J. Sleep Res.

(2002) 11, 183190

A simple way to measure daily lifestyle regularity

T I M O T H Y H . M O N K , E L L E N F R A N K , J A I M E M . P O T T S and DAVID J. KUPFER
Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA

Accepted in revised form 22 April 2002; received 3 December 2001

SUMMARY

A brief diary instrument to quantify daily lifestyle regularity (SRM-5) is developed and compared with a much longer version of the instrument (SRM-17) described and used previously. Three studies are described. In Study 1, SRM-17 scores (2 weeks) were collected from a total of 293 healthy control subjects (both genders) aged between 19 and 92 years. Five items (1) Get out of bed, (2) First contact with another person, (3) Start work, housework or volunteer activities, (4) Have dinner, and (5) Go to bed were then selected from the 17 items and SRM-5 scores calculated as if these ve items were the only ones collected. Comparisons were made with SRM-17 scores from the same subject-weeks, looking at correlations between the two SRM measures, and the eects of age and gender on lifestyle regularity as measured by the two instruments. In Study 2 this process was repeated in a group of 27 subjects who were in remission from unipolar depression after treatment with psychotherapy and who completed SRM-17 for at least 20 successive weeks. SRM-5 and SRM-17 scores were then correlated within an individual using time as the random variable, allowing an indication of how successful SRM-5 was in tracking changes in lifestyle regularity (within an individual) over time. In Study 3 an SRM-5 diary instrument was administered to 101 healthy control subjects (both genders, aged 2059 years) for two successive weeks to obtain normative measures and to test for correlations with age and morningness. Measures of lifestyle regularity from SRM-5 correlated quite well (about 0.8) with those from SRM-17 both between subjects, and within-subjects over time. As a detector of irregularity as dened by SRM-17, the SRM-5 instrument showed acceptable values of kappa (0.69), sensitivity (74%) and specicity (95%). There were, however, dierences in mean level, with SRM-5 scores being about 0.9 units [about one standard deviation (SD)] above SRM-17 scores from the same subject-weeks. SRM-5 scores also deviated more from a Gaussian distribution than did SRM-17 ones. In a study with a sample size of 101, the new SRM-5 instrument yielded scores with a mean of 4.11 and an SD of 1.13. Correlations between lifestyle regularity and age, and between lifestyle regularity and morningness appeared similar whether 5-item or 17-item SRM measures were used. When a gender dierence in lifestyle regularity appeared, it was detected by both SRM-5 and SRM-17 measures. keywords circadian rhythm, human, sleepwake cycles, social rhythm metric

INTRODUCTION In much the same way that there are physiological circadian rhythms in variables such as core body temperature and
Correspondence: Timothy H. Monk, WPIC Room E1123, 3811 OHara Street, Pittsburgh, PA 15213, USA. Tel.: (1) 412-624-2246; fax: (1) 412-624-2841; e-mail: monkth@msx.upmc.edu 2002 European Sleep Research Society

plasma hormone concentrations, so too, are there behavioral circadian rhythms related to the timing with which various social, work, feeding and rest related activities occur. Indeed, early human circadian rhythm researchers using time isolation laboratories were careful to have the subject record when activities such as meals took place, so that the subjective day could be plotted out in relation to successive sleepwake cycles

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depressed and non-depressed elderly bereaved persons (Brown et al. 1996; Prigerson et al. 1996), depressed inpatients (Szuba et al. 1992), depressed out-patients in remission (Monk et al. 1991), anxiety disorder patients (Shear et al. 1994) and new parents (Monk et al. 1996). SRM score appears to increase over the life span when dierent age groups are studied (Monk et al. 1997). While the full 17-item SRM yields a rich harvest of results, including measures of activity level and other person involvement, it is fairly burdensome to subjects, and may represent an unacceptable load when measures of lifestyle regularity need to be gleaned from a study for which the SRM is not the prime area of interest. To that end we have developed a shorter ve-item version, which is the focus of the present paper.

