|
 
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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 5
| Issue : 1 | Page : 9-16 |
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Impact of rumination on severity and persistence of anxiety and depression in cardiac patients
Ying Yi Guan1, Lisa Phillips1, Barbara Murphy2, Susan Crebbin3, Michael Le Grande4, Marian U Worcester5, Alun Jackson6
1 School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
2 School of Psychological Sciences, University of Melbourne; Australian Centre for Heart Health, Melbourne; Faculty of Health, Deakin University, Geelong, Victoria, Australia
3 School of Psychological Sciences, University of Melbourne; Australian Centre for Heart Health, Melbourne, Victoria, Australia
4 Australian Centre for Heart Health, Melbourne; Faculty of Health, Deakin University, Geelong, Victoria, Australia
5 Australian Centre for Heart Health, Melbourne, Victoria, Australia, India
6 Australian Centre for Heart Health, Melbourne; Faculty of Health, Deakin University, Geelong, Victoria, Australia; Centre on Behavioral Health, University of Hong Kong, Hong Kong, PRC
| Date of Submission | 18-Nov-2020 |
| Date of Acceptance | 22-Feb-2021 |
| Date of Web Publication | 27-Mar-2021 |
Correspondence Address:
Dr. Barbara Murphy
Associate Director, Australian Centre for Heart Health, PO 2137 Royal Melbourne Hospital
Australia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/hm.hm_38_20
Background: Anxiety and depression are common after an acute cardiac event. While many studies have investigated the predictors of anxiety and depression, few have focused on the role of rumination. The aim of this study was to identify the ruminative styles that predict anxiety and depression in the 2 years' postcardiac event. Methods: A total of 426 cardiac patients, 210 admitted for acute coronary syndrome (ACS), and 216 to undergo coronary artery bypass graft surgery were recruited from three metropolitan hospitals in Melbourne, Australia. Participants completed self-report questionnaires at the time of their event and at 12- and 24-months postevent. Anxiety and depression were assessed at all three time points, whereas ruminative styles were assessed at 24 months. Clinical information was retrieved from the participants' medical records. Bivariate and multivariate analyses were undertaken to identify the factors associated with and predictive of anxiety and depression at 24-months postevent. Results: A diagnosis of ACS, history of depression, smoking, and brooding and intrusive rumination were associated with both anxiety and depression, while female gender was associated with anxiety only. Brooding and intrusive rumination were the unique predictors of anxiety and depression, after controlling for other factors. Limitations: Generalizability of the findings is limited by the preponderance of men in the sample and by participant attrition over the study period. Conclusion: The findings indicate the importance of screening for rumination styles after a cardiac event to enhance targeting of psychological treatments for cardiac patients at risk of persistent anxiety or depression.
Keywords: Anxiety, cardiac, coronary heart disease, depression, rumination, screening
How to cite this article:
Guan YY, Phillips L, Murphy B, Crebbin S, Grande ML, Worcester MU, Jackson A. Impact of rumination on severity and persistence of anxiety and depression in cardiac patients. Heart Mind 2021;5:9-16 |
How to cite this URL:
Guan YY, Phillips L, Murphy B, Crebbin S, Grande ML, Worcester MU, Jackson A. Impact of rumination on severity and persistence of anxiety and depression in cardiac patients. Heart Mind [serial online] 2021 [cited 2023 May 28];5:9-16. Available from: http://www.heartmindjournal.org/text.asp?2021/5/1/9/312309 |
| Introduction | |  |
Coronary heart disease (CHD) affects the physical, emotional, and social aspects of an individual's life. Having an acute cardiac event confers an increased risk of anxiety and depression,[1],[2],[3],[4],[5],[6] which in turn exacerbates susceptibility to future events and premature mortality.[7],[8],[9],[10] Importantly, even mild depressive symptoms confer an increased mortality risk.[11],[12] Approximately 40% of patients report elevated depressive symptomatology after a cardiac event, with around 20% meeting criteria for major depressive disorder,[1],[3],[4],[5] representing a four-fold increased risk compared to the general population. Rates of anxiety are somewhat higher, with around one in three patients reporting anxiety over the first postevent period.[2],[3],[6] As such, researchers have called for increased understanding of the mechanisms underlying the association between anxiety, depression, and heart health to ensure the identification and support for at-risk patients.[4],[5]
