be considered in relation to the study question. Often there are accompanying investigations about the safety and side-effects of medication(s). using a validated. Several considerations can be reviewed when selecting instruments for a particular study. does the instrument use words largely free of double meanings? For insomnia patients. will some need to be modiﬁed. or to other self-report measures of fatigue? In addition. to lowered levels of alertness. depressed) provide different questionnaire responses. A researcher is wise to stipulate a study’s speciﬁc measurement objectives carefully and to decide if an available instrument meets those objectives. Moul et al. First. another intervention. is the instrument at the correct reading level for the study sample? Second.g. ‘Now’ reporting enhances internal validity because the self-reporting time frame is Study aims: some general types A speciﬁc study’s research design might ﬁt into one of several general categories that occur commonly and that share rationales for instrument selection. study-appropriate instrument only upgrades a study’s scientiﬁc value. If the goal of the study is to ﬁnd differences between treatments. We will avoid review of instruments with time frames of one-day (e. Concurrent validity in relation to insomnia refers to how the instrument correlates to other existing measures of phenomena related to chronic insomnia. is there a reasonable correspondence between the sample in which the instrument’s psychometrics were studied and the sample in the particular study? D. given the general kind of question. what are the practical constraints of using a particular instrument? Lastly.’ which different patients use variously to refer to an actual tendency to fall asleep.10 So for the question of long-term effectiveness of hypnotics. insomnia vs. First. depending on the circumstances. in addition to broad symptom coverage and overall summary scoring. Empirical tests of a words’ semantics in the target population may be required before it can be used in a questionnaire. Validating questionnaires requires psychometric testing that includes test – retest reliability and validity (i. relative temporal precision. or placebo. What is the general kind of question that is asked in efﬁcacy studies for insomnia? The general question is whether one can detect a statistically signiﬁcant difference in one or more deﬁned outcome variables between comparable samples of subjects ideally differing only by the speciﬁc medication or intervention to which they were exposed. one needs to employ a measure that produces timely and precise numerical changes as soon as the subject experiences symptomatic improvement in target symptoms. asking these four questions in turn. . compared to another medication. a few general criteria for instrument selection are worth noting. a particularly difﬁcult word here is ‘sleepiness. However. the overuse of study-speciﬁc measures has contributed to uncertainties about prescribing hypnotics.g. What are the measurement priorities in efﬁcacy studies for insomnia? The attributes of highest importance are those of treatment responsivity. diaries) or ‘now’ (e. Third. Before discussing the role that the study aims have in guiding instrument selection. how related is the instrument to PSG measures of sleep. does the instrument use words that local subjects normally use to refer to subjective states? For example.g. For example. will one or more established instruments sufﬁce. self-reports at time of awakening) reporting (reviewed by Spielman et al. what are the usual measurement priorities for this study type? Third. ‘truth value’) assessments.180 another chose self-reported quality of life.11). Thus. or will a new instrument need to be invented? We review several general situations by way of illustration. A weekly time frame of self-report questionnaires is a critical external validity issue for studies that investigate the stability and/or safety of longitudinal interventions because that comparison is made to clinical contexts where only weekly visits are usually possible. or to increased feelings of somatic fatigue. discriminant validity testing asks if different samples of subjects (e. Scenario 1: efﬁcacy studies One common study design tests the efﬁcacy of a particular hypnotic medication or deﬁned behavioral intervention. and focus more on instruments with a week-to-week time frame. Finally. considering the study’s speciﬁc aims? Second. what general kind of research question is being asked. Completing such psychometric studies is specialized and time-consuming. continuous measurement scaling.e. Why not only use well-validated. and transparency of scoring.E. a questionnaire in Spanish written in Spain may not be suitable for use in Mexico. ‘brand-name’ instruments? This may be a good strategy as well.
The QOLI does not query subjective sleep parameters. The popular SF-3620 is suboptimal in insomnia populations because some of its quality-of-life questions (e. none of which are the primary focus of efﬁcacy studies. has been useful in documenting clinical change. Hoelscher’s Insomnia Impact Scale (IIS)17 covers a broad range of subjective distress and cognitive items in a uniform Likert-scale format. Will one or more instruments sufﬁce to answer the general outcome question across medication efﬁcacy studies. and theory relevance. The AIS attempts to integrate daytime with nighttime perceptions. and has been used in outcome studies. Subdomain and quality of life attributes help localize where the therapeutic beneﬁts occur. then their inclusion as items in the outcome measure will reduce the chances of demonstrating a treatment effect. If a medication has side-effects that resemble the one or more symptoms of insomnia (e. creates potential non-response biases. AIS. mechanisms of disease. then the cost of employing. but has a 2-week reporting period. mild sleepiness. fatigue). The IIS focuses more on subjective distress. and not a validity. the SPQ has not been used in efﬁcacy trials. All these questionnaires appear to have at least some psychometric validity.Self-report measures of insomnia in adults: rationales. The PSQI does integrate nocturnal and daytime assessments that include parameters. and decreases the overall likelihood of demonstrating a treatment effect.12 constructed for use in medication trials.) Breadth of coverage and overall summary scoring protects the study against individual differences in symptoms or in their semantic descriptions. but without items reﬂecting subjective distress. The SPQ is short. The ISI has been translated into French.g. but uses a one-month recall period and complicated scoring rules. Jenkins’ Sleep Problems Questionnaire (SPQ)18 asks for the number of nights/days with four kinds of sleep difﬁculties in the last month. but awaits use in a clinical trial.14 a set of visual analogue scales. has been used quite successfully in documenting treatment efﬁcacy. ‘Now’ self-reports are not more or less valid than weekly self-reports (unless the respondents are consciously lying) because these time frames of reporting exist in a phenomenological. ‘Does your health now limit you in…lifting or . The current best questionnaires for week-to-week assessments probably are the LSEQ. but does not attempt to obtain subjective sleep parameters. Transparent scoring rules ensure that the data obtained will be conceptually and statistically unambiguous. To our knowledge. If the instrument needed is actually an interview conducted by properly trained clinical interviewers. and supervising these interviewers can be high. ISI and SISQ. in the absence of an ‘objectively’ subjective standard. These last attributes are more appropriate for questions about diagnosis. (The debate about long-term hypnotic use has been illserved by studies using questionnaires and laboratory-based studies that facilitate only high internal validity. A special caution is worth noting about symptoms in efﬁcacy studies. or mechanisms of action. The ISI and SISQ focus mostly on daytime symptoms. but have limitations as efﬁcacy measures. Too many dropouts degrades a study’s ease and quality of analysis. or is there a need for better instruments? Several instruments have been used successfully in aiding investigators to establish the efﬁcacy of treatments for insomnia. The Pittsburgh Sleep Quality Index (PSQI)16 has robust psychometric characteristics related to general sleep quality and is widely applicable in adult populations. high diagnostic speciﬁcity. The ISI. It has been used in several efﬁcacy trials. SPQ are brief. training. but it does not reﬂect how the week-by-week and longitudinal effectiveness of interventions are usually assessed by clinicians. The recently described Athens Insomnia Scale (AIS)15 attempts to integrate daytime with nighttime perceptions in one metric. The Quality of Life in Insomnia (QOLI) scale19 might also be considered in efﬁcacy trials where broader outcomes are considered.g. The Leeds 181 Sleep Evaluation Questionnaire (LSEQ). In some circumstances. data collection may be possible only using interviews or related methods. PSQI. Attributes of medium priority are scoring of symptom subdomains and quality of life. and is designed for use in medication rather than behavioral trials. The PSQI and QOLI have been more widely translated. What practical constraints should be weighed in selecting an instrument for an efﬁcacy study? One major consideration is whether the data collection process may be too burdensome for the subjects so that they drop out from the study. Spielman’s Insomnia Symptom Questionnaire (SISQ). The LSEQ asks about both nighttime and morning domains. but does not include subjective sleep parameters. Yet the QOLI is preferred where quality of life in relation to insomnia is the main focus. Attributes of low priority for efﬁcacy studies include trait measurement. and contains 51 wordy items in differing response formats. choices. SISQ. relationship to one another. uses the reference to ‘usual’ experience. and needs more immediate. Morin’s Insomnia Severity Index (ISI)13 has been used successfully in conjunction with comparisons of medication versus cognitive-behavioral treatments of insomnia.
