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Cited by 11Cardiac Health and Mental HealthAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychosomatic Disorders and Their Treatments

Perseverative negative thinking predicts depression in people with acute coronary syndrome

Open access
Trick, Leanne, Watkins, Edward R., Henley, William, Gandhi, Manish M., Dickens, Chris·2019·General Hospital Psychiatry
DOI 10.1016/j.genhosppsych.2019.06.012
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Abstract

Objective Depression is common in people who have experienced recent Acute Coronary Syndrome (ACS), and predicts worse medical outcomes. Mechanisms underpinning the development of depression and its association with poor medical outcomes are unclear however. The aim of this study was to investigate the role of perseverative negative thinking (e.g. worry and rumination) in predicting depression in people with recent ACS.Methods Adults attending specialist inpatient and outpatient cardiology services who had recently experienced ACS were invited to participate in this observational prospective cohort study. Questionnaire assessments were completed within 6months of index ACS (baseline), then 2months and 6months later.Results 169 participants (131 male (78%), median age 68 (±16) years) completed baseline questionnaires, and 111 completed follow-ups. After controlling for the effects of key covariates, baseline rumination was a significant predictor of depression at 6months, accounting for 2% of the variance in depression. This association was partially mediated by poor problem-solving ability and lack of social support. Neither worry nor rumination at baseline were significant predictors of quality of life at 6months.Conclusions Rumination is a significant independent predictor of depression, and this association may be partially explained by deficits in problem-solving ability and reduced social support. Both rumination and problem solving may provide useful targets for the development of evidence-based interventions to reduce depression among people with coronary heart disease.

AI snapshot

Written from the paper’s full text.

TL;DR

In a prospective cohort of people with recent acute coronary syndrome (ACS), baseline rumination—but not worry—predicted depression 6 months later after adjustment for covariates and baseline depression. The association was partially mediated by poor problem-solving and reduced social support, while neither rumination nor worry predicted quality of life.

Key findings

  • Baseline rumination significantly predicted depression at 6 months, contributing 2% of the variance; the full model explained 64% of variance in 6-month depression (F(8,97)=24.68, p≤0.001).
  • Baseline worry did not predict depression at 6 months (change in R²=0%; full model explained 60% of variance).
  • Neither worry nor rumination at baseline significantly predicted generic or cardiac-specific health-related quality of life at 6 months.
  • Mediation analyses showed the rumination–depression association was partially mediated by negative problem orientation (40.2% of total effect), low social support (10.5%), and reduced pleasant activities (9.3%); in multiple mediation, low social support plus impaired problem solving mediated 40.3%, with problem solving the strongest mediator.

Methods

  • Observational prospective cohort study of adults attending specialist inpatient and outpatient cardiology services in south west England between September 2014 and May 2015 who had experienced ACS within the previous 6 months; 169 completed baseline questionnaires and 111 completed follow-ups at 2 and 6 months.
  • Measures included the Penn State Worry Questionnaire (worry), Ruminative Responses Scale brooding subscale (rumination), PHQ-8 (depression), EQ5D and Seattle Angina Questionnaire (quality of life), and ESSI, SPSI-R:S, and PES-E (potential mediators: social support, problem solving, instrumental behaviours).
  • Staged multivariable linear regressions entered covariates, baseline outcome scores, then baseline worry or rumination; mediation used a causal steps approach with bootstrapping (5,000 samples, bias-corrected confidence intervals), and sensitivity analyses used multiple imputation by chained equations.

