Journal of Clinical Psychology in Medical Settings, Vol. 13, No. 1, March 2006 ( C© 2006)DOI: 10.1007/s10880-005-9008-1

Depression in Women with Heart Disease: The Importance of Social RolePerformance and Spirituality

Karin E. Larsen,1 Kristin S. Vickers,1,3 Shirlene Sampson,1 Pamela Netzel,1 and Sharonne N. Hayes2

Published online: 21 March 2006

Compared with men, women are more likely to experience depression, and depression in-creases risk of morbidity and mortality in individuals with heart disease. Psychosocial inter-ventions have been developed for depressed patients with heart disease; however, women’sexperience of chronic disease differs from men’s and women may benefit from interventionstailored to address their difficulties. Spirituality and social roles have been related to de-pressive symptoms in other populations. To identify the relationship between depression andspirituality and social role performance (i.e., role concerns, role rewards and confidence inability to fulfill roles) in women with heart disease, we assessed depressive symptoms, spir-ituality, social role functioning and medical history in 125 women with heart disease. Aftercontrolling for age and severity of medical conditions, spirituality, role confidence and roleconcerns were significantly associated with depressive symptoms. Consideration of spiritual-ity and aspects of social role performance may be important when developing psychosocialinterventions for depressed women with heart disease.

KEY WORDS: depression; heart disease; women; social roles; spirituality; self-efficacy.

Historically, research with heart disease patientshas focused on men resulting in a relative deficitof knowledge regarding women with heart disease.While deaths from cardiovascular disease have de-clined over the last 25 years for men, deaths forwomen have remained fairly constant such that to-day heart disease is the number one cause of deathfor women in the US, claiming more lives per yearthan all types of cancer combined (American HeartAssociation, 2005). Reasons for these gender differ-ences remain largely unexplored. Women are morelikely to die following myocardial infarction and areless likely to engage in and complete cardiac reha-bilitation programs (Grace et al., 2002; King, 2001;Vaccarino, Krumholz, Yarzebski, Gore, & Goldberg,

1 Department of Psychiatry and Psychology, Mayo Clinic,Minnesota.

2 Department of Cardiovascular Diseases, Mayo Clinic,Minnesota.

3 Correspondence should be addressed to Kristin Vickers, MayoClinic, 200 First Street SW, Rochester, Minnesota 55905; e-mail:vickersdouglas.kristin@mayo.edu.

2001). Women with heart disease also differ fromtheir male counterparts from a psychosocial stand-point as they report different psychosocial stressors,experience higher rates of depression, use differentcoping responses, experience lower quality of life andlower levels of partner support than men (Emeryet al., 2004; Naqvi, Naqvi, & Merz, 2005). These find-ings suggest that in comparison with men, women ex-perience different medical risks, different behavioralresponses to heart disease and experience poorer ad-justment to their illness, and thus may benefit fromgender-specific psychosocial interventions targetingtheir specific needs and concerns.

Depression

Depression is of particular concern to providersworking with heart disease patients as researchstrongly indicates that depression increases riskof morbidity and mortality for men and womendiagnosed with heart disease (Frasure-Smith &

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40 Larsen, Vickers, Sampson, Netzel, and Hayes

Lesperance, 2005; Mendes de Leon et al., 1998;Wassertheil-Smoller et al., 2004). Approximately20% of individuals with heart disease will experiencean episode of major depression; however, psy-chological interventions targeting depression havebeen largely unsuccessful in producing clinicallysignificant reductions in depression levels (Frasure-Smith & Lesperance, 2003). Following myocardialinfarction women are at significantly greater riskfor depression even after controlling for medicalcomorbidity and age (Frasure-Smith, Lesperance,Juneau, Talajic, & Bourassa, 1999; Wiklund et al.,1993). However until recently, heart disease hasbeen construed as a man’s disease, and consistentwith this focus, psychosocial interventions have beendeveloped without understanding which elements, ifany, of these interventions might prove beneficial towomen (Lockyer & Bury, 2002). Moreover, evidencesuggests that some psychosocial interventions fordepressed patients who have had a myocardialinfarction may actually increase risk for future car-diac events in female but not male patients (Naqvi,Naqvi, & Merz, 2005). Reasons for this difference areunknown but physiological as well as psychosocialfactors may be responsible. Because being femaleand having heart disease significantly increases riskfor depression, and because depression is associatedwith decreased quality of life and increased mor-bidity and mortality in patients with heart disease, abetter understanding of the variables associated withdepression in women with heart disease is needed sothat effective interventions for these women can bedeveloped.

Spirituality

Until recently research has focused more on re-ligiosity than spirituality resulting in a relative deficitin understanding of the links between spirituality andemotional well being in medical patients. Spiritual-ity and religiosity are not mutually exclusive; how-ever, religiosity is more concerned with adherenceto an organized religion, whereas spirituality focuseson the individual’s search for meaning in life. Reli-giosity has been associated with increased well-beingand lower levels of depression (Mueller, Plevak, &Rummans, 2001; Murphy et al., 2001; Van Ness& Larson, 2002) and some evidence suggeststhis association is stronger for women than men(Strawbridge, Shema, Cohen, & Kaplan, 2001). Inmedical patients religious beliefs and comfort de-

rived from these beliefs have been linked with lowerdepression levels while religious behaviors were notassociated with depression (Contrada et al., 2004;Woods, Antoni, Ironson, & Kling, 1999). If depres-sion is more strongly related to religious beliefs thanto religious behavior; spirituality, which includes thesearch for meaning and purpose within or outside oforganized religion may be more highly related to de-pression levels.

Studies investigating spirituality as a philosophy,attitude or outlook have found that medically ill pa-tients who report greater spirituality have lower lev-els of depression (McClain, Rosenfeld, & Breitbart,2003; Smith et al., 1993). A study of patients withend-stage pulmonary disease found a relationshipbetween higher levels of spiritual discontent and highlevels of depression (Burker, Evon, Sedway, & Egan,2004). Some research suggests that spirituality maybe particularly important for women diagnosed withcancer (Ashing-Giwa, 1999; Ashing, Padilla, Tejero,& Kagawa-Singer, 2003; Gall & Cornblat, 2002;Feher & Maly, 1999); however, this research hasbeen largely qualitative and more research usingquantitative methods is necessary to better un-derstand this link. If spirituality is associated withdepression in women with heart disease, this infor-mation could inform the development of effectivepsychosocial interventions for depression with thispopulation.

Social Roles

Concerns and activities related to socialroles have been linked with women’s cardiachealth (Breznika & Kittel, 1995; Eaker, Sullivan,Kelly-Hayes, Agostino, & Benjamin, 2003;Kristofferzon, Lofmark, & Carlsson, 2003; Orth-Gomer et al., 2000; Rosengren et al., 2004), butless is known about links between social rolesand emotional well being in women with heartdisease. Findings from a qualitative study of 11premenopausal women with heart disease indicatedthat ability to fulfill mother and partner role respon-sibilities and to perform housework and paid workduties were common areas of concern (LaCharity,1999). Indeed, evidence suggests that resuming theroles related to paid work and household tasks areimportant to women with heart disease. Comparedwith men, after myocardial infarction women reportmore disruption in performing household work andengage in more household activities often using the

Depression in Women with Heart Disease 41

demands of household responsibilities rather thantheir physical health concerns to determine theiractivity levels (King, 2001). While some evidencesuggests returning to paid work may be less impor-tant to women following myocardial infarction thanmen (Kristofferzon, Lofmark, & Carlsson, 2003),other findings indicate that women are as likely toreturn to work outside the home at four monthsafter myocardial infarction even though womenreport lower functional class with regard to physicalactivities (Riegel & Gocka, 1995). Because womenwith heart disease are likely to push themselves toaccomplish household and paid worker roles andbecause demands and difficulties related to jobroles have been linked to depression and distressin individuals with cardiovascular disease, a betterunderstanding of this link in women may proveimportant in treating their depression (Rozanski,2005).

In addition to worker roles inside and outsideof the home, other social roles or aspects of theseroles may also be related to depression in womenwith heart disease. In community samples, women’sappraisals of their social roles and the demandsand satisfaction related to these roles have beenrelated to women’s emotional well-being (Baruch &Barnett, 1986; Reid & Hardy, 1999; Thornton & Leo,1992). Research with women experiencing postpar-tum depression suggests that concerns or problemsin the domains of work, household, and socialactivities are related to depression levels (Logsdon,Wisner, Hanusa, & Phillips, 2003). Another studyof postpartum women found emotional distress wasassociated with job demand, role restriction, andperceptions of infant distress (Klein, Hyde, & Esses,1998). For women who perform the role of caregiverto an adult relative, stress in the roles of motherwife and employee has been shown to exacerbatethe effect of caregiver role stress on depression(Stephens & Townsend, 1997). Taken together thesestudies suggest that aspects of various social roles areimportantly associated with depression; however, weidentified only one study investigating links betweendepression and social roles in women with heartdisease. This study surveying women following heartsurgery included data on eight different social roles.Findings indicated that a positive role balance (i.e.,role rewards minus role concerns) was associatedwith lower levels of depression (Plach & Heidrich,2002). To what extent social roles are related todepression in women with heart disease and whataspects of these roles might explain this link is

unknown. In the current study, these links wereexplored using several different measures of socialroles comprising social role performance. Social roleperformance was operationalized using measuresof social role rewards, role concerns and role con-fidence (i.e., social role self-efficacy) with referenceto women’s roles as mother, spouse, homemaker,grandmother, relative, paid worker, volunteerworker, and friend. Self-efficacy is a construct re-flecting an individual’s confidence in his/her ability toperform a specific behavior and greater self-efficacyto perform various behaviors has been related tolower levels of depression in other medical popu-lations (Bandura, 1997; Robinson-Smith, Johnston,& Allen, 2000). If social role performance (socialrole rewards, role concerns and role self-efficacy)is related to depression in women with heart dis-ease, interventions addressing social roles mayprove beneficial for depressed women with heartdisease.

Study Goals

The overall goal of the study was to provide agreater understanding of the need for effective inter-ventions for depressed women with heart disease andto identify variables related to depression in thesewomen so that such interventions may be developed.The first aim was to provide descriptive informationregarding levels of depression and treatment for de-pression in a small convenience sample of womenwith heart disease. The second aim was to determinethe relationships between depression and spiritual-ity as well as social role performance variables af-ter controlling for severity of medical conditions andage.

METHOD

Participants and Procedures

Women with heart disease who completed a pa-tient advocacy symposium, the Science and Lead-ership Symposium for Women with Heart Disease(sponsored by WomenHeart, The National Coali-tion for Women with Heart Disease, and MayoClinic, Rochester Minnesota), participated in thiscrossectional study. Symposium attendees had tobe over age of 18 and have been diagnosed witha form of heart disease. WomenHeart solicited

42 Larsen, Vickers, Sampson, Netzel, and Hayes

applications for symposium participation via health-care providers, their website, and monthly newslet-ters to members. Women who applied for the sym-posium were selected to participate on the basis oftheir ability to complete advocacy and educationalactivities for women with heart disease in their homecommunities, as well as for their ethnic, religious, re-gional and socioeconomic diversity. Participants at-tended the 4-day symposium which included infor-mational sessions on (a) diagnosis and treatment ofheart disease; (b) media skills; (c) the psychologicalaspects of coping with heart disease; and (d) commu-nity education planning.

This convenience sample was drawn from allsurviving women attending the annual symposiumbetween 2002 and 2004. Invitations to participate in astudy of women and heart disease as well as consentforms and study questionnaires were mailed to theirhomes. Upon receiving completed questionnaires thefirst author contacted by phone or letter all partic-ipants whose depression scores were elevated (i.e.,CES-D score ≥ 16), and information regarding de-pression in individuals with heart disease and theimportance of appropriate evaluation and treatmentwas provided.

Measures

The study questionnaire packets included a de-mographic survey including the following items: age,ethnicity, educational level, income level, marital sta-tus, and time since diagnosis of heart disease. Mea-sures of depression, medical conditions, spiritualityand social role performance were also included.

Depression

The Center for Epidemiological Studies Depres-sion Scale (CES-D) is a 20-item self-report ques-tionnaire developed for use with community samples(Radloff, 1977). Items describe symptoms of depres-sion and answers are indicated on a 4-point Likertscale ranging from “Rarely or Not At All,” to “Mostof the time.” Scores range from 0 to 60. The CES-Dis reliable and well validated (Beekman et al., 1997)and has been used in studies of male and femalepatients with heart disease (Borowicz et al., 2002;Wassertheil-Smoller et al., 1996). Scores greater thanor equal to 16 indicates clinically elevated symptomsof depression.

By indicating “yes” or “no,” women providedadditional information regarding their treatment fordepression (medications and/or psychotherapy) forthe following specified durations: (a) at any timesince diagnosis of heart disease, and (b) current.

Medical Severity

For purposes of this study, a checklist includ-ing cardiac conditions and procedures as well ascomorbid medical conditions was developed. Itemsincluded cardiac risk factors (e.g., hypertension),cardiac procedures (e.g., coronary artery bypasssurgery), cardiac conditions/events (e.g., myocardialinfarction), and comorbid conditions (e.g., cancer,degenerative joint disease). Participants were askedto include relevant medical conditions that were notlisted. A cardiologist (SNH), weighted each item formedical severity and the total medical severity scorewas the sum of these weighted items.

Spirituality

The Functional Assessment of Chronic IllnessTherapy- Spiritual Well-Being Scale (FACIT-Sp) isa 12-item measure developed for assessing the roleof spirituality and/or faith in chronically ill popu-lations (Peterman, Fitchett, Brady, Hernandez, &Cella, 2002). Items are summed to compute a totalscore. The FACIT-Sp is moderately correlated withother measures of religiosity and spirituality includ-ing religious activity and has been used with AIDSpatients, breast cancer patients and other chronicallyill populations.

Social Role Performance

Role Rewards and Concerns. The Role QualityMeasure (RQM; Plach & Heidrich, 2001) is an 80-item measure developed for women, surveying eightrole domains (mother, wife, grandmother, worker,friend, volunteer, relative, and homemaker). Foreach domain, five items reflecting concerns and fiveitems reflecting rewards are presented and a Likert-scale (1 = “not at all” to 4 = “extremely or a lot”)response format is provided. Individuals’ responsesindicate to what extent each item is rewarding orconcerning for each identified role. The RQM wasdeveloped for female cardiac patients and has alsobeen used with female rheumatoid arthritis patients.

Depression in Women with Heart Disease 43

Reliability is good (α’s = .71 to .94; Plach & Heidrich,2001; 2002).

Role Self-Efficacy. The Role Evaluation Scale(RES) was developed for this study and comprises8 items corresponding to each of the roles identifiedon the RQM. Based on self-efficacy theory (Bandura,1997) the RES was designed to be consistent withother self-efficacy measures. Women were asked toreflect on their ability to perform each of eight so-cial roles and indicate their answer using the follow-ing Likert scale: 1 (not at all confident) to 10 (totallyconfident).

Statistical Analyses

To determine whether there were differences instudy variables based on years since participation inthe symposium, women were placed in one of threegroups based on their year of participation. Groupdifferences for continuous variables were determinedusing one-way analyses of variance (ANOVAs), andchi-square statistics were calculated to determine sig-nificant group differences for categorical variables.For all analyses of group differences, a conservativeapproach was used to identify any confounding vari-ables such that they might be controlled in subse-quent statistical analyses (p < .10).

Pearson zero-order correlations among age,medical variables and psychosocial variables, werecomputed using a significance level of p < .05. Vari-ables significantly related to depression scores wereincluded in the hierarchical regression equation pre-dicting depression levels. Control variables were en-tered in the first step of the regression equation andpsychological variables were entered in the secondstep.

RESULTS

Descriptive Statistics

Of the 174 symposium attendees who weremailed invitations to participate in the study, twowere returned with address unknown, and 136women consented to participate in the study result-ing in a response rate of 78%. However, because11 women did not complete all items on each mea-sure, they were dropped from further analyses andresults are reported for the remaining 125 women.Women reported medical conditions including the

Table I. Demographic, Psychological, and Medical Variables

Mean (%) SD

Age (years) 54.7 9.43Income (%)

$0–39,999 15.0$40,000–79,999 45.8$80,000+ 39.2

Marital status (%)Married or living with partner 73.6Divorced 19.2Other 7.0

Employment status (%)Full time 41.9Part time 21.0Retired 16.9Disabled 12.1Other (student, homemaker,

unemployed)8.1

Ethnicity (%)Caucasian 83.2Black/non-hispanic 5.6Native American 7.2Hispanic 2.4Asian or Pacific Islander 1.6Years since heart disease diagnosis 7.3 9.6CES-D 12.6 10.4

following: myocardial infarction (51.2%), left ven-tricular dysfunction (20.0%), coronary artery bypasssurgery (40.8%), and heart failure (16.8%).

Group comparisons based on year of partici-pation in the WomenHeart Symposium did not re-veal significant differences on demographic vari-ables, years since heart disease diagnosis, medicalseverity, or psychological measures (p’s > .10). De-mographic information is provided for the entiresample in Table I. The majority of participants wereCaucasian, employed, and married or living with apartner. Incomes of $40,000 or greater were reportedby 85% of the women, and 48% had completed atleast four years of college.

On average, depression scores were below theCES-D cut-score of 16, (M = 12.59, SD = 10.36).Women scoring 16 or above (30%) were consid-ered “depressed.” Of these women, 37% reportedthat they were not receiving any current medica-tion and/or psychological intervention for depres-sion. In total 53.2% of participants reported receiv-ing treatment for depression since their heart diseasediagnosis.

The eight-item scaled developed for this studyto measure social role self-efficacy, the Role Evalu-ation Scale, evidenced adequate internal consistency(Cronbach’s α = .64).

44 Larsen, Vickers, Sampson, Netzel, and Hayes

Table II. Intercorrelations between Age, Medical Severity and Psy-chosocial Variables

1 2 3 4 5 6

1. Age —2. Medical severity .05 —3. Spirituality .24∗∗ −.20∗ —4. Role concerns −.27∗∗ .06 −.30∗∗ —5. Role rewards .07 −.03 .31∗∗ —6. Role confidence .16 −.26∗∗ .62∗∗ −.30∗∗ —7. CES-D −.24∗∗ .32∗∗ −.61∗∗ .41∗∗ −.13 −.60∗∗

∗p < .05. ∗∗p < .01.

Correlational and Heirarchical Multiple Regression Analyses

Pearson zero-order correlations among studyvariables are presented in Table II. All variables ex-cept for role rewards were significantly related to thedependent variable of interest, depressive symptoms.Time since diagnosis (i.e., years of living with heartdisease) was unrelated to depression levels (p > .10)and was not included in the regression equation pre-dicting depression.

All study variables significantly related to CES-D scores (p’s < .05) were included in the regressionequation reported in Table III. In the first step, ageand medical severity were entered to control forthe effects of age and disease on depression scores.The adjusted R2 for this step was .153 indicatingthat these variables accounted for 15.3% of thevariance in depression. The R2 change (.385) forthe second step including spirituality and the socialrole functioning variables (i.e., role concerns androle self-efficacy) indicated that these variables ac-counted for significantly more variance in depressionthan the control variables (Table III). When thepsychosocial variables were entered, age was nolonger significant. Both steps were significant and

Table III. Summary of Hierarchical Regression Analysis for Vari-ables Predicting Depression Levels (N = 125)

Variable B SE B β p

Step 1Age −0.28 0.09 −0.25 .003Medical severity 1.39 0.35 0.33 < .001

Step 2Age −0.14 0.07 −0.01 .851Medical severity 0.60 0.27 0.14 .028Spirituality −0.30 0.09 −0.27 .001Role concerns 3.35 1.37 0.17 .016Role confidence −2.30 0.48 −0.40 < .001

F(5, 119) = 29.88; p < .001.

in the final equation the adjusted R2 accounted for53.8% of the variance in CES-D scores.

DISCUSSION

Our findings provide additional information onthe prevalence of depressive symptoms in womenwith heart disease. Thirty percent of participants re-ported elevated symptoms of depression (i.e., CES-D ≥ 16) although on average depression scores werenot considered elevated (M = 12.66). Other stud-ies of women with heart disease have found eleva-tions in depressive symptoms ranging from 31 to 50%based on women’s response to self-report measuresof depression (Frasure-Smith et al., 1997; Linfante,Allan, Smith, & Mosca, 2003; Plach & Heidrich,2002). While the specificity and sensitivity of self-report measures, such as the CES-D, in heart dis-ease patients are currently unknown (Davidson,Rieckmann, & Rapp, 2005), even mild elevations indepressive symptoms as reflected on self-report mea-sures may be associated with increased risk of ad-verse cardiovascular events (Kubzansky, Davidson,& Rozanski, 2005).

Our findings also suggest that many womenwith heart disease who are experiencing elevatedsymptoms of depression are not receiving treatment,or the treatment they are receiving is not resulting insymptom relief. Thirty-seven percent of the womenwhose depression scores were elevated did not reportreceiving treatment for depression. Furthermore,49% of the participants who were currently receivingmedication and/or psychotherapy treatment for de-pression had elevated levels of depressive symptoms.One reason for the high rates of elevated symptomsin women with heart disease may be that they arereluctant to be screened for depression, thus theycannot be identified and referred for treatment(Glassman et al., 2002). Research indicates that

Depression in Women with Heart Disease 45

psychosocial interventions for women with heartdisease have generally had no impact on psycholog-ical symptoms and some evidence even suggests thatwomen who receive psychosocial interventions mayhave a greater risk for mortality than women whoreceive usual care (Frasure-Smith et al., 1997; Naqviet al., 2005). Reasons for these findings are unclearbut it is possible that interventions may increasedistress in women by reminding them of their diffi-culties, providing unhelpful strategies, or failing toaddress their particular difficulties. Our findings areconsistent with this research as the high percentageof women with elevated symptoms of depressionwhile in treatment suggests that their treatment is notproviding symptomatic relief. Because women werenot asked to specify whether they were receivingpharmacotherapy or psychotherapy or both, it is un-clear whether we can attribute these findings to a lackof medication or psychotherapy efficacy. Addition-ally, it is possible that some of these women recentlyinitiated treatment and thus these interventions wereof too short duration to provide symptom relief.However, based on these findings we can concludethat research to develop effective interventions fortreating symptoms of depression in this population isneeded.

Because spirituality and social role functioningaccounted for 38.5% of the variance in depressionscores after controlling for age and medical condi-tion, these variables appear be importantly associ-ated with emotional well being in women with heartdisease. A recent review of religion and spirituality incancer patients concludes that while some evidencesupports the link between these variables and lowerdepression levels, conclusions are premature due toscarcity of studies and methodological concerns in re-ported studies (Stefanek, McDonald, & Hess, 2005).Our findings add to the growing body of researchfinding significant associations between depressionand spirituality. Moreover the moderately high cor-relation between depression levels and spirituality inthe current study (r = −.61, p < .01) stands in con-trast to the correlation reported between religiousbeliefs and depression in a mixed-gender sample ofheart surgery patients (r = .17, p < .05; Contradaet al., 2004). Whether spirituality or religiosity ex-plains more variance in depression levels of patientswith heart disease and whether this effect is moder-ated by gender is a subject for future research.

Social role functioning in this study was opera-tionalized using measures of social role concerns, re-wards and a measure of self-efficacy or confidence in

ability to fulfill roles. While role rewards were not re-lated to depression levels, social role concerns andself-efficacy were significantly related to depressionlevels. In a sample of women who had undergoneheart surgery, Plach and Heidrich (2002) also foundthat depression was related to concerns regardingwomen’s social roles and their appraisal of their abil-ity to meet their own ideals for fulfilling these roles.Our findings are consistent with findings from studiesof female caregivers, postpartum women, and com-munity women suggesting that aspects of women’ssocial roles are importantly related to their adjust-ment and depression levels (Baruch & Barnett, 1986;Logsdon et al., 2003; Stephens & Townsend, 1997).While we know of no other studies evaluating so-cial role self efficacy with respect to depression, otherresearchers have investigated links between depres-sion and heart disease patients’ self-efficacy to per-form other behaviors. Findings from these studiessuggest that self-efficacy to perform health behav-iors or control physical symptoms has been linkedto improved physical functioning and lower depres-sion levels (Gilboy, 1994; Robertson & Keller, 1992;Sullivan, LaCroix, Russo, & Katon, 1998). However,Clark & Dodge (1999) found that self-efficacy forengaging in health behaviors (i.e., diet, exercise andstress management) was unrelated to depression lev-els in a sample of women with heart disease. Self-efficacy is behavior specific and further research willbe needed to determine the behaviors/performancesthat are most important in explaining any links be-tween self-efficacy and depression in women withheart disease.

Some limitations of the study should be ac-knowledged. Participants were well educated andmost were Caucasian. Although the current sam-ple was not randomly selected, a comparison ofstudy scores on psychosocial measures suggests thatthe sample was similar to other samples of womenwith heart disease and other chronic illnesses. Themean CES-D score for our sample was similar toanother study of women with heart disease (M =13.12; SD = 9.60; Plach & Heidrich, 2002). Spiritu-ality (FACIT-Sp) mean scores for the current studysample (M = 35.93; SD = 9.46) are on average be-tween reported FACIT-Sp scores for a sample ofwomen with breast cancer (M = 28.34; SD = 9.24;Cotton, Levine, Fitzpatrick, Dold, & Targ, 1999), andfor a sample (70% female) with cancer at varioussites (M = 38.5; SD = 8.1; Peterman et al., 2002).Average RQM of women in the current study (re-wards: M = 3.45; SD = .30; concerns: M = 2.21;

46 Larsen, Vickers, Sampson, Netzel, and Hayes

SD = .51) were comparable to RQM scores for asample of women who had undergone heart surgery(rewards: M = 3.34, SD = .67; concerns: M = 2.10;SD = .82; S. Plach, personal communication, June29, 2005). Thus, while results from the current studyare not generalizable to all women with heart dis-ease, mean scores on psychosocial measures sug-gest that the current sample has some similaritiesto other samples of women with heart disease orother chronic illnesses and that our findings shouldbe replicated with a randomly selected sample ofwomen with heart disease.

Because all of the women self-selected to partic-ipate in a symposium providing education, includinginformation on depression in women with heart dis-ease, our sample may possess more knowledge aboutheart disease or depression or have other character-istics that make them different than a random sam-ple of women with heart disease. It is hard to judgehow this knowledge may have affected women’s re-sponses; however, it is notable that despite such ed-ucation, over one-third of the sample with elevateddepression scores did not report current medical orpsychotherapeutic interventions for their mood diffi-culties. Possibly the percentage of untreated womenin our sample is lower than in the general patientpopulation as women who have not participated insuch educational programs may be even less likely torecognize and pursue treatment for depression.

This study relied entirely on self-report such thatmethod variance may contribute to statistical errorin our findings. Because a self-report measure wasused to measure depression levels, the number ofwomen experiencing clinical depression is unknown.Future studies should incorporate random selectionprocedures for recruiting study participants and in-clude a structured diagnostic interview so that par-ticipants experiencing episodes of clinical depressioncan be identified. Furthermore, prospective studiesincluding men and women may provide informationon how social role performance and spirituality mayaffect depression levels over time and how gendermay moderate these relationships. Such informationmay prove beneficial in developing gender-specificinterventions for depressed patients with heartdisease.

Depression in patients with heart disease is as-sociated with a two-fold increase in risk of morbidityor death. In addition to its adverse affects on physicalhealth, depression has a strongly negative impact onquality of life. Compared with men, women are atgreater risk for developing depression and they are

at greater risk for morbidity and mortality followinga cardiac event. To date no studies have identi-fied successful interventions for depressed womenwith heart disease. Results from the current studysuggest that psychosocial interventions addressingspirituality and social roles may be important towomen with heart disease and elevated symptomsof depression. While we know of no interventionsaddressing both these aspects of women’s lives, in-terpersonal psychotherapy (IPT) provides for a focuson women’s social roles and some evidence suggestsit be helpful in decreasing symptoms of depressionin patients with heart disease (Koszycki, Lafontaine,Frasure-Smith, Swenson, & Lesperance, 2004;Stuart & Cole, 1996). Interventions focusing on spiri-tuality have been developed to improve physical andemotional health for cardiac patients and other pop-ulations (Hawks, Hull, Thalman, & Richins, 1995;Kennedy, Abbott, & Rosenberg, 2002). Includingsome of the strategies outlined in these interventionsmay prove beneficial to women struggling withdepression, social role performance, and spiritualityin the context of heart disease.

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