(Wever 1979). Very often the gap in timing between, for example, breakfast and lunch, could predict subjective day length as a whole in free-running conditions (Ascho et al. 1986). However, because of the utility of physiological measures in exploring the underlying circadian mechanisms, more attention has typically focused on the physiological variables than on the behavioral ones, despite the latters more obvious salience to the person involved. Indeed, for most individuals, the only observable impact to them of the circadian system is when it aects hunger or sleepiness at a particular time (Monk 1991). Inter-individual phase dierences in the timing of behavioral events can be seen when morning larks are compared with night owls (Horne and Ostberg 1976). There are also interindividual dierences in lifestyle regularity, which can be considered as the analog of circadian amplitude within the behavioral domain. Simple observation reveals that some people have very regimented lives with events taking place at the same time each day, while others have much more irregular schedules. Similarly, within the same individual, lifestyle regularity may decrease when the individual is on vacation rather than being at work, for example. The Social Rhythm Metric (SRM) (Monk et al. 1990, 1994) was developed to quantify the extent to which a persons life was regular vs. irregular on a daily basis with respect to event timing. The aim was to have an instrument yielding a numerical index of lifestyle regularity, with higher numbers representing greater regularity, lower numbers less regularity. In its full original form, the SRM is a diary-like instrument with one page per day. It is completed each evening before bed and requires the subject to record when and with whom 17 event categories occurred. The 17 events are: (1) Get out of bed, (2) First contact with another person, (3) Morning beverage, (4) Breakfast, (5) Go outside, (6) Start work, housework or volunteer activities, (7) Lunch, (8) Afternoon nap, (9) Have dinner, (10) Exercise, (11) Evening snack or drink, (12) TV news, (13) Other TV program, (14) Activity A, (15) Activity B, (16) Return home last time, and (17) Go to bed. Activity A and Activity B are activities idiosyncratic to the individual which are written-in for the duration of the study. The seven sheets from a given week are then scored as a unit. First the habitual time for each event is calculated (for events occurring three or more times per week) using an outlier elimination algorithm. Then a count is made of how many events in the week occurred within 45 min of the habitual time (i.e. could be scored as a hit) with a maximum of 7, for example, when the event was performed at the same time each day of the week. Averaging these hit counts over the contributing event categories (items) then yields an overall score on a continuum between 0 and 7. This SRM score then represents the subjects level of daily lifestyle regularity for that week (higher number more regular). More detail of the scoring algorithm is given in Monk et al. (1991, 1994). A number of studies using the full 17-item SRM have been conducted exploring lifestyle regularity in healthy young adults (Monk et al. 1994), older persons (Monk et al. 1992),

METHODS Overview Three studies are described. In Study 1, SRM-17 scores (2 weeks) were collected from a total of 293 healthy control subjects (both genders) aged between 19 and 92 years. Five items: (1) Get out of bed, (2) First contact with another person, (3) Start work, housework or volunteer activities, (4) Have dinner, and (5) Go to bed, were then selected from the 17 items and SRM-5 scores calculated as if these ve items were the only ones collected. Comparisons were made with SRM-17 scores from the same subject-weeks, looking at correlations between the two SRM measures, and the eects of age and gender on lifestyle regularity as measured by the two instruments. Using a categorization of subjects as irregular, intermediate or regular by SRM-17, the sensitivity and specicity of SRM-5 was calculated. In Study 2 trends over time in SRM-17 and SRM-5 were studied in a group of 27 subjects who were in remission from unipolar depression after treatment with psychotherapy and who completed SRM-17 for at least 20 successive weeks as part of a MacArthur Foundation funded study of depression (P.I. David Kupfer, M.D). SRM-5 and SRM-17 scores were then correlated within an individual using time as the random variable, allowing an indication of how successful SRM-5 was in tracking changes in lifestyle regularity (within an individual) over time. In Study 3 an SRM-5 diary instrument was administered to 101 healthy control subjects (both genders, aged 2059 years) for two successive weeks to obtain normative measures and to test for correlations with age and morningness. Development of SRM-5 A factor analysis of 96 normal healthy subjects (48 males, 48 females, aged 2040 years) who completed the SRM-17 for 2 weeks (see Monk et al. 1994 for further details of data collection) revealed two major factors, one dominated by morning events, the other by afternoon evening events. We selected (1) Get out of bed, (2) First contact with another person, (3) Start work, housework or volunteer activities, as
2002 European Sleep Research Society, J. Sleep Res., 11, 183190

