Health Psychology Copyright 1995 by the American Psychological Association, Inc.

1995, Vol. 14, No. 2,152-163 0278-6133/95/S3.00

Social Support, Coping, and Depressive Symptoms in a

Late-Middle-Aged Sample of Patients Reporting Cardiac Illness
Charles J. Holahan Rudolf H. Moos
University of Texas at Austin Department of Veterans Affairs and Stanford University
Medical Centers, Palo Alto

Carole K. Holahan Penny L. Brennan

University of Texas at Austin Department of Veterans Affairs and Stanford University
Medical Centers, Palo Alto
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

This study tests a 1-year predictive model of depressive symptoms in a late-middle-aged sample of
patients reporting diagnoses of cardiac illness. Results based on 325 individuals (248 men and 77
women) diagnosed with chronic cardiac illness, 71 individuals (52 men and 19 women) diagnosed
with acute cardiac illness, and 219 healthy controls (129 men and 90 women) strongly supported the
hypotheses. Compared with healthy persons, individuals with chronic and those with acute cardiac
illness reported more depressive symptoms at follow-up. Women overall showed more depressive
symptoms than did men, and women with cardiac illness were particularly vulnerable to behavioral
manifestations of depressive symptoms. Integrative time-lag and prospective structural equation
models indicated that, for individuals with cardiac illness, social support and adaptive coping
strategies predicted fewer depressive symptoms.

Key words: cardiac illness, depressive symptoms, social support, coping

Increasingly, the biomedical view of illness is being supple-
mented by broader perspectives recognizing that psychological
processes and outcomes are central to understanding and
treating physical disease (Kaplan, 1990; Peterson, 1989). For
example, in cardiac rehabilitation emotional factors are of as
much concern as medical status (Jenkins, Jono, Stanton, &
Stroup-Benham, 1990; Kaplan, 1988). In fact, psychosocial
factors can outweigh physical health status in predicting return
to normal functioning in recovery from cardiac disease (Neill
et al., 1985). New cardiac treatments that enhance survival
increase the need to understand psychological functioning
among persons living with long-term cardiac conditions (Allen,
Fitzgerald, Swank, & Becker, 1990). Here, we test a 1-year
predictive model of depressive symptoms in a late-middle-aged
sample of patients reporting diagnoses of cardiac illness,
Charles J. Holahan, Department of Psychology, and Carole K.
Holahan, Department of Educational Psychology, University of Texas
at Austin; Rudolf H. Moos and Penny L. Brennan, Department of
Veterans Affairs and Stanford University Medical Centers, Palo Alto, CA
This work was supported by National Heart, Lung, and Blood
Institute Grant 1-RO3-HL48063; American Heart Association Texas
Affiliate Grants 90G-404 and 91R-404; National Institute of Alcohol
Abuse and Alcoholism Grant AA06699; and Department of Veterans
Affairs Health Services Research and Development Service funds.
We gratefully acknowledge the assistance of John Potthoff, Jennifer
Mertens, Bernice Moos, Kathleen Mackie, Hugh Crean, and Ashley
Merritt in data analysis and of Deborah Blankfeld, Liza Bonin, and
David Valentiner in library research.
Correspondence concerning this article should be addressed to
Charles J. Holahan, Department of Psychology, University of Texas,
Austin, TX 78712.
focusing on the protective roles of social support and adaptive
coping strategies.
Cardiac Illness and Depressive Symptoms
Fear and uncertainty are common among cardiac patients,
with a significant subset of patients vulnerable to serious
depression (Forrester et al., 1992). For example, in a sample of
almost 300 patients experiencing myocardial infarction
(Schleifer et al., 1989), almost half met diagnostic criteria for
major or minor depression 1 week after infarction and one
third met these criteria 3 to 4 months later. High levels of
depression also have been reported for a significant number of
individuals approximately 1 year postinfarction (Follick et al.,
1988; Wiklund, Sanne, Vendin, & Wilhelmsson, 1984) and
after cardiac surgery (Langeluddecke, Fulcher, Baird, Hughes,
& Tennant, 1989; Magni et al., 1987).
Although longer term psychosocial adjustment to cardiac
disease has received less study, there is evidence that chronic
cardiac illness also is psychosocially debilitating. For example,
among 400 men recovering from a first myocardial infarction,
one third showed substantial depressed mood at a 3-year
follow-up (Waltz, Badura, Pfaff, & Schott, 1988). Similarly,
Havik and Maelands (1990) found that, among almost 300
patients recovering from myocardial infarction, almost 20%
had failed to achieve emotional adjustment at a 3- to 5-year
follow-up.
