Ruminative coping among patients with dysthymia before and after pharmacotherapy

DEPRESSION AND ANXIETY 24:233–243 (2007)

Research Article

RUMINATIVE COPING AMONG PATIENTS WITHDYSTHYMIA BEFORE AND AFTER PHARMACOTHERAPY

Owen Kelly, Ph.D.,1 Kim Matheson, Ph.D.,2 Arun Ravindran, M.B., Ph.D.,3 Zul Merali, Ph.D.,1

and Hymie Anisman, Ph.D.2�y

The pivotal role of rumination in relation to other coping strategies was assessed inchronically depressed (dysthymic disorder) individuals versus nondepressed controls.Individuals with dysthymia demonstrated elevated use of rumination and otheremotion-focused strategies (emotional expression, emotional containment, self- andother-blame). Among patients with dysthymia, rumination was linked to thislimited array of emotion-focused efforts and diminished use of cognitivedisengagement, whereas among controls, rumination was correlated with a broadconstellation of problem- and emotion-focused strategies. Following 12 weeks ofpharmacotherapy (sertraline), despite attenuation of depressed mood and reducedrumination, the limited relations between rumination and emotion-focused effortspersisted. Inflexibility in the ability to combine various coping efforts effectively maybe characteristic of individuals with dysthymia, potentially increasing risk forrecurrence. Depression and Anxiety 24:233–243, 2007. & 2006 Wiley-Liss, Inc.

Key words: rumination; coping; social functioning; dysthymia; depression;pharmacotherapy

INTRODUCTIONAlthough stressful events are frequent antecedentsof affective illness [Brown and Harris, 1989; Paykel,2001], pronounced interindividual differences occur inthis respect [Griffiths et al., 2000]. This variability maybe attributable to numerous individual differencefactors relating to stressor responses, including bothbiological [e.g., monoaminergic or peptidergic distur-bances; Nemeroff, 1996; Ordway et al., 2002] andpsychosocial processes affecting stressor appraisals, andthe perceived availability of various coping resourcesand strategies [Carver et al., 1989; Folkman andLazarus, 1985]. Consistent with this hypothesis,affective disorders have frequently been associated witha reduction in the endorsement of problem-focusedcoping strategies (e.g., cognitive restructuring, activeproblem solving) coupled with an increase in the use ofemotion-focused coping [e.g., emotional expression,self-blame; Endler and Parker, 1994; Holohan et al.,1999; Matheson and Anisman, 2003; Ravindran et al.,1999, 2002; Zlotnick et al., 2000]. In this regard, it hasbeen argued that ruminative coping may play a pivotalrole in individuals’ ability to manage distress effectively[Nolen-Hoeksema, 1998]. Importantly, the influence ofrumination on well-being may be a function of how it is

used in conjunction with other, more or less adaptivestrategies [Matheson and Anisman, 2003].

Whereas some behaviors may be symptomatic ofdepression, they might also represent the use of aparticular coping strategy in the face of adverse events.

Published online 26 September 2006 in Wiley InterScience (www.

interscience.wiley.com).

DOI 10.1002/da.20236

Received for publication 10 January 2006; Revised 2 May 2006;

Accepted 16 May 2006

Contract grant sponsor: Canadian Institutes of Health Research;

Contract grant sponsor: Pfizer Canada, Inc.

�Correspondence to: Hymie Anisman, Institute of Neuroscience,

Carleton University, Ottawa, Ontario K1S 5B6, Canada.

E-mail: [email protected]

yHolds a Canada Research Chair in Neuroscience and is an

Ontario Mental Health Senior Research Fellow.

1University of Ottawa Institute of Mental Health Research,

Ottawa, Ontario, Canada2Institute of Neuroscience, Carleton University, Ottawa, Ontario,

Canada3Department of Psychiatry, University of Toronto, Toronto,

Canada

rr 2006 Wiley-Liss, Inc.

Ruminative coping, which is characterized by self-reflection, and repetitive and passive focus on thesymptoms, implications, and consequences associatedwith one’s negative mood state [Morrow and Nolen-Hoeksema, 1990; Nolen-Hoeksema, 2000; Nolen-Hoeksema and Morrow, 1991; Nolen-Hoeksemaet al., 1994, 1999], has been associated with ongoingdepression and has been shown to predict symptomseverity, as well as the onset of major depressiveepisodes. Indeed, rumination may promote and pro-long depressed mood states by facilitating negativethinking about the past, present, and future [Lyubo-mirsky and Nolen-Hoeksema, 1993; Lyubomirskyet al., 1998]. Moreover, rumination may reducethe availability of social support to the depressedindividual, because friends and family grow tired oflistening to ruminations [Nolen-Hoeksema and Davis,1999].

The conceptualization of ruminative coping wasrevisited and refined, and important distinctions weremade between ‘‘reflective pondering’’ and ‘‘brooding’’:Whereas reflective pondering comprises a determinedeffort to employ cognitive problem solving in hopesof reducing the negative effects of the stressor,brooding reflects a passive comparison of the indivi-dual’s situation with an imagined normative state[Treynor et al., 2003]; importantly, these factors appearto predict different depressive symptoms, as well as tomediate gender differences. This distinction betweenreflective pondering and brooding suggests that rumi-nation does not occur in isolation; instead, theexpression of rumination reflects the confluence ofother cognitive factors that occur concurrently.