Limitations

  • The paper states high attrition was the main limitation: only 66% completed 6-month assessments, reducing power and possibly introducing selection bias; non-completers had higher white cell count and C-reactive protein at admission. It also notes variability in time since ACS and follow-up timing, reliance of causal steps on correct model specification, possible omitted-variable confounding, small sample size limiting conclusions about other mediators, retrospective medical-record assessment of depression history, and a relatively “well” sample in which strong baseline depression may have masked small effects.
  • Evident from the text: the study was single-centre, predominantly male (131/169, 78%), observational, and therefore cannot establish causation; social support was self-reported, so the paper notes it is unclear whether reduced support was actual or perceived.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.genhosppsych.2019.06.012

Cites

102 of 102 references verified0 citation errors · 0 not checkable

Statistics

9 tests recomputed · 0 with the reported and recomputed p on opposite sides of .05

Claims the paper makes

0 of 66 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Baseline rumination contributed 2% to the overall variance of 6-month depression in the rumination model (p≤0.05).

    “with rumination contributing 2% to the overall variance of 6 month depression (p≤0.05,Table 2).”
    • Also stated in: § Discussion · plain
      “We found a small but significant association of rumination with depression in this study (rumination at baseline accounted for 2% of variance in depression at follow-up).”
    Quote in the paperSubstantial claim
  • Findingown data

    Baseline depression was a significant predictor of 6-month depression in the worry model.

    “with social support and depression at baseline significant predictors of 6 month depression”
    Quote in the paperNot a substantial claim
  • Findingown data

    Baseline rumination remained a significant predictor of 6-month depression after controlling for each potential mediating variable at 2 months, consistent with partial mediation.

    “In each case rumination at baseline remained a significant predictor of depression at 6 month follow-up after controlling for the potential mediating variable at 2 months, consistent with partial mediation.”
    • Also stated in: § Multiple mediation · plain
      “Rumination at baseline remained a significant predictor of depression at 6 month follow-up after controlling for the potential mediating variables at 2 months, consistent with partial mediation.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The underlying regression models in the causal steps approach are correctly specified.
  • Findingown data

    The model including baseline rumination in the third step predicted 64% of variance in 6-month depression (F(8,97)=24.68, p≤0.001).

    “The model including baseline rumination in the third step predicted 64% of variance in 6 month depression (F(8,97)=24.68,p≤0.001).”
    Quote in the paperSubstantial claim
  • Findingown data

    Baseline social support was a significant predictor of 6-month depression in the worry model.

    “with social support and depression at baseline significant predictors of 6 month depression”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 48
  • May combine two claims. 22
  • The quote only partly states this claim. 5

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Twenty-four participants (14.4%) were depressed (PHQ≥10) at baseline.

    “Twenty-four participants (14.4%) were depressed (PHQ≥10) at baseline.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The addition of time since ACS as a covariate did not substantially alter the overall model (F(9,92)=20.21, p≤0.001) or any other associations.

    “the addition of time since ACS did not substantially alter the overall model (F(9,92)=20.21,p≤0.001) or any other associations.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The addition of time since baseline as a covariate did not substantially alter the overall model (F(9,96)=23.67, p≤0.001) or any other associations.

    “its addition as a covariate did not substantially alter the overall model (F(9,96)=23.67,p≤0.001) or any other associations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Time since baseline was a significant predictor of depression at 6-month follow-up (β=-0.14, p=0.018).

    “Time since baseline was a significant predictor of depression at 6 month follow-up (β=-0.14, p=0.018)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Depression scores were greatest when the interval between baseline and 6-month follow-up assessments was smallest.

    “although our findings suggested that depression scores were greatest when the interval between baseline and 6 month follow-up assessments was smallest.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Neither time from ACS nor the interval between baseline assessments and 6-month follow-up significantly impacted upon the overall models.

    “Neither time from ACS nor the interval between baseline assessments and 6 month follow-up significantly impacted upon our overall models”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    In the imputed rumination model, baseline PHQ-8 score predicted PHQ-8 depression at 6 months (β=0.58, SE=0.10, t=5.94, p≤0.001).

    “Q1 PHQ-8 0.58 0.10 5.94 a”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    The full rumination model predicting PHQ-8 depression at 6 months was significant, F(8,129.9)=24.42, p≤0.001.

    “Full model F(8,129.9)=24.42 a”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In the imputed worry model, baseline PSWQ worry score was not a significant predictor of PHQ-8 depression at 6 months (β=0.02, SE=0.02, t=0.64).