The highest priority attributes in such circumstances are treatment responsivity. These include sleep hygiene interventions. relaxation training. even while such instruments are necessary as measures of ﬁnal therapeutic outcomes. hot baths) work. on principle. etc. From a medical point of view. At the present time there is no established instrument best suited to broad-based efﬁcacy evaluations in clinical trials. in theories explaining how hypnotic medications work.182 carrying groceries?’) relate poorly to the health concerns of insomnia patients. For the later kinds of theories. maintenance. sleep restriction. In theories explaining how physical interventions (e. and high temporal precision.’ Several limited attempts at designing questionnaires in the positive style can be found among insomnia efﬁcacy studies. yet those theories do not rely as much upon self-report data for veriﬁcation. construct validity.E. For example. the characteristics of the self-report instruments used to measure intermediate effects in a causal series becomes critical because it is such data that are needed to substantiate whether the particular theoretical mechanism occurs as postulated. have been designed to instrument symptoms. What is the general kind of question that is asked in studies of theory-based interventions for insomnia? These studies ask the general question of how the sequence of intermediate outcomes occur during the intervention to produce the therapeutic outcome. sleep restriction. In the case of medication-based or physical interventions. be related to physiological improvements in the sleep of insomnia patients. These process theories concern antecedents. The same cannot be claimed for behavioral or psychological theories. Parallel requirements are also present for theories about the mechanism(s) of action of pharmacological interventions. Since the neuroscience of behavioral interventions for insomnia is still unavailable. All mechanistic theories about interventions must provide time-series predictions that explain the explicit order in which various phenomena occur during the therapeutic transformation.. theories stipulate two main requirements: particular latent variables and temporal sequences. theory-relevant process measurement. with the theory stipulating what phenomena occur ﬁrst. Many questionnaires. self-report instruments are largely irrelevant as measures of intermediate effects or outcomes. intermediate outcomes or effects. the explanation of a hypnotic’s chemical effects on neurons relies in no way on any self-report. behavioral theories can now only be properly tested in relation to whether they accurately stipulate the sequence of phenomena occurring in the therapeutic process along the path to the ﬁnal therapeutic outcome(s).g. the study goal is not so much to advance knowledge of effects as it is to advance knowledge of causes. regarding how hypnotics work chemically). To our knowledge. Studies have documented the efﬁcacy of each of these interventions with the exception of sleep hygiene. in explicit sequence. a theory about insomnia therapy explains how an intervention improves sleep onset. including the PIRS. all theories must provide the linkage of neural phenomena back to the self-reportable states that underpin patients’ symptom reports. no instrument is available with psychometrics for use in this ‘positive’ sense. With theorytesting studies. Where such neuroscience is unavailable. Recently. some temporally prior outcomes concern the physiological effects of the physical exposures on intermediate brain phenomena in the path to sleep induction.g. second. At the end of the transforming time series. By providing such an account. some intermediate effects normally cited are those of the medications on neuronal receptors and ion channels in the chain of events that result in patients going to sleep. although the LSEQ asks about comparisons to ‘usual. Here. What are the measurement priorities in theorybased interventions for insomnia? For theories explaining the mechanism of action of hypnotics or physical interventions. D. The instrument(s) should have theory-driven construct validity for those latent variables that change during Scenario #2: testing a theory-based intervention Several behavioral and psychological interventions are available for helping insomnia patients. stimulus control. rather than to obtain endorsements of improvements. or quality. Medical theories explaining the physiological mechanisms of action of behavioral interventions require studies to actually test the theories underlying these interventions. Moul et al. the theoretical linkage is drawn through a time series of phenomenal data. these interventions must. For example. and cognitive therapy. this linkage is normally given in a theoretical account derived from pre-clinical neuroscience (e. A related and more discriminating kind of question is whether the therapeutic change occurs more in accordance with one or another particular mechanistic theory of action. our group has begun testing the Pittsburgh Insomnia Rating Scale (PIRS)21 which we hope will meet this need. such . and ﬁnal therapeutic outcomes.