Rumination, a form of repetitive thinking or “perseverative cognition,” is a stable personality trait associated with both anxiety and depression.[13],[14],[15],[16],[17] Dysphoric symptoms are maintained by repetitive processing of negative information, interfering with one's functionality such as problem-solving and behavior activation.[18],[19],[20] In terms of its impact on physical health, rumination is associated with decreased parasympathetic activity and prolonged sympathetic activation, thereby explaining its shared role in both depression and heart disease.[21]
Several subtypes of rumination have been identified and found to be differentially associated with depression. Extending the seminal work of Nolen-Hoeksema and colleagues, Treynor delineated between brooding and reflective rumination.[13],[14],[22] Brooding rumination involves the passive focus on the discrepancies between one's expectations and current state, thereby exacerbating depression, whereas reflective rumination involves a contemplative and deliberate engagement of problem-solving, thereby reducing depression.[22] Calhoun and Tedeschi differentiated between intrusive and deliberate rumination in individuals who have experienced highly stressful or traumatic incidents.[23] Intrusive rumination involves repeated unsolicited intrusion of thoughts about the event and is linked with distress, while deliberate rumination comprises purposeful and voluntary thought processing aimed at understanding the event and problem-solving and is associated with improved emotional well-being.[23] The two “negative” ruminative styles, brooding and intrusive, prevent disengagement from one's emotional state, hence their link with distress. In contrast, the two “positive” ruminative styles, reflective and deliberate, are linked with problem-solving and attempts to identify the positive outcomes of any traumatic or stressful event.[19],[23]
Given that different ruminative subtypes may be linked to different outcomes after an acute cardiac event, it has been suggested that studies investigate the relationship between ruminative styles and anxiety and depression in cardiac patients.[16],[24] Few previous studies have focused on this area, with notable exceptions being a qualitative study illuminating the nature of perseverative negative thinking in anxious and depressed cardiac patients[25],[26] and a quantitative study on the role of brooding rumination in predicting and maintaining depression in cardiac patients.[27] No study has examined the four different ruminative styles and cardiac anxiety and depression in a single study.
The aim of the present study was to investigate the association between the four rumination styles – brooding, reflective, intrusive, and deliberate – and anxiety and depression, over a 24-month postcardiac event period. The study also aimed to identify which ruminative styles independently predicted anxiety and depression and to explore the impact of the negative ruminative styles on the persistence of anxiety and depression over time.
| Methods | | |
Study design
The present study was part of a larger study originally designed to investigate the resumption of work during the first 12-months after a cardiac event; the method and results of the original study are described elsewhere.[28] Assessments were undertaken at the time of patients' hospitalization for their cardiac event and again 12 and 24 months later. All assessments were completed using self-report hardcopy questionnaires. Baseline data were collected in hospital, whereas follow-up questionnaires were mailed to participants' home address and returned by pre-paid mail.
Patient recruitment
Participants were recruited from three metropolitan hospitals in Melbourne, Australia. Eligible patients were those admitted to hospital to undergo coronary artery bypass graft surgery (CABGS), or with acute coronary syndrome (ACS), with sufficient English language to provide informed consent and in the paid workforce (a requirement for the original study). Patients were excluded if they had a major physical or psychiatric illness comorbid to their cardiac disease. Ethics approval was obtained from the Human Research Ethics Committees of the participating hospitals.
As shown in [Figure 1], while 677 patients met the inclusion criteria, 251 were later excluded due to patient refusal or inadequate English language proficiency. Subsequently, 426 participants were interviewed at baseline. Over the first 12 months, 27 (6%) withdrew from the study and a further 39 (9%) were unavailable or unable to be contacted at the time of the 12-month follow-up. Thus, 360 (85%) of the original sample were included at the first follow-up. Over the next 12 months, a further 17 (4%) participants withdrew and 142 (33%) were unable to be contacted at the time of the 24-month follow-up. Thus, 201 (47%) of the original sample were included at the second follow-up.
Measures
Sociodemographic information, including age, gender, marital status, and education level, was collected from the participants at baseline. Smoking status was also collected by self-report. All self-report variables were dichotomized to aid statistical analyses.