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representative of the morning factor, and (4) Have dinner and (5) Go to bed as representative of the afternoon evening factor. These ve items correlated highly with the nal SRM score (accounting for between 65 and 80% of the variance). They were also less likely to be skipped (on average, they were carried out better than 95% of subject-days, compared with an average of 66% of subject-days for the other 12 items), and spanned the waking day. We also avoided the two write-in activities, idiosyncratic to the individual. Thus, the selection of the ve items was not only statistically based, but also met other more pragmatic requirements. The weeks worth of diary could be tted on a single page (Fig. 1) which the subject was encouraged to keep (with a pen) on his or her bedside table. Study 1 From a wide variety of studies conducted at the University of Pittsburgh over the past 10 years we collected together a total of 293 2-week 17-item SRM studies completed by healthy control subjects. Ages ranged from 19 to 92 years; there were 129 males (mean age 46.9 years, SD 21.7 years) and 164 females (mean age 50.2 years, SD 24.2 years). All analyses were based on average SRM scores of the 2 weeks. Subjects were required to be free from a history of past or present mental or sleep disorders. Shift workers, and those who recently returned from dierent time zones were not studied. Two analyses were performed on each subjects data. First an SRM-17 score for each subject was calculated using the entire instrument. Secondly, the other 12 items were discarded, and a SRM-5 score calculated by applying exactly the same algorithm to the ve items: (1) Get out of bed, (2) First contact with another person, (3) Start work, housework or volunteer activities, (4) Have dinner and (5) Go to bed. Frequency histograms for SRM-17 and SRM-5 were plotted; the correlation coecient calculated and regression line plotted between SRM-5 and SRM-17; the correlation coecients calculated between SRM-17 and age, and between SRM-5 and age, and the eects of gender studied for SRM-17 and SRM-5. Using the SRM-17 as a gold standard, subjects were categorized as irregular (more than one SD below the mean), regular (more than one SD above the mean), or intermediate (otherwise). A parallel categorization based only on SRM-5 scores was then undertaken using the SRM-5 mean and SD, constructing a 3 3 contingency table. This allowed the kappa, sensitivity and specicity of SRM-5 as a detector of irregularity to be calculated. Study 2 As part of a larger year-long study of out-patient unipolar depression, which included other subjects not meeting these criteria in terms of remission and recurrence (see below), 27 subjects (6M, 21F, mean age 37.7 years, SD 8.6 years) were recruited in at least their second episode of depression (Buysse et al. 1992a, b). The mean age (SD) for males (39.9 10.5 years) and females (37.0 8.2 years) did not
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dier. Subjects were then treated with interpersonal psychotherapy until they met criteria for remission, which were three consecutive weeks with a score of less than 8 on the 17-item Hamilton Depression Rating Scale (Hamilton 1967) without pharmacotherapy. For a 12-month period, or until they experienced a recurrence of symptoms, these subjects then completed the SRM-17 daily. The present analysis will focus on the rst 20 complete weeks of SRM-17 after remission, eliminating any subjects who had a recurrence within 20 weeks. Thus although formerly suering from depression, all 27 of these subjects were well at the time (i.e. during the 20 weeks) that they were studied here. As in Study 1, two endpoints were derived from each subjects data, separately for each week. First an SRM-17 score for each subject-week was calculated using the entire instrument. Secondly, the other 12 items were discarded, and an SRM-5 score for that subjectweek calculated by applying exactly the same algorithm to the ve items listed above. The analysis then proceeded subject by subject. A simple Pearson correlation coecient was calculated for each subject between SRM-5 and SRM-17 using the 20 weeks as the random variable, and the slope and intercept of the least squares regression line calculated. The resulting correlation coecients (together with the slopes and intercepts of the tted regression lines) were then treated as endpoints and the mean and SD of each of these endpoints calculated (after a z-transformation for the correlation coecients). A simple count was also made of the number of statistically reliable (P < 0.05) correlations that occurred. Study 3 An SRM-5 instrument which allowed a single sheet to be used for an entire week (Fig. 1) was administered to a convenience sample of 101 healthy control subjects aged between 20 and 59 years (mean age 33.5 years, SD 13.2 years). There were 48 males (mean age 33.6 years, SD 12.9 years) and 53 females (mean age 33.3 years, SD 13.6 years). Subjects were required to complete the SRM-5 every evening for 14 consecutive nights and to complete several questionnaires including the Composite Scale of Morningness (Smith et al. 1989) assessing the degree to which the individual was a morning-type vs. an evening-type person. Recruitment was by word of mouth and iers placed around the university district of Pittsburgh. About 30 of the subjects were met by one of the authors (J.M.P) who explained the study to them in a brief (<5 min) interview. The remainder telephoned indicating their interest and were then sent a packet of material (including a brief instruction sheet see Appendix) through the mail, together with a stamped preaddressed envelope for the return of completed consent forms, diaries and questionnaires. Telephone back-up to explain the instruments was available and used by about 15 subjects. A total of 116 subjects originally signed informed consent agreeing to take part. Nine of the 116 then did nothing further, two returned incomplete SRM-5 diaries, two returned incomplete questionnaires, and two returned their packets too late to be included, leaving a