Research on psychosocial adjustment to cardiac illness has
focused primarily on men, and much less is known about
women's adjustment to cardiac disease (Wenger, Speroff, &
Packard, 1993). The importance of understanding women's

152
 DEPRESSIVE SYMPTOMS AND CARDIAC ILLNESS
adjustment to cardiac illness is underscored by recent concern
that women may receive less appropriate cardiac treatment
than men (Killer, 1992; Maynard, Litwin, Martin, & Weaver,
1992). Moreover, emerging findings suggest that women with
cardiac illness are more symptomatic, more depressed, and
experience poorer functional capacity than men (Shumaker &
Czajkowski, 1993). For example, in cross-sectional analyses
(Holahan, Moos, Holahan, & Brennan, in press), we found
that on average individuals with chronic cardiac illness were
more depressed than were persons free of illness and that
women's adjustment to cardiac illness was poorer than men's.
Social Support
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Investigators are focusing increasingly on the determinants
of individual differences in psychosocial adjustment among
cardiac patients, with particular attention addressed to the
protective roles of social support and adaptive coping strate-
gies. Growing evidence links social support to quality of life
after cardiac illness (Jenkins et al., 1990). Social support is
defined as the perception of emotional sustenance, informa-
tional guidance, and tangible assistance (Davidson, 1987).
Esteem support, which involves perceptions of being valued and
competent, appears to be especially valuable after cardiac
surgery (King, Reis, Porter, & Norsen, 1993).
For example, long-term psychosocial adaptation to cardiac
illness was better among married men in high-intimacy in
contrast with low-intimacy marriages, even when their physical
health was poor (Waltz et al., 1988). The psychosocial benefits
of a healthy marital relationship probably derive from a low
level of interpersonal stressors as well as a positive emotional
quality (Badura & Waltz, 1984; Waltz, 1986). Moreover,
although research has focused most on spousal support,
psychosocial adjustment during cardiac rehabilitation derives
from various sources of social support, including the family,
work setting, and broader social network (Davidson, 1987;
Roberts et al., 1986).
Coping Strategies
In contrast with early assumptions that focused simply on
denial, current research indicates that coping with cardiac
illness entails a wide variety of cognitive and behavioral
strategies involving both avoidance and active efforts to master
the situation (Scherck, 1992). Active, approach-oriented cop-
ing is positively related to quality of life among persons
recovering from cardiac surgery (Scheier et al., 1989). Al-
though avoidant forms of coping, such as denial, sometimes
can be beneficial in the initial interval after a health crisis
(Levenson, Mishra, Hamer, & Hastillo, 1989), they are gener-
ally detrimental in the longer term (Levine et al., 1987; Suls &
Fletcher, 1985). For example, Mayou and Bryant (1987) found
that patients who adopted a passive approach to coronary
artery surgery showed poorer quality of life 1 year after
surgery.
Holahan and Moos (1987,1990, 1991) proposed a resources
model of coping in which coping functions as one mechanism
through which resources, such as social support, relate to
adjustment. Lazarus and Folkman (1984), defining resources
153
as what an individual "draws on in order to cope," also argued
that resources "precede and influence coping" (p. 158).
Similarly, Thoits (1986) viewed social support as coping
assistance. In a cross-sectional test of this model with almost
400 individuals with chronic cardiac illness (Holahan et al., in
press), we found that social support related to depression both
directly and indirectly through adaptive coping strategies.
The Present Study
The purpose of this study was to test a 1-year predictive
model of depressive symptoms in a late-middle-aged sample of
patients reporting diagnoses of cardiac illness, focusing on the
protective roles of social support and adaptive coping strate-
gies. The study extends earlier research in several ways. First,
we integrate two key sets of psychosocial factors—social
support and adaptive coping strategies—identified in previous
research in a unifying predictive framework. In addition, we
focus on social support in a number of distinct life domains.
Moreover, we strengthen the causal model by examining the
role of social support in predicting subsequent depressive
symptoms, controlling for prior depressive symptoms. This
controls for the possibility that the predictive role of social
support may be affected by ongoing depressive symptoms, that
is, that depressed individuals may both withdraw socially and
be less sought after interpersonally. Furthermore we examine
psychological adjustment to both chronic and acute cardiac
illness. Finally, in light of increasing concern about cardiac
illness in women, we examine change in depressive symptoms
over a 1-year period among both men and women.
On the basis of previous research (Havik & Maelands, 1990;
Schleifer et al., 1989; Waltz et al., 1988), we predicted that
both individuals with chronic and those with acute cardiac
illness would report more depressive symptoms than would
persons free of illness at a 1-year follow-up. We tested these
predictions with 325 individuals diagnosed with chronic car-
diac illness, 71 individuals diagnosed with acute cardiac illness,
and 219 healthy controls. We also hypothesized that cardiac
illness would relate to depressive symptoms more strongly
among women than among men (see Shumaker & Czajkowski,
1993).
