Skip to main content Accessibility help

Response style and severity and chronicity of depressive disorders in primary health care

  • K. Riihimäki (a1) (a2), M. Vuorilehto (a1) (a3), P. Jylhä (a1) (a3) and E. Isometsä (a1) (a3)



Response styles theory of depression postulates that rumination is a central factor in occurrence, severity and maintaining of depression. High neuroticism has been associated with tendency to ruminate. We investigated associations of response styles and neuroticism with severity and chronicity of depression in a primary care cohort study.


In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 adult patients was screened for depression using the Prime-MD. Depressive and comorbid psychiatric disorders were diagnosed using SCID-I/P and SCID-II interviews. Of the 137 patients with depressive disorders, 82% completed the prospective five-year follow-up with a graphic life chart enabling evaluation of the longitudinal course of episodes. Neuroticism was measured with the Eysenck Personality Inventory (EPI-Q). Response styles were investigated at five years using the Response Styles Questionnaire (RSQ-43).


At five years, rumination correlated significantly with scores of Hamilton Depression Rating Scale (r = 0.54), Beck Depression Inventory (r = 0.61), Beck Anxiety Inventory (r = 0.50), Beck Hopelessness Scale (r = 0.51) and Neuroticism (r = 0.58). Rumination correlated also with proportion of follow-up time spent depressed (r = 0.38). In multivariate regression, high rumination was significantly predicted by current depressive symptoms and neuroticism, but not by anxiety symptoms or preceding duration of depressive episodes.


Among primary care patients with depression, rumination correlated with current severity of depressive symptoms, but the association with preceding episode duration remained uncertain. The association between neuroticism and rumination was strong. The findings are consistent with rumination as a state-related phenomenon, which is also strongly intertwined with traits predisposing to depression.


Corresponding author

Corresponding author at: Department of Psychiatry, Faculty of Medicine, University of Helsinki, P.O. Box 22, 00014 Helsinki, Finland. Tel.: +358 9 471 63728; fax: +358 9 471 63735. E-mail (E. Isometsä).