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2002 European Sleep Research Society, J. Sleep Res., 11, 183190

Figure 1. Sample page of the SRM-5 instrument.

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total of 101 subjects. Subjects were paid $25 on completion of the study. By self report, no subject was recently returned from a dierent time zone, a shift worker, pregnant, or a parent of a child under 2 years. In addition to determining the normative distribution of SRM-5 scores, correlations between SRM-5 and age, and between SRM-5 and morningness score were calculated, and gender dierences in SRM-5 tested. RESULTS Study 1 The distributions of SRM scores over the 293 subjects are illustrated in the upper and lower panels of Fig. 2. SRM-17 had a mean of 3.90 and SD of 0.83, SRM-5 a mean of 4.84 and SD of 0.98. The dierence of 0.94 units between the two means was statistically reliable (t 3.46, P < 0.001). Median values
45 40 35 30 Mean = 3.90 SD = 0.83 n = 293

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were 3.96 (SRM-17) and 5.00 (SRM-5). When the regression of SRM-5 against SRM-17 was calculated, a correlation of r 0.866 (P < 0.001) emerged, thus accounting for about 75% of the variance. The slope of the regression line of SRM-5 (y-axis) on SRM-17 (x-axis) was 1.02 and the intercept was 0.84 (see Fig. 3). Summing over days, weeks, and subjects, a count of events marked did not do (and thus not contributing to the SRM score) indicated that far fewer SRM-5 events were skipped (4.9%) than SRM-17 events (25.3%). Table 1 presents the results of casting the 293 subjects into irregular, intermediate and regular categories (see above) by both SRM-17 (using the SRM-17 mean and SD) and by SRM5 (using the SRM-5 mean and SD). Considering SRM-5 as a test for detecting irregularity as dened by the gold standard SRM-17, the kappa value was calculated to be 0.69 (P < 0.001) with a sensitivity of 74% and a specicity of 95%. When the eect of age was considered, a signicant correlation (Spearmans q) between SRM and age emerged

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Figure 3. Scattergram of SRM scores from SRM-5 vs. SRM-17 analyses using a sample of 293 subjects, together with best-tting regression line. Each SRM score is the average for two consecutive weeks.

