SpaniSh tranSlation of the mood rhythm inStrument: a novel approach to mood evaluation

Introduction: The Mood Rhythm Instrument (MRI) is a questionnaire developed to assess the circadian rhythm of mood-related behaviors. The aim of this study was to translate this instrument from Brazilian Portuguese into Spanish. Methods: The translation process consisted of forward translation, adjustment, back translation, back translation review and harmonization. Results: Comparing the initial Spanish translation and the final Spanish version, there were no semantic differences and the items were not changed. Conclusions: The Spanish version of the MRI is ready to be tested in a Spanish population. In the future, assessing and comparing mood-related behaviors in transcultural studies will be possible. Keywords: Circadian rhythms; daily rhythms; mood; psychometric; chronobiology.

The psychiatric classification system was initially developed with the intention of standardizing a diagnostic framework to all patients, regardless of country of origin or cultural background 1,2 .The diagnosis of mental disorders was based on medical research of categorical and qualitative variables through the actual and retrospective presence of patient symptomatology and the longitudinal quality of these symptoms 3 .The instruments created during the development of modern psychiatry identify and measure the intensity and evolution of psychiatric symptoms, which were structured according to diagnostic manuals, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 4 .This approach considers only the presence or absence of symptoms and not aspects of their circadian rhythmicity or the variability of mood symptoms over 24 hours.
Recently, Souza et al. 5 developed the Mood Rhythm Instrument (MRI), which detects individual rhythms of cognitive and behavioral measures associated with mood states, such as self-esteem, social relationship, sadness, sexual arousal, pessimism and alertness.This variability in individual rhythms is important to the diagnosis of mood disorders and should be relevant to patient approach and treatment management.In a bipolar spectrum disorder, an improvement of the response of lithium treatment among core clock genes has been demonstrated 6 .Evidence of environmental disruptions related to exacerbation or precipitation of mood episodes has been described especially in shift work, travel across time zones, and irregular social schedules 7 .Taking into account this theoretical framework, a new approach in psychotherapy has been developed with a focus on social rhythmicity 8 .Consequently, patients with rhythm disruption could have more benefits, and symptoms related to chronodisruption could be identified.Since Spanish is one of the most spoken languages in the world 9 , the aim of this study was to translate the MRI from Brazilian Portuguese into Spanish.This will allow the application of this instrument to Spanish-speaking populations, thus enabling the performance of transcultural studies in the future.

Mood Rhythm Instrument
The MRI is a self-assessment questionnaire developed by de Souza et al. 5 .Fifteen self-assessed items evaluate how individuals have felt for most of the time during the previous 15 days.The instrument assesses whether or not behavior items have a peak during the 24 hours of the day and, if so, the exact hour in which they occur.In a Brazilian population, the MRI had a satisfactory Cronbach's alpha of 0.73 5 .

Procedure
In collaboration with the University of Barcelona in Spain, we performed the Spanish translation process.The focus group consisted of a team of experienced researchers from different fields: psychiatry, nutrition, psychology and biomedicine.
The translation steps, which followed those described by Wild et al. 10 , are presented in a flowchart (figure 1).Table 1 shows MRI versions during the translation process and the final version.The MRI final version is available in supplementary material (Annex 1).
This study was conducted in accordance with the provisions of the Declaration of Helsinki 11 and was approved by the Research Ethics Committee of Hospital de Clínicas de Porto Alegre (approval number 15-0266 GPPG/HCPA).

RESULTS
The main alteration in the final Spanish translation can be found in the instructions.For the Spanish MRI, in the field asking for age ("edad"), the phrase "in years" ("en años") was added as well as the birthdate.Besides, the clause "in the absence of any events that have caused you distress" was removed.
Comparing the Brazilian Portuguese version and the back-translated version, there were no semantic differences.Only two words were adapted on items 4 and 7.There were small adjustments with synonyms, such as on question 4, in which "esteja melhor" was replaced by "é mais alta"; and on question 7, in which "aumentada" was replaced by "esteja maior".In all questions, "na qual" was replaced by "em que".

DISCUSSION
The MRI, originally developed and validated in Brazilian Portuguese, is an easy and non-expensive instrument aimed to fill the gap of psychiatry research regarding mood and its circadian rhythmicity.This study accomplished all steps of the translation process and, after a few modifications, it now allows the application of the instrument to Spanish-speaking populations.
To our knowledge, concerning the instruments validated for evaluation and diagnosis of mood disorders, only one question in the Hamilton Depression Rating Scale 12 takes diurnal variability of sadness into account, and a higher score is applied if there is any variability in this symptom.This criterion did not consider the normal daily intra-variability of mood.An instrument assessing mood rhythmicity, such as the MRI, could be an important tool for diagnosis and evaluation of mood disorders.For instance, chronotherapeutic interventions, such as sleep deprivation 13,14 , light therapy 15 and interpersonal and social rhythm therapy 16,17 , have already shown effects on the improvement of mood symptoms 18 .
The limitation of this study is that the instrument has not been validated in a Spanish-speaking population.This process will allow a direct comparison of mood rhythms between samples from Spain and Brazil.The Spanish version of the MRI is an important tool to be employed in epidemiological studies and to compare different populations.

Figure 1 :
Figure 1: Flowchart of the study.

Table 1 :
Steps for the translation of the Mood Rhythm Instrument into the Spanish language and the final Spanish version.has received grants from the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).CAVI has received a scholarship from the undergraduate research project at Universidade Federal do Rio Grande do Sul (UFRGS).MABO, RCF and MPH have received funding from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). AC