Running head: MISCARRIAGE, SLEEP, GRIEF, DEPRESSION, AND ANXIETY Assessing the Role of Sleep, Grief, Anxiety, and Depression in a Miscarriage Population A Thesis Submitted to the Faculty of Drexel University By Amy Gencarelli In partial fulfillment of the requirements for the degree of Master of Science March 2016 MISCARRIAGE,&SLEEP,&GRIEF,&DEPRESSION,&AND&ANXIETY& ii& & && & © Copyright 2016 Amy Gencarelli. All Rights Reserved MISCARRIAGE, SLEEP, GRIEF, DEPRESSION, AND ANXIETY iii Table of Contents List of Tables ........................................................................................................................................................... v List of Figures ........................................................................................................................................................ vi Abstract ................................................................................................................................................................... vii 1. Introduction .................................................................................................................................................... 10 1.1 The Association of Bereavement and Sleep with Anxiety, Depressed Mood, and Miscarriage ........................................................................................................................................................... 13 1.2 The Importance of Carefully Measuring Bereavement as a Distinct Construct from Depressed Mood ................................................................................................................................................. 16 1.3 The Specific Association Between Bereavement and Sleep ...................................................... 18 1.4 Potential of Research to Assist in Treatment Formulation ........................................................ 21 1.5 Bereavement in the Context of Miscarriage .................................................................................... 22 1.6 Health Care Implications for Women who Experience Miscarriage ...................................... 23 1.7 Partners of Women Who Miscarry: Male-Specific Considerations ........................................ 24 1.8 Partners of Women Who Miscarry: Female-Specific Considerations .................................... 26 1.9 Partners of Women Who Miscarry: Health Care Considerations ............................................ 28 1.10 The Current Study ................................................................................................................................... 30 1.11 Proposed Aims and Hypotheses ........................................................................................................ 31 1.12 Exploratory Aims ................................................................................................................................... 32 2. Methods ............................................................................................................................................................. 33 2.1 Participants .................................................................................................................................................. 33 2.2 Measures ........................................................................................................................................................ 34 2.3 Procedure ..................................................................................................................................................... 38 2.4 Aims, Hypotheses, and Proposed Data Analytic Strategy .......................................................... 39 3. Results ............................................................................................................................................................... 43 3.1 Sample Characteristics ............................................................................................................................ 43 3.2 Preliminary Analyses ............................................................................................................................... 45 3.3 Primary Analyses ....................................................................................................................................... 46 3.4 Post-hoc Analyses ...................................................................................................................................... 49 4. Discussion ........................................................................................................................................................ 53 Sleep Disturbance .............................................................................................................................................. 54 Insomnia ................................................................................................................................................................ 55 MISCARRIAGE, SLEEP, GRIEF, DEPRESSION, AND ANXIETY iv Bereavement ........................................................................................................................................................ 56 Sequelae of Miscarriage ................................................................................................................................... 58 Potential Pathways ............................................................................................................................................ 59 The Relationship Between Bereavement, Depression, and Sleep quality ................................... 60 Factors That May Affect the Psychological Sequelae of Miscarriage ............................................. 60 4.1 Limitations ................................................................................................................................................... 62 4.2 Future Directions ....................................................................................................................................... 63 4.3 Conclusions .................................................................................................................................................. 65 References ............................................................................................................................................................ 68 Appendix A: Demographics Questionnaire for Women Who Have Miscarried ......................... 93 Appendix B: Demographics Questionnaire for POWM ...................................................................... 107 Appendix C: The Pittsburg Sleep Quality Index ................................................................................... 121 Appendix D: Perinatal Bereavement Scale ............................................................................................. 125 Appendix F: Insomnia Severity Index ...................................................................................................... 129 Appendix G: Waiver of Consent .................................................................................................................. 130 MISCARRIAGE, SLEEP, GRIEF, DEPRESSION, AND ANXIETY v List of Tables Table 1: Demographic Information ............................................................................................................. 77 Table 2: Internal Consistency of Primary Measures ............................................................................ 80 Table 3: Means of Main Measures................................................................................................................ 81 Table 4: Correlation Matrix of Primary Variables of Interest ........................................................... 82 Table 5: Clinical Thresholds ........................................................................................................................... 83 Table 6: Comparison: Currently Pregnant vs Not Currently Pregnant on Main Measures ... 84 Table 7: Comparison: 1 vs 2 Miscarriages on Main Measures .......................................................... 85 Table 8: Comparison: Sleep Duration on Dependent Measures ...................................................... 86 Table 9: Comparison: Additional Miscarriages Beyond 1 Year on Main Measures .................. 87 Table 10: Post-Hoc Correlation Matrix ...................................................................................................... 88 MISCARRIAGE, SLEEP, GRIEF, DEPRESSION, AND ANXIETY vi List of Figures Figure 1: Sleep Disturbance ........................................................................................................................... 89 Figure 2: Anxiety ................................................................................................................................................ 90 Figure 3: Depression ......................................................................................................................................... 91 Figure 4: Insomnia ............................................................................................................................................. 92 MISCARRIAGE, SLEEP, GRIEF, DEPRESSION, AND ANXIETY vii Abstract Assessing the Role of Sleep, Grief, Anxiety, and Depression in a Miscarriage Population Amy Gencarelli Jacqueline D. Kloss, Ph.D. Miscarriage occurs at a relatively high rate in women who become pregnant