This position is not unlike the contention thatrumination is endorsed in conjunction with othercoping strategies, and that analyses of coping inrelation to pathological states would be best servedby considering the profile (combination) of responsesendorsed [Carver et al., 1989; Matheson and Anisman,2003]. For instance, two individuals may both employrumination as a dominant strategy; in one individual,rumination may be accompanied by problem solving orcognitive restructuring, whereas in the other, rumina-tion may be coupled with blame. The formercombination may lead to finding meaning and valuein the distressing situation [Janoff-Bulman and Frantz,1997], whereas the latter may be associated with self-pity or thoughts of vengeance (although possiblysatisfying, this is likely less productive). Furthermore,rumination may be accompanied by strategies such asemotional containment, possibly because individualsfeel that they have no one to talk to [Nolen-Hoeksemaand Davis, 1999], and may occur to the exclusion ofother coping methods such as distraction, whichtypically serve to buffer the individual against negativeaffect [Ingram, 1990; Lyubomirsky and Nolen-Hoek-sema, 1995].

Inasmuch as ruminative coping is related to theevolution and maintenance of depressive affect [Lyubo-

mirsky and Nolen-Hoeksema, 1993; Lyubomirsky et al.,1998; Nolen-Hoeksema and Davis, 1999], we assessedin our investigation the combination of coping strategiesassociated with dysthymic disorder, a subtype ofdepressive illness involving low-grade depressive affectof at least 2 years’ duration. We previously observed thatthe broader coping profiles of individuals diagnosedwith dysthymic disorder were not distinguishable fromthose of patients with major depression, but they weredistinctively different from those of nondepressedcontrols [Matheson and Anisman, 2003]. We hypothe-sized that nondepressed individuals would exhibitreduced levels of rumination relative to patients withdysthymic disorder. Moreover, we anticipated thatamong nondepressed individuals, rumination wouldoccur in conjunction with both emotion-focused strate-gies and increased use of strategies such as problemsolving and cognitive restructuring. In contrast, amongindividuals with dysthymia, a narrow range of copingstrategies would accompany rumination, and thesewould likely involve emotion-focused efforts.

Our second aim in this investigation was to ascertainwhether coping profiles, and particularly the interrela-tions between rumination and other coping strategies,would be altered with successful pharmacotherapy(12 weeks of sertraline treatment). Although there is apaucity of evidence concerning the impact of pharma-cotherapy on changes in the endorsement of particularcoping strategies, we previously reported that withattenuation of dysthymic symptoms, the excessivereliance on emotional expression and emotional con-tainment diminished, whereas seeking social supportincreased [Ravindran et al., 1999]. Given these altera-tions in the extent to which certain strategies were usedwhen symptoms were alleviated, we hypothesized thatsuccessful treatment with sertraline would result in adecrease in the endorsement of emotional-focusedcoping strategies (in particular, rumination), whileconcurrently evoking an increase in the endorsementof problem-focused coping. Moreover, we anticipatedthat the pattern of co-occurrence of coping strategiesamong treatment responders would resemble thatof control participants; namely, that rumination wouldco-occur more frequently with a wider range of copingstrategies.

METHODSPARTICIPANTS

Fifty-six patients with dysthymia, 27 males (meanage 5 40.5, SD 5 8.46 years) and 29 females (meanage 5 40.7, SD 5 8.48 years), were either consecutivereferrals to the outpatient Mood Disorders Clinic ofthe Royal Ottawa Hospital who met the study criteriaand agreed to participate or respondents to newspaperadvertisements that specified the symptoms of dysthy-mia. Participants comprised blue- and white-collargovernment and private sector employees, and basedon the responses of those reporting racial background,

234 Kelly et al.

Depression and Anxiety DOI 10.1002/da

this sample was predominately Euro-Caucasian(94.6%), with a smaller number of Asian (3.57%) andEast Asian (1.78%) participants. Patients with dysthy-mia were screened and included only those thatsatisfied DSM-III-R/DSM-IV criteria for primarydysthymia. These patients exhibited symptoms ofmoderate severity as measured by the Clinical GlobalImpressions scale [CGI; Guy, 1976]. Based on sub-jective responses from patients, early-onset dysthymia(under 21 years of age) was present in 31 patients, andthe average duration of the dysthymia was 19.19 years(SD 5 10.80), being comparable in males and females.Only four of the patients were currently being treatedwith psychotropic medication, and none were currentlyreceiving either cognitive or psychotherapy; fewerthan 5% had previous cognitive-behavioral therapy orpsychotherapy.

At the time of diagnosis, patients were free of majordepression. As well, exclusion criteria comprised anyphysical illness, such as severe allergies, multipleadverse drug reactions, hypertension, significant re-current dermatitis, and malignant, hematological,endocrine, pulmonary, cardiovascular, renal, hepatic,gastrointestinal, or neurological disease. Finally, preg-nant or lactating women were not included in theinvestigation.

We assessed nondepressed comparison participantsto obtain normative data regarding coping styles andaffective/social functioning. The nondepressed com-parison group was recruited through advertisementsand comprised 24 males (mean age 5 34.0, SD 56.42 years) and 31 females (mean age 5 36.5,SD 5 8.86 years) with similar socioeconomic statusand ethnicity to that of the experimental group. Theywere screened with (1) a semistructured clinical inter-view, the Mini-International Neuropsychiatric Inter-view [MINI; Sheehan et al., 1992] to exclude past orpresent DSM-IV Axis I disorders, and (2) had a score ofless than 4 on the 13-item Beck Depression Inventory[BDI; Beck and Beck, 1972], with a score of 0 on thefirst question of this scale (‘‘I do not feel sad’’).Comparison participants had never been treated withpsychotropic medications. Exclusion criteria for allparticipants also included self-reported illicit drug useduring the preceding month, viral illness during thepreceding 2 weeks, pregnancy or lactation in women,or any medical disorder that required chronic drugtreatment. Ethical clearance was provided by therelevant institutional review boards, and our studymet ethics guidelines of the American PsychologicalAssociation and the Canadian Tricouncil.