Table 1 Study 1 (n 293): number of subjects falling into irregular (<mean 1 SD), regular (>mean + 1 SD), or intermediate (otherwise) categories, by gold standard SRM-17 (columns), and by SRM-5 (rows). Note that the SRM-5 categorization was in terms of the SRM-5 mean and SD (see text) SRM-17 irregular SRM-5 irregular SRM-5 intermediate SRM-5 regular 37 13 0 SRM-17 intermediate 13 169 17 SRM-17 regular 0 19 25

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Figure 2. Distribution of SRM scores from SRM-17 (upper panel) and SRM-5 (lower panel) analyses using a sample of 293 subjects. Each SRM score is the average for two consecutive weeks. A Gaussian curve with corresponding mean and SD is superimposed on each distribution. 2002 European Sleep Research Society, J. Sleep Res., 11, 183190

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eect of gender (M: 4.12, F: 4.09, t < 1, NS), but (like Study 1) there was a statistically reliable correlation between SRM and age (q 0.54, P < 0.001), indicating increased lifestyle regularity with increasing age. As was found in a previous normative study of a sample of 98 healthy control subjects using SRM-17 (Monk et al. 1994), there was also a statistically reliable positive correlation between SRM and morningness (q 0.435, P < 0.001, morning types more regular). DISCUSSION The positive ndings from the three studies conrm that the ve-item SRM can be a useful instrument in assessing lifestyle regularity, with positive correlations of about 0.8 between SRM-5 and SRM-17 scores, whether assessed across subjects or across time within subjects. Thus, the SRM-5 instrument appeared able to track changes in lifestyle regularity which had been detected by the gold standard SRM-17 instrument, either as trends over time or as inter-individual dierences. As a detector of irregularity as dened by SRM-17, the SRM-5 instrument showed acceptable values of kappa (0.69), sensitivity (74%) and specicity (95%). Moreover, in variables such as age, morningness and gender, eects that were detected using SRM-17 were also detected (and were fairly similar in magnitude) when SRM-5 was used. Thus, the abbreviated instrument would appear to be as eective as the full instrument in evaluating how lifestyle regularity might vary between dierent groups of people. The lack of a gender eect in Study 3 (SRM-5) may have occurred because of the reduced age range relative to Study 1, as our normative sample of 98 subjects aged between 20 and 40 years (which used SRM-17) also failed to show any gender dierence (Monk et al. 1994). In terms of interindividual variability, standard deviations of SRM scores all hovered around the value of 0.9 found previously (Monk et al. 1990, 1994), whether assessed in the present studies by SRM-17 (Study 1: 0.83) or SRM-5 (Study 1: 0.98, Study 3: 1.13). Our initial expectation was that the regression lines between SRM-5 and SRM-17 would have a slope of one and an intercept of zero. Thus we had hoped that a unit increase in SRM-5 would correspond to a unit increase in SRM-17 (slope of one), and that there would be no systematic dierence between SRM-5 and SRM-17 in mean level (intercept of zero). The slope was indeed very close to unity, both when dierences between subjects were being assessed (1.02 in Study 1), and also when changes within subjects, across time were being evaluated (1.01 in Study 2). Thus, both between individuals, and within an individual, one unit of SRM-5 was essentially equal to one unit of SRM-17. In terms of the intercept of the regression line between SRM-17 and SRM-5, the value was 0.84 for Study 1 and 0.91 for Study 2, neither of which were acceptably close to zero. Expressed in a dierent way, there was for both studies a statistically reliable dierence of about 0.9 units (about 1 SD) between SRM-5 scores and SRM-17 scores from the same subject-weeks, with SRM-5 scores being uniformly higher than
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for both SRM-17 (q 0.45, P < 0.001) and SRM-5 (q 0.37, P < 0.001), indicating increased lifestyle regularity with increasing age. Signicant gender eects also emerged both for SRM-17 (M: 4.09, F: 3.75, t 3.46, P < 0.001), and for SRM-5 (M: 5.02, F: 4.69, t 2.94, P < 0.004). Study 2 Of the 27 subjects, ve had one incomplete week, ve had two (separated) incomplete weeks, but all were included in the analysis. When the regression of SRM-5 against SRM-17 over time was calculated separately for each subject, all 27 correlations were positive and statistically signicant (P < 0.05). Correlation coecients (Pearsons r) ranged from 0.48 to 0.93. After the standard z-transformation, the (re-transformed) mean r-value was 0.89 with a 95% condence interval from 0.80 to 0.95, accounting for an average of about 79% of the variance. The mean slope of the regression line (tted subject by subject) was 1.01 (SD 0.29) and the mean intercept was 0.91 (SD 1.18). As in Study 1, mean SRM-5 scores were consistently higher than mean SRM-17 scores by about 0.9 units (SRM-17: 3.52, SRM-5: 4.39, t 13.84, P < 0.0001). Summing over days, weeks and subjects, a count of events marked did not do (and thus not contributing to the SRM score) indicated that far fewer SRM-5 events were skipped (6.0%) than SRM-17 events (28.9%). Study 3 All SRM-5 scores were based on the average of 2 weeks. The frequency distribution of SRM-5 scores from the 101 subjects is illustrated in Fig. 4. The mean score was 4.11, the SD 1.13, and the median 4.20. Unlike Study 1, there was no signicant