quality of life measurement. What practical constraints should be weighed in selecting an instrument for a theory-testing study? An instrument’s everyday practicality is not important for a theory-testing study. Investigators need to use or . then speciﬁcity in that sense may be rather important. or represent outcomes rather than precursors. then using the SII would be clearly important. Table 2 provides a listing of questionnaires that investigators have used to address theories in relation to insomnia. and trait measurement. false. if a theory postulates that insomnia patients are cognitive worriers. and needs the therapeutic intervention(s). If the theory is speciﬁc to one kind of insomnia. Morin’s own therapy-optimizing studies focus on patients with primary insomnia. trait measurement may be important for identifying those psychological types for whom the theory is especially descriptive. Such selection will create 183 sampling biases. However. then some instruments are required to measure such cognitive events in exact temporal series. then using a theory’s standardized instrument is rather mandatory. These attributes can be important. choices. then currently available questionnaires are poorly suited to elucidating causal processes in insomniac patients. or transportability to usual clinical settings. If the instrument(s) cannot place intermediate events exactly in the postulated event series. its questions are more focused at a dispositional (e. investigators are wise to select subjects willing to complete exhaustively all the therapeutic interventions and measurement activities. then using a well-standardized instrument simply because it is well known may not properly test the new theory. then the selected instrument(s) should quantify cognitive worrying faithfully in relation the postulated theory in order that the study may substantiate the theory. Lower priority attributes are wide symptom domain. Instead.g. not a ﬁnal outcome or ordinary clinical feasibility. For example. These last attributes are generally unimportant because the design tests a theory. if the sleep patterns of insomniacs behave chaotically in the mathematical sense. or is there a need for better self-report instruments? Several established questionnaires can be productively used for some theories and some purposes. In this case. For theory-based studies. It is a sad calamity when a theory-based study lacks the design quality to test the postulated theory because of poor instrument selection: No new knowledge becomes available. if an investigator has a new intervention based on a new theory. Testing a theory usually requires ‘laboratory-grade’ conditions with high internal validity. Will one or more instruments sufﬁce to answer theory-testing question across studies. ‘Are you now the kind of person who…’) time-scale. transparency of scoring. For example. Using less than ‘laboratorygrade’ measurements actually contradicts the underlying research aim. Since many theories are relevant in insomnia research. many of the questionnaires address process theories only indirectly. Furthermore. the Minnesota Multiphasic Personality Inventory was used in this way. Medium-priority attributes for theory-testing studies are continuous measurement scaling. speciﬁcity. then the study design cannot comment on whether the theory is true. Likewise. Yet the SII does not have the temporal resolution necessary to conﬁrm or disconﬁrm this clinical theory. and frankly wrong to select a self-report instrument with a long recall period. yet it is not clear how to use such research predictively in clinical or psychophysiological laboratory settings because dispositional notions are probabilistic rather than deterministic in their predictive capacity. where the sample and therapeutic exposures are very carefully characterized. This seems intuitively correct. In the past. too. it would be highly important to select a selfreport instrument with a short recall period. depending on the circumstances. In constructing this table.Self-report measures of insomnia in adults: rationales. we refrained from providing reliability and validity data because we believe it is the responsibility of individual investigators to ascertain whether particular instruments have reliability and validity in their own samples and research contexts. Helpful theories have been constructed at dispositional levels of time-scale. Continuous measurement scaling may be critical for statistical power considerations. A good example of a theory-based measure is Morin’s use of the SII and related instruments22 that track the cognitive aspects of insomnia patients. For example. if one wanted to know whether the same theory also applied to bipolar disorder patients with insomnia. the SII was constructed with a conception that dysfunctional cognitions are an important interference in the sleep of insomnia patients. yet the presence of sampling biases is only a secondary consideration in theorytesting studies. If a study focuses on a theory’s generalizability in new populations. or misattuned. but with variable results. if a theory states that dysfunctional cognitions mediate between the intention to sleep and sleep itself. Theory-postulated intermediate states should be well instrumented with high (even instantaneous) temporal precision in order to test whether therapeutic processes are accurately predicted by the theory. On the other hand. On general review.
however. periodic limb movement disorder. morning restedness Fourteen mixed-format items. sleep onset difﬁculty.’ Factors of mental activity. awakening quality. and dream disturbance.184 Table 2 Selected conceptual frameworks in insomnia research and related questionnaires. Domains of sleep parameters. Reports on medication/pillow use. Conceptual frameworka Sleep Sleep evaluation Sleep Disorders Questionnaire37 Indeﬁnite Questionnaire Time-frame Commentsb D. and psychiatric sleep disorder Eight hundred and sixty-three mixed-format items. directed at diagnosis. and depth Eleven mixed-format check-box items for medication studies. many with checkboxes. Moul et al. sleep onset difﬁculty. bedpartner presence. Available in French47 Nine mixed-format items. directed at exhaustive survey of causes and consequences of sleep problems of all types Twenty-one mixed-format items. sleep quality. Reports on sleep parameters. awakenings. awakenings. but their relationships to reports from other time frames needs clearer description.’ ‘during the night. Domains of ‘going to bed. These instruments focus on the past night Eight VAS (Visual Analogue Scale) items for hospital patients. evening/night ailments. narcolepsy. length. narcolepsy. Subscalesc for sleep apnea. insomnia symptoms. medication effectiveness. awakening quality Four mixed-format items: sleep onset difﬁculty. Domains of fragmentation.’ and ‘on awakening. Domains of various speciﬁc sleep qualities and morning restedness (continued on next page) VSH sleep scale42 Today Sleep and signs and symptoms questionnaire43 Today The post-sleep inventory44 Today Wolff’s morning questions45 Today St. sleep quality. sleepiness in evening. Sleep questionnaire and assessment of wakefulness38 Basic nordic sleep questionnaire (PNSQ)39 Dutch sleep disorders questionnaire40 Lacks’ sleep history questionnaire41 Post-sleep evaluation Indeﬁnite Past 3 months Indeﬁnite Indeﬁnite Diagnostic questionnaires are desirable. morning alertness. sleep factors. morning factors. Domains of healthy. delay. Reports on sleep parameters. Domains of sleep patterns.E. and dream emotion Eight Yes/No items. sleep onset difﬁculty. snoring. and sleep goodness Six VAS and three sleep parameter items. designed to focus diagnostic questioning in a structure sleep history interview ‘Now’ instruments have the greatest intuitive appeal for ‘accurate’ reports. the validity of these questionnaires to ﬁnal diagnoses is not established One hundred and seventy-ﬁve ﬁve-point scale items. and apnea Forty-eight mixed-format items. directed at diagnosis. sleep quality. sleep length. with additional clinician-rated side-effect items Thirty thirteen-point-scale items. excessive sleepiness One hundred and seventy-six ﬁve-point scale items. sleep depth. sleep length. depression. dream amount. Mary’s hospital sleep questionnaire46 Today Kryger’s subjective measurements48 Morning sleep questionnaire49 Subjective evaluation of sleep50 Today Today Today .
post-sleep evaluation. sleep quality. Available in numerous languages Fifty-nine mostly ﬁve-point-scale items. evening psychological composure. dream recall/vividness. Factors of ‘mental anxiety. post-sleep evaluation. Available from the authors of this paper. sleep parameters. difﬁculties waking. Factors of sleep quality. evening psychological composure.g. allow development of new hypotheses. Under evaluation.Self-report measures of insomnia in adults: rationales. and needs Table 2 (continued) Conceptual frameworka Questionnaire Time-frame Commentsb 185 Schlaffregebogen A (SF-A)51 Today Twenty-three mixed-format items written in German.’ ‘stress problem pattern. dream recall. daytime functioning.’ and ‘physical tension’ Twenty-nine mixed-format items written in German. Some scales (e. sleep –wake regulation Sleep latency is an obvious focus for questionnaires on insomnia. Algorithm for global score from components of sleep quality. sleep latency. and inform public health polices about insomnia and its treatments (continued on next page) Sleep quality Pittsburgh sleep quality index16 Past month Sleep questionnaire52 Indeﬁnite Sleep disturbance questionnaire53 Schlaffregebogen B (SF-B)51 Indeﬁnite Past 2 weeks Sleep onset Nocturnal sleep onset scale (NSOS)54 Generic outcomes Past 2 weeks Spielman insomnia symptom questionnaire (SISQ)14 Athens insomnia scale (AIS)55 Pittsburgh insomnia rating scale (PIRS)21 Past week Past month Past week Leeds sleep evaluation questionnaire (LSEQ)57 Indeﬁnite Epidemiology . Asks about sleep onset. sleep disturbance. Factors of sleep depth. habitual sleep efﬁciency.5 min to fall to sleep Relatively theory-independent outcome measures are desirable for enabling generalizable comparisons of results across various kinds of efﬁcacy and theory-based studies Thirteen VAS items covering nighttime and daytime symptoms Eight four-point-scale items covering nighttime and daytime symptoms Sixty-ﬁve four-point-scale items. taking . Yet there remains a need to assess poor sleeping and its consequences in a comprehensive fashion Nineteen mixed-format items and ﬁve roommate-rated items. choices. evening psychological exhaustion. use of sleeping medication. awakening quality. The process of sleep onset should be more completely investigated. Domains of nighttime/daytime symptom distress. sleep latency. sleep duration. and somatic symptoms in sleep ‘Sleep quality’ is a term of art. masculine/feminine) go beyond themes in other scales Twelve ﬁve-point-scale items. negative affect/dreams. both clinically and scientiﬁcally Two four-point-scale items: Difﬁculty falling asleep. sleep length. sleep irregularity. Domains of sleep quality. evening psychological exhaustion.56 Ten VAS items with some comparing experience with a hypnotic to that of usual experience. Available in French47 Epidemiological studies provide prevalence data. Eighteen scales derived. somatic symptoms in sleep. and quality of life.
more speciﬁcity in stimulus identiﬁcation and speciﬁc stimulus-response patterns is needed Six mixed-format daily items for clinical logging across one week (continued on next page) Relaxation training Tension thermometer35 Stimulus control Now Practice record-stimulus control41 Today . Covers nighttime sleep difﬁculties. . Normed on an aging sample Scales for rating physical tension have been rather overlooked.186 Table 2 (continued) Conceptual frameworka Questionnaire Time-frame Commentsb D. daytime sleepiness. Translated for use in several languages Historical descendent of the Diagnostic Interview Schedule. awakening tired Four three-point-scale items written in French. difﬁculty returning to sleep. ICSD. Three three-point-scale items for nighttime (sleep latency . sleep worry. yet deﬁnitions of sleep hygiene vary. Factors of active behaviors (11 items). Moul et al. Angst’s questions58 Indeﬁnite Chevalier’s questions59 Past month Hatoum’s questions60 Sleep problems questionnaire18 Leger’s Q1 Questionnaire61 ´ Indeﬁnite Past month Indeﬁnite SLEEP-EVAL30 Various Composite international diagnostic interview (CIDI)29 Various Ten VAS scale items. and appropriate sleep behaviors may vary by age group Actually three scales: Sleep Hygiene Knowledge (13 seven-point-scale items). and are needed to help distinguish somatic from cognitive stimuli that may interfere with sleep in insomnia patients A single VAS from ‘not at all tense’ to ‘very tense’ A useful motivating concept for many behavioral interventions. Able to make DSM and ICSD diagnostic estimates with a structured interview Behavior therapies Sleep hygiene Sleep hygiene awareness and practice scale41 Past week Sleep behavior self-rating scale62 Sleep hygiene questionnaire63 Sleep behaviors scale: 60 þ 35 Indeﬁnite Indeﬁnite Indeﬁnite A generally useful clinical focus. Estimates diagnoses of DSM-IV primary insomnia.E. relaxation (8 items).6 ho sleep) and one three-way (tired/irritable/neither) daytime item Five Yes/No items. being unrested. For clinical and theoretical reasons. and Sleep Hygiene Practice (19 items counting days/nights of particular activities) Twenty ﬁve-point-scale items. It makes diagnostic classiﬁcations for DSM. nightmare. trouble staying asleep. and cognitive arousal (5 items). Insomnia graded into Level I and Level II severity Four ﬁve-point-scale frequency items: trouble falling asleep.20 min. Caffeine Knowledge (18 Yes/No items). panic. and ICD systems under conditions of inferential uncertainty. Contrasts bedtime and daytime items Ten Yes/No items asking about particular practices Thirty ﬁve-point-scale items. waking up at night. grading insomnia into mild and severe Computer assisted personal interview (CAPI) system in which an interviewer asks verbatim questions given by the computer.
napping. Designed for use in aging samples Ten mixed-format items. with items on sleep difﬁculty. Still others identify no mental events interfering with sleep. napping sleep aid/alcohol use. choices. functional impairment. the interfering events are images. Reports sleep parameters by weekday/weekend. Reports sleep parameters. and medication use. In some. Domains of insomnia severity. Factors of immediate consequences.Self-report measures of insomnia in adults: rationales. nocturnal events. nightmare frequency Nine mixed-format items with item deﬁnitions. Thoughts interfere with sleep in many patients. and needs Table 2 (continued) Conceptual frameworka Questionnaire Time-frame Commentsb 187 Sleep restriction The Pittsburgh sleep diary64 Today The Karolinska sleep diary65 Today DGSMAbend/MorganProtokolle fur Schlaffuntersuchungen66 ¨ Today Johns’ Instrument67 1 Week Sleep questionnaire68 Today Morin’s sleep diary22 Today Lacks’ daily sleep diary41 Today Visuelle Analogskala zur Erfassung von Schlafqualitat (VIS-A)69 ¨ Cognitivebehavioral Today Sleep log data addresses the therapeutic mechanism of sleep restriction because they provide subjective sleep parameters Twenty-three complex mixed-format items. Reports sleep parameters. and sleep-promoting practices Ten items from the DBAS. control and predictability of sleep. Has evening (daily feeling summaries. and daytime functioning Twenty-eight mixed-format items written in German. sleep parameters. mental/physical activation. sleep parameters) sub-forms The cognitive perspective postulates that adverse mental events occur between the intention to sleep and actual sleeping. Factors of sleep anxiety. nocturnal events. mood and alertness Thirteen mixed-format items plus a derived sleep efﬁciency items. sleep parameters. and beliefs about medication use (continued on next page) Insomnia severity index13 Past week Dysfunctional beliefs and attitudes about sleep scale22 Indeﬁnite Dysfunctional beliefs and attitudes about sleep scale-10 Fragebogen zu schlafbezogenen Kognitionen70 Indeﬁnite Indeﬁnite . many questionnaires are needed for the cognitive perspective on insomnia Seven ﬁve-point-scale items. Thus. morning refreshment and sleep restedness Ten mixed-format items. and bedtime arousing-stimulus items Eleven mixed-format items. causal attributions of insomnia. quality rating. self-composure. daytime naps. and ratings of sleep quality. daytime naps. positive selfinstructions. Themes of consequences of insomnia. sleep hygiene. sleep requirement expectations. catastrophizing. Records sleep parameters and sleep quality items Twenty-seven complex mixed-format items written in German with separate evening and morning reports. Reports daily food and drug intakes. long-term consequences. social concern. sleep worry. sleep quality. Reports some sleep parameters. Records daily food and drug intakes. and sleep satisfaction Thirty VAS items. exercise. and need for control Thirty four-point-(never to always)-scale items written in German. napping report) and morning (awakening quality.
Focused on general pathological worrying. Available from the authors of this paper Twenty-ﬁve ﬁve-point-scale items for use in normal adults. other-oriented perfectionism. Factors of non-clinical dysphoria. and napping Treatment effectiveness may depend upon how the patient views the insomnia problem or the offered treatment Nine ﬁve-point-scale items. eating.E. Moul et al. body care and movement. emotions. sleep need. Penn State worry questionnaire: past week71 Hewitt’s multidimensional perfectionism scale72 Past week Indeﬁnite Anxious self-statements questionnaire73 Past week The Self-Statement Test: 60 þ 74 Indeﬁnite Post-sleep evaluation questionnaire Today Floyd-Medler sleep beliefs scale75 Indeﬁnite Fifteen six-point-scale items. and independent categories. home management. mental images. Factors of a) inability to maintain coping and a negative view of the future. alertness. Main dimensions of physical. emotional. Factors of generalized positive thinking. Categories of ambulation. 45 items discussed. social interaction. emotional behavior. Translated into a number of languages Twenty-ﬁve ﬁve-point-scale items. white noise. mobility. and health consequences of insomnia is important for justifying the public health need for research on insomnia Fifty mixed-format items mainly focused on domains of daily functioning. coping strategies. psychosocial. and sleep-related thoughts Twenty-eight VAS items with Yes/No lead-in branch points. sleep and rest. and bodily sensations that occurred during prior night’s sleep onset. and social discomfort Forty ﬁve-point-scale Agree/Disagree items focusing on insomnia-related distress symptoms One hundred and thirty-six Yes/No items. sleepiness/cognitive inefﬁciency. possibly distinct from sleep worry Fifteen seven-point-scale items in publication. sleeping in. Domains for behavioral and pharmacological treatments Expectancy and acceptability Self-efﬁcacy scale41 Insomnia treatment acceptability scale22 Impacts and states Insomnia impacts Indeﬁnite Indeﬁnite Quality of life of insomnia19 Indeﬁnite Sleep effects index76 Past week Insomnia impact scale (IIS)17 Sickness impact proﬁle (SIP)77 Past 2 Weeks Indeﬁnite Documenting the behavioral. recreation. b) selfdoubt/questioning. health consequences. Dimensions of next-day consequences.188 Table 2 (continued) Conceptual frameworka Questionnaire Time-frame Commentsb D. psychological consequences. and pastimes (continued on next page) . motor impairment. behavior. Describes selfefﬁcacy about sleeping Sixteen VAS items. work. and c) confusion and worry about future plans Thirty-four ﬁve-point-scale frequency-based items asking about thoughts during wakefulness. Perfectionism is a possible impediment to sleep Thirty-two four-point-scale frequency-based items. communication. social prescribed perfectionism. Asks about thoughts. Domains of self-oriented perfectionism. sleep regularity. generalized negative thinking.
non-speciﬁc symptom of insomnia patients that needs more careful and precise descriptions Twenty ﬁve-point-scale items. embedded factors of activation and sleepiness. family relations. choices. Subscales for Faces. psychological fatigue. vitality. hostile outlook. Popular. deactivation-sleep from the AD ACL long form83 Thirty-eight ﬁve-point-scale items. high activation. leisure.Self-report measures of insomnia in adults: rationales. reduced activity. and angerout Fatigue is a common. role emotional. global affect Sixty-ﬁve four-point-scale items. ‘arousal’ will need to be deﬁned in relation to something other than the likelihood of sleeping. neurocognitive aspects. These questionnaires assess dimensions of arousal possibly relevant to insomnia research Twenty-six four-point-scale items focusing or reactivity to events and stimuli Twelve ﬁve-point-scale frequency-based items focusing on reactivity Fifteen ﬁve-point-scale items concerning presleep experiences. Domains of cognitive and somatic arousal Twenty four-point-scale items. general health. Factors of anger arousal. occupational. motivation. and needs Table 2 (continued) Conceptual frameworka Questionnaire Time-frame Commentsb 189 SF-3620 Past month Marchini monitoring inventory78 Leger’s Q2 questionnaire79 ´ Now Indeﬁnite Thirty-six ﬁve-point-scale items. but not designed speciﬁcally for insomnia Twenty-one ﬁve-point-scale items. anger-in. There is evidence it has separate. Indices for physical function. and mental fatigue Eight VAS items. driving/accidents. What they report when reporting sleepiness remains unclear Eight four-point-scale items rating the ‘tendency to doze’ in particular situations. physical fatigue. and Sleepiness Some insomnia patients seem to feel sleepy. reduced motivation. Factors of general activation. Reports on daily activity rates Fifty-four Yes/No items written in French. Available in French. role physical.47 One item with seven ordinal categories. Consciousness. yet may not be able to sleep or to nap. physical fatigue. Subscales of general fatigue. social. and social relations To move beyond the truism that arousal prevents sleep. Domains of global vigor. general deactivation. Available in French. range of anger-eliciting situations. Energized. Anergy. Consequence domains include domestic aspects. mental health.47 (continued on next page) Arousal Hyperarousal scale80 Arousability predisposition scale81 Pre-sleep arousal scale82 Indeﬁnite Indeﬁnite Indeﬁnite Activation-deactivation adjective checklist short form Now The multidimensional anger inventory84 Indeﬁnite Fatigue Multidimensional fatigue inventory (MFI-20)85 ‘Lately’ Global vigor and affect instrument86 FACES87 Today Sleepiness Epworth sleepiness scale88 Past week Stanford sleepiness scale89 Now .
asleep during conversations. Improved testing of . money problems. and the relationships may vary from person to person. Likewise. but the causal sequences are not always clear. Theory-based instrumentation lives on the frontier of self-report questionnaires because theories place greater demands on discriminating between potential causal explanations. drowsy when still. Factors of excessive daytime sleepiness. Intended as a sleepiness scale Eight four-point-scale items: Fell asleep as passenger.190 Table 2 (continued) Conceptual frameworka Questionnaire Time-frame Commentsb D. asleep when with friends. psychic distress. the formatting could not be entirely consistent without misrepresenting the unique qualities of the questionnaires. illnesses. Too many scales to mention here Somatic symptoms may impair sleep. ability to relax. One among many life events checklists available Insomnia complaints often accompany irregular or non-standard sleep–wake activity patterns. Summary measures of these patterns may help to place an insomnia complaint in context Nineteen mixed-format items. Subscales of intrusive thoughts and avoidance behaviors Ten Yes/No items about events: separations. (Pain metrics not included here) Twenty-six ﬁve-point-scale items about various somatic sensations Anxiety and depression Somatic focus Somatic symptom inventory91 Indeﬁnite Extrinsic factors Stress and strain Impact of event scale92 Life events scale93 Past week Past 6 months Stressful events and strains may precipitate or maintain insomnia. We use the term ‘subscales’ to refer to authors’ intentions to provide sub-metrics. and nocturnal sleep. and ‘report’ to refer to sleep parameters or more concretized information. Estimating the degree of focus patients have on somatic symptoms is important in understanding an insomnia complaint.E. loss of driver’s license. deaths. design instruments that are properly tuned to their theories. Available in French [47: 2403] Fifteen time-reporting items about regular daily activities. Provides a summary score along the dimension of morningness-eveningness. Designed for aging populations. being a victim of crime. social desirability. household moves. sleepy after reading. retirement. We attempted to format comments with as much consistency as possible. energy level. insomnia may itself be a stress or strain. Designed to quantify the overall regularity of activities Circadian Morning–eveningness questionnaire94 Indeﬁnite Social rhythm metric36 Daily a b c This framework is provided only to generate convenience categories in the presentation of a heterogeneous collection of questionnaires. ‘factor’ to refer to results from factor analyses. The sleep–wake activity inventory90 Indeﬁnite Daytime sleepiness scale54 Past 2 Weeks Fifty-nine VAS items. some assessment of stresses and strains is warranted Fifteen four-point-scale items. Moul et al. ‘domain’ to refer to generalized themes in a questionnaire. because of the heterogeneity of the instruments. and dosing when relaxed Depression and anxiety are likely both causes and consequences of insomnia. and select instruments with appropriate validities suitable for answering their own theorybased research questions. However. drowsy driving. In either case.
191 Scenario #3: epidemiological. The second kind of study focuses on analyzing available data to ﬁnd risk factors for a particular disease or disorder. but also attempt to conﬁrm or disconﬁrm theoretical accounts of the series of events or phenomena occurring with poor sleeping and during various therapeutic transformations. tasks where it is more important to know what medical service demands a population may make than it is to know exactly what their medical conditions are. Results from studies that rigorously test process theories in behavioral interventions will help clinicians select and monitor interventions for various subtypes of insomnia patients. and facilitate their export to everyday clinical settings. but often forms comparator groups based on outcomes observed in convenience samples. much attention is focused on the deﬁnition of diseases or disordered functioning. since there is a severity spectrum of insomnia in the population. Less important attributes are continuous measurement scaling.Self-report measures of insomnia in adults: rationales. The ﬁrst type of study focuses on population descriptions. and especially for case – control studies. and detailed reviews of symptoms that are not directly linked to the syndromal deﬁnition(s). yet case deﬁnitions are the core of these study designs.’ Observational studies fall into two general types. Classifying people accurately is often more important than scaling a latent construct. the nature of the population studied. because the diagnosis serves as the outcome and the researcher is looking for potential risk factors. and genetic studies: observational studies An ‘observational study’ generally refers to a study in which the investigator collects information largely without manipulating therapeutic or other exposures: The researcher just ‘observes. In these circumstances. What is the general kind of question that is asked in studies of epidemiological or case – control studies of insomnia in populations? The main aim of many epidemiological studies is to characterize the pattern of disease or disorder in the target population. which is exactly contrary to the goal of accurate classiﬁcation of cases. transparency of scoring. Since the interface between distress and perceived insomnia remains a quandary. and potential measurement problems. but it is not the main priority if unambiguous riskfactor analysis is attempted. analytic type of study can also use random samples.26 so our generalizing about them here should be taken as heuristic. and needs theories must not only measure end-point dimensional outcomes. Having good process theories that clearly explain the mechanisms of action of various interventions will enhance the intelligibility of interventions. On the other hand. the measurement of co-morbidities and independent risk factors are additional high priorities in analytic epidemiological studies. Many current self-report instruments do not address this requirement for theory testing. especially in longitudinal and case – control studies. There is a wide variety of observational study designs.25 future theory-based questionnaire development can be expected to take advantage of knowledge advancements regarding perceived insomnia distress and its inﬂuences over other questionnaire responses. The second. choices. Studies that sample on the basis of outcome are called case– control studies. What are the measurement priorities in observational studies on insomnia? If the study is focused on measuring general disability in the population. To guard against confounding. potential sampling biases. Yet for most epidemiological studies. case control. high diagnostic speciﬁcity is usually a high priority. In those preliminary studies. Yet in a number of preliminary studies. respondents that endorsed having insomnia were perforce required to use their own deﬁnitions. then a high priority attribute for instrument selection is high sensitivity. increase their clinical speciﬁcity. ideally using samples drawn randomly from probability-weighted population strata. . For good epidemiological studies. the psychologies of self-monitoring23 and of self-interpretation24 raise methodological difﬁculties that may have special characteristics in insomnia. insomnia prevalence was estimated from answers to inadequate questions like ‘Do you have insomnia?’ without deﬁning insomnia as a condition. Genetic studies fall within the general class of observational studies as well. an epidemiologically useful insomnia instrument should differentiate depression-related insomnias from psychophysiologic or primary insomnias. For example. This means that the instrument identiﬁes as many persons as possible who have the disease or condition. multidimensional scaling. In good epidemiological work. Case deﬁnitions of insomnia vary considerably across studies. Case–control studies are often used by clinical researchers when they explore for differences between insomnia patients and controls. sensitivity has some importance. the diagnostic speciﬁcity of an instrument is an especially high priority because these studies usually focus on one or more speciﬁc diseases or disorders. General disability questions are asked by investigators planning medical services or formulating government policies.
In circumstances where the insomnia researcher is inserting substudy questions into a larger epidemiological study. Actually taking blood levels or doing daily pill counts is impossible in epidemiological studies. More recently. without regard to diagnosis. estimate diagnoses from the DSM of the American Psychiatric Association.27 who constructed an interview from questions on the Hopkins Symptom Checklist-90.3 The DIS and the Composite International Diagnostic Interview (CIDI)29 (its historical descendant) are a reasonably good instruments to use where direct interviewing is possible. use of a computer-assisted phone interview (CAPI) may be best. Because sleeping pill use is often a topic of some public concern. Ohayon30 has developed a computer-assisted interview (SLEEP-EVAL) that can be used to estimate prevalence not only of primary insomnia. or is there a need for better instruments? Early innovators in the epidemiology of insomnia were Balter et al.. but this may be a problem if the sample population does not have a phone. Using branching question structures that drop non-productive lines of questioning may improve the instrument’s performance by reducing its usual length. also provided some prevalence estimates from the Epidemiologic Catchment Area Study but in reference to formally modeled psychiatric diagnoses.E.192 Low priority attributes for epidemiological studies are psychological construct validities. In ﬁeld studies. called confounding by indication. Short question sequences may overlook relevant nighttime or daytime symptoms. Since benzodiazepine medications can be used as both hypnotics and anxiolytics. a study’s quality hinges on getting a large sample size in order to obtain prevalence or incidence estimates with narrow conﬁdence intervals and on minimizing potential non-response bias. although symptoms are not explored in detail. Such approaches may be more useful for services planning or policy formulation. This approach probably favored sensitivity. Will one or more instruments sufﬁce for observational studies. These latter two interviews are clinically based. but did not instrument psychiatric syndromes very well. the Structured Clinical Interview for DSM-IV Axis I Disorders31 is a well-regarded interview that reviews psychiatric diagnoses systematically (but not sleep disorders). It is better if the instrument or interview can be easily completed by respondents from a wide range of backgrounds and with a minimum of ambiguity and bias.28 utilizing data from the Diagnostic Interview Schedule (DIS). the overall administrative ﬁt between the instrument and the other instruments used in the study should be assessed. theory-dependence. It can provide research diagnostic classiﬁcations based both on the DSM system. Pretesting the interview should also address recall biases. Moul et al. and managing data quality impose substantial costs. so much so that pretesting the questionnaire may be mandatory. In some circumstances. written to D. The best methods for determining pill use involve the use of color photographic displays of pills or actual inspections of home medicine cabinets. In recent years. Question wording. In some cases. The DIS is a structured interview given to respondents by trained interviewers. and ordering are critical for a study’s knowledge value. By contrast. disentangling whether prescriptions were given appropriately involves not only determining what medication was actually prescribed and how it was consumed. However. Some investigators18 have devised short question sequences designed to gain estimates of insomnia prevalence. so nocturnal symptoms are not explored in depth in the DIS or CIDI.32 have developed the Structured Interview for DSM-III-R sleep disorders. and with the ICSD. but also of other confounding conditions. Its disadvantage is that it. but runs the risk of respondents using ‘no’ answers to shorten the data collection process. or treatment responsivity. Pharmacoepidemiological components to such studies add signiﬁcantly to a study’s design complexity. For more clinically based studies. likelihood-of-indication markers are postulated from dose/frequency relationships . like the DIS. which are major confounds of primary insomnia diagnoses. The latter methodological problem. or does not answer phone requests. so present some risk of missed ﬁndings. Ford and Kamerow. does not query nocturnal symptoms in depth.33 Simply measuring pill usage is largely uninformative. Schramm et al. hierarchy.2 The SLEEP-EVAL interview also offers the advantage of distinguishing between sleep dissatisfaction and a clear insomnia complaint. What practical constraints should be weighed in selecting an instrument for a epidemiological study? In epidemiological studies. photocopying forms. but also whether the medication was actually prescribed uniquely as a hypnotic for ‘pure’ insomnia. epidemiological studies of insomnia often are concerned with the estimation of sleeping pill use. the DIS was not designed with insomnia as its central focus. so studies investigating the appropriateness of prescribing and use require careful methodological ﬁts between the epidemiologies of the insomnias and mental health with the epidemiologies of psychotropic use. training and paying interviewers. is a very common problem in pharmacoepidemiological studies.
With this in mind. It will be even more difﬁcult to place 80-year-olds into diagnostic subtypes of insomnia than it is to classify 20year-old insomniacs into such archetypes. Since both determining the medications taken and the indications for use involve possible faults of memory in the respondents. and possibly reduces the homoeostatic drive for sleep. but might not address use for insomnia versus for nightmares. the elderly may report symptoms of demoralization. Stroke or dementia may further injure a person’s ability to regulate one’s sleep–wake schedule. lightens sleep. The elderly renegotiate their philosophies of daily activities and sleeping (e. Medication use often sustains one’s independence. or perhaps the CIDI. Advancements in knowledge about insomnia are now likely to require improvements in such instruments tailored to answer speciﬁc questions about risk factors for or consequences of insomnia. cognitive brittleness. These and other considerations imply that the study designs used in aging studies are likely to require a careful subgroup focus and/or great care in selecting instruments to measure confounding variables.g. Many aged persons also develop health conditions too numerous to list here. as follows. and whether such prescribing is safe and effective. the SLEEP-EVAL. In the Epidemiologic Catchment Area Study. Yet the dimensional approach may guide instrumenting chronic insomnia more meaningfully. 193 Scenario #4: geriatric insomnia What is the general kind of question that is asked in studies of geriatric insomnia? The heterogeneity in health statuses in aging populations makes it unlikely that there is one general kind of question.g. disabilities in spouses. data from the DIS supported the conclusion that depression was not a highly prevalent problem in the aged. but also as cognitive impairment may affect self-reporting. owing to the need to manage the sampling protocols. Given the public concern about whether sleeping pill use is appropriate or not. pharmacoepidemiological instrumentation will continue to be an enduring methodological challenge. In addition. What are the measurement priorities in aging studies on insomnia? Speciﬁcity in measuring health conditions is an obvious high priority.34 Evidently. Jenkins’ questionnaire may provide good information with a minimum of subject burden. normal aging reduces slow-wave sleep. Thus. and use of hypnotics may be more acceptable than earlier in life. depression. For services research studies. or insomnia in different ways from younger populations. This diagnostic approach is more appropriate for case – control studies. and monotonous daily routines all may facilitate difﬁculties with sleeping. What practical constraints should be weighed in selecting an instrument for study among the aging? One clear difﬁculty is whether to approach the measurement of insomnia more in a categorical sense. there are no standardized instruments available for pharmacoepidemiological studies of hypnotics. Physical disabilities. worries. An additional high priority is the speciﬁcation of cognitive level. When investigators need face-to-face interviews. increases the number of awakenings. which may also inﬂuence the timing of sleep and napping. which may be a useful strategy.Self-report measures of insomnia in adults: rationales. the interviewers should have the skills for working . Epidemiological studies largely depend upon deﬁnitions of disease or disorder. it is important that the selected instrument(s) used reﬂect how the elderly subpopulation thinks about its sleep and other life difﬁculties. of napping) across a range of opportunities and constraints. and needs (e. a separate study in a large substudy using the Present State Examination suggested otherwise. Even by itself. This is the usual context in which epidemiological studies are conducted. or in a dimensional sense. the measurement issues are likely to resemble those observed in geriatric depression. For a symptom such as insomnia. where stark contrasts are desired. not all retirements are ﬁnancially or socially secure. choices. trazodone 50 mg qhs). Furthermore. special methodological difﬁculties await researchers who desire to understand whether hypnotics are prescribed appropriately for insomnia. minimizing respondent burden by selecting shorter instruments with simply worded items may provide better information across the aged study sample. may be regarded as acceptable instruments for epidemiological studies if interviewers can be used. however. and lead to institutionalization. Investigators cannot ignore the implications of choosing between these approaches. Extrinsically. These interviews offer some measures of competing causes of insomnia other than primary insomnia. both as a health correlate. reduced coping skills. the way DIS wording and criteria were organized did not reﬂect how the elderly themselves might report poor mood functioning. retirement from work generally results in fewer daily scheduled events. The potential value of conceptualizing insomnia diagnostically is that criteria can be stipulated across subpopulations. Due to cohort biases or cognitive changes. Currently.
194 with the selected aging subpopulation(s). Since so many studies rely on case – control methodology. Improved instruments for tracking stimulus control and cognitive behavior therapy interventions in the in-bed time domain. 6. or is there a need for better instruments? The shallower and more fragmented sleep of normal aging poses interesting challenges for investigators in differentiating normal sleep from sleep that is dissatisfying to the person but not a medical complaint. 1. Improved longitudinal instruments to track the course of insomnia. Improved techniques for experience sampling insomnia patients during the daytime. non-pathological worry. caregiver-based questionnaires designed to identify poor sleeping in demented Questionnaire development needs for the insomnia ﬁeld Insomnia research at this time probably is in a similar situation to psychiatric research in the 19th century in that even the deﬁnitions of the terms employed remains open to debate. 4. with ability to detect periodicities of episodes. paradoxical fatigued alertness. Moul et al. Improved screening instruments for use in primary care. ﬁnding risk factors for different kinds of insomnia will be much more difﬁcult. Instrumentation for understanding how insomnia patients decide between treatments that may be offered. anxiety. 11. dissatisfying but tolerable sleep. as designed for different populations and from differing theoretical perspectives. The SLEEP-EVAL examination by Ohayon appears to approach this question to some extent in epidemiological studies. Such an instrument may require careful empirical studies of ‘sleepiness’ semantics among chronic insomnia patients. Without this. the extremely light and fragmented sleep of demented elderly patient also requires evaluation from the standpoint of the elder’s caregiver. but it is not clear that the SLEEP-EVAL exam is fully ready for aging population studies. designed to assist in triaging insomnia complaints between depressive. with specialized techniques to account for confounding by indication. Since insomnia is a risk factor for institutional placement of demented persons living in the community. and (2) to assist with identifying and assessing patterns of poor sleeping as they may affect health outcome and social independence. sleep that causes a medical complaint. and ‘pure’ alertness at bedtime. but being unable to sleep or nap). D. progress in insomnia research will depend in part upon advancements in questionnaire design. sleep anxiety.e. 2. sleep worry. and quality of life domains for use in outcome-based studies. since the interviewers may introduce biases by virtue of their expertise or prior experience. deactivation. Instruments to clarify kinds of arousal between general activation. 10. and primary insomnia disorders. Improved methods to query hypnotic medication use in populations. but sleep research on the aging will continue to need specially adapted questionnaires (1) to understand elderly subjects’ beliefs and experiences of sleeping and activity regulation. Thus. several needs for questionnaire development can be identiﬁed: .E. 8. 9. Using skilled interviewers is a trade-off against rote standardization. Better instruments to place insomnia in the context of multiple medical comorbidities. and from sleep that generates a complaint but no obvious PSG abnormality. and insomnia that causes substantial daytime distress or disability. The work of Morin and colleagues has likewise established the suitability of the SII in studies of aging insomnia patients. From this review. medical. subjective sleep parameters. somatic activation. Resolution of such debates will depend partly on review of data provided by self-report questionnaires. Monk’s Social Rhythm Metric36 must be regarded as especially relevant in examining the circadian stability of the daily regimens of aging persons. general worry. 12. there is a great need for the development of diagnostic questionnaires and interview schedules that can select kinds of insomnia with high grades of deﬁnitional speciﬁcity. An instrument for the kind of subjective sleepiness that insomnia sufferers endorse (i. 5. Will one or more instruments sufﬁce for insomnia studies in the aging. in both primary and secondary data sources. generalized anxiety. 3. 7. some investigators have begun useful lines of inquiry regarding insomnia in the elderly. Fichten and colleagues have approached the question of instrumenting sleep distress in the aged with the Sleep Behaviors 60 þ Questionnaire35 in concert with an ensemble of other measures. feeling sleepy. Clearly. Past-week insomnia rating scale integrating daytime and nighttime distress. especially in the framework of relative utility and cost-beneﬁt thinking. Such instruments could be especially useful if they enabled the distinction between qualitative classes of sleep: good sleep. At more clinical levels. adequate sleep. While not ‘insomnia’ in the usual sense of the term.
195 Research agenda General goals include: † Validation of insomnia as a unique syndrome through identiﬁcation of potential biomarkers that may be correlated with insomnia self-report data. Diagnostic and Statistical Manual of Mental Disorders: DSMIV. Where reasonable. Even after an investigator decides what deﬁnition to select for a study. hours of sleep).) Handbook of survey research. A comparison of prospective and retrospective assessments of sleep. Kubany ES. Conclusion Designing studies about insomnia in adult populations begins with the problem of the deﬁnition of insomnia itself. * 5. Practice points † While insomnia is a common problem with diverse causes. Mod Probl Pharmacopsychiatry 1974. whether they report in favor or against such use.. choices. Hartse K. theory tests.Self-report measures of insomnia in adults: rationales. An American Academy of Sleep Medicine report. diagnose.g. Anderson WM. Concerning semantic problems in psychological evaluation. Washington. 49: 455—460. and decreased quality of life. or monitor the speciﬁc clinical population served. Psychol Assessment 1995. † Development of improved instruments for use in clinical trials. Amherst. Wise M. and needs persons may assist in targeting caregivers for costeffective interventions. Selecting the ‘best’ questionnaire for a particular clinical practice context involves considering carefully how the questionnaire will exactly help screen. † Great caution is needed when interpreting epidemiological studies of sleeping pill use. Lavidor M. † A variety of insomnia-related instruments are available for use in clinical settings. Standards of Practice Committee of the American Academy of Sleep Medicine. JD Wright. Acknowledgements The authors thank David Kupfer. * 6. Littner M. J Clin Epidemiol 1996. Ph. Davila D. Haynes SN. collected prospectively and with various time-frames of self-reports. for helpful suggestions. Johnson S. Such studies usually cannot properly address the reasons and contexts in which prescribing was actually undertaken. observational studies. Bohrnstedt GW. Ronald Dahl. . 3. Sleep 2000. Practice parameters for the evaluation of chronic insomnia. Richard DCS. 7: 8—22. 23: 237—241. 7: 238—247. Pinard G. * 7. and the theory of insomnia that is modeled. and Anne Germain. Rochester. Content validity in psychological assessment: a functional approach to concepts and methods. 2. Chesson Jr A. its consequences span nighttime distress. However. AG00972. daytime distress. In: P Rossi. References * 1. Rafecas J. AB Anderson (eds. The International Classiﬁcation of Sleep Disorders: Diagnostic and Coding Manual. and aging studies. M. DC: American Psychiatric Association 1994. the kind of study anticipated. Babkoff H. M. 4th ed.D. there are signiﬁcant scientiﬁc beneﬁts from using questionnaires that others have developed and/or characterized. Tetreault L. sleep parameters (e.D. MH16804 and MH01554. This work was supported by grants AG15138. Weller A. * The most important references are denoted by asterisk. Measurement. † Integrated and consensus-based multidomain descriptions of insomnia. The authors also thank the peer reviewers of this article for helpful suggestions. sleep latency. MA: Academic Press 1983. American Sleep Disorders Association. whether an investigator is using a well established questionnaire or inventing a new one. 69—121. MH30915. it remains his or her responsibility to consider the reliability and validities of the questionnaires used if the study is to contribute to the advancement of knowledge about insomnia. The process of selecting an ensemble of questionnaires wisely begins with consideration of factors that include the population sampled. functional impairments. * 4.D. MN: American Sleep Disorders Association 1990. he or she must still consider carefully what selfreport measures to use. American Psychiatric Association Task Force on DSM-IV.
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