Medical information, which was obtained from patients' hospital medical records at the time of the index event, included event type; hypertension, hypercholesterolemia, family history of CVD, diagnosed diabetes mellitus, body mass index (BMI), and history of depression. BMI was dichotomized into “healthy” (from 18.5 to 24.9) or “unhealthy.”
Anxiety and depression were assessed at each timepoint using the Hospital Anxiety and Depression Scale (HADS), a 14-item self-report questionnaire.[29] The scale has good construct validity and high internal consistency[30] and has been validated with cardiac patients.[31] Patients with HADS-A scores of ≥8 were classified as anxious[29] and based on recommendations for cardiac samples, those with HADS-D scores of ≥4 were classified as depressed.[32] Cronbach's alphas for this study ranged from 0.81–0.87 for HADS-A to 0.77–0.84 for HADS-D across the three, assessment time-points.
Rumination was assessed at the 24-month follow-up. Brooding and reflective rumination were measured using the Rumination-Brooding and Reflective Scale (R-BRS) (5 items each, 5-point response scale).[22] The R-BRS has demonstrated good convergent validity, discriminant validity, and internal consistency.[33] Cronbach's alphas for brooding and reflective subscales in the present study were 0.87 and 0.86, respectively. Intrusive and deliberate rumination were measured using the 20-item event-related rumination inventory (ERRI) (10 items each, 4-point response scale).[34] The ERRI has demonstrated good discriminant validity and internal consistency.[34] Cronbach's alphas for intrusive and deliberate rumination in the present study were 0.94 and 0.84, respectively. For each rumination style, participants' scores were trichotomized; the top third were classified as “high ruminators” and the lower two thirds as “low ruminators.”
Statistical analysis
T-tests were used to examine the associations between patient characteristics (sociodemographic, medical, and ruminative styles) and anxiety and depression at 24 months. T-tests and Chi-square tests were used to examine the baseline differences between CABGS and ACS patients. The results were considered significant at P < 0.05. Hierarchical regression analyses were used to identify the significant predictors of anxiety and depression at 24 months. Significant factors from the bivariate analyses were entered into the regression analyses. Repeated-measures analysis of variance (ANOVA) was used to explore the interaction effect between time and the two negative rumination styles on anxiety and depression.
| Results | | |
Characteristics of the baseline sample
As shown in [Table 1], 216 CABGS and 210 ACS patients participated at baseline. Participants' ages ranged from 29 to 75, with a mean (standard deviation [SD]) age of 54.8 (8.55), with almost half aged from 50 to 60 years. Participants were predominantly male, partnered, born in Australia, and had at least 10 years of formal education. A majority of participants had CHD risk factors such as hypertension, high cholesterol, and BMI in the unhealthy range. At baseline, 45% of the participants were classified as anxious and 58% as depressed. By the 24-month follow-up, 29% and 33% of the participants were classified as anxious and depressed, respectively. | Table 1: Sociodemographic and medical characteristics of eligible participants
Click here to view |
There were two significant differences between CABGS and ACS patients. Namely, CABGS patients were older than ACS patients (mean age 57.77 years, SD = 7.89 vs. mean 52.1 SD = 8.12, P < 0.001) and were less likely to be smokers (6.8% vs. 44.6%, P < 0.001). There were no other significant baseline differences between ACS and CABGS patients in terms of either sociodemographic or medical characteristics.
There were relationships between sociodemographic, medical and ruminative styles, and anxiety and depression.
Associations between patient characteristics (sociodemographic, medical, and ruminative styles) and anxiety and depression is shown in [Table 2] and [Table 3], respectively. | Table 3: Patient characteristics associated with depression at 24 months
Click here to view |
As shown in [Table 2], females, those with ACS, those with a history of depression, current smokers, and those who engaged in higher levels of brooding and intrusive rumination reported higher levels of anxiety. All other participant characteristics, including partner status, country of birth, age, education, main language, hypertension, high cholesterol, family history, diabetes, BMI, and reflective and deliberate rumination, were not significantly associated with anxiety. As shown in [Table 3], those with ACS, those with a history of depression, current smokers, and those who engaged in higher levels of brooding and intrusive rumination reported the higher levels of depression. All other participant characteristics were not significantly associated with depression.