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equivalent SRM-17 scores. The consistency of this nding across the two studies suggests that a re-scaling factor of 0.9 may need to be subtracted from an SRM-5 score to bring it in line with an SRM-17 score, although the problem of ceiling eects (see below) would still remain. Of course, such a re-scaling would only be needed if access to the raw diary data were not available; if access were available, then an SRM-5value could be calculated from the 17-item instrument, as we have done in Studies 1 and 2. It is noteworthy that in both Studies 1 and 3 there was a slight deviation from a normal Gaussian distribution in SRM-5 that was not apparent in SRM-17 (Figs 2 and 4). This appeared to be due to a peak or blip in SRM-5 values at around 5.0, combined with a general shift (of about 0.9) to higher values. The ceiling eect cut-o at 7.0 (the maximum allowable SRM score) then led to an apparent truncation of the right tail of the SRM-5 distribution. Analysis of the data using the ShapiroWilkes test indicated that whereas the SRM-17 showed a fairly good Gaussian t, the same was not true for SRM-5, which signicantly failed the test for Normality in both Study 1 (P < 0.001) and Study 3 (P < 0.005). Inspection of the SRM-5 QQ plots indicated that deviations were greatest at the tails of the distribution. As measures with Gaussian distributions are more powerful than those without them, this nding reinforces the desirability of using SRM-17 should one be able to. The SRM-5 is better regarded as a substitute for SRM-17 when mandated by limitations in subject time and willingness. In mitigation, however, it should be noted that in both Study 1 and Study 2, a greater percentage of subject-event-days were skipped (marked did not do) for the SRM-17 than for the SRM-5. Thus in the SRM-17 there was a greater likelihood that an SRM score resulted from an unequal sampling of the events (items) than there was for the SRM-5. Recognizing that most people in the Pittsburgh area work a 5-day week, the blip at an SRM-5 score of 5, mentioned above, suggests that employment status might be important. The SRM score essentially reects the number of days per week that hits occur (events done at times acceptably close to habitual times). By restricting the events to only ve it was possible that extra emphasis was given to workday vs. weekend dierences in the shorter instrument than in the full 17-item version which included more recreational events. Thus those who worked a 5-day week may show an increased likelihood of SRM scores of ve in the shorter instrument, reecting this pattern. As a posthoc analysis, testing this explanation, we were able to determine the employment status of 84 of the Study 1 subjects who were aged between 25 and 65 years (and thus less likely to be younger students or older retired persons). This yielded 58 full-time (FT) employed subjects (by self report) and 26 non-FT subjects (home-makers, part-timers or students). SRM scores were remarkably similar in the two groups, whether assessed by SRM-17 (FT: 4.0, non-FT: 3.9) or SRM-5 (FT: 5.1, non-FT: 5.0). A regression analysis conrmed that neither the main eect of employment, nor the interaction of employment with measure (SRM-17 vs. SRM-5)
