Sleep Medicine 12 (2011) 70–75

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

Original Article

Validation of the Brazilian Portuguese version of the Pittsburgh Sleep Quality Index
Alessandra Naimaier Bertolazi ⇑, Simone Chaves Fagondes, Leonardo Santos Hoff,
Eduardo Giacomolli Dartora, Ilsis Cristine da Silva Miozzo, Maria Emília Ferreira de Barba,
Sérgio Saldanha Menna Barreto
Sleep Disorders Center, Pulmonary Service, Hospital de Clínicas de Porto Alegre (HCPA), School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The Pittsburgh Sleep Quality Index (PSQI) is a questionnaire that assesses sleep quality and
Received 19 January 2010 disturbances over a 1-month period. It is a valuable tool for research purposes. The aim of this study was
Received in revised form 20 April 2010 to validate a Brazilian Portuguese version of the PSQI.
Accepted 24 April 2010
Methods: The Brazilian Portuguese version (PSQI-BR) was developed according to the following steps: (a)
Available online 9 December 2010
translation, (b) back-translation, (c) comparison between translation and back-translation performed by
a group of experts, and (d) pretest in bilingual individuals. Between January 2006 and September 2007,
Keywords:
the PSQI-BR was applied to a group of consecutive patients who were submitted to overnight polysom-
Sleep quality
Pittsburgh Sleep Quality Index
nography with clinical suspicion of obstructive sleep apnea syndrome (OSAS) or insomnia. As in the ori-
Validation studies ginal article, a group of patients with depression and a control group were included. The depression group
Cultural adaptation was composed of patients from the Mood Disorders Unit of the Psychiatry Department of Hospital de
Sleep disorders Clínicas de Porto Alegre (HCPA), Brazil. The control group was composed of subjects with a history of nor-
Sleep questionnaires mal sleep habits, without noticed snoring.
Results: A total of 83 patients and 21 controls completed the questionnaire and were submitted to over-
night polysomnography. The seven-component scores of the PSQI-BR had an overall reliability coefficient
(Cronbach’s a) of 0.82, indicating a high degree of internal consistency. The groups included 43 patients
with OSAS, 21 with insomnia, 19 with depression and 21 controls. The mean (±SD) PSQI-BR score was
8.1 ± 4.0 for patients with OSAS, 12.8 ± 3.7 for insomnia patients, 14.5 ± 3.7 for those with depression
and 2.5 ± 2.0 for control subjects. The one-way ANOVA demonstrated significant differences in PSQI-BR
scores across the four diagnostic groups (p < 0.001). Post hoc tests between paired groups showed that
scores for OSAS, depression and insomnia were significantly higher than for controls (p < 0.05). PSQI-
BR scores for insomnia did not differ from those obtained for depression (p > 0.05), but both were higher
than for OSAS (p < 0.05).
Conclusions: The results of the present study demonstrate that the PSQI-BR is a valid and reliable instru-
ment for the assessment of sleep quality and equivalent to its original version when applied to individ-
uals who speak the Brazilian Portuguese language. Despite relevant influences of language and cultural
background, no major cultural adaptations were necessary during the validation process. The PSQI-BR
can be a tool either for clinical management or research.
Ó 2010 Elsevier B.V. All rights reserved.

1. Introduction suffer from these disorders, the effect of their symptoms on their
quality of life often prompts them to seek medical attention for
Neurobiological processes associated with sleep are virtually diagnosis and treatment [2,3]. This has encouraged researchers to
necessary in all species for maintenance of physical and cognitive develop tools for assessing and further investigating these disor-
health. Sleep disorders may cause impairment in school perfor- ders. But most of these tools have been validated in English and
mance, work, family and social relationships and are also associ- targeted for English-speaking populations. If one wishes to apply
ated with increased risk for accidents [1]. For individuals who these tools in other populations, proper cross-cultural adaptation
and validation are required [4–6].
Subjective measurement tools can be used in clinical practice
for diagnostic purposes, for monitoring treatment responses, in
⇑ Corresponding author. Address: Otávio Alves de Oliveira, 330/402, 97050-550
Santa Maria, RS, Brazil. Tel.: +55 55 3222 5599.
epidemiological studies and in clinical research. Some of them
E-mail addresses: [email protected], [email protected] are designed for the assessment of specific sleep disorders, such
(A.N. Bertolazi). as sleepiness or presence of awakenings, while others evaluate