Predictors of anxiety
[Table 4] shows the results of hierarchical regression of anxiety on different ruminative styles at 24 months, while controlling for gender, index event, history of depression, and smoking status. Model 1 shows that gender (P = 0.005), ACS event type (P = 0.026), and history of depression (P = 0.028) were the significant predictors of anxiety. When brooding rumination was added into Model 2, it accounted for a statistically significant proportion (32.3%) of variance in anxiety, while controlling for gender, index event, history of depression, and smoking status (ΔF (1186) =105, P < 0.001). When intrusive rumination was entered into Model 3, it accounted for a statistically significant proportion (7.1%) of variance of anxiety (ΔF (1185) =26.3, P < 0.001). Thus the final model identified both brooding and intrusive rumination as unique predictors of anxiety at 24-months postevent.
Predictors of depression
[Table 5] illustrates the results of hierarchical regression of depression on different ruminative styles, at 24 months, while controlling for index event, history of depression, and smoking status. Model 1 showed that ACS event (P = 0.025) and history of depression (P = 0.002) were the significant predictors of depression. When brooding rumination was added into Model 2, it accounted for a statistically significant proportion (17.7%) of variance in depression, whereas controlling for index event, history of depression, and smoking status (ΔF (1187) =46.4, P < 0.001). When intrusive rumination was entered into Model 3, it accounted for a statistically significant proportion of variance (7.1%) of depression (ΔF (1186) =4.60, P = 0.033). Thus, the final model identified both brooding and intrusive rumination as unique predictors of depression at 24 months postevent.
Relationship between rumination and anxiety and depression over time
Results of repeated-measures ANOVA to investigate the association between brooding and intrusive rumination and levels of anxiety and depression over the 24-month period are shown in [Figure 2]. | Figure 2: Change over time in anxiety and depression for low and high ruminators after adjusting for significant confounders
Click here to view |
For anxiety, there was a significant interaction between time and level of brooding rumination, F (2202) =4.66, P = 0.010, partial η2 = 0.044), after controlling for gender, index event, smoking status, and history of depression. For low brooders, anxiety decreased significantly from Time 1 to Time 2 (M = 1.70, 95% confidence interval [CI] [0.520, 2.89], P = 0.002), with maintenance from Time 2 to Time 3 (M = 0.856, 95% CI [−0.191, 1.90], P = 0.147). High brooders maintained their high anxiety over time, with no change in anxiety levels from Time 1 to Time 2 (M = 0.165, 95% CI [−1.18, 1.51], P > 0.05), or from Time 1 to Time 3 (M = 0.370, 95% CI [−1.02, 1.76], P > 0.05). High brooders had higher mean anxiety scores than low brooders at all three timepoints: Time 1 (M = 3.02, 95% CI [1.52, 4.53], P < 0.001), Time 2 (M = 4.56, 95% CI [3.07, 6.05], P < 0.001), and Time 3 (M = 5.21, 95% CI [3.93, 6.50], P < 0.001).
There was also a significant interaction between time and level of intrusive rumination for anxiety, F (1.95, 204) =4.29, P = 0.016, partial η2 = 0.039, after controlling for gender, index event, smoking status, and history of depression. For low intrusives, anxiety decreased significantly from Time 1 to Time 2 (M = 1.56, 95% CI [0.381, 2.74], P = 0.005), with maintenance from Time 2 to Time 3 (M = 0.899, 95% CI [−0.079, 1.88], P = 0.082). High intrusives maintained their high anxiety over time, with no change in anxiety levels from Time 1 to Time 2 (M = 0.510, 95% CI [−0.796, 1.82], P > 0.05), or from Time 1 to Time 3 (M = 0.374, 95% CI [−1.05, 1.80], P > 0.05). High intrusives had higher mean anxiety scores than low intrusives at all three timpoints: Time 1 (M = 2.76, 95% CI [1.27, 4.25], P < 0.001), Time 2 (M = 3.82, 95% CI [2.40, 5.24], P <.001), and Time 3 (M = 4.85, 95% CI [3. 57, 6.13], P <.001).