Over the course of the study, five drug-treated(sertraline) and four placebo-treated participants withdysthymia dropped out. In no case was this due to anadverse drug reaction. Rather, the treatment was nothaving a positive effect [confirmed by a HamiltonDepression Rating Scale (HAM-D) conducted at Week8], and participants wished to terminate the trial. TheHAM-D score at Week 8 was included in the analysis

as an intent-to-treat score. The baseline HAM-Dscores, as well as the quality of social interaction scoresof those patients who dropped out of the study, did notdiffer from those who continued (Fo1).

PROCEDURES

At the screening visit, written informed consent wasobtained, as was demographic information and char-acteristics of the current episode among patients withdysthymia. Informed consent included informationregarding the potential side effects of the antidepres-sant medication, and that a portion of the participantswould receive placebo treatment. Moreover, it wasemphasized that participants could discontinue treat-ment at any time without repercussions concerningfurther treatment they would receive.

After the screening visit, all patients underwent a1-week washout period. Those patients (less than 10%)in treatment with psychotropic medication wererequired to undergo a further washout equivalent tofive times the half-life of the medication they hadreceived. At the ensuing visit, patients underwent afull physical examination and clinical evaluation, whichincluded full blood count, urinalysis, and electrocar-diogram (EKG). At this time, we measured symptomsof depression using the 17-item HAM-D. In addition,because interpersonal interaction has frequently beenfound to be a useful index of functional changes ofdepression [e.g., Ravindran et al., 1999], we assessedthis using a component of the Battelle Quality of LifeScale [Ravicki et al., 1992].

After the placebo run-in phase, patients wererandomly assigned to the sertraline and placeboconditions, maintaining an approximately 2:1 drug:-placebo ratio. Of the patients with dysthymia, 19 males(Mean age 5 40.6, SD 5 7.52 years) and 21 females(Mean age 5 40.8, SD 5 9.99 years) were assigned to asertraline treatment condition, and 7 males (Meanage 5 40.2, SD 5 11.61 years) and 9 females (Meanage 5 40.6, SD 5 7.66 years) were assigned to theplacebo condition. As indicated in Table 1, at baseline,participants in the sertraline and placebo conditions didnot differ significantly on symptoms of depression asmeasured by the HAM-D. Researchers and nursesinvolved in the experimental component of the study,

TABLE 1. HAM-D scores and proportion of subjectsshowing positive treatment response before treatmentor after 12-week treatment with sertraline or placebo

Before treatment After 12 weeksPositiveresponseM SD M SD

Sertraline 19.69 3.80 6.83� 6.01 27/40�

Placebo 19.42 2.81 15.17 9.15 3/16

�Po.001.

235Research Article: Ruminative Coping and Dysthymia


as well as the patient her/himself, were unaware of thepharmacological treatment they received. The initialdose of sertraline was 50 mg, with 50 mg incrementsoccurring every 2 weeks, to a maximum dose of200 mg, as determined by treatment response andadverse events. The dose at Week 8 was carriedthrough to 12 weeks. At the termination of the12-week treatment period (and after a 12-week periodin the comparison sample), the 17-item HAM-D, theSystem of Coping Profile Endorsements (SCOPE),and the interpersonal functioning component of theBatelle Quality of Life Scale were again administered.If patients indicated that they did not want to continuethe study through to Week 12, then an interim HAM-D was determined at Week 8. Aside from pharma-cotherapy, no other treatments (supportive or cognitivetherapy) were provided to patients during the courseof the study. At the termination of the study, thosepatients who had not shown a positive treatmentresponse, those who had received placebo, as wellas patients that terminated the study early, wereprovided with alternative pharmacotherapy and/orsupportive therapy.

MEASURES

Hamilton Depression Rating Scale (HAM-D).The HAM-D [Hamilton, 1960] is a 17-item, clinician-administered screening instrument designed to mea-sure the severity of illness in adults diagnosed withdepression. The HAM-D is widely used for measuringoutcome in mood disorders and has demonstrated highvalidity and reliability in measuring responses totreatment.

Quality of social interaction. We have used thisself-report measure of quality of life [Ravicki et al.,1992] extensively to assess several domains of function-ing, although of particular interest in this study was thedimension reflecting the quality of participants’ socialinteractions. This subscale includes eight items, ratedby respondents rate on a 1 (none of the time) to 6 (all ofthe time) point rating scale, that are averaged to createa total score (Cronbach’s a5 .85).

Coping styles. Although there exist a number ofmultidimensional coping measures that we could haveused [Carver et al., 1989; Endler and Parker, 1994;Moos, 1988], we chose to use a 44-item SCOPE scaleto assess 12 coping styles that reflect a broad spectrumof cognitive-behavioral (problem solving, cognitiverestructuring, active and cognitive distraction, andrumination) and socioemotional responses (humor,seeking social support, emotional expression, other-and self-blame, emotional containment, and passiveresignation); scale development and psychometricproperties of the SCOPE are described in Mathesonand Anisman [2003]. In our past research, we foundthat the SCOPE demonstrates good reliability andis useful in distinguishing between stress-relateddisorders (e.g., depression) and the presence of post-

trauma symptoms associated with various events,including natural disasters and relationship abuse[Mantler et al., 2005; Matheson, 2003; Matheson andAnisman, 2003]. In an independent sample, the copingsubscales were significantly correlated with thoseassessed in the commonly used scale developed by[Carver et al., 1989; Matheson et al., 2005]. Thus, itappears that both concurrent and construct validityexist with respect to the SCOPE.