    “Q1 PSWQ 0.02 0.02 0.64”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    The full worry model predicting PHQ-8 depression at 6 months was significant, F(8,130.7)=21.60, p≤0.001.

    “Full model F(8,130.7)=21.60 a”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data

    In the imputed rumination model, baseline ESSI social support score negatively predicted PHQ-8 depression at 6 months (β=-0.17, SE=0.06, t=-3.06, p≤0.01).

    “Q1 ESSI -0.17 0.06 -3.06 b”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Depression following ACS is associated with worse health-related quality of life.

    “Depression following ACS is important as it is associated with worse physical health outcomes, including worse health-related quality of life (Dickens, Cherrington, & McGowan, 2012;Dickens et al., 2006)”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Dickens, Cherrington, & McGowan, 2012

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    • cites Dickens et al., 2006

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    Premisecitation

    Depression is common in people who have experienced recent acute coronary syndrome (ACS).

    “Forty per cent of people who experience Acute Coronary Syndrome (ACS) will suffer from significant depression in the weeks or months following their cardiac event (Rudisch & Nemeroff, 2003;Thombs et al., 2006).”
    • Also stated in: § Abstract · plain
      “Depression is common in people who have experienced recent Acute Coronary Syndrome (ACS), and predicts worse medical outcomes.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Rudisch & Nemeroff, 2003

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    • cites Thombs et al., 2006

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    Premisecitation

    Depression following ACS is associated with doubling of the risk of subsequent morbidity and mortality.

    “doubling of the risk of subsequent morbidity and mortality (Barth, Schumacher, & Herrmann-Lingen, 2004;Nicholson, Kuper, & Hemingway, 2006;Van Melle et al., 2004)”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Barth, Schumacher, & Herrmann-Lingen, 2004 source

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    • cites Nicholson, Kuper, & Hemingway, 2006 source

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    • cites Van Melle et al., 2004 source

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    Premisecitation

    Depression following ACS is associated with greater healthcare costs.

    “greater healthcare costs (Frasure-Smith et al., 2000;Rutledge et al., 2009)”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Frasure-Smith et al., 2000

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    • cites Rutledge et al., 2009

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    Premisecitation

    The negative effects of rumination on depression may be mediated by interference with effective problem solving, engagement in instrumental rewarding behaviours, or access to social support.

    “with evidence that this may in part be due to interference with effective problem solving, engagement in instrumental rewarding behaviours or access to social support, which have been proposed as mediators of the negative effects of rumination (Lyubomirsky & Tkach, 2004;Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008;E. R. Watkins, 2008).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Lyubomirsky & Tkach, 2004

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    • cites Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008 source

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    • cites E. R. Watkins, 2008 source

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    Premisecitation

    Perseverative negative thinking is associated with negative effects on mood in otherwise healthy samples.

    “several strands of evidence suggest it is associated with negative effects on mood in otherwise healthy samples”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Aldao, Nolen-Hoeksema, & Schweizer, 2010 source

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    • cites Mor & Winquist, 2002 source

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    • cites Teismann, Steinfeld, Willutzki, & Michalak, 2011

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  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    In non-cardiac populations, perseverative negative thinking predicts the onset, maintenance and relapse of depression.

    “Recent findings in non-cardiac populations indicate that perseverative negative thinking predicts the onset, maintenance and relapse of depression”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Borkovec, Robinson, Pruzinsky, & DePree, 1983 source

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    • cites Calmes & Roberts, 2007

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    • cites Ciesla & Roberts, 2007

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    Premisecitation

    Mechanisms linking depression to adverse health outcomes have not been established.

    “mechanisms linking depression to adverse health outcomes have not been established (Dickens, 2015).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Dickens, 2015

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    Premisecitation

    Depression following ACS is associated with greater use of unscheduled care.

    “greater use of unscheduled care (Dickens, Katon, et al., 2012)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Dickens, Katon, et al., 2012

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Poor problem solving is prospectively associated with depressive and anxious symptoms and mediates the association of stressful life events with depression and anxiety.