In addition, on the basis of research on the roles of social
support (King et al., 1993; Waltz et al., 1988) and adaptive
coping strategies (Affleck, Tennen, & Croog, 1987; Levine et
al., 1987; Mayou & Bryant, 1987) in adjustment to cardiac
illness, we predicted that more social support and more
adaptive coping strategies would relate to fewer depressive
symptoms at follow-up. Finally, applying Holahan and Moos's
(1987,1990,1991) resources model of coping, we hypothesized
that social support would predict subsequent depressive symp-
toms both directly and indirectly through adaptive coping
strategies. On the basis of evidence that these factors play a
protective role with a wide range of life stressors (see Holahan
& Moos, 1994), we expected that these relations would hold
for both chronic and acute cardiac illness. This set of predic-
tions is shown graphically in Figure 1 as a structural equation
model that includes a measurement model for social support,
percentage of approach coping, and depressive symptoms
latent constructs in a time-lag model. We tested this model
 154 HOLAHAN, MOOS, HOLAHAN, AND BRENNAN
Figure 1. Hypothesized structural equation and measurement models for a time-lag model predicting
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
depression over a 1-year period. Latent constructs are shown in ellipses, and observed variables are shown
This document is copyrighted by the American Psychological Association or one of its allied publishers.
in rectangles.
with the combined samples of 396 individuals diagnosed with
cardiac illness using both single-group and multigroup (chronic
and acute illness) LISREL analyses (Joreskog & Sorbom,
1989).
Method
Sample Selection and Characteristics
The present research is part of a larger project examining stress,
coping, and health-related outcomes among late-middle-aged and
older adults (see Brennan & Moos, 1990; Moos, Brennan, Fondacaro,
& Moos, 1990). The sample at Time 1 included individuals between
the ages of 55 and 65 who had contact with one of two large medical
centers. Psychosocial and physical health data were obtained from
self-report inventories at two time points 1 year apart. Intensive
telephone and mail follow-ups were used to maximize the response
rate and to obtain complete data. Of eligible respondents contacted,
96% agreed to participate in the survey, and 89% (1,884) of them
provided complete data at Time 1. Of the 1,838 Time 1 respondents
still living at Time 2,95% (1,755) provided complete data at follow-up.
Although this is not a random sample of late-middle-aged individu-
als, the sample is roughly comparable with other community samples
of older adults with respect to health characteristics such as hospital-
ization and prevalence of chronic illness (for additional information on
the full sample, see Brennan & Moos, 1990). For example, in the
National Health Survey (Vital and Health Statistics, 1986) 18% of
individuals between the ages of 45 and 64 years had been hospitalized
in the past year, with an average stay of 12 days. In our sample of 55- to
65-year-olds, 26% had been hospitalized, with an average stay of 14
days. Chronic heart disease was reported by 13% (14% of men and
12% of women) of National Health Survey respondents; chronic heart
disease was reported by 19% (24% of men and 12% of women) of the
participants in our sample.
Among those providing complete data at both assessments, the 325
respondents (19%; 248 men and 77 women) who reported diagnosed
chronic cardiac illness at Time 1 constituted the chronic cardiac illness
group. The 71 respondents (4%; 52 men and 19 women) who reported
at Time 2 that cardiac illness was first diagnosed during the preceding
year constituted the acute cardiac illness group. The healthy control
group consisted of the 219 respondents (13%; 129 men and 90 women)
who reported no diagnosed illnesses of any type at either of the two
assessments. There were no significant demographic differences be-
tween the chronic and acute cardiac illness groups. However, both the
chronic cardiac illness (M = 61.8 years, SD = 3.16) and the acute
cardiac illness (M = 61.1 years, SD = 2.93) groups were older than
the healthy control group (M = 60.8 years, SD = 3.27) at Time 1,
F(2, 612) = 6.92, p < .01. In a 3 (illness) x 2 (gender) analysis of
variance (ANOVA), there was a significant main effect of gender on
age, F(\, 596) = 4.11, p < .05, with men nearly 1 year older than
women. This difference mirrors the age distribution in the overall
sample in which the median age for men was 1 year older than that for
women.
In the two cardiac illness samples, three quarters of the respondents
were men, most respondents (94%) were of Anglo-Saxon descent, two
thirds were married, one third was employed full or part time, and they
had an average family income of $33,000. The predominant reasons for
unemployment in the cardiac illness samples were poor health (40%)
and retirement (46%). Compared with the healthy control group, the
cardiac illness groups consisted of more men, x2(2, N = 615) = 19.25,
p < .01, fewer employed persons, x2(2, N - 615) = 34.03, p < .01, and
lower family incomes, F(2,601) = 17.83, p < .01.
