Journal of Traumatic Stress, Vol. 18, No. 4, August 2005, pp. 343–346 ( C© 2005)

Sleep Quality in Complicated Grief

Anne Germain,1,2 Krissa Caroff,1 Daniel J. Buysse,1 and M. Katherine Shear1

The aim of the present study was to evaluate severity of sleep disturbances in a group of 105 indi-viduals presenting with complicated grief (CG) accompanied or not by comorbid depression and/orposttraumatic stress disorder (PTSD). A sample of 105 adults meeting criteria for CG was includedin this study. All completed the Pittsburgh Sleep Quality Index (PSQI). The total sample presented amean global PSQI score of 9.44, indicating overall poor sleep quality. Comorbid depression, but notPTSD, further worsened sleep quality. Further studies are required to investigate the potential role ofpoor sleep quality as a modifiable risk factor of complicated grief response.

Grief refers to the ensemble of feelings, thoughts, andbehaviors following the loss of a loved one. Complicatedgrief (CG) is characterized by recurrent intrusive pangsof grief, persistent yearning and longing for the deceased,intrusive thoughts of death, and avoidance of remindersof the lost individual (Horowitz et al., 1997; Prigersonet al., 1996). Although CG is a clinical construct dis-tinct from those of depression and anxiety (Boelen, vanden Bout, & de Keijser, 2003; Prigerson et al., 1996;Prigerson, Frank et al., 1995), major depression disorder(MDD) complicates grief in 20% to 30% of bereaved in-dividuals (Clayton, 1990; Melham et al., 2001; Zisook& Shuchter, 1991), and symptoms of posttraumatic stressdisorder (PTSD) are endorsed by 10% to 30% of bereavedindividuals (Melhem et al., 2001).

Poor sleep quality and objective sleep anomalies areboth associated with MDD onset, recurrence, and poortreatment response (e.g., Buysse et al., 1999, 2001; Ford& Kamerow, 1989). In addition, poor sleep characterizesbereavement-related depression, whereas maintenance ofgood sleep quality accompanies “successful” bereave-

1Department of Psychiatry, University of Pittsburgh School of Medicine,Pittsburgh, Pennsylvania.

2To whom correspondence should be addressed at Department of Psychi-atry, University of Pittsburgh School of Medicine, 3811 O’Hara Street,Room E-1124, Pittsburgh, Pennsylvania 15213; e-mail: germaina@upmc.edu.

ment (Brown et al., 1996; McDermott et al., 1997; Paster-nak et al., 1992; Reynolds et al., 1993). Sleep disturbancealso complicates clinical outcomes related to trauma ex-posure and PTSD (e.g., Koren, Arnon, Lavie, & Klein,2002; Krakow et al., 2000; Mellman, Bustamante, Fins,Pigeon, & Nolan, 2002; Nishith, Resick, & Mueser, 2001).More generally, poor sleep quality is a risk factor for psy-chiatric morbidity and mortality (Dew et al., 2003; Ford& Kamerow, 1989). Sleep quality has not been directlyevaluated in CG in relation to the presence or absence ofcomorbid depression or PTSD. Because sleep is a mod-ifiable behavior, the study of sleep in individuals withCG may yield important refinements and more effectiveprevention and therapeutic efforts.

The aim of the present study was to assess sleep qual-ity in individuals presenting with CG with and withoutcomorbid MDD and/or PTSD. We hypothesized that in-dividuals presenting with CG and comorbid MDD and/orPTSD would exhibit poorer sleep quality than individualswith CG but without comorbid MDD or PTSD.

Method

Participants

Written informed consent was obtained for all par-ticipants. Data were obtained from 105 adult men and

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C© 2005 International Society for Traumatic Stress Studies • Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jts.20035

344 Germain, Caroff, Buysse, and Shear

women who were recruited to participate in a larger, on-going study (NIH-MH60783) of the treatment of compli-cated grief (Shear et al., 2001). Participants were includedif they were at least 6 months post loss (M = 3.95 years,SD = 5.02), and if they endorsed an Inventory of Com-plicated Grief (ICG) score greater than or equal to 30(Prigerson, Maciejewski et al., 1995). The ICG is a 19-item scale that assesses symptoms of complicated griefand has an acceptable internal consistency (Cronbach’salpha = .94) and test–retest reliability (r = .80). A scoreof 25 or higher is associated with significant functionalimpairments (Prigerson, Maciejewski, et al., 1995). Theonly pretreatment data presented and discussed here arethose relevant to the study aim.