For depression, there was a significant main effect of brooding rumination after controlling for index event, smoking status, and history of depression. (F (1102) = 21.9, P <.001), partial η2 = 0.177). High brooders had a significantly higher mean depression score than low brooders (M = 2.51, 95% CI [1.45, 3.58], P < 0.001). The main effect of time and the interaction between time and brooding were both non-significant (F (1.82, 186) = 0.639, P = 0.515, partial η2 = 0.006; and F (1.82, 186) =1.99, P = 0.144, partial η2 = 0.019, respectively).
There was also a significant main effect of intrusive rumination after controlling for index event, smoking status, and history of depression (F (1106) =22.5, P < 0.001, partial η2 = 0.175). High intrusives had a significantly higher mean depression score than low intrusives (M = 2.37, 95% CI [1.38, 3.36], P < 0.001). The main effect of time and the interaction between time and intrusive rumination were both non-significant (F (1.75, 185) =1.58, P = 0.210, partial η2 = 0.015; and F (1.75, 185) = 0.448, P = 0.613, partial η2 = 0.004, respectively.
| Discussion | | |
This study has identified both brooding and intrusive rumination as significant and unique predictors of anxiety and depression, affirming the results of previous studies.[13],[14],[15],[17],[23] By focusing on the role of both brooding and intrusive rumination in predicting postevent distress, the present findings extend previous work in the cardiac area.[27] The findings corroborate previous research indicating both brooding and intrusive rumination as maladaptive cognitive styles, preventing active problem-solving, and sustaining psychological distress.[35],[36] Conversely, the nonsignificant relationships between reflective and deliberate rumination and distress provide further support of the adaptive nature of these two positive rumination styles.[24],[27],[34]
Perhaps, not surprisingly, the negative rumination subtypes were more strongly associated with anxiety than with depression. Anxiety is often characterized by intrusive and uncontrollable thoughts,[25],[37] and worry is considered a key component of both rumination[17] and anxiety.[25],[37] Consistently, the HADS-A includes the item “worrying thoughts go through my mind,” which taps directly into negative rumination.
With respect to anxiety, high brooding and intrusive ruminators exhibited higher anxiety than low-ruminators at all time-points up to 24 months postevent, with no reduction in anxiety symptoms over time. This finding accords with earlier studies demonstrating long-term adverse relationships between rumination and anxiety.[14],[16] In contrast, low ruminators experienced a decrease in the anxiety levels over time. The persistence of anxiety for high ruminators could be due to the intolerance of uncertainty[38] and increased sense of hopelessness[16] associated with high rumination. When faced with circumstantial uncertainties, high ruminators resort to increased rumination in the hope of generating greater insight and solutions to their problems.[18] However, due to the cognitive impairments such as reduced attentional focus and problem-solving deficits that are characteristic of rumination,[14],[18],[36] high ruminators experience greater uncertainty and distress, trapping them in a vicious cycle of rumination that perpetuates their ruminative thoughts,[25],[36],[39] and exacerbates anxiety levels.[14],[25] Given that one's prognosis after a cardiac event is often shrouded in ambiguity, it is not surprising that cardiac patients with ruminative tendencies experience elevated and persistent levels of anxiety.
The pattern of change for depression was similar to that of anxiety, though less pronounced. Overall, high ruminators had higher depression levels than low ruminators, consistent with previous studies.[13],[14],[15],[17],[23] Similarly, low ruminators demonstrated a tendency for reduced depression over time, whereas high ruminators showed a tendency for persistent depression over time. Explanations for this relationship include increased recollection of negative experiences and memories, increased pessimism about the future, impaired attentional processing, problem-solving deficits, and difficulty finding meaning in the event.[14],[18],[19],[35] That the effects were less significant for depression than for anxiety is possibly due to the relatively low mean depression scores for participants in the present study, resulting in a floor effect. Nonetheless, the pattern of results points to rumination as a risk factor for persistent depressive symptomology over 24 months postevent.