Hide All
[1]Nolen-Hoeksema, S.Responses to depression and their effects on the duration of depressive episodes. J Abnorm Psychol 1991; 100: 569582
[2]Nolen-Hoeksema, S.Morrow, J.Fredrickson, B.L.Response styles and the duration of episodes of depressed mood. J Abnorm Psychol 1993; 102: 2028
[3]Nolen-Hoeksema, S.Wisco, B.E.Lyubomirsky, S.Rethinking rumination. Perspect Psychol Sci 2008; 3: 400424
[4]Nolen-Hoeksema, S.Emotion regulation and psychopathology: the role of gender. Annu Rev Clin Psychol 2012; 8: 161187
[5]Wilkinson, P.O.Croudace, T.J.Goodyer, I.M.Rumination, anxiety, depressive symptoms and subsequent depression in adolescents at risk for psychopathology: a longitudinal cohort study. BMC Psychiatry 2013; 13: [250-244X-13-250]
[6]Nolen-Hoeksema, S.The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. J Abnorm Psychol 2000; 109: 504511
[7]McLaughlin, K.A.Nolen-Hoeksema, S.Rumination as a transdiagnostic factor in depression and anxiety. Behav Res Ther 2011; 49: 186193
[8]Roelofs, J.Huibers, M.Peeters, F., et al.Rumination and worrying as possible mediators in the relation between neuroticism and symptoms of depression and anxiety in clinically depressed individuals Behav Res Ther 2008; 46: 12831289
[9]Armey, M.F.Fresco, D.M.Moore, M.T., et al.Brooding and pondering: isolating the active ingredients of depressive rumination with exploratory factor analysis and structural equation modeling Assessment 2009; 16: 315327
[10]Watkins, E.R.Depressive rumination and co-morbidity: evidence for brooding as a transdiagnostic process. J Ration Emot Cogn Behav Ther 2009; 27: 160175
[11]Treynor, WGonzales, RNolen-Hoeksema, S.Rumination reconsidered: a psychometric analysis. Cogn Ther Res 2003;27:247–59.
[12]Whitmer, A.J.Gotlib, I.H.Brooding and reflection reconsidered: a factor analytic examination of rumination in currently depressed, previously depressed, and never depressed individuals. Cogn Ther Res 2011; 35: 99107
[13]Pervin, L.A.Cervone, D.John, O.P.Personality: theory and research 9th ed. 2005; Wiley; Hoboken, NJ:
[14]Ormel, J.Jeronimus, B.F.Kotov, R., et al.Neuroticism and common mental disorders: meaning and utility of a complex relationship Clin Psychol Rev 2013; 33: 686697
[15]Ormel, J.Bastiaansen, A.Riese, H., et al.The biological and psychological basis of neuroticism: current status and future directions Neurosci Biobehav Rev 2013; 37: 5972
[16]Kendler, K.S.Neale, M.C.Kessler, R.C., et al.A longitudinal twin study of personality and major depression in women Arch Gen Psychiatry 1993; 50: 853862
[17]Kendler, K.S.Gatz, M.Gardner, C.O.Pedersen, N.L.Personality and major depression: a Swedish longitudinal, population-based twin study. Arch Gen Psychiatry 2006; 63: 11131120
[18]Ormel, J.Oldehinkel, A.J.Vollebergh, W.Vulnerability before, during, and after a major depressive episode: a 3-wave population-based study. Arch Gen Psychiatry 2004; 61: 990996
[19]Boyce, P.Parker, G.Barnett, B., et al.Personality as a vulnerability factor to depression Br J Psychiatry 1991; 159: 106114
[20]Clayton, P.J.Ernst, C.Angst, J.Premorbid personality traits of men who develop unipolar or bipolar disorders. Eur Arch Psychiatry Clin Neurosci 1994; 243: 340346
[21]Hirschfeld, R.M.Klerman, G.L.Lavori, P., et al.Premorbid personality assessments of first onset of major depression Arch Gen Psychiatry 1989; 46: 345350
[22]Jylha, P.Melartin, T.Rytsala, H.Isometsa, E.Neuroticism, introversion, and major depressive disorder–traits, states, or scars?. Depress Anxiety 2009; 26: 325334
[23]Kendell, R.E.DiScipio, W.J.Eysenck personality inventory scores of patients with depressive illnesses. Br J Psychiatry 1968; 114: 767770
[24]Bagby, R.M.Parker, J.D.A.Relation of rumination and distraction with neuroticism and extraversion in a sample of patients with major depression. Cogn Ther Res 2001; 25: 91102
[25]Shull, A.M.Rumination mediates impact of personality on depression [Honors Thesis] 2014 University of Michigan
[26]Spasojevic, J.Alloy, L.B.Rumination as a common mechanism relating depressive risk factors to depression. Emotion 2001; 1: 2537
[27]Aldao, A.Nolen-Hoeksema, S.Schweizer, S.Emotion-regulation strategies across psychopathology: a meta-analytic review. Clin Psychol Rev 2010; 30: 217237
[28]Knowles, R.Tai, S.Christensen, I.Bentall, R.Coping with depression and vulnerability to mania: a factor analytic study of the Nolen-Hoeksema (1991) Response Styles Questionnaire. Br J Clin Psychol 2005; 44: 99112