    “poor problem solving is prospectively associated with depressive and anxious symptoms and it mediates the association of stressful life events with depression and anxiety (Anderson, Goddard, & Powell, 2011;Kant, D'Zurilla, & Maydeu-Olivares, 1997;Nezu, 1985;Nezu & Ronan, 1988).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Anderson, Goddard, & Powell, 2011

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    • cites Kant, D'Zurilla, & Maydeu-Olivares, 1997

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    • cites Nezu, 1985

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    Premisecitation

    Perseverative negative thinking may predict adverse physical outcomes such as worse cardiovascular health, impaired wound healing and immune dysfunction.

    “perseverative negative thinking may predict adverse physical outcomes such as worse cardiovascular health, impaired wound healing and immune dysfunction (Broadbent, Petrie, Alley, & Booth, 2003;Kubzansky et al., 1997;Segerstrom, Solomon, Kemeny, & Fahey, 1998)”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Broadbent, Petrie, Alley, & Booth, 2003

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    • cites Kubzansky et al., 1997

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    • cites Segerstrom, Solomon, Kemeny, & Fahey, 1998

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    Premisecitation

    Negative beliefs about illness predict worse quality of life as well as depression.

    “a systematic review by Foxwell, Morley & Frizelle (2013) showed that negative beliefs about illness predicted worse quality of life as well as depression.”
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    • cites Foxwell, Morley & Frizelle, 2013

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    Premisecitation

    Rumination interferes with multiple aspects of problem solving.

    “previous studies have shown both that i) rumination interferes with multiple aspects of problem solving.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites McMurrich & Johnson, 2008

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    • cites Ward, Lyubomirsky, Sousa, & Nolen-Hoeksema, 2003

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    • cites Lyubomirsky, Tucker, Caldwell, & Berg, 1999

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Low social support is associated with depression, anxiety and worse quality of life in people with coronary heart disease (CHD).

    “the inability to form and maintain close relationships, low perceived availability of social support, and the number of close network members have all been associated with depression, anxiety and worse quality of life in people with CHD”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Bosworth et al., 2000

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    • cites Brummett et al., 1998

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    • cites Dickens et al., 2004

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    Study design and conductcitation

    The Penn State Worry Questionnaire (PSWQ) has good test-retest reliability (r>0.90) and high internal consistency (Cronbach α>0.88) in undergraduates, community volunteers and older adults with anxiety disorders.

    “It has good test-retest reliability (r>0.90) and high internal consistency (Cronbach α>0.88) in undergraduates, community volunteers and older adults with anxiety disorders (Beck, Stanley, & Zebb, 1995;Brown, Antony, & Barlow, 1992;Meyer et al., 1990).”
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    • cites Beck, Stanley, & Zebb, 1995

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    • cites Brown, Antony, & Barlow, 1992 source

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    • cites Meyer et al., 1990 source

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    Study design and conductnone given

    Full ethical permission from the South West -Frenchay Research Ethics Committee was obtained prior to commencement of this study.

    “Full ethical permission from the South West -Frenchay Research Ethics Committee was obtained prior to commencement of this study.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In a prior study of ACS patients, rumination predicted subsequent depression but did not predict subsequent health-related quality of life.

    “The study found that rumination predicted subsequent depression, but did not predict subsequent health-related quality of life (Baker, 2014)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Baker, 2014

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    Study design and conductcitation

    A sample size calculation indicated that 113 participants assessed at baseline, 2 months and 6 months would provide 90% power to detect a bivariate association of 0.30 at the p=0.05 significance level.

    “A sample size calculation indicated that 113 participants assessed at baseline, 2 months and 6 months would provide 90% power to detect a bivariate association of 0.30 at the p=0.05 significance level.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Green, 1991 source

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    Premisecitation

    Rumination is associated with subsequent depression in patients with coronary heart disease over short durations.