Other patient characteristics that predicted anxiety and depression included ACS event type, smoking at baseline, history of depression and for anxiety only, and female gender. History of depression and cigarette smoking are commonly associated with anxiety and depression in both CABGS and ACS patient populations.[3],[40],[41] Together with the relatively high smoking rates for ACS patients, the fact that they were significantly younger than their CABGS counterparts might further explain their higher rates of mental health problems, as younger age also commonly predict anxiety and depression[3],[40],[41] The higher rates of anxiety for female patients are also consistent with previous research.[42]
The present study had some limitations. First, with the majority of the participants being men, results from this study apply primarily to male CHD patients. This is important as females in the general population engage in the higher levels of rumination and experience greater psychological distress than their male counterparts[13],[42] While this gender imbalance is typical of cardiac patient samples recruited as consecutive hospital admissions,[43] it was exacerbated by the eligibility requirement in the original study that participants be in the paid workforce, and therefore younger. Second, despite efforts to re-engage participants, the high dropout rate during the second phase limits the generalisability of the findings. Importantly, however, participant recruitment from three large metropolitan hospitals and the initial large sample size enhance the generalizability of the findings to the general cardiac population. Third, despite the longitudinal nature of this study, rumination data were only collected at the third phase. However, as rumination is generally regarded as a stable response style,[14],[44],[45] or as habitual behavior,[46] it is arguably unlikely that participants' ratings would be drastically different if measured at baseline.
The stability of ruminative cognitive style has been discussed extensively in the literature and addressed in several studies. In their review of models of rumination and the various ways it is assessed, Smith and colleagues[47] concluded that “given that rumination has been consistently reported in response to negative mood over varying intervals of time, rumination may be best conceptualized as a stable, individual trait.”[47] They reported that “direct assessment of rumination's stability has demonstrated significant retest reliability for the RSQ (the Response Style Questionnaire, the longer form of the R-BRS used in the present study to measure Brooding and Reflective rumination) administered 2–3 months, 5-months, and 1 year apart” in several studies[47] (p5). In a longitudinal study of recently bereaved people, the RSQ showed an intraclass correlation of. 75 across five interviews over an 18-month period, despite changes in depression level.[48] While the ERRI used in the present study to measure intrusive and deliberate rumination was designed to take into account more transitory cognitive states,[34] it is interesting that the pattern of findings was so similar for both the R-BRS and the ERRI. Nonetheless, findings related to intrusive and deliberate rumination reported here should perhaps be interpreted with some caution.
Clinical implications
The findings of the present study have two important clinical implications. First, in light of the improvement of anxiety and depression symptoms observed in many patients during the 1st year postevent,[43] it has been observed that psychological interventions to treat anxiety and depression are more efficacious and cost-effective when initiated later in patients' recovery, to address persistent rather than initial distress.[49] Early identification of patients with a negative ruminative style should assist in targeting psychological treatment to those at risk of persistent distress. Indeed, screening for ruminative styles close to the time of the cardiac event is indicated. Second, by providing increased understanding of the rumination subtypes associated with psychological distress in cardiac patients, the present findings can also assist in the development of more targeted interventions, such as the use of rumination-focused cognitive behavior therapy[50] or metacognitive therapy[26] to alleviate maladaptive cognitive processes and improve cardiac outcomes. Indeed, it has been suggested that “an individual who responds to triggering events with rumination will likely continue to do so unless rumination itself, or the metacognitive beliefs that contribute to selection of rumination as a coping strategy, are targeted in treatment.”[47] Interestingly, severely depressed high ruminators have been shown to respond better to cognitive therapy and experience more rapid recovery of depressive symptomatology than their low-ruminator counterparts.[51]
| Conclusion | | |
This study has highlighted the important role of brooding and intrusive rumination in postcardiac event anxiety and depression. The findings demonstrate the longitudinal relationship between rumination and anxiety and depression, indicating the need for screening, identification, and psychological treatment for patients with a ruminative response style. In considering the role of rumination in elevating distress and its accompanying detrimental effects on the prognosis of cardiac patients, health-care providers should pay greater attention to these maladaptive cognitive styles to ensure early provision of adequate and targeted interventions to these at-risk patients.
Acknowledgement
We would like to acknowledge the contributions of Peter C. Elliott, Alyna Turner, Jeremy J. Pereira, Katherine L. Middleton, Hema S. Navaratnam, John K. Nguyen, Jan Kleinman, Robert W. Newman, James Tatoulis and Alan Goble who were involved in the original study. We are grateful to the research participants and staff from the participating hospitals.
Financial support and sponsorship
Funding for the original study was received from the Fred P Archer Charitable Trust and the Eirene Lucas Foundation.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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