Measures

At study entry, all subjects underwent structured clin-ical interviews conducted by trained, certified raters. TheStructured Clinical Interview for DSM-IV (First, Gib-bon, & Williams, 1995) was used to assess the presenceof MDD and PTSD. Depression symptom severity wasassessed with the Hamilton Rating Scale for depression(HRSD), 17-item version (Hamilton, 1960). The PSQI(Buysse, Reynolds, Monk, Berman, & Kupfer, 1989)was used to assess sleep quality. The Pittsburgh SleepQuality Index (PSQI) is a 19-item self-report question-naire that assesses seven clinically relevant componentsof sleep quality (subjective sleep quality, sleep latency,duration, efficiency, disturbances, use of sleep medica-tion, and daytime dysfunction) in the preceding month.Each component is rated on a 0 to 3 scale referringto the composite score derived from the frequencies ofeach disturbance, where 0 = not in the past month, and3 = three or more times a week, with a global scorerange from 0 to 21. A cutoff score of 5 has been shownto discriminate between good and bad sleepers (Buysseet al., 1989). The PSQI has acceptable internal consis-tency (Cronbach’s alpha = .83), and test–retest reliability(r = .85).

Table 1. Mean Clinical Scores for the Groups Based on the Presence or Absence of Major Depressive Disorder(MDD) and Posttraumatic Stress Disorder (PTSD)

Total sample CG only CG + PTSD CG + MDD CG + PTSD + MDD(n = 105) (n = 37) (n = 13) (n = 30) (n = 25)

Variables M SD M SD M SD M SD M SD

ICG 44.76 11.06 42.20 8.63 42.92 8.70 46.28 7.90 47.84 16.58Global PSQI score 9.44 4.19 8.14 3.30 9.31 4.53 10.10 4.54 10.71 4.45

Note. CG = Complicated Grief; ICG = Inventory of Complicated Grief; PSQI = Pittsburgh Sleep Quality Index.

Statistics

Descriptive statistics were first conducted to charac-terize sleep quality in the total sample. Thirty-seven par-ticipants (35.2%) met criteria for complicated grief only(CG group); 13 (12.4%) met criteria for both CG and cur-rent PTSD (CG + PTSD group); 30 (28.6%) met criteriafor CG and current MDD (CG + MDD); and 25 (23.8%)met criteria for all three disorders (CG + PTSD + MDD).An analysis of variance (ANOVA) using a 2 (presence vs.absence of MDD) × 2 (presence vs. absence of PTSD)design was conducted to determine whether sleep qualitydiffered according to presence/absence of these two dis-orders. Group differences were further quantified usingCohen’s d effect sizes (Cohen, 1988). A Cohen’s d valueof .20 reflects a small effect size, a value of .50 representsa medium effect size, and a value equal to or above .80 in-dicates a large effect size. Positive d values indicate groupdifferences in the expected direction.

Results

Sixteen men (M age = 51.6 years, SD = 10.5) and89 women (M age = 45.9 years, SD = 12.0) composedthe sample. The sample included a majority of Cau-casian (76.2%) and African American (22.1%) partici-pants. Twenty-eight participants were married, 28 werewidowed, 22 were divorced or separated, and 25 had nevermarried. Marital status was not available for two partici-pants. Mean number of losses was 1.58 ± 0.94 (range =1 to 5; mode = 1). Information regarding violent versusnonviolent losses was available for 98 participants. Forty-two participants (43%) had experienced at least one lossdue to violent death. Sample mean clinical scores are pre-sented in Tables 1 and 2. At study entry, 46 participants(43.81%) were taking antidepressants, 26 were receivingbenzodiazepines (24.76%), and eight were receiving otheranxiolytics (7.62%). Only 12 of the 105 participants hadobtained PSQI scores < 5, indicative of minimal sleep dis-turbances (five participants with CG only, three with CG

Sleep Quality in Complicated Grief 345

Table 2. Mean Clinical Scores for the Total Sample and Groups Based on the Presence or Absence of Major DepressiveDisorder (MDD)

Absence of current Presence of currentMDD (n = 51) MDD (n = 54)

Variables M SD M SDStudent t test

(df = 88) Cohen’s d

ICG 42.39 8.57 47.00 12.57 3.27** .43Global PSQI score 8.45 3.63 10.40 4.50 2.72** .48

PSQI component 1: Sleep quality 1.56 .86 1.96 .86 2.59* .46PSQI component 2: Sleep latency 1.59 1.12 1.85 1.12 1.92 .23PSQI component 3: Sleep duration 1.00 1.12 1.30 1.26 1.31 .22PSQI component 4: Sleep efficiency .69 .95 1.26 1.25 2.54* .51PSQI component 5: Sleep disturbances 1.67 .74 1.98 .92 2.53* .37PSQI component 6: Medications .92 1.29 1.17 1.37 1.10 .19PSQI component 7: Daytime disturbances 1.14 .60 .91 .71 1.92 .35

Note. ICG = Inventory of Complicated Grief; PSQI = Pittsburgh Sleep Quality Index.*p < .05. **p < .01

and comorbid MDD, two with CG and comorbid PTSD,and two with all three conditions).

The four groups did not differ on age, F(3, 101) =1.23. Mean ICG and PSQI scores for the four groupsare presented in Table 1. For ICG scores, the MDD ×PTSD interaction was not significant, F(1, 104) = 0.03.There was a marginally significant main effect of MDD,F(1, 104) = 3.82, p =.05, but no main effect of PTSD,F(1, 104) = 0.25, ns. For the mean global PSQI scores,the MDD × PTSD interaction was again not significant,F(1, 103) = 0.11. There was a marginally significant maineffect of MDD, F(1, 103) = 3.76, p < .10, but no maineffect of PTSD, F(1, 103) = .97, ns.

To further characterize the effect of comorbid MDDon overall and components of sleep quality in this sample,one-way ANOVAs and effect sizes were computed byregrouping CG participants with (n = 54) and without(n = 51) current comorbid MDD. Findings are presentedin Table 2. The Cohen’s d effect sizes ranged from mildto moderate for overall sleep quality and its components.

Finally, to determine whether poor sleep quality wasattributable only to depression symptom severity, ratherthan grief severity, a hierarchical regression was con-ducted. ICG was entered first in the model, and HRSDscores were then entered. PSQI global scores were usedas the dependent variable. ICG scores (β = .20, p < .05)and HRSD scores (β = .42, p < .001) both predicted poorsleep quality.

Discussion

Complicated grief is associated with poor sleep qual-ity. The mean global PSQI score of 9.44 obtained by thissample exceeds the clinical cutoff score ≤ 5 (Buysse et al.,1989). The presence of comorbid MDD further decreased

sleep quality and sleep efficiency (or sleep duration overtotal time spent in bed). These observations are consistentwith prior findings on the relationship between bereave-ment, sleep quality, and depression (Brown et al., 1996;McDermott et al., 1997; Pasternak et al., 1992; Reynoldset al., 1993). Additionally, disrupted social rhythms andlow activity levels are associated with poor sleep qualityin bereaved depressed individuals (Brown et al., 1966).Given that participants with and without CG did not dif-fer on sleep latency and sleep duration (included in thesleep efficiency calculation), the results may relate to be-havioral changes associated with grief and/or depression(e.g., increased time in bed while awake, decreased activ-ity levels), or changes in social rhythm stability. Furtherstudies are required to identify the determinants of sleepin the CG-MDD comorbidity.

The relatively small sample size limited the statisti-cal power necessary to detect potential group differencesin sleep quality, especially given the small number of par-ticipants with comorbid PTSD (n = 38). These resultsmust be replicated in larger samples, including bereavedindividuals without CG, and PTSD and MDD sampleswithout CG. Longitudinal assessments initiated earlier inthe bereavement process are also necessary to better char-acterize the relationships between CG, MDD, and sleepdisruption. The present findings suggest that further in-vestigation into the relationship between CG, depression,and sleep and may provide new clinical insights to com-plement future therapeutic efforts.

Acknowledgments

This work was supported by the National Instituteof Health (MH60783, MH30915, MH00295, MH37869,MH43832, MH24652) and the Canadian Institutes of

346 Germain, Caroff, Buysse, and Shear

Health Research. Special thanks to Jacqueline Fury andRussell Silowash for data management and processing.

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