Respondents indicated their endorsement of whether(yes) or not (no) they had demonstrated each of thebehaviors as a way of dealing with problems or stressesin recent months. We obtained scores for each of the12 strategies by taking the average score of the relevantsubscale items. Although the specific coping strategiesare sometimes combined to form two to three super-ordinate categories of coping, analysis of the uniqueproperties of the multiple and diverse strategies thatcomprise the scale provides a richer understanding ofthe coping responses of individuals with stress-relatedsymptoms [Matheson and Anisman, 2003]. Addition-ally, this approach facilitates assessment of how copingprocesses evolve over time and across situations[Carver et al., 1989; Matheson and Anisman, 2003],and how they might be used in conjunction with otherstrategies depending on the individual or the situation.

Cronbach’s a’s for each of the coping dimensions aredisplayed in Table 2. Although some interitem reli-abilities are low, these results are similar to thoseobserved with other frequently employed measuresof coping [e.g., the Ways of Coping Scale; Folkmanand Lazarus, 1988] that determine endorsement ofbroad dimensions of coping using a variety of behaviors[Matheson and Anisman, 2003]. Indeed, although avariety of behaviors (and consequently items) couldbe appropriately used to reflect a given coping strategy,not all of these items might be endorsed concurrently.For instance, although ‘‘doing things that you typically

TABLE 2. Internal reliabilities (Cronbach’s a) for theSCOPE subscales (all participants)

SubscaleNo. ofitems

Baseline Posttreatment

a a

Problem solving 4 .44 .73Cognitive restructuring 4 .70 .80Activity (active

disengagement)5 .54 .56

Avoidance (cognitive) 3 .75 .78Rumination 3 .89 .87Humor 3 .63 .63Seeking social support 4 .73 .70Emotional expression 5 .70 .63Other blame 3 .75 .67Self-blame 3 .61 .60Emotional containment 4 .83 .88Passive resignation 3 .58 .65

236 Kelly et al.


enjoy,’’ ‘‘exercising,’’ and ‘‘went shopping’’ might allcomprise forms of ‘‘active disengagement’’ from aparticular problem or stressor, a given individualresponding to the questionnaire may endorse only asubset of these items. Across many individuals, thiscould lead to reduced interitem reliabilities.

Of particular interest in this study was the subscaleassessing rumination. It comprised three items, includ-ing ‘‘went over your problems in your mind over andover again,’’ ‘‘thought about your problems a lot,’’ and‘‘worried about your problems a lot.’’ In an indepen-dent sample (N 5 202), this subscale demonstratedreasonable construct validity, in that it was significantlymoderately correlated with the brooding (r 5 .46) andreflective pondering (r 5 .30) dimensions of the Rumi-native Responses Scale [RRS; Treynor et al., 2003].These moderate correlations were not unexpectedgiven that there is only a partial correspondencebetween the items comprising the rumination dimen-sion of the SCOPE and the RRS subscales. Moreover,although the particular function of rumination can beinferred directly from the RRS subscales, the purpo-sefulness of rumination as assessed by the SCOPE isdetermined by its relation to other types of copingstrategies. For example, the use of rumination incombination with problem solving may reflect theproactive use of rumination to facilitate the resolutionof a stressor and, in this instance, is reminiscent ofreflective pondering; the endorsement of rumination intandem with self-blame or emotional containment maybe more aligned with the use of ruminative coping ina brooding context.

STATISTICAL ANALYSES

To compare the HAM-D scores as a function of thedrug treatment that patients received, we performeda mixed measures analysis of variance (ANOVA) inwhich treatment (sertraline vs. placebo) was a between-subjects variable and measurement points (baseline vs.posttreatment) was a within-subjects variable. Func-tional changes were evaluated in terms of the qualityof social interactions and coping strategies endorsed.We assessed social interactions using a mixed-measuresANOVA, with treatment (control vs. drug-treated vs.placebo) as the between-subjects factor, and measure-ment points (baseline vs. posttreatment) as the within-subjects variable. In a similar fashion, we assessedchanges in the endorsement of coping strategies using amixed measures ANOVA, in which measurementpoints (baseline vs. posttreatment) and coping strategy(the 12 coping strategies derived from the SCOPE)were treated as within-subjects variables and treatment(control vs. drug-treated vs. placebo) as a between-subjects factor. To determine whether social function-ing and coping varied between treatment responders(both drug and placebo) and nonresponders, wefollowed up the main analyses with additional mixedmeasures ANOVAs in which measurement points

(baseline vs. posttreatment) and coping were treatedas within-subjects variables and improvement (respon-ders vs. nonresponders) as a between-subjects variable.