Measures
In addition to sociodemographic data, the database included self-
report information on participants' physical health, depression, social
support, and coping strategies. Independent health service data also
were available for approximately one quarter of respondents in the
cardiac samples. All of the self-report indexes were designed for
survey research with community samples. The indexes have strong
psychometric properties and are associated with one another and with
psychological adjustment in expected ways. Descriptive and psychomet-
ric information on the measures is available from the following
sources: (a) the Life Stressors and Social Resources Inventory (LISRES;
Moos & Moos, 1994) for the physical health, negative life events, and
social support measures; (b) the Coping Responses Inventory (CRI;
Moos, 1993) for the coping strategies measure; and (c) the Health and
Daily Living Form (HDL; Moos, Cronkite, & Finney, 1990) for the
depressive symptoms measure.
Chronic illness. Chronic medical conditions were assessed with the
LISRES. Respondents were asked to indicate whether any of 13
medical conditions (e.g., heart trouble, cancer, and arthritis) had been
diagnosed by a doctor during the previous year, and if so, whether the
condition had begun prior to the previous year. Chronic cardiac illness
was defined by affirmative responses to the "heart trouble" item at
Time 1 when the condition was reported as having begun before the
previous year. Acute cardiac illness was defined by affirmative re-
sponses to the "heart trouble" item at Time 2 when no heart trouble
 DEPRESSIVE SYMPTOMS AND CARDIAC ILLNESS
was reported at Time I.1 To sharpen our focus on cardiac illness,
individuals reporting medical conditions on the list that related to
broader vascular or circulatory problems (e.g., stroke and high blood
pressure) were not included in the cardiac illness groups when these
were the only conditions reported. However, individuals reporting
both heart trouble and vascular or circulatory problems were included
in the cardiac illness groups. Healthy controls were individuals who
reported no chronic or acute medical conditions at either Time 1 or
Time 2.
Physical symptoms associated with cardiac illness. Physical symp-
toms at follow-up also were assessed with the LISRES. Respondents
were asked to indicate whether they had experienced any of five
symptoms often associated with cardiac illness (i.e., pain in the heart
or tightness or heaviness in the chest, trouble breathing or shortness of
breadth, swollen ankles, getting very tired in a short time, and trouble
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
climbing stairs or getting outdoors) during the previous year.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Social support. The measure of social support at Time 1 comprised
10 subscales in three domains—family, work, and social network—
taken from the LISRES (for scoring details see Moos & Moos, 1994).
Consistent with the idea that the benefits of social resources derive
from reduced interpersonal strains as well as emotional support
(Badura & Waltz, 1984; Waltz, 1986), the measure assesses negative
aspects of social relationships, such as conflict and criticism from
others, as well as positive ones, such as confiding and understanding.
The family support measure consisted of 38 items derived from four
subscales assessing both positive and negative (reverse scored) aspects
of social support from both spouse and children. For example,
respondents were asked of their spouse "Does he or she really
understand how you feel about things?" and "Does he or she get angry
or lose his or her temper with you?" Responses were scored on a
5-point scale, ranging from 0 (never) to 4 (often). The total score for
family support was derived by averaging the scores (standardized) for
the four component subscales; the mean of support from spouse and
children was used when data were available from at least one of these
sources. Moos and Moos (1994) reported Cronbach alphas between
.81 and .91 for the component subscales in the overall sample (N =
1,884). For the entire family support measure, Cronbach's alpha was
.92 in the overall sample.
The work support measure consisted of 12 items derived from two
subscales assessing both positive and negative (reverse scored) aspects
of social support in the workplace. For example, respondents were
asked "Do you talk with your fellow employees about your work
problems?" and "Does your supervisor criticize you over minor
things?" Responses were scored on the same 5-point scale used for the
family support items, and the total score for work support was derived
by averaging the scores (standardized) for the two component sub-
scales. Moos and Moos (1994) reported Cronbach alphas between .50
and .69 for the component subscales in the overall sample. For the
entire work support measure, Cronbach's alpha was .55 in the overall
sample.
The social network support measure consisted of 48 items derived
from four subscales assessing both positive and negative (reverse
scored) aspects of social support from friends and relatives. For
example, respondents were asked "Do you confide in any of your
friends?" and "Are any of your friends critical or disapproving of
you?" Responses were scored on the same 5-point scale used for the
family and work support items. The total score for social network
support was derived by averaging the scores (standardized) for the
four component subscales; the mean of support from friends and
relatives was used when data were available from at least one of these
sources. Moos and Moos (1994) reported Cronbach alphas between
.77 and .92 for the component subscales in the overall sample. For the
entire social network support measure, Cronbach's alpha was .86 in
the overall sample. The social support measures were moderately
stable over the two assessments (Time 1-Time 2 rs = .70, .59, and .54
155
for family, network, and work support, respectively, for the combined
cardiac samples), with stability somewhat higher for the acute com-
pared with the chronic illness group.
Percentage approach coping. Coping was measured at Time 2 with
four CRI subscales (Moos, 1993). Respondents were asked to identify
the "most important problem or stressful situation" they had experi-
enced in the past 12 months and to rate how frequently they had
engaged in each of a variety of cognitive and behavioral coping
responses to deal with it, using a 4-point scale ranging from 0 (not at
all) to 3 (fairfy often). The coping problems respondents selected were
coded into 12 categories. The predominant problem category for
subjects in the cardiac illness samples was their own illness (34%). The
next most common categories for these subjects involved problems
that often accompany chronic illness: problems with one's spouse and
children (25%) and financial and work-related problems (18%). The
remaining problem categories primarily involved interpersonal prob-
lems with one's extended family.
We conceptualized coping strategies according to two major foci—
approach and avoidance—with each of these foci subdivided according
to cognitive and behavioral coping methods (for a fuller discussion, see
Moos & Schaefer, 1993; for an application, see Valentiner, Holahan,
& Moos, 1994). Two subscales indexed approach coping. Positive
reappraisal involves cognitive attempts to actively restructure a prob-
lem in a positive way while accepting the reality of the situation.
Problem solving involves behavioral attempts to deal directly with the
problem. For example, respondents were asked "Did you think about
how this event could change your life in a positive way?" (positive
reappraisal) and "Did you make a plan of action and follow it?"
(problem solving).
Two other subscales indexed avoidance coping. Cognitive avoidance
involves cognitive attempts to avoid thinking realistically about the
problem. Emotional discharge involves behavioral attempts to reduce
tension by expressing negative feelings rather than directly dealing
with the problem. For example, respondents were asked "Did you try
to deny how serious the problem really was?" (cognitive avoidance)
and "Did you take it out on other people when you felt angry or
depressed?" (emotional discharge). In the overall sample, Cronbach
alphas were .73, .66, .71, and .60, respectively, for the measures of
positive reappraisal, problem solving, cognitive avoidance, and emo-
tional discharge. In interpreting the internal consistency of the coping
subscales, it should be kept in mind that the use of one coping response
may reduce the need to use other responses from the same category.
On the basis of earlier research demonstrating predictive advan-
tages of relative versus absolute coping scores (Vitaliano, Maiuro, &
Russo, 1987) and following our earlier research (Holahan & Moos,
1990, 1991), we examined percentage of approach coping. The four
coping subscale scores allowed us to compute separate indices of the
percentage of cognitive and behavioral approach coping. Percentage
cognitive approach coping was computed by dividing positive reap-
praisal by total cognitive coping (i.e., the sum of positive reappraisal
and cognitive avoidance). Percentage behavioral approach coping was
computed by dividing problem solving by total behavioral coping (i.e.,
the sum of problem solving and emotional discharge).
Depressive symptoms. Depressive symptoms at both the initial and
follow-up assessments were tapped by an index of 12 symptoms
experienced during the previous month derived from Research Diagnos-
tic Criteria (RDC; Spitzer, Endicott, & Robins, 1978). For each item,
respondents indicated how often they had experienced the symptoms
during the past month on a 5-point scale from 0 (never) to 4 (often).
Following Billings, Cronkite, and Moos (1983) and Holahan and Moos
1
Although "heart trouble" taps broadly defined cardiac illness,
evidence suggests that psychosocial adjustment is similar across
diverse cardiac conditions, from ventricular dysrhythmia without loss
of consciousness to cardiac arrest (Kolar & Dracup, 1990).
 156 HOLAHAN, MOOS, HOLAHAN, AND BRENNAN
(1991), the depression measure was divided into two subscales:
Depressed Mood and Ideation and Depressive Features. Depressed
Mood and Ideation is the sum of 7 items that tap mood-related
symptoms (e.g., feeling guilty, worthless, or down on yourself and
feeling negative or pessimistic; Cronbach's a = .91 in the overall
sample). Depressive Features is the sum of 5 symptoms that tap
behavioral manifestations of depression (e.g., crying and feeling
resentful, irritable, and angry; Cronbach's a = .81 in the overall
sample). To avoid confounding symptoms of physical illness with
symptoms of depression, items tapping endogenous depression (e.g.,
physical symptoms or complaints) were removed from the index of
depressive features (see Moos, Cronkite, & Finney, 1990).
Although indexes of this type do not measure clinical illness, they
tap a consistent and meaningful aspect of psychological distress that
may be associated with clinical disorder (Link & Dohrenwend, 1980).
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
In a validity check with a set of depressed patients (Billings & Moos,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
1985), the depressive symptoms index was highly correlated with the
Beck Depression Inventory at treatment intake (r = .88, n = 54) and at
posttreatment follow-up (r = .92, n = 31).
Results
Comparisons of Cardiac and Control Samples
Validity Checks
Convergent validity. To test the convergent validity of respon-
dents' self-reported cardiac illness, we compared the chronic
cardiac illness, acute cardiac illness, and healthy control
groups at Time 2 on the heart-related physical symptoms they
experienced during the previous year. To control for demo-
graphic differences among groups, age, family income, and
employment status were used as covariates in a one-factor
(illness) analysis of covariance (ANCOVA). Results showed
significant differences among the three groups on heart-
related physical symptoms, F(2, 596) = 14.53, p < .01. Group
contrasts showed that the combined cardiac illness groups
reported significantly (p < .01) more heart-related symptoms
than did healthy controls; chronically and acutely ill individu-
als did not differ significantly on these symptoms.
Follow-up univariate ANCOVAs indicated that each of the
five heart-related physical symptoms was significantly higher
for the combined cardiac illness groups than for the control
group (p < .01). Pain in the heart was reported by 47% of
respondents in the cardiac samples, compared with only 2% of
healthy controls. Trouble breathing, swollen ankles, getting
tired very quickly, and trouble climbing stairs were reported by
an average of 37% of respondents in the cardiac samples,
compared with an average of less than 5% of healthy controls.
To examine the role of gender, we compared the combined
cardiac illness groups and healthy controls in a 2 (illness) x 2
(gender) ANCOVA (again controlling for age, family income,
and employment status). Although there was no main effect
for sex, the Illness x Gender interaction was significant, F(l,
595) = 5.08, p < .05, reflecting particularly high levels of
heart-related symptoms for women in the cardiac samples.
Criterion-related validity. A test of the criterion-related
validity of self-reported cardiac illness was possible from
independent data that were available for those respondents
who had relatively recent inpatient episodes in Department of
Veterans Affairs (VA) Medical Centers. These data were
derived from the VA Patient Treatment File, which includes
diagnostic information on inpatients treated in VA Medical
Centers. We adopted a conservative approach whereby medi-
cal diagnoses of broader cerebrovascular (e.g., stroke) or
circulatory (e.g., hypertension) disorders were not included in
identifying cardiac diagnoses. This approach also is conserva-
tive because cardiac illness appears as a diagnosis in the
Patient Treatment File only if it is a primary or contributing
factor in a particular inpatient episode. Thus, patients with
cardiac disease who were hospitalized for unrelated conditions
would not receive a cardiac diagnosis.
Data about recent inpatient treatment were available for
107 (30%) of the individuals in the chronic cardiac illness
group at Time 1. Of these individuals, 82 had a cardiac
diagnosis (e.g., ischemic heart [coronary artery] disease), on
the basis of International Classification of Diseases: Clinical
Modification classifications (Commission on Professional and
Hospital Activities, 1986), as a primary or contributing factor
to an inpatient hospitalization in the 4 years prior to our Time
1 assessment. Recognizing that some individuals with existing
chronic cardiac illness might not have experienced a hospital-
ization related to their cardiac illness until after our assess-
ment was made, we also examined the 4-year period immedi-
ately after our initial assessment. Of the remaining 25
respondents, an additional 7 persons showed a cardiac diagno-
sis as a primary or contributing factor to an inpatient hospital-
ization.
For respondents in the acute cardiac illness group, we
limited our search to the period covering the 4 years after our
initial assessment because their cardiac diagnosis postdated
that assessment. Diagnostic data were available for 14 (20%)
of these individuals. Of these, 11 individuals showed a cardiac
diagnosis as a primary or contributing factor to an inpatient
hospitalization in the 4 years after our Time 1 assessment.
Combining these data for the two cardiac samples, a total of
100 (83%) of the 121 respondents for whom data were
available showed a cardiac diagnosis as having contributed to
an inpatient hospitalization. Because this validation sample
consisted overwhelmingly (98%) of men, these criterion-
related validity data apply essentially only to men.
Depressive Symptoms at Follow-Up
We compared the chronic cardiac illness, acute cardiac
illness, and healthy control groups on depressive symptoms at
follow-up. To control for demographic differences among
groups, age, family income, and employment status were used
as covariates, and gender was included as a factor. Cell means
and standard deviations for Time 2 depressed mood and
depressive features are reported in Table 1.
Separate 3 (Illness) x 2 (Gender) ANCOVAs showed that
the three illness groups differed significantly on both de-
pressed mood, F(2, 593) = 13.47, p < .01, and depressive
features, F(2, 593) = 24.37, p < .01, at follow-up. As
predicted, group contrasts showed that the combined cardiac
illness groups scored significantly (p < .01) higher than did the
control group on both measures of depressive symptoms.