[29]Just, N.Alloy, L.B.The response styles theory of depression: tests and an extension of the theory. J Abnorm Psychol 1997; 106: 221229
[30]Nolen-Hoeksema, S.Parker, L.E.Larson, J.Ruminative coping with depressed mood following loss. J Pers Soc Psychol 1994; 67: 92104
[31]Nolen-Hoeksema, S.McBride, A.Larson, J.Rumination and psychological distress among bereaved partners. J Pers Soc Psychol 1997; 72: 855862
[32]McEvoy, P.M.Watson, H.Watkins, E.R.Nathan, P.The relationship between worry, rumination, and comorbidity: evidence for repetitive negative thinking as a transdiagnostic construct. J Affect Disord 2013; 151: 313320
[33]Lam, D.Smith, N.Checkley, S., et al.Effect of neuroticism, response style and information processing on depression severity in a clinically depressed sample Psychol Med 2003; 33: 469479
[34]Bagby, R.M.Rector, N.A.Segal, Z.V., et al.Rumination and distraction in major depression: assessing response to pharmacological treatment J Affect Disord 1999; 55: 225229
[35]Donaldson, C.Lam, D.Rumination, mood and social problem-solving in major depression. Psychol Med 2004; 34: 13091318
[36]Kasch, K.L.Klein, D.N.Lara, M.E.A construct validation study of the Response Styles Questionnaire Rumination Scale in participants with a recent-onset major depressive episode. Psychol Assess 2001; 13: 375383
[37]Kuehner, C.Huffziger, S.Response styles to depressed mood affect the long-term course of psychosocial functioning in depressed patients. J Affect Disord 2012; 136: 627633
[38]Kuehner, C.Huffziger, S.Factors predicting the long-term illness course in a cohort of depressed inpatients. Eur Arch Psychiatry Clin Neurosci 2013; 263: 413423
[39]Schmaling, K.B.Dimidjian, S.Katon, W.Sullivan, M.Response styles among patients with minor depression and dysthymia in primary care. J Abnorm Psychol 2002; 111: 350356
[40]Teismann, T.Steinfeld, B.Willutzki, U.Michalak, J.Rumination and distraction: selected findings related to the response styles theory. Psychother Psychosom Med Psychol 2011; 61: 126132
[41]Vuorilehto, M.Melartin, T.Isometsa, E.Depressive disorders in primary care: recurrent, chronic, and co-morbid. Psychol Med 2005; 35: 673682
[42]Riihimaki, K.A.Vuorilehto, M.S.Melartin, T.K.Isometsa, E.T.Five-year outcome of major depressive disorder in primary health care Psychol Med 2011 111
[43]Nolen-Hoeksema, S.Morrow, J.A prospective study of depression and posttraumatic stress symptoms after a natural disaster: the 1989 Loma Prieta Earthquake. J Pers Soc Psychol 1991; 61: 115121
[44]Eysenck, H.Eysenck, S.Manual of the Eysenck Personality Inventory London: University of London Press Ltd; 1964
[45]Floderus, B.Psychosocial factors in relation to coronary heart disease and associated risk factors. Nordisk Hygienisk Tidskrift 1974; Suppl. 6:1148
[46]Roberts, J.E.Gilboa, E.Gotlib, I.H.Ruminative response style and vulnerability to episodes of dysphoria: gender, neuroticism, and episode duration. Cogn Ther Res 1998; 22: 401423
[47]Miranda, R.Nolen-Hoeksema, S.Brooding and reflection: rumination predicts suicidal ideation at 1-year follow-up in a community sample. Behav Res Ther 2007; 45: 30883095
[48]Surrence, K.Miranda, R.Marroquin, B.M.Chan, S.Brooding and reflective rumination among suicide attempters: cognitive vulnerability to suicidal ideation. Behav Res Ther 2009; 47: 803808
[49]Johnson, D.P.Whisman, M.A.Gender differences in rumination: a meta-analysis. Pers Individ Dif 2013; 55: 367374
[50]Muris, P.Roelofs, J.Rassin, E., et al.Mediating effects of rumination and worry on the links between neuroticism, anxiety and depression. Pers Individ Dif 2005; 39: 11051111
[51]Van Loey, N.E.Oggel, A.Goemanne, A.S., et al.Cognitive emotion regulation strategies and neuroticism in relation to depressive symptoms following burn injury: a longitudinal study with a 2-year follow-up. J Behav Med 2014; 37: 839848
[52]Nolen-Hoeksema, S.Sex differences in unipolar depression: evidence and theory. Psychol Bull 1987; 101: 259282


Response style and severity and chronicity of depressive disorders in primary health care

  • K. Riihimäki (a1) (a2), M. Vuorilehto (a1) (a3), P. Jylhä (a1) (a3) and E. Isometsä (a1) (a3)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.

Response style and severity and chronicity of depressive disorders in primary health care

  • K. Riihimäki (a1) (a2), M. Vuorilehto (a1) (a3), P. Jylhä (a1) (a3) and E. Isometsä (a1) (a3)
Submit a response


No Comments have been published for this article.


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *