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The Spanish version of the Insomnia Severity

Index: A confirmatory factor analysis
ARTICLE in SLEEP MEDICINE DECEMBER 2011
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Sleep Medicine 13 (2012) 207210

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Sleep Medicine
journal homepage: www.elsevier.com/locate/sleep

Original Article

The Spanish version of the Insomnia Severity Index: A conrmatory factor analysis
Julio Fernandez-Mendoza a,, Alfredo Rodriguez-Muoz b, Antonio Vela-Bueno c,
Sara Olavarrieta-Bernardino c, Susan L. Calhoun a, Edward O. Bixler a, Alexandros N. Vgontzas a
a

Sleep Research and Treatment Center, Department of Psychiatry, College of Medicine, Penn State University, Hershey, PA, USA
Department of Social Psychology, School of Psychology, Universidad Complutense de Madrid, Spain
c
Department of Psychiatry, School of Medicine, Universidad Autnoma de Madrid, Spain
b

a r t i c l e

i n f o

Article history:
Received 7 March 2011
Received in revised form 10 June 2011
Accepted 11 June 2011
Available online 14 December 2011
Keywords:
Insomnia Severity Index
Spanish
Psychometric properties
Conrmatory factor analysis
Validation
Mood
Fatigue

a b s t r a c t
Objective: To examine the psychometric properties of the Spanish version of the Insomnia Severity Index
(ISI) and to determine its factor structure with conrmatory factor analysis (CFA).
Methods: Self-reported information was collected from a sample of 500 adults (mean age 39.13 [standard
deviation 15.85] years) drawn from a population of medical students and their social networks. Together
with the ISI, a measure of the subjective severity of insomnia, subjects completed the Pittsburg Sleep
Quality Index, the Epworth Sleepiness Scale, and the Prole of Mood States to study concurrent validity
of the ISI. CFA was used to test alternative models to ascertain the factorial structure of the ISI.
Results: The Spanish version of the ISI showed adequate indices of internal consistency (Cronbachs
a = 0.82). CFA showed that a three-factor structure provided a better t to the data than one-factor
and two-factor structures. The ISI was signicantly correlated with poor sleep quality, fatigue, anxiety,
and depression, and discriminated between good and poor sleepers.
Conclusions: The ISI is a reliable and valid instrument to assess the subjective severity of insomnia in
Spanish-speaking populations. Its three-factor structure (i.e., night-time sleep difculties, sleep dissatisfaction and daytime impact of insomnia) makes it a psychometrically robust and clinically useful
measure.
2011 Elsevier B.V. All rights reserved.

1. Introduction
Insomnia is the most common sleep disorder, with prevalence in
the general population ranging from 9% for chronic insomnia to 30%
for occasional sleep difculties or poor sleep [1]. Brief, easyto-administer, and valid patient-reported questionnaires to screen
and assess for insomnia are needed for clinical practice and
research.
The Insomnia Severity Index (ISI) [2] is a brief self-report instrument measuring a patients perception of the severity of his/her
insomnia. The ISI captures, in part, the diagnostic criteria for
insomnia outlined in the Diagnostic and Statistical Manual of
Mental Disorders [3] and the International Classication of Sleep
Disorders [4]. The ISI comprises seven items targeting the severity
of sleep onset difculties, sleep maintenance difculties, and early
morning awakening; satisfaction with current sleep; interference

Corresponding author. Address: Sleep Research and Treatment Center, Department of Psychiatry, Penn State College of Medicine, 500 University Drive H073,
Hershey, PA 17033, USA. Tel.: +1 7175310003x285570.
E-mail address: jfernandezmendoza@hmc.psu.edu (J. Fernandez-Mendoza).
1389-9457/$ - see front matter 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.sleep.2011.06.019

with daily functioning; noticeability of impairment attributed to

the sleep problem; and degree of distress or concern caused by
the sleep problem.
To date, the psychometric properties of the English [2,5,6],
French [7], Spanish [8], and Chinese [9,10] versions of the ISI have
been examined. These previous studies have shown that the ISI is
a reliable instrument and that its concurrent validity with other
questionnaires or sleep diaries is adequate [2,510]. Moreover,
the factor structure of the ISI has only been examined using
exploratory factor analysis, with mixed and inconsistent results
[2,5,7,8,10]. No studies to date have used conrmatory factor
analysis (CFA) to explore the factor structure of the ISI. Therefore,
it is unknown which factor structures reported in the literature best
explain the structure of the ISI.
Preliminary evidence suggests that the Spanish version of the
ISI has adequate psychometric properties. However, this evidence
comes from a study that used a relatively small, very homogenous
group of older adults that participated in a cognitive rehabilitation
programme [8]. Acknowledging that Spanish is the second most
spoken language in the world, it is essential to develop and validate
patient-reported instruments to assess insomnia in Spanishspeaking populations. This study aimed to validate the Spanish
version of the ISI using CFA.

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2. Methods
2.1. Participants
Five hundred adults from the general population (307 females,
mean age 39.13 [standard deviation 15.85] years, range
1970 years) were recruited by a snowball technique [11] in
which third-year medical students and two adults (age P35 years)
from each students social network (typically their relatives) were
invited to participate in a research survey on vulnerability to
insomnia during October and November 2007 [12]. All subjects
anonymously completed a survey packet that included published
self-report questionnaires that have shown acceptable indexes of
validity and reliability in their original versions. The study and
all procedures were approved by the Institutional Review Board
of the Universidad Autonoma of Madrid (CEI 20-417), and written
informed consent was obtained from all individuals. The characteristics of the sample are available online as Supplementary material.
2.2. Measures
The survey collected sociodemographic information from the
subjects (e.g., gender, age, weight, height) [12]. The Spanish version
of the ISI was used to assess the subjective severity of insomnia
over a 1-week period [13]. Each item was rated on a ve-point Likert scale (e.g., 0 = no problem, 4 = very severe problem), yielding a
total score ranging from 0 to 28 [2]. Subjects also completed the
Pittsburgh Sleep Quality Index (PSQI) [14], the Epworth Sleepiness
Scale (ESS) [15], and the depression, anxiety, and fatigue scales of
the Prole of Mood States (POMS) [16].
2.3. Statistical analyses
The analysis consisted of three steps. First, the reliability of the
questionnaire was examined by calculating its internal consistency
with Cronbachs a. Second, CFA of the items was performed to
examine the structure of the questionnaire. Maximum likelihood
estimation was employed using a covariance matrix [17]. Specic
details about the CFA procedure, goodness-of-t indices, and their
references are provided online as Supplementary material. Third,
to determine concurrent validity, zero-order correlation analyses
between the ISI scales and other, theoretically related, constructs
were performed. Statistical analyses were performed using
Statistical Package for the Social Sciences Version 15.0 (SPSS Inc.,
Chicago, IL, USA) and AMOS Version 17.0 [18].
3. Results
Cronbachs a for the ISI was 0.82. The items were homogeneous
since the corrected item-to-total correlation for the items ranged
from 0.47 to 0.71 (see online Supplementary material).
Three alternative factor models were tested using CFA. Model 1
(M1) was proposed as the null hypothesis, which postulated a
single factor on which all the items load. Model 2 (M2) postulated
a two-factor structure with correlated factors, similar to the factor
solution found in previous studies [7,9,10]. Model 3 (M3) proposed
a three-factor structure with two correlated factors [2]. Table 1 displays the t indices of the competing models, as well as the model
comparisons.
M3 provided a better t to the data, according to the Chisquared difference, compared with M1 (Dv2 = 235.99, Dd.f. = 5,
P < 0.001) and M2 (Dv2 = 119.4, Dd.f. = 4; P < 0.001). In addition,
in terms of t indices and parsimony, M3 showed the best t of
goodness-of-t index, comparative t index, NNFI, non-normed
t index, root mean square residual and Akaike information

Table 1
Fit indices for the estimated models (N = 500).
Model

v2

d.f.

CFI

GFI

NNFI

RMR

AIC

One factor model

Two factor model
Three factor model

267.64
151.05
31.65

14
13
9

0.79
0.89
0.98

0.84
0.91
0.98

0.69
0.82
0.95

0.09
0.06
0.03

295.64
181.05
69.65

CFI, comparative t index; GFI, goodness-of-t index; RMR, root mean square
residual; NNFI, non-normed t index; AIC, Akaike information criterion.
Levels P0.90 for GFI, CFI, and NNFI, and 60.08 for RMR indicate that the models t
the data well. As a rule of thumb, the model with the smallest AIC value is considered to be the best model.

criterion (see Table 1). The three factors in M3 were named

night-time sleep difculties (Item 1, sleep onset; Item 2, sleep
maintenance; Item 3, early morning awakening), impact of
insomnia (Item 5, interference; Item 6, noticeability; Item 7, distress), and sleep dissatisfaction (Item 1, sleep onset; Item 4, satisfaction; Item 7, distress) [2]. Cronbachs a for these factors was
0.60, 0.81 and 0.75 for night-time sleep difculties, impact of
insomnia and sleep dissatisfaction, respectively. Mean inter-item
correlations were 0.35 (night-time sleep difculties), 0.59 (impact
of insomnia), and 0.50 (sleep dissatisfaction).
As shown in Table 2, concurrent validity analyses indicate that
the ISI and its three factors show signicant correlation with the
PSQI and the anxiety, depression, and fatigue scales of the POMS,
and weak to non-signicant correlation with the ESS. Moreover,
85% of subjects classied as insomniacs in the ISI (total score
P8) [7] were classied as poor sleepers in the PSQI (total score
>5), and 33% of non-insomniacs were classied as poor sleepers
(P < 0.0001).
4. Discussion
The ndings of the present study suggest that the ISI is a reliable
and valid instrument to assess the subjective severity of insomnia
in Spanish-speaking populations. Furthermore, this study gives
conrmatory support to the three-factor structure of the ISI, which
covers the severity of night-time sleep difculties, sleep dissatisfaction, and daytime impact of insomnia. Thus, the ISI is a psychometrically robust and clinically useful measure.
Previous studies have reported on the factor structure of the ISI
using exploratory analysis, but the results have been mixed and
inconsistent. Bastien et al. [2] rst proposed a three-factor structure
of the ISI (i.e., night-time sleep difculties, sleep dissatisfaction, and
daytime impact of insomnia) that explained 72% of the total variance in a clinical sample of middle-aged insomniacs. Savard et al.
[7], in two samples of cancer patients, reported a two-factor structure of the ISI (i.e., night-time sleep difculties and daytime impact
of insomnia) that explained between 58% and 62% of the total variance. Sierra et al. [8], using the Spanish version of the ISI in a group
of older adults, reported a one-factor solution that explained 69% of
the total variance. Finally, Yu [9] explored the factor structure of the
Chinese version of the ISI and found a two-factor solution (i.e.,
night-time sleep difculties and daytime impact of insomnia) that
explained 61% of the total variance. A similar two-factor solution
has been found in a Chinese sample of adolescents [10]. The present
study tested these alternative models against each other using CFA,
and found that the three-factor model best explains the structure of
the Spanish version of the ISI. Therefore, this study, using the Spanish version of the ISI in a non-clinical sample of young and middleaged adults, gives conrmatory support to the exploratory factor
structure obtained by Bastien et al. [2] in a clinical sample of middle-aged insomniacs.
Furthermore, the present results suggest that changes in the
total ISI score (primary outcome) and each of the three factors

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Table 2
Correlations between ISI and other constructs (N = 500).

Impact of insomnia
Sleep dissatisfaction
Sleep difculties
Total score

PSQI

ESS

POMS
fatigue

POMS
depression

POMS
anxiety

0.49**
0.68**
0.62**
0.68**

0.26**
0.11*
0.04
0.18**

0.45**
0.34**
0.23**
0.40**

0.38**
0.27**
0.22**
0.34**

0.41**
0.33**
0.23**
0.38**

PSQI, Pittsburgh Sleep Quality Index; ESS, Epworth Sleepiness Scale; POMS, Prole
of Mood States.
*
P < 0.05.
**
P < 0.01.

(secondary outcomes) should be examined in clinical practice and

treatment studies. The ISI provides a brief measure to examine
whether treatment for insomnia not only targets night-time sleep
difculties and sleep dissatisfaction, but also the impact of the disorder on daytime functioning (e.g., daytime fatigue, ability to function at work/daily chores, quality of life, etc.).
In the present study, the ISI correlated positively and moderately with the PSQI. The vast majority of individuals classied as
insomniacs with the ISI (85%) were classied as poor sleepers with
the PSQI. Also, the ISI correlated signicantly with the depression
and anxiety scales of the POMS, a nding that is consistent with
previous studies [12,19]. Taken together, these data provide adequate concurrent validity for the ISI. Interestingly, the ISI correlated more strongly with fatigue than sleepiness. Sleepiness has
been dened as a subjective feeling of physical and mental tiredness associated with increased sleep propensity, whereas fatigue
is a subjective feeling of physical or mental tiredness that is not
associated with increased sleep propensity [20]. Insomniacs, in

209

spite of their subjective complaints of daytime fatigue and signicantly less nocturnal sleep, do not show increased sleepiness compared with normal sleepers [20], which suggests that insomnia is a
condition of 24-h hyperarousal.
This study has several limitations. First, part of the sample was
drawn from a population of medical undergraduates, so the results
should be generalized with caution. Second, the concurrent validity
of the ISI should be explored against other scales that specically
assess the severity of insomnia, and not just general sleep quality
as measured by the PSQI. Third, the absence of a clinical diagnosis
of insomnia in this Spanish validation did not allow the sensitivity
and specicity of the ISI cut-off scores to be determined
empirically. Finally, it would be interesting to test the linguistic
properties of the ISI in other Spanish-speaking populations. As
there are fewer regional differences in written Spanish than, for
example, written English, the authors believe that the Spanish
version of the ISI can be used in different Spanish-speaking
populations (Fig. 1).
Notwithstanding these limitations, it is concluded that the ISI
is a reliable and valid instrument to assess the subjective severity
of insomnia in Spanish-speaking populations. Its three-factor
structure (i.e., severity of night-time sleep difculties, sleep
dissatisfaction, and daytime impact of insomnia) supports the
ISI as a psychometrically robust and clinically useful measure.

Conicts of interest
The ICMJE Uniform Disclosure Form for Potential Conicts of
Interest associated with this article can be viewed by clicking on
the following link: doi:10.1016/j.sleep.2011.06.019.

Fig. 1. Path representation of the proposed three-factor model.

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References
[1] National Institutes of Health. National Institutes of Health State of the Science
Conference statement on manifestations and management of chronic insomnia
in adults, June 1315, 2005. Sleep 2005;28:104957.
[2] Bastien CH, Vallires A, Morin CM. Validation of the insomnia severity index as
a clinical outcome measure for insomnia research. Sleep Med 2001;2:297307.
[3] American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. Washington: American Psychiatric Association; 2000.
[4] American Academy of Sleep Medicine. International classication of sleep
disorders: diagnostic and coding manual. 2nd edn. Westchester: American
Academy of Sleep Medicine; 2005.
[5] Smith S, Trinder J. Detecting insomnia: comparison of four self-report
measures of sleep in a young adult population. J Sleep Res 2001;10:22935.
[6] Morin CM, Belleville G, Blanger L, Ivers H. The Insomnia Severity Index:
psychometric indicators to detect insomnia cases and evaluate treatment
response. Sleep 2011;34:6018.
[7] Savard MH, Savard J, Simard S, Ivers H. Empirical validation of the Insomnia
Severity Index in cancer patients. Psychooncology 2005;14:42941.
[8] Sierra JC, Guilln-Serrano V, Santos-Iglesias P. Insomnia Severity Index: some
indicators about its reliability and validity on an older adult sample. Rev
Neurol 2008;47:56670.
[9] Yu DS. Insomnia Severity Index: psychometric properties with Chinese
community-dwelling older people. J Adv Nurs 2010;66:23509.
[10] Chung KF, Kan KK, Yeung WF. Assessing insomnia in adolescents: comparison
of Insomnia Severity Index, Athens Insomnia Scale and Sleep Quality Index.
Sleep Med 2011; doi:10.1016/j.sleep.2010.09.019.

[11] Thompson SK. Sampling. New York: John Wiley and Sons; 1992.
[12] Fernandez-Mendoza J, Vela-Bueno A, Vgontzas AN, et al. Cognitive-emotional
hyperarousal as a premorbid characteristic of individuals vulnerable to
insomnia. Psychosom Med 2010;72:397403.
[13] Morin CM. Insomnio: asistencia y tratamiento psicolgico. Barcelona: Ariel;
1998.
[14] Macias JA, Royuela A. La versin espaola del ndice de calidad del sueo de
Pittsburg [The Spanish version of the Pittsburg Sleep Quality Index]. Inf
Psiquiatr 1996;146:46572.
[15] Arce-Fernandez C, Andrade-Fernandez EM, Seoane-Pesqueira G. Problemas
semnticos en la adaptacin del POMS al castellano [Semantic problems in the
Spanish adaptation of the POMS]. Psicothema 2000;12:4751.
[16] Izquierdo-Vicario Y, Ramos-Platon MJ, Conesa-Peraleja D, Lozano-Parra AB,
Espinar-Sierra J. Epworth sleepiness scale in a sample of the Spanish
population. Sleep 1997;20:6767.
[17] Byrne BM. Structural equation modeling with AMOS. Mahwah, NJ: Lawrence
Erlbaum; 2002.
[18] Arbuckle JL. AMOS 17.0 Users Guide. Crawfordville, FL: Amos Development
Corporation; 2008.
[19] Bluestein D, Rutledge CM, Healey AC. Psychosocial correlates of insomnia
severity in primary care. J Am Board Fam Med 2010;23:20411.
[20] Vgontzas AN, Zoumakis E, Papanicolaou DA, et al. Chronic insomnia is
associated with a shift of interleukin-6 and tumor necrosis factor secretion
from nighttime to daytime. Metabolism 2002;51:88792.