    “Previous studies have shown that rumination is associated with subsequent depression in patients with coronary heart disease over short durations (Baker, 2014;Denton, Rieckmann, Davidson, & Chaplin, 2012)”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Baker, 2014

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    • cites Denton, Rieckmann, Davidson, & Chaplin, 2012

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    Premisecitation

    In non-cardiac populations, social support, problem solving and instrumental behaviours may be important in explaining the association of rumination with depression.

    “Research in non-cardiac populations suggests these factors may be important in explaining the association of rumination with depression (Lyubomirsky & Tkach, 2004;Nolen-Hoeksema et al., 2008;E. R. Watkins, 2008)”
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    • cites Lyubomirsky & Tkach, 2004

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    • cites Nolen-Hoeksema et al., 2008 source

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    • cites E. R. Watkins, 2008 source

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    Study design and conductnone given

    All participants provided written informed consent.

    “All participants provided written informed consent.”
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    Study design and conductcitation

    The Social Problem Solving Inventory-revised short version (SPSI-R:S) has good internal consistency (Cronbach α≥0.80) and test-retest reliability (r=0.68 to r=0.91).

    “internal consistency (Cronbach α≥0.80) and test-retest reliability (r=0.68 to r=0.91) of the SPSI-R:S are good, and normative data is available for healthy adults and clinically depressed populations (D'Zurilla et al., 2002;Hawkins, Sofronoff, & Sheffield, 2009)”
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    Study design and conductcitation

    Internal consistency of the Seattle Angina Questionnaire (SAQ) subscales is good in people with coronary heart disease (Cronbach α=0.67 to 0.91).

    “Internal consistency of the SAQ subscales is good in people with coronary heart disease (Cronbach α=0.67 to 0.91)) (Kimble et al., 2002;Spertus et al., 1995).”
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    Study design and conductown data

    In this sample, the PHQ-8 had Cronbach α=0.89.

    “and α=0.89 in this sample.”
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    Study design and conductcitation

    The PHQ-8 has sensitivity and specificity of 88% for detecting depressive disorders using a cut point of ≥10.

    “Psychometric properties of the PHQ-8 are equivalent to the more commonly used 9 item version (PHQ-9), with sensitivity and specificity of 88% for detecting depressive disorders using a cut point of ≥10 (Kroenke, Spitzer, Williams, & Lowe, 2010;Kroenke et al., 2009).”
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    • cites Kroenke, Spitzer, Williams, & Lowe, 2010 source

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    Study design and conductcitation

    The EuroQol-5D (EQ5D) has validity and reliability in cardiovascular research.

    “The EQ5D has been used extensively in cardiovascular research and its validity and reliability in this population is supported (e.g.(Dyer, Goldsmith, Sharples, & Buxton, 2010;Schweikert, Hahmann, & Leidl, 2006)).”
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    • cites Dyer, Goldsmith, Sharples, & Buxton, 2010

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    • cites Schweikert, Hahmann, & Leidl, 2006

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    Study design and conductcitation

    The Ruminative Responses Scale (RRS) brooding subscale has good internal consistency (Cronbach α=.77) and test-retest reliability (r=0.62).

    “It has previously been shown to have good internal consistency (Cronbach α=.77) and test-retest reliability (r=0.62)(Treynor et al., 2003).”
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    • cites Treynor et al., 2003 source

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    Study design and conductcitation

    The Enhancing Recovery in Coronary Heart Disease study Social Support Inventory (ESSI) has good internal reliability (Cronbach α=0.88) and test-retest reliability (r=0.94).

    “the ESSI has been shown to correlate with the social functioning subscale of the Short Form-36, and its internal reliability (Cronbach α=0.88) and test-retest reliability (r=0.94) are good (Vaglio et al., 2004)”
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    • cites Vaglio et al., 2004

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    Study design and conductown data

    In this sample, the RRS brooding subscale had Cronbach α=.85.

    “In this sample Cronbach α =.85.”
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    Study design and conductown data

    In this sample, the PSWQ had Cronbach α=.91.

    “In this sample Cronbach α=.91.”
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    Study design and conductown data

    Participants who consented did not differ significantly in age or sex compared to those who declined to be involved (p's > 0.05).

    “Participants who consented did not differ significantly in age or sex compared to those who declined to be involved (p's > 0.05).”
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    Study design and conductown data

    169 participants completed baseline questionnaires.

    “169 participants (131 male (78%), median age 68 (±16) years) completed baseline questionnaires, and 111 completed follow-ups.”
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    Study design and conductown data

    Compared to completers, non-completers at 6 months were more likely to have raised CRP at hospital admission (55.6% vs 30.9%; χ2(1)=5.48, p=0.019).

    “and raised CRP (55.6% vs. 30.9%;χ 2 (1)=5.48,p=0.019) at hospital admission.”
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    Study design and conductown data

    111 participants completed follow-ups.

    “169 participants (131 male (78%), median age 68 (±16) years) completed baseline questionnaires, and 111 completed follow-ups.”
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    Study design and conductcitation

    The Pleasant Events Schedule for the elderly (PES-E) correlates well with the original long version of the Pleasant Events Schedule, which correlates with daily diary reports of activity (r=0.68 to 0.81) and depression scores.

    “the PES-E correlates well with the original long version of the Pleasant Events Schedule, which correlates with daily diary reports of activity (r=0.68 to 0.81) and depression scores (MacPhillamy & Lewinsohn, 1982).”
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    • cites MacPhillamy & Lewinsohn, 1982

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Compared to completers, non-completers at 6 months were more likely to have raised white cell count at hospital admission (41.1% vs 24.3%; χ2(1)=4.92, p=0.027).

    “Compared to completers, non-completers at 6 months were more likely to have raised white cell count (41.1% vs. 24.3%; χ 2 (1)=4.92,p=0.027)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Of 169 participants who completed baseline assessments, 58 (34.3%) did not complete the 6-month questionnaire pack.

    “Of 169 participants who completed baseline assessments, 58 participants did not complete the 6 month questionnaire pack (i.e.34.3%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    To evaluate the impact of missing data on our findings, the final step of each of the staged multivariable linear regression models and mediation analyses based on complete cases was replicated using imputed datasets, generated using multiple imputation by chained equations (MICE).

    “To evaluate the impact of missing data on our findings, the final step of each of the staged multivariable linear regression models and mediation analyses based on complete cases (as described above) was replicated using imputed datasets, generated using multiple imputation by chained equations (MICE).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Analyses repeated using imputed missing values provided the same results as for participants who remained in the study, so participant attrition did not undermine the findings.

    “Analyses repeated using imputed missing values provided the same results as for participants who remained in the study, so we do not believe that participant attrition undermined our findings.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Missing data at 6-month follow-up are missing at random, so multiple imputation for chained equations yields valid estimates.

  • May combine two claims.

    Interpretationown data

    The association between baseline rumination and 6-month depression was mostly mediated by poor problem-solving ability, but also by reduced social support.

    “and was mostly mediated by poor problem-solving ability, but also by reduced social support.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The underlying regression models in the causal steps approach are correctly specified.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The causal steps approach relies on the correct specification of the underlying regression models and may give biased results if there are omitted variables that confound the relationship between predictors and mediators, or between mediators and outcomes.

    “The causal steps approach we adopted relies on the correct specification of the underlying regression models and may give biased results if, for example, there are omitted variables that confound the relationship between predictors and mediators, or between mediators and outcomes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Study design and conductnone given

    The self-report measures of perseverative negative thinking used in this study were selected carefully to minimise artefactual associations between rumination and depression.

    “Furthermore, the self-report measures of perseverative negative thinking used in this study were selected carefully to minimise artefactual associations between rumination and depression.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    Only 66% of recruited participants completed assessments at 6 months, which is lower than similar recent studies using postal follow-up assessments.