1389-9457/$ - see front matter Ó 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.sleep.2010.04.020
 A.N. Bertolazi et al. / Sleep Medicine 12 (2011) 70–75 71

sleep in a broad spectrum, especially with regard to sleep quality Brazil, between January 2006 and September 2007. Those patients
[7]. Assessing sleep quality is a complex task, since it involves were clinically diagnosed with depression, psychophysiological or
quantitative parameters, such as sleep duration, sleep latency idiopathic insomnia or OSAS. The questionnaire was applied by a
and number of awakenings, in addition to qualitative parameters, previously trained researcher during sleep outpatient clinic visits,
which are purely subjective. which could precede PSG in at most 2 weeks. The depression group
The Pittsburgh Sleep Quality Index (PSQI) [8], developed by Buy- was selected from patients under treatment at the outpatient clinic
sse, appraises sleep quality through a standardized questionnaire, of Psychiatry of HCPA who had scored 17 or more points on the
which can be easily understood and answered, differentiating be- Hamilton [14] depression rating scale. For each patient data
tween ‘‘good sleepers’’ and ‘‘poor sleepers.’’ It assesses sleep quality regarding age, sex, body mass index (BMI), neck circumference
over a 1-month time interval. This is an intermediate period be- (cm), comorbidities, and use of medications were recorded.
tween those questionnaires that evaluate only the last night’s sleep Patients who could not understand the questions; those with
and cannot detect dysfunctional patterns, and those that evaluate overlapping diagnoses, such as OSAS and depression; shift workers;
sleep quality over longer periods and cannot determine the severity those with polysomnographic findings suggesting disorders other
of a disorder at the present time. In addition, since its development, than OSAS, insomnia or depression were excluded from the study.
the PSQI has been widely used to measure sleep quality in different The control group consisted of patients from the Outpatient
patient groups, such as in patients with renal and intestinal dis- Clinic of Ophthalmology of HCPA as well as of hospital staff mem-
eases, with asthma and with cancer [9–13], and also in those with bers who did not have any sleep complaints and whose PSG find-
psychiatric or sleep disorders. This way, the combination of quanti- ings were normal.
tative and qualitative information on sleep quality should be high- The diagnoses of OSAS and insomnia followed the standards
lighted as an important feature of this questionnaire. established by the American Academy of Sleep Medicine (AASM)
The present study was carried out to translate the PSQI and val- [15].
idate its use in Brazil.
2.4. Statistical analysis
2. Patients and methods
Quantitative variables were expressed as mean ± SD, and quali-
2.1. Research tool tative variables were expressed as percentage values. Two-tailed P
values of 0.05 or less were regarded as statistically significant, and
The PSQI assesses sleep quality over a 1-month period. The 95% confidence intervals were calculated for results.
questionnaire consists of 19 self-rated questions and 5 questions Group data are described by means and standard deviations
that should be answered by bedmates or roommates. The latter (SD). For comparisons between groups, an analysis of variance
questions are used only for clinical information. The 19 questions (ANOVA) was performed. The effects of age, sex, body mass index
are categorized into 7 components, graded on a score that ranges (BMI) and apnea–hypopnea index (AHI) on the PSQI-BR scores
from 0 to 3. The PSQI components are as follows: subjective sleep were evaluated by analysis of covariance (ANCOVA). Internal con-
quality (C1), sleep latency (C2), sleep duration (C3), habitual sleep sistency of the PSQI-BR was assessed by Cronbach’s a statistics. A
efficiency (C4), sleep disturbances (C5), use of sleeping medication probability of p < 0.05 was considered statistically significant. Data
(C6) and daytime dysfunction (C7). The sum of scores for these 7 were analyzed by the Statistical Package for the Social Sciences for
components yields one global score, which ranges from 0 to 21, Windows (SPSS), version 12.0.
where the highest score indicates worst sleep quality. A global PSQI
score greater than 5 indicates major difficulties in at least 2 com-
2.5. Ethical aspects
ponents or moderate difficulties in more than 3 components [8].

The study protocol was approved by the Research Ethics Com-

2.2. Translation
mittee of the Graduate Research Program (GPPG) of Hospital de
Clínicas de Porto Alegre (HCPA), in accordance with International
The PSQI was translated into Brazilian Portuguese by 2 indepen-
and National Guidelines.
dent translators, who were aware of the study objectives. The
All patients and controls signed an informed consent form be-
translations were compared by researchers until a final version
fore inclusion in the study.
could be obtained. Back-translations into English were carried
out by another 2 translators, who did not participate in any of
the previous steps. The author of the scale, Daniel J. Buysse, as- 3. Results
sessed the back-translations and a final version was then obtained.
The comparison of the PSQI with the final back-translation was 3.1. Cross-cultural adaptation
made by individuals who were fluent in English and who were not
involved in the research study. Each of the items in both versions No structural modifications to the questionnaire were necessary
was analyzed following the method described in the literature during the cross-cultural adaptation process. After the analysis of
[6]. After this procedure, the final version of the PSQI, in Brazilian the translations, the authors decided to keep the translation of
Portuguese, known as PSQI-BR, was obtained (see Appendix). the term ‘‘bad dreams’’ in the item ‘‘Had bad dreams,’’ as we con-
In order to assess the linguistic interchangeability between the sidered that not only nightmares could interfere with sleep quality,
translation and the original questionnaire, a separate group of 14 but negative dreams could have the same effect. We added exam-
bilingual individuals answered firstly the PSQI and then PSQI-BR ples of activities in the item ‘‘During the past month, how often
at 4 week intervals. Their scores on each version were correlated. have you had trouble staying awake while driving, eating meals,
or engaging in social activity?’’ since we believed respondents
2.3. Patients could have some difficulty understanding which activities were in-
volved. In the question ‘‘During the past month, how much of a
The PSQI-BR was applied to a group of consecutive patients problem has been for you to keep up enough enthusiasm to get
aged 18–65 years who underwent polysomnography (PSG) at the things done,’’ we added the expression ‘‘your habitual activities’’
Sleep Laboratory of Hospital de Clínicas de Porto Alegre (HCPA), between brackets.
72 A.N. Bertolazi et al. / Sleep Medicine 12 (2011) 70–75

The scores of the PSQI-BR and of the original PSQI, both an-
swered by 14 bilingual individuals, yielded means (±SD) of
6.1 ± 3.4 and 5.6 ± 3.3, respectively, showing significant correla-
tions (r = 0.881; CCI = 0.878; p < 0.001) and indicating a good lin-
guistic interchangeability between the translation and the
original questionnaire. The internal consistency of the PSQI-BR
and of the original PSQI, measured by Cronbach’s a coefficient,
amounted to 0.73 and 0.75, respectively, when applied to this
group of bilingual individuals.

3.2. Characteristics of the groups and their respective PSQI-BR scores

A total of 83 patients and 21 controls completed the question-

naire and were included in the study after being submitted to over-
night polysomnography. The demographic characteristics of these
patients and controls are listed in Table 1. The 83 patients were
classified into the following groups: 19 in the depression group,
21 in the insomnia group, and 43 in the OSAS group. The mean
score for the Hamilton depression rating scale among patients with
depression was 20.9 ± 3.3 (±SD).
The 7-component scores of the PSQI-BR had an overall reliability
coefficient (Cronbach’s a) of 0.82, indicating a high degree of internal
consistency. The mean (±SD) PSQI-BR score was 2.5 ± 2.0 for control
subjects, 8.1 ± 4.0 for OSAS, 12.8 ± 3.7 for insomnia, 14.5 ± 3.7 for Fig. 1. Box plots demonstrating median, upper and lower quartils, minimum and
maximum PSQI-BR scores for each group of patients and control group.
depression. The one-way ANOVA demonstrated significant differ-
ences in PSQI-BR scores across the 4 diagnostic groups (p < 0.001).
There was a weak correlation between sleep latency obtained
Post hoc tests between the paired groups revealed that the PSQI-
by PSG and C2 (sleep latency) assessed by the PSQI-BR (r = 0.201;
BR scores for OSAS, depression and insomnia were significantly
p < 0.05). The same occurred between sleep efficiency obtained
higher than for the controls (p < 0.05). The scores for the insomnia
by PSG and C4 (habitual sleep efficiency) assessed by the PSQI-
group did not differ from those of the depression group (p > 0.05),
BR (r = 0.201; p < 0.05).
but both were higher than in the OSAS group (p < 0.05).
All patients in the insomnia and depression groups had scores
greater than 5, and 31 of 43 patients (72.1%) with OSAS had scores 4. Discussion
greater than 5, as shown in Fig. 1. Note that only one individual in
the control group had a score greater than 5. The scores for the PSQI-BR, measured by Cronbach’s a coeffi-
The one-way ANOVA showed significant difference in terms of cient components, showed good internal consistency, i.e., each of
age across the 4 groups (p < 0.001). Post hoc tests between the the 7 components of the questionnaire assesses a particular aspect
paired groups showed significant differences between the OSAS of sleep quality. Similar internal consistencies were obtained by
and depression groups comparatively to controls (p < 0.05) and be- other validation studies of the PSQI-BR in other languages
tween the OSAS and insomnia groups (p < 0.05). But there was a [16,17]. The application of the questionnaire to the group of bilin-
weak correlation between age and the PSQI-BR scores (r = 0.254; gual individuals helped to demonstrate the good linguistic inter-
p = 0.009). changeability between the translation and the original
The analysis of covariance (ANCOVA) showed that the differ- questionnaire. The PSQI-BR also showed adequate psychometric
ences in PSQI-BR scores across the diagnostic groups were statisti- properties, which allow its application to different groups of pa-
cally significant even after the adjustments for age, sex, sleep tients, such as the ones assessed in the present study.
efficiency, AHI, and sleep latency (p < 0.001). Submitting all study participants to PSG was a determining fac-
No correlations were observed between the PSQI-BR scores and tor in the selection of the groups. This allowed excluding patients
the nadir oxygen saturation (p = 0.48) and between the PSQI-BR with depression or insomnia who had a concomitant diagnosis of
scores and AHI (p = 0.56). OSAS. PSG also permitted a more accurate assessment of controls,

Table 1
Characteristics of the groups and their respective PSQI-BR scores.*

Depression (n = 19) Insomnia (n = 21) OSAS (n = 43) Controls (n = 21)

Age (years) 45.4 ± 10.3 40.9 ± 12.8 49.9 ± 9.1 36.1 ± 8.0
(19–60) (18–61) (27–65) (23–46)
Female/male 15/4 14/7 19/24 12/9
BMI (kg/m2) 26.9 ± 7.1 24.2 ± 2.9 30.9 ± 7.0 23.0 ± 2.7
(16.7–47.0) (17.4–30.1) (18.3–58.4) (18.4–29.2)
AHI 1.83 ± 1.36 0.68 ± 0.93 30.39 ± 24.78 0.77 ± 0.95
(0.2–4.8) (0–3.7) (5.5–104.8) (0–3.7)
PSQI-BR Score 14.5 ± 3.7a,b,c 12.8 ± 3.7a,b 8.1 ± 4.0a 2.5 ± 2.0
(6–20) (8–20) (2–17) (0–8)

OSAS, obstructive sleep apnea–hypopnea syndrome; AHI, apnea–hypopnea index; BMI, body mass index.
*
Data are presented as mean ± SD (range) unless otherwise stated.
a
p < 0.05 compared with controls group.
b
p < 0.05 compared with OSAS group.
c
p > 0.05 compared with insomnia group.
 A.N. Bertolazi et al. / Sleep Medicine 12 (2011) 70–75 73

excluding those individuals with abnormal polysomnographic find- The discriminatory power of the PSQI-BR between ‘‘good sleep-
ings, even if they were seemingly unrelated to clinical conditions. ers’’ and ‘‘poor sleepers’’ was properly demonstrated by the results
The mean PSQI-BR scores were similar to those of the original of the present study. By using a cutoff score of 5, as recommended
questionnaire in the control group. As with the OSAS, insomnia in the original study [8], one observes that all patients diagnosed
and depression groups, the mean PSQI-BR scores were higher than with insomnia or depression had scores greater than 5, which sug-
those obtained by Buysse et al. [8]. These dissimilar findings may gests poor sleep quality. Nevertheless, 12 out of 43 patients with
be ascribed to the differences between groups, since the diagnostic OSAS (27.9%) had scores lower than 5. This finding may be related
criteria used for the development of the PSQI were established to the fact that poor sleep quality is not the major complaint by pa-
according to the classification of 1979 [18], whereas in this study, tients with OSAS, as it is common knowledge that these patients
the OSAS and insomnia groups were defined according to AASM usually seek medical care due to snoring and apnea [20]. In addi-
criteria [15]. In any case, the results obtained with the original tion, one should take into account that the PSQI-BR is a subjective
questionnaire regarding the comparison between groups were tool for the assessment of sleep quality and, therefore, it is open to
reproduced in the present study, i.e., the scores achieved by control individual interpretations.
individuals were significantly different from those of the OSAS,
depression and insomnia groups, and the scores for the insomnia
and depression groups were higher than those for the OSAS group. 5. Conclusions
The fact that the scores for the insomnia group were not signifi-
cantly different from those of the depression group, as Buysse The results of the present study demonstrate that the PSQI-BR is
et al. [8] had found, comes as no surprise, since insomnia is the a valid and reliable instrument for the assessment of sleep quality,
most common sleep disorder among patients with depression. being equivalent to its original version when applied to individuals
As in the study for the development of the PSQI and further who speak Brazilian Portuguese. The PSQI-BR can be easily under-
publications [8,19], the PSQI-BR scores were not correlated with stood and answered combined with the advantage of allowing
polysomnographic findings. The different sleep patterns observed differentiation between ‘‘good sleepers’’ and ‘‘poor sleepers.’’
every night and the effect of spending the first night in a sleep lab- Therefore, given its considerable advantage of combining quantita-
oratory may be related to the differences between polysomno- tive and qualitative sleep data, the PSQI-BR is useful for the assess-
graphic findings and the subjective sleep parameters. Also, it ment of patients with disorders that are likely to affect sleep
should be highlighted that the questionnaire assessed sleep quality quality.
over the past month and that it is not sensitive to daily fluctuations
in sleep patterns.
Selecting diverse groups for this study apparently did not inter- 6. Disclosure statement
fere with the results, since such results were similar to those ob-
tained in other PSQI validation studies. The authors report no conflicts of interest.

Appendix Índice. de qualidade de sono de Pittsburgh (PSQI-BR)

Nome:_________________________________________________ Idade:_____ Data:____________

Instruções:
As seguintes perguntas são relativas aos seus hábitos de sono durante o último mês somente. Suas respostas devem indicar a
lembrança mais exata da maioria dos dias e noites do último mês. Por favor, responda a todas as perguntas.
1. Durante o último mês, quando você geralmente foi para a cama à noite?
Hora usual de deitar ___________________
2. Durante o último mês, quanto tempo (em minutos) você geralmente levou para dormir à noite?
Número de minutos ___________________
3. Durante o último mês, quando você geralmente levantou de manhã?
Hora usual de levantar ____________________
4. Durante o último mês, quantas horas de sono você teve por noite? (Este pode ser diferente do número de horas que você ficou na
cama).
Horas de sono por noite _____________________
Para cada uma das questões restantes, marque a melhor (uma) resposta. Por favor, responda a todas as questões.
5. Durante o último mês, com que freqüência você teve dificuldade de dormir porque você...

(a) Não conseguiu adormecer em até 30 minutos

Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(b) Acordou no meio da noite ou de manhã cedo
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(c) Precisou levantar para ir ao banheiro
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(d) Não conseguiu respirar confortavelmente
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
74 A.N. Bertolazi et al. / Sleep Medicine 12 (2011) 70–75

1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____

(e) Tossiu ou roncou forte
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(f) Sentiu muito frio
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(g) Sentiu muito calor
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(h) Teve sonhos ruins
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(i) Teve dor
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(j) Outra(s) razão(ões), por favor descreva _______________________________
Com que freqüência, durante o último mês, você teve dificuldade para dormir devido a essa razão?
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
6. Durante o último mês, como você classificaria a qualidade do seu sono de uma maneira geral?
Muito boa _____
Boa _____
Ruim ____
Muito ruim _____
7. Durante o último mês, com que freqüência você tomou medicamento (prescrito ou ‘‘por conta própria’’) para lhe ajudar a dormir?
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
8. No último mês, com que freqüência você teve dificuldade de ficar acordado enquanto dirigia, comia ou participava de uma atividade
social (festa, reunião de amigos, trabalho, estudo)?
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
9. Durante o último mês, quão problemático foi para você manter o entusiasmo (ânimo) para fazer as coisas (suas atividades habituais)?
Nenhuma dificuldade _____
Um problema leve _____
Um problema razoável _____
Um grande problema _____
10. Você tem um(a) parceiro [esposo(a)] ou colega de quarto?
Não ____
Parceiro ou colega, mas em outro quarto ____
Parceiro no mesmo quarto, mas não na mesma cama ____
Parceiro na mesma cama ____
Se você tem um parceiro ou colega de quarto, pergunte a ele/ela com que freqüência, no último mês, você teve ...

(a) Ronco forte

Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(b) Longas paradas na respiração enquanto dormia
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(c) Contrações ou puxões nas pernas enquanto você dormia
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(d) Episódios de desorientação ou confusão durante o sono
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana _____
(e) Outras alterações (inquietações) enquanto você dorme; por favor, descreva _____________________________________
____________________________
Nenhuma no último mês _____ Menos de 1 vez/ semana _____
1 ou 2 vezes/ semana _____ 3 ou mais vezes/ semana ____
 A.N. Bertolazi et al. / Sleep Medicine 12 (2011) 70–75 75

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