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was statistically signicant (P > 0.5). This suggested that employment status was not a potent factor with regard to SRM (remembering that shift workers were specically excluded from the study). The SRM-5 instrument appeared to be acceptable to subjects. There was remarkably little missing data from Study 3. The 101 subjects here reported all returned complete SRM data, only two further subjects were enrolled in the study and returned incomplete SRM-5 diaries (nine other subjects signed informed consent but then did nothing further, two returned full SRM-5 diaries but incomplete questionnaires, and two returned everything too late). This was despite the fact that remarkably little training was given to subjects, in contrast to the quite extensive training required for the SRM-17 instrument. Thus, subjects appear to readily understand what is required of them for SRM-5 and to not mind completing the instrument each evening for 2 weeks despite receiving only a fairly modest honorarium ($25). The SRM-5 is currently being collected in the NIMH (U.S. National Institute of Mental Health) large-scale national study, Systematic Treatment Eectiveness Program for Bipolar Disorder (STEP-BD). CONCLUSIONS Lifestyle regularity can be assessed using a fairly simple single page diary instrument (SRM-5). The resulting measures of lifestyle regularity correlated quite well (about 0.8) with scores from the full 17-item instrument both between subjects and within-subjects over time. Correlations between lifestyle regularity and age, and between lifestyle regularity and morningness appeared similar whether 5-item or 17-item SRM instruments were used. As a detector of lifestyle irregularity as dened by the SRM-17, the SRM-5 had a sensitivity of 74% and a specicity of 95%. ACKNOWLEDGEMENTS Primary support for this work was provided by NASA Grant NAG9-1036. Additional support was provided by NASA Grant NAG9-1234, National institute on Aging Grants AG-13396 and AG 15136, National Institute of Mental Health Grant MH 30915, GCRC Grant RR 00056, and the John D. and Catherine T. MacArthur Foundation Mental Health Research Network on the Psychobiology of Depression and Other Aective Disorders. Sincere thanks to the many sta and faculty whose research projects contributed data to Study 1, to the many therapists and sta involved in Study 2, to Kathy Kennedy for help with Study 3, and to Jean Degrazia, Lynda Rose, Jean Miewald, Patricia Houck, Ann McEachran, and Alhaji Buhari for data and statistical analysis. REFERENCES
Ascho, J., von Goetz, C., Wildgruber, C. and Wever, R. A. Meal timing in humans during isolation without time cues. Journal of Biological Rhythms, 1986, 1: 151162.

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APPENDIX The following Instruction sheet was enclosed with the SRM-5 diary: Completing the SRM-Short Form Please complete this form at the end of each day for the period of two consecutive weeks. Write the day of the week (Su, M, T, W, H ,F, Sa) and write the date (mm dd yy) for which the form was completed. There are ve activities per day. For each activity, indicate the time you started it. Circle AM or PM so that we know whether the time you entered is in the morning or evening. If you did not do a particular activity, check the Did Not Do box. The ve activities are dened as follows: 1. Out of bed This refers to the time that you actually got out of bed to start the day. This does not refer to the time that you woke-up or went to the bathroom and then returned to bed. 2. First contact (in person or by phone) with another person This refers to the time that you had your rst contact with another person. This contact can be either verbal, physical (e.g. standing in the same room ) or by telephone. 3. Start work, school, housework, volunteer activities, child or family care Work is dened here as your job, schoolwork, housework, volunteer activities and child or family care. It does not necessarily have to occur away from home. 4. Have dinner This refers to the time that you ate dinner. 5. Go to bed This refers to the time you physically got into bed. This does not reect the time you attempted to fall asleep.

2002 European Sleep Research Society, J. Sleep Res., 11, 183190