    “Only 66% of recruited participants completed assessments at 6 months, which is lower than similar recent studies using postal follow-up assessments (Baker, 2014;Garnefski, Kraaij, De Graaf, & Karels, 2010).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Baker, 2014

      Not checked in the free run.

    • cites Garnefski, Kraaij, De Graaf, & Karels, 2010

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    The prospective design allows tentative causal inferences from the findings, though these fall short of proving causation.

    “Particular strengths of our study include our prospective design, which allows us to draw some tentative causal inferences from our findings, though these fall short of proving causation.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Because a large amount of variance was accounted for by baseline depression, small but significant effects of other variables could have been masked and the effect sizes of brooding and worry could have been underestimated.

    “Since a large amount of variance was accounted for by baseline depression, small but significant effects of other variables could have been masked and the effect sizes of brooding (and worry) could have been underestimated.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    A bootstrapping approach was used to address non-normality of the sampling distribution when testing the indirect effects.

    “A bootstrapping approach was used to address non-normality of the sampling distribution when testing the indirect effects.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Because social support was self-reported, it is unclear whether the mediation via social support reflects an actual reduction in availability of social support or simply the perception that support is reduced.

    “although since the assessment of social support was self-reported, it is unclear whether this is the result of an actual reduction in availability of social support or simply the perception that support is reduced.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The underlying regression models in the causal steps approach are correctly specified.

  • May combine two claims.

    Interpretationreasoning

    Due to the small sample size, other mediating variables cannot be concluded to be unimportant in explaining the association of rumination with subsequent depression; poor problem solving and lack of social support were important predictors of depression among the participants.

    “However, due to our small sample size, we cannot conclude that other mediating variables are unimportant in explaining the association of rumination with subsequent depression, merely that poor problem solving and lack of social support were important predictors of depression among our participants.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The underlying regression models in the causal steps approach are correctly specified.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The use of a multidimensional health-related quality of life outcome may have obscured associations seen with more specific measures in previous research.

    “It may be that the use of a multidimensional health-related quality of life as an outcome obscured the associations seen with more specific, and sometimes physiological, measures used in previous research.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Bias-corrected confidence intervals were used because power was a concern.

    “We used bias-corrected confidence intervals since power was a concern.”
    Quote in the paperNot a substantial claim
61 of 61

  • The paper relies on this without support.

    The prior study's failure to use a recommended method for scoring the quality of life measure may have obscured an association.

    “although this study did not use a recommended method for scoring the quality of life measure, which may have obscured an association.”

  • The paper relies on this without support.

    It is unclear if the findings on rumination extend to other forms of perseverative negative thinking such as worry, or if perseverative negative thinking predicts other outcomes such as quality of life in this group.

    “although it is unclear if these findings extend to other forms of perseverative negative thinking such as worry, or if perseverative negative thinking predicts other outcomes such as quality of life in this group.”

  • The paper relies on this without support.

    This is the first study to explore social support, problem solving and instrumental behaviours as mediators of the association of rumination with depression in people with ACS.

    “however to our knowledge this is the first study to explore social support, problem solving and instrumental behaviours as mediators of this relationship in people with ACS.”

  • The paper relies on this without support.

    Missing data at 6-month follow-up are missing at random, so multiple imputation for chained equations yields valid estimates.

    “We explored the impact of missing data by repeating the third and final step of each of the staged multivariable regression models using multiple imputation for chained equations.The findings were consistent with those of the models using non-imputed data.”

  • The paper relies on this without support.

    The underlying regression models in the causal steps approach are correctly specified.

    “The causal steps approach we adopted relies on the correct specification of the underlying regression models and may give biased results if, for example, there are omitted variables that confound the relationship between predictors and mediators, or between mediators and outcomes.”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Statistics that don’t add up

Each reported p-value recomputed from its test statistic and degrees of freedom.

  • Inconsistent p-value: z=3.37, p = .007

    Minor

    The paper reports p = .007 here; recomputing from the test statistic and its degrees of freedom gives p < .001 (two-tailed). The check cannot tell whether the statistic or the p-value is the misprint.

    Reported p = .007 · recomputed p < .001

1 of 1

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Doesn’t add upz = 3.37reported p = .007 · recomputed p < .001

    “z=3.37, p = .007”

  • Consistentχ²(1) = 7.44reported p = .006 · recomputed p = .006

    “χ 2 (1)=7.44,p = .006”

  • Consistentχ²(1) = 6.26reported p = .012 · recomputed p = .012

    “χ 2 (1)=6.26,p = .012”

  • Consistentχ²(1) = 12.41reported p = 0 · recomputed p < .001

    “χ 2 (1)=12.41,p = .000”

  • Consistentχ²(1) = 14.68reported p = 0 · recomputed p < .001

    “χ 2 (1)=14.68,p = .000”

  • Consistentχ²(1) = 4.92reported p = .027 · recomputed p = .027

    “χ 2 (1)=4.92,p = .027”

  • Consistentz = 1.26reported p = .209 · recomputed p = .208

    “z=1.26, p = .209”

  • Consistentχ²(1) = 4.92reported p = .027 · recomputed p = .027

    “χ2(1)= 4.92, p = .027”

  • Consistentχ²(1) = 5.48reported p = .019 · recomputed p = .019

    “χ2(1)= 5.48, p = .019”

9 of 9

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Relationship percentages conflict with the overall figure

    Major

    The text says 23.3% of depressed participants and 50.0% of those without depression were in a relationship. The overall percentage cannot exceed both subgroup percentages, yet Table 1 reports 72.62%.

  • Negative problem orientation has the wrong sign for its reported indirect effect

    Major

    The reported path coefficients for rumination-to-mediator and mediator-to-depression multiply to −0.4048, whereas Table 3 reports a positive indirect effect of 0.40. This reverses the direction of a principal reported mediation pathway.

    Reported 0.4 · recomputed -0.4048

  • Living-alone percentage does not match the count

    Minor

    Table 1 lists 43 participants as living alone in a baseline sample of 169. That is 25.44%, not 74.40%.

    Reported 74.4 · recomputed 25.443787

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Baker, L. (2014). A prospective longitudinal study of repetitive thought as a vulnerability factor for depression in patients with coronary heart disease. (DClinPsych DClinPsych), University of Exeter, University of Exeter ORE. Retrieved from http://hdl.handle.net/10871/15386

Cited by

Sorted by citations

Related

Authors
Trick, L., Watkins, E. R., Henley, W., Gandhi, M. M., & Dickens, C.
Affiliations
  • University of Exeter (GB)
  • Royal Devon & Exeter NHS Foundation Trust (GB)
Corresponding author
Trick, Leanne
ORCID
Venue
General Hospital Psychiatry
Publisher
Elsevier BV
Published
2019-11
Volume
61
Pages
16-25
ISSN
0163-8343 (ISSN-L)
DOI
10.1016/j.genhosppsych.2019.06.012
OpenAlex
W2955646038
Cited by
11
References
102
Citations by year
2026: 1 · 2025: 1 · 2024: 2 · 2023: 5 · 2021: 2
FWCI
0.36
Type
journal article
Language
en
Open access
Licence
Locations
  • General Hospital Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • Open Research Exeter (University of Exeter) (submittedVersion, cc-by-nc-nd)
  • Figshare (submittedVersion, cc-by-nc-nd)
  • Durham Research Online (Durham University) (submittedVersion, cc-by)
  • Royal Devon and Exeter Research Repository (Royal Devon and Exeter) (submittedVersion)
Funders
  • National Institute for Health Research
  • University of Exeter
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
Keywords
depression, acute coronary syndrome, rumination, worry, problem-solving skills, social support, quality of life, coronary artery disease
MeSH terms
Rumination, Cognitive, Aged, Aged, 80 and over, Depression, Female, Humans, Male, Middle Aged, Problem Solving, Prospective Studies, Thinking, Acute Coronary Syndrome

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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