Although acutely ill individuals scored somewhat higher on
 DEPRESSIVE SYMPTOMS AND CARDIAC ILLNESS 157

Table 1
Means and Standard Deviations for Men and Women in the Chronic Cardiac Illness, Acute
Cardiac Illness, and Healthy Control Groups on Time 2 Depressive Symptoms
Chronic cardiac Acute cardiac
illness illness Healthy control
Variable Men Women Men Women Men Women
Depressed mood
M 7.32 8.43 7.96 10.58 5.09 5.78
SD 5.63 5.50 6.21 6.67 4.96 4.15
Depressive features
M 5.50 7.43 5.94 9.42 3.70 4.58
SD 3.73 4.06 4.18 3.92 3.17 3.17
n 248 77 52 19 129 90
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

both indexes of depressive symptoms, the two illness groups
did not differ significantly on either index.
Women experienced significantly more depressed mood,
F(l, 593) = 5.34,/j < .05, and depressive features, F(l, 593) =
26.47, p < .01, than did men. Moreover, the Illness x Gender
interaction was significant for depressive features, F(2,593) =
3.63, p < .05, reflecting a particularly high level of depressive
features for women with cardiac illness, particularly among
women who were acutely ill.
Although on average individuals with cardiac illness re-
ported more depressive symptoms than did healthy controls,
the level of depressive symptoms in the cardiac groups varied
markedly. Some individuals with cardiac illness reported no
depressive symptoms, whereas others reported very high lev-
els—as high as all 12 symptoms of depression experienced
"fairly often." We next examine the determinants of depres-
sive symptoms in the cardiac samples.
Integrative Predictive Models for Cardiac Samples
Formulation of the LISREL Models
We tested our predictive framework with the combined
cardiac samples in a structural equation model using both
single-group and multigroup (chronic and acute illness) LIS-
REL analyses (Joreskog & Sorbom, 1989). The time-lag model
included three latent variables. An exogenous variable for
Time 1 social support was measured with three indicators:
family support, work support, and social network support. An
endogenous variable, Time 2 percentage approach coping, was
measured with two indicators (percentage cognitive approach
coping and percentage behavioral approach coping) and was
included in the model as a mediator between initial social
support and subsequent depression. A second endogenous
variable, Time 2 depressive symptoms, was measured with two
indicators (depressed mood and depressive features) and was
included as an outcome variable.
To examine the predictive role of social support indepen-
dent of ongoing depressive symptoms, a more conservative test
controlled for initial depressive symptoms. This prospective
model included an additional endogenous variable for Time 1
depressive symptoms, which also was measured with two
indicators (depressed mood and depressive features). To
provide a metric for the latent constructs and to identify the
measurement model, the first indicator loading for each latent
construct was set to 1.0 in the unstandardized solution for each
model.
Zero-order correlations among the study variables for the
combined cardiac samples are presented in Table 2. Pairwise
deletion of missing values was used. Missing values substan-
tially affected only work support; it should be kept in mind that
the social support latent construct was indexed by three
indicators for respondents who were employed and by two
indicators for those who were unemployed. Variance-
covariance matrices were used in the LISREL analyses.
Consistent with our cross-sectional findings (Holahan et al.,
in press), the pattern of intercorrelations among the variables
in the model was comparable for men and women. However, to
ensure that the analyses were independent of gender we

Table2
Zero-Order Correlations Among the Study Variables for the Combined
Cardiac Samples (N = 396)
Variable 1
Time 1
1. Family support — .25 .42 -.33 -.33 .20 .22 -.32 -.34
2. Work support — .29 -.30 -.31 .19 .22 -.36 -.41
3. Social network support — -.27 -.28 .14 .24 -.30 -.27
4. Depressed mood — .80 -.29 -.37 .72 .63
5. Depressive features -.29 -.41 .67 .74
Time 2 —
6. % cognitive approach coping .38 -.35 -.33
7. % behavioral approach coping —
-.52 -.53
8. Depressed mood .83
9. Depressive features —
 158 HOLAHAN, MOOS, HOLAHAN, AND BRENNAN
controlled for gender in the variance-covariance matrices for
all analyses. A comparison of men and women in the combined
cardiac samples revealed mean differences for gender on two
of the predictive variables in the model. Men scored higher
than women on percentage behavioral approach coping, F(l,
382) = 6.01, p < .05, whereas women scored higher than men
on social network support, F(l, 394) = 6.52,;? < .05.
Estimation of the Time-Lag LISREL Model
The results of the LISREL test of the hypothesized time-lag
model are presented graphically in Figure 2, which includes
standardized estimates of parameters in the measurement and
structural models. In the figure 8 and e represent unique
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
variance in the observed X and Y variables, respectively. The
This document is copyrighted by the American Psychological Association or one of its allied publishers.
time-lag model provided a good fit to the data, overall x2(10,
N = 396) = 12.05, p > .20 (goodness-of-fit index [GFI] = .99
and adjusted GFI = .98).2 All parameter estimates for the
measurement model were significant at the .01 level for all
three latent variables. In addition, all parameter estimates in
the structural model were significant at the .01 level. Social
support was significantly related to both percentage approach
coping and depressive symptoms at follow-up, and percentage
approach coping also was significantly associated with depres-
sive symptoms. Thus, social support showed a direct relation-
ship to subsequent depressive symptoms as well as an indirect
relationship mediated by percentage approach coping.
Moreover, additional correlational analyses showed that the
negative aspects of relationships, such as conflict and criticism
from family and friends, were as strongly related to poor
adjustment as the positive aspects of support were related to
better adjustment. The combined items reflecting positive
aspects of Time 1 support across domains showed a correlation
of -.31 (df = 396, p < .01) with overall Time 2 depressive
symptoms (depressed mood plus depressive features). The
combined items reflecting negative aspects of Time 1 support
across domains showed a correlation of .41 (df = 396,/j < .01)
with overall Time 2 depressive symptoms.
Estimation of the Prospective LISREL Model
The results of the LISREL test of the hypothesized prospec-
tive model are presented graphically in Figure 3, which
includes standardized estimates of parameters in the measure-
ment and structural models. The prospective model provided a
good fit to the data, overall X2(19, N = 396) = 20.91, p > .30
(GFI = .99 and adjusted GFI = .97).3 All parameter estimates
for the measurement model were significant at the .01 level for
all four latent variables. In addition, all parameter estimates in
the structural model were significant at the .05 level. Thus,
even controlling for initial depression, social support contin-
ued to show a direct relationship to subsequent depressive
symptoms as well as an indirect relationship mediated by
percentage approach coping.
Additional LISREL Analyses
The pattern of intercorrelations among the variables in the
model was comparable for individuals with acute and chronic
cardiac illness. However, to more systematically examine the fit
of the model for both cardiac samples, we tested the prospec-
tive model in a multigroup (chronic and acute illness) LISREL
analysis. The multigroup analysis of the variance-covariance
matrices, with both measurement model and structural model
parameters equated across groups, provided an adequate fit to
the data, overall x2(52, combined W = 396) = 62.83, p > .10
(GFIs = .98 and .91 for chronic and acute groups, respec-
tively).4 All parameter estimates in the measurement and
structural models remained significant (a = .05), with param-
eter estimates very close to those in the single-group analysis
with the combined cardiac samples. Moreover, there was a
nonsignificant change in model fit when the structural models,
X2(9, combined N = 396) = 10.45, p > .30, and then the
measurement models, x2(4, combined N = 396) = 3.11, p >
.50, were allowed to vary across cardiac groups.
Because the standard errors and chi-square GFIs supplied
by LISREL may be less reliable with pairwise deletion of
missing values, we repeated the LISREL analyses for both the
time-lag and prospective models using listwise deletion of
missing values (« = 129). For both models, LISREL analyses
using listwise deletion of missing values resulted in essentially
the same results as those using pairwise deletion. For both
models, the overall model fit and the size and statistical
significance of the hypothesized path coefficients were compa-
rable to those reported above using pairwise deletion.5 We
have presented findings involving pairwise deletion because
they are based on more information than those involving
listwise deletion and because including only individuals who
are employed would greatly restrict the study's external validity.
2
Following earlier cross-sectional research with this data base
(Holahan et al., in press), a parameter reflecting correlation (e.g.,
shared method variance in parallel items) between the unique vari-
ances for the measures of family support and social network support
was included in the model.
3
The construct loadings in the measurement model for depression
across the two measurement times were constrained to be invariant;
this constraint led to a nonsignificant change in model fit. Also,
parameters reflecting correlation between the unique variances for the
measures of depressed mood over time and between the unique
variances for the measures of depressive features over time were
included in the model. These are common procedures in structural
models involving lagged measures over time (e.g., Holahan & Moos,
1991).
4
The parameters reflecting correlation between the unique vari-
ances for the measures of family support and social network support
and between the measures of depressive features over time were not
significant in the acute illness group and were retained only in the
model for the chronic illness group. On the basis of examination of the
modification indices, a parameter reflecting correlation between the
unique variances for the Time 2 measures of percentage behavioral
approach coping and depressed mood was included in the model for
the acute illness group.
5
For the time-lag model, overall x2(H, N = 129) = 7.77, p > .70
(GFI