For each of the analyses, we assessed the assumptionof sphericity using Mauchley’s test of sphericity(Mauchly’s W). Where this assumption was violated(as denoted by a significant Mauchly’s W), a Huynh–Feldt e correction was applied to the degrees offreedom for both the effect and error term in eachanalysis with a within-subjects component. In all cases,significant interactions were followed up with simpleeffects analyses and post hoc comparisons (usingBonferroni-corrected t-tests to maintain familywise aat Po.05) to assess potential differences betweengroups. Finally, to assess rumination, a style that hasbeen regarded as central to the functioning ofdepressed patients, zero-order correlations betweenthis strategy and each of the remaining strategies wereexamined at both baseline and following 12 weeks oftreatment for the sertraline, placebo, and comparisongroups. Comparisons of these patterns of correlationwere also made between treatment responders andnonresponders.

RESULTSTREATMENT RESPONSIVENESS

Prior to assessing variations in coping as a functionof depressive affect and pharmacotherapy, it wasimportant to ascertain the effectiveness of drug (sertra-line) treatment on depressive symptoms and interper-sonal functioning. A 2 (treatment: sertraline vs.placebo; between-subjects)� 2 (measurement points:baseline vs. posttreatment; within-subjects) mixedmeasures ANOVA of the HAM-D scores of patientswith dysthymia yielded a significant drug treat-ment�measurement points interaction [F(1, 45) 512.78, Po.001, Z2 5 .221]. Subsequent post hoccomparisons confirmed that, unlike the comparableHAM-D scores prior to treatment [t(46) 5 .44,P 5.33], after 12 weeks, the decline of HAM-D scoreswas more pronounced in the sertraline condition thanamong patients who received placebo [t(46) 5 4.89,Po.001 (Table 1). Furthermore, those patients whoshowed a positive treatment response (a HAM-D scoreo10 following treatment, and the decline of theirHAM-D score was at least 50%) could not bedistinguished from nonresponders on the basis of theirpretreatment HAM-D scores (Fo1). Likewise, maleand female patients who received drug treatment didnot differ at baseline and displayed similar reductionsof HAM-D scores (Fo1).

Functional improvements following therapy werealso evaluated in terms of the quality of socialinteractions. A 3 (condition: nondepressed control vs.drug-treated vs. placebo)� 2 (measurement points)mixed measures ANOVA on self-reported quality ofinterpersonal interactions indicated a significant inter-



action [F(2, 43) 5 7.44, Po.01, Z2 5 .257]. Posthoc comparisons indicated that, at baseline, thequality of social interaction among patients withdysthymia was significantly lower than that ofthe nondepressed control group [t(45) 5 9.02,Po.001]. As illustrated in Table 3, over time, inter-personal functioning was unchanged in the controlgroup [t(45) 5 .33, P 5.37], increased modestly inplacebo-treated patients [t(45) 5 .84, P 5.20] but sig-nificantly in the drug-treated patients [t(45) 5 5.01,Po.001]. It ought to be underscored that the perceivedquality of interpersonal interactions in the drug-treatedpatients, as a whole, still fell significantly below thatof the nondepressed control group [t(45) 5�3.63,P 5.001].

A separate analysis in which patients, irrespectiveof treatment, were divided into treatment respondersversus nonresponders, as defined earlier, revealed thatthe extent to which interpersonal functioning changedover time varied with treatment efficacy [F(1,24) 5 3.97, Po.05, Z2 5 .142]. Post hoc analysesindicated that the perceived quality of social interac-tions following treatment was higher among thosepatients who showed a positive treatment response(M 5 73.67, SD 5 24.10) than among those who didnot [M 5 55.91, SD 5 21.49; t(25) 5 2.70, P 5.006],although, once again, the level of functioning was stillbelow that previously observed for the nondepressedcomparison group.

COPING ASSOCIATEDWITH DYSTHYMIC DISORDER

To assess whether the coping profiles of patients withdysthymia and controls differed, and whether thisdifference was evident both prior to and followingtreatment, a 3 (condition)� 2 (measurement points)� 12 (the 12 coping strategies derived from theSCOPE) mixed measures ANOVA was conducted.The three-way interaction was significant [F(22,836) 5 2.91, Po.001, Z2 5 .071]. As seen in Table 4and confirmed by simple effects analyses, the copingprofiles of the patients with dysthymia prior totreatment (i.e., in both those patients who were toreceive placebo and those who were to receive sertra-

line) were markedly different from the comparison(nondysthymic) group [F(11, 1100) 5 12.0, Po.001].Specifically, post hoc comparisons revealed that thepatients with dysthymia endorsed significantly morerumination and emotion-focused coping, includingemotional expression, other-blame, self-blame, andemotional containment. In addition, participants weremore likely to endorse cognitive efforts to distractthemselves. The initial coping strategies endorsed bythe patients with dysthymia who received drug versusplacebo treatment did not differ [F(11, 484) 5 1.30,nonsignificant (NS)].

Following the 12-week treatment period, the profileof coping strategies endorsed by participants in thecontrol group remained unchanged [F(11, 473) 5 1.07,NS], suggesting that despite any life changes thatmay have occurred among these individuals, theircoping methods were stable. The coping profilesamong patients with dysthymia who receivedplacebo treatment likewise did not vary significantlyover the two measurement points [F(11, 66) 5 1.28,NS]. However, drug-treated patients demonstratedsignificant change of coping profiles [F(11,297) 5 5.75, Po.001]. Specifically, as seen in Table 5,following treatment, the levels of rumination declinedmarkedly in these patients. They also showed sig-nificant reductions of emotional expression and emo-tional containment.

To further assess the effects of the treatment, weanalyzed coping changes according to whether ornot patients exhibited a positive treatment response(as defined earlier). ANOVA confirmed the significantmeasurement points� coping strategy interaction[F(11, 363) 5 4.89, Po.001, Z2 5 .129], but the treat-ment response (improved vs. nonimproved)�measure-ments point� coping strategy interaction did not reachstatistical significance [F(11, 363) 5 1.62, P 5.09,Z2 5 .047]. Nevertheless, because a priori predictionshad been made anticipating changes in coping stylesfollowing successful therapy, and this three-way inter-action was marginal, we examined the simple effectsassessing whether the changes in coping for treatmentresponders versus nonresponders. These comparisonsindicated that in the main, where changes occurred,they were common both to those who did or did not

TABLE 3. Mean (SD) quality of social interaction scores before or after 12 weeks of sertraline or placebo treatmentof dysthymic patients and in a nondysthymic comparison group

Before treatment After 12 weeks

M SD M SD

Nondepressed controls 86.87 13.22 85.40 16.36Patients with dysthymia

Sertraline 46.94 16.02 69.37�,�� 24.03Placebo 51.21 16.40 57.42 24.58

�Po.001 relative to pretreatment.��Po.05 relative to placebo.

238 Kelly et al.


improve, in that over time, reduced levels of emotionalexpression, self-blame, and emotional containmentwere evident among both treatment responders andnonresponders. Importantly, however, unique to thepatients who showed an improvement, there was asubstantial decline in the endorsement of rumination[t(34) 5 2.78, P 5.004].

The sex of participants did not appreciably influencethe coping styles endorsed nor did it interact with anyof the other variables. At baseline, females tendedto use somewhat greater social support seeking(M 5 0.53, SD 5 0.36) and emotional expression(M 5 0.38, SD 5 0.33) than did males (M 5 0.40,SD 5 0.36; M 5 0.26, SD 5 0.31, respectively), and thispattern remained evident following treatment. Simi-larly, separate analyses in which age was included as acovariate indicated that the age of participants did not

exert a significant influence on any of the variables ofinterest.

INTERRELATIONS AMONGCOPING STRATEGIES

A central prediction of our investigation was thatpatients with dysthymia would differ from non-depressed individuals, not only with respect to theprofile of coping strategies endorsed but also in termsof the pattern of correlations between rumination andother coping strategies. As seen in Table 6, at baseline,rumination among the nondepressed comparisonparticipants was significantly related to 8 out ofthe 11 other coping methods, including both emo-tion-focused strategies (emotional expression, other-blame, self-blame, and emotional containment), as well

TABLE 4. Mean (SD) endorsement of coping strategies among patients with dysthymia prior to treatment relativeto a nondepressed comparison group

Nondepressed (n 5 52) Dysthymic (n 5 46)

t (97) PM SD M SD

Problem solving .75 .50 .67 .29 �1.02 .16Cognitive restructuring .71 .35 .62 .32 �1.56 .06Activity (active disengagement) .78 .23 .63 .28 �1.93 .03Avoidance (cognitive) .33 .35 .57 .41 3.45 .001�

Rumination .39 .44 .87 .29 6.86 .001�

Humor .63 .37 .53 .36 �1.45 .08Seeking social support .50 .36 .43 .38 �.85 .20Emotional expression .22 .29 .45 .32 3.53 .001�

Other blame .13 .27 .33 .38 3.08 .001�

Self-blame .28 .29 .52 .33 3.73 .001�

Emotional containment .34 .39 .80 .30 6.57 .001�

Passive resignation .16 .25 .28 .34 1.82 .04

�Significant with critical a adjusted to P 5.004.

TABLE 5. Mean (SD) endorsement of coping strategies among patients with dysthymia prior to and following 12-weektreatment with sertraline

Baseline (n 5 28) Posttreament (n 5 28)

t (27) PM SD M SD

Problem solving .62 .32 .61 .32 �.12 .45Cognitive restructuring .53 .29 .62 .34 1.36 .09Activity (active disengagement) .56 .30 .64 .34 .60 .28Avoidance (cognitive) .52 .44 .54 .43 .34 .37Rumination .90 .27 .51 .46 �5.63 .001�

Humor .52 .39 .58 .36 1.19 .12Seeking social support .32 .36 .36 .35 .55 .29Emotional expression .42 .30 .23 .29 �2.81 .004�

Other blame .25 .35 .17 .32 �1.19 .12Self-blame .48 .33 .34 .32 �2.12 .02Emotional containment .83 .29 .64 .44 �2.85 .004�

Passive resignation .23 .32 .33 .40 1.56 .07

�Significant with critical a adjusted to P 5.004.



as problem-solving efforts, distraction techniques(cognitive and active behavioral), and seeking socialsupport. In contrast to the profile observed in thenondepressed control condition, among drug-treatedpatients with dysthymia, rumination prior to treatmentwas only significantly related to self-blame and emo-tional containment, and inversely related to cognitiveavoidance. Differences in the correlations betweenrumination and the other coping strategies across thetwo groups were assessed by means of hierarchicalregression analyses, in which we determined whetherthe interaction between group (control or dysthymic)and each individual coping strategy accounted forunique variance in reported levels of rumination. Theseanalyses revealed that the relations between ruminationand the endorsement of activities, avoidance, andemotional expression were indeed qualified by groupmembership (Pso.01). No between-group differenceswere evident with respect to the other copingstrategies.

The pattern of interrelations between ruminationand the various coping styles was, for the most part,maintained at the 12-week follow-up, although therewas some variation in the specific strategies demon-strating significant correlations (e.g., the associationswith active disengagement and other-blame werediminished, whereas the relation with cognitive re-structuring increased). Importantly, among controls,rumination continued to be related to a broad spectrumof strategies that reflected emotion- and problem-focused efforts, and seeking social support. Followingtreatment, among patients with dysthymia, the negativecorrelation between rumination and cognitive avoid-ance was no longer evident, whereas the relation toself-blame and emotional containment persisted. Ineffect, it seemed that rumination among dysthymicindividuals was distinguishable from that in the controlgroup, being more singularly aligned with emotion-focused coping, and even after treatment, their general

profile did not conform to that of the control group.Examination of whether the correlations at the12-week follow-up were significantly moderated bygroup membership (dysthymic vs. controls) usinghierarchical regression analyses indicated that onlythe relation between rumination and the endorsementof problem solving was conditional upon groupmembership.

Interestingly, among patients with dysthymia, treat-ment responders appeared to differ from those who didnot show a positive treatment response. Specifically,among treatment responders, baseline rumination waspositively correlated with problem solving (r 5 .38) andsocial support seeking (r 5 .36), as well with emotionalexpression (r 5 .41) and self-blame (r 5 .46), andinversely related to cognitive avoidance (r 5�.43). Incontrast, among treatment non-responders, ruminationwas initially correlated only with emotional contain-ment (r 5 .96), and inversely related to humor(r 5�.74). In effect, these data suggest that amongtreatment responders, as among control participants,rumination was related not only to emotional-focusedstyles but also to the more functionally effectiveproblem-focused methods, whereas this was not thecase among the nonresponders. It is uncertain whetherthese differences in the use of coping strategies are dueto individual difference factors or severity of illness.These findings, however, may suggest that analysesof such interrelations may serve as a means ofpredicting responsivity to subsequent antidepressanttreatment.

DISCUSSIONAs frequently observed [Griffiths et al., 2000;

Hellerstein et al., 1993, 1996; Kocsis et al., 1997;Ravindran et al., 1999, 2000; Thase et al., 1996],chronic treatment with an selective serotoninreuptake inhibitor (SSRI), in this instance, 12 weeks

TABLE 6. Zero-order Pearson’s correlations between rumination and other coping strategies among controlparticipants and sertraline-treated patients with dysthymia at baseline and after 12 weeks of antidepressant treatment

Nondepressed (n 5 52) Dysthymic (n 5 35)

Baseline 12 wk Baseline 12 wk

Problem solving .30� .41� .26 �.25Cognitive restructuring .17 .31� �.12 �.04Activity (active disengagement) �.39�� .09 .16 �.06Avoidance (cognitive) .40�� .40�� .40�� .14Humor �.17 .01 �.07 .11Seeking social support .34� .46�� .12 .13Emotional expression .63�� .41� .27 .30Other blame .32� .07 .03 .23Self-blame .51�� .42� .47�� .38�

Emotional containment .38� .48�� .43�� .46�

Passive resignation .16 .26 �.02 .06

�Po.05; ��Po.01.

240 Kelly et al.


of sertraline, resulted in a significant reduction ofdysthymic symptoms, well beyond that seen inplacebo-treated patients. Indeed, a 50% reduction ofthe HAM-D scores (which fell to 10 or below) wasevident in 67.5% of sertraline-treated patients, whereasa similar outcome was apparent in only 18.0% ofplacebo-treated patients. Clinical improvement, aspreviously reported [Friedman, 1993; Hirschfeldet al., 2000; Kocsis et al., 1997; Rapaport and Judd,1998], was accompanied by augmented interpersonalfunctioning, although this did not reach the levelordinarily evident in a nondepressed comparisonsample [see also Miller et al., 1998; Ravindran et al.,2000]. Inasmuch as dysthymia is a long-standingdisorder, it might simply be the case that moreprolonged pharmacotherapy is needed to realize a levelof interpersonal functioning approaching that ofnondepressed individuals. Alternatively, the relativelypoor quality of interpersonal functioning may be a traitcharacteristic among those with dysthymic disorder.

The coping profiles of patients with dysthymiadiffered from that of nondepressed controls, in thatthey endorsed relatively high levels of emotion-focusedcoping strategies, including emotional expression,emotional containment, and self- and other-blame.Importantly, as observed in the case of major depres-sion [Nolen-Hoeksema, 2000; Nolen-Hoeksema andMorrow, 1991; Nolen-Hoeksema et al., 1999; Treynoret al., 2003], rumination was particularly high amongpatients with dysthymia. Following treatment withsertraline, coping profiles were modified in concertwith the alleviation of depression levels, particularlywith respect to rumination. In contrast, among theplacebo-treated patients, rumination was still asmarked as it had been prior to treatment. Parallelingthis latter finding, of those who received drugtreatment, rumination levels were uniquely reducedamong those demonstrating a positive treatmentresponse. Taken together, these findings suggest thatrumination may indeed serve as a particularly sensitiveindex of depressive affect.

The conclusion that rumination was a fundamentalvariable associated with depression, and that thepropensity to engage in ruminative behaviors dimin-ished as depressive symptoms were attenuated is not anew one [Lam et al., 2003; Nolen-Hoeksema et al.,1993]. However, it is important to underscore thatruminative style did not occur in isolation from otherstrategies. For instance, it has been reported thatdysphoric individuals were not only more likely toendorse a ruminative style but also exhibited reluctanceto engage in distracting activities. This occurred even ifthey believed that such activities would enhance theirmood, possibly because this would limit the opportu-nity to gain insights into their emotions [Lyubomirskyand Nolen-Hoeksema, 1993; Lyubomirsky et al.,1998].

In this investigation, it appeared that the patternof relations between rumination and other strategies

differed for patients with dysthymia and controls.Specifically, among nondepressed individuals, rumina-tion was associated with both emotion-focused copingstrategies and problem-focused coping efforts, cogni-tive distraction, and seeking social support. This arrayof co-occurring strategies points to the possibility thatnondepressed individuals may be flexible in how theycombine coping strategies, conceivably permittingrumination to serve multiple functions. Coincidingwith the low levels of rumination among nondepressedindividuals was the finding that rumination waspositively related to cognitive distraction, suggestingthat efforts were being made to minimize overindul-gence in the use of rumination, which may beimportant in facilitating effective alternative responsesacross situations and time. In this respect, the dynamicand reciprocal nature associated with the implementa-tion of various coping strategies, and the sequencingof their usage, may be important in determiningeffectiveness.

In contrast to the interrelations observed in thecontrol condition, among patients with dysthymia,rumination co-occurred with a restricted set of copingstrategies, being most closely aligned with self-blameand emotional containment. As well, unlike the controlparticipants, in whom rumination was positively relatedto cognitive avoidance strategies, among patients withdysthymia, rumination was negatively correlated withcognitive distraction. In effect, as indicated by Lyubo-mirsky and Nolen-Hoeksema [1993], patients withdysthymia were more apt to resist disengagementin conjunction with rumination, possibly accountingfor the self-perpetuating aspects of ruminative styles.The patients with dysthymia generally did not endorserumination in conjunction with problem-focused ormore active behavioral distraction efforts, or with morepositive interpretational processes (cognitive restruc-turing). Instead, they tended to use rumination withemotion-focused strategies, pointing to the dominanceof a ‘‘ruminative brooding’’ style [Treynor et al., 2003].These data are consistent with those of Nolen-Hoeksema et al. [1993] regarding the multiple formsof rumination that exist, and support the contentionthat these can be discerned by evaluating the co-occurrence of rumination with other coping methods.

Following pharmacotherapy, the co-occurrence ofrumination with other strategies in the dysthymicgroup was still very different from that of thecomparison group. The high correlations betweenrumination and the two emotion-focused strategies(emotional containment and self-blame) were stillapparent, although the inverse relation between rumi-nation and cognitive avoidance was no longer evident.Clearly, although ruminative coping was less pro-nounced following pharmacotherapy, the way thisstrategy was endorsed could still be dissociated fromthat seen in nondepressed controls. It is unclearwhether the persistence of rumination co-occurringsolely with emotion-focused strategies is a trait



characteristic of individuals with dysthymia or stemsfrom incomplete recovery, as previously noted inrelation to their still limited interpersonal functioning.In either case, it is conceivable that the continued linkbetween rumination and emotion-focused copingwould dispose them toward relapse. It has indeed beenreported that ruminative coping is not only associatedwith depressed mood but is also predictive of thepersistence of depression [Nolen-Hoeksema et al.,1993] and the onset of new depressive episodes[Nolen-Hoeksema, 2000].

Beyond the finding that the amelioration of dysthy-mic symptoms by sertraline was accompanied by areduction in rumination, it was of particular interestthat the diminution of depressive symptoms was mostpronounced among those patients that, prior totreatment, exhibited a ruminative style that did in factco-occur with problem-focused coping. Conversely,treatment nonresponders tended to use ruminationexclusively in conjunction with emotional containmentand actually appeared to shy away from cognitiverestructuring. In effect, it seems that it is not onlypossible to distinguish coping profiles of participantswith dysthymia and controls, but also the pretreatmentcoping profiles may be predictive of the potentialefficacy of a pharmacological treatment strategy amongpatients with dysthymia. As already indicated, theantidepressant treatment itself did not result in theco-occurrence of rumination with problem-focusedcoping; however, if that profile was already present,then the effectiveness of the antidepressant medicationwas enhanced. Of course, it is possible that thoseindividuals using the rumination–problem-focusedcoping combination were less depressed or had under-gone a different history of depression (in terms ofduration of illness or the occurrence of doubledepression), and hence may have been more amenableto treatment. However, in our investigation, initialHAM-D scores were related neither to treatmentefficacy nor to the coping strategies endorsed.

Limitations: The number of participants in thisinvestigation was relatively small, particularly thosewho were treatment nonresponders; thus, the conclu-sions we have drawn are highly provisional. Still, it mayultimately be possible to assess which coping combina-tions confer resistance to treatment, and further,whether certain coping profiles are associated withillness recurrence and relapse. Relative to this issue, thenumber of participants was small compared to thenumber of variables incorporated into the coping scale.Although coping is often considered in terms of a fewbroad categories (e.g., problem-focused vs. emotion-focused coping or active vs. avoidant coping), becauseour express purpose was to detail the co-occurrence ofparticular coping strategies with rumination (which isoften considered, perhaps inappropriately, as a dimen-sion of emotional expression), it was essential that eachof the individual coping strategies examined beconsidered in terms of their unique contributions in

relation to ruminative coping. Importantly, it should beunderscored that many of the observed effect sizes wererelatively large, accounting for an impressive amountof the variance. Moreover, there were no instances inwhich meaningful effect sizes were observed, but thecorresponding test of statistical significance was non-significant, which can indicate low power. That said, itis appreciated that data reduction strategies may haveprovided greater power to detect effects that weremarginal.

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Ruminative coping among patients with dysthymia before and after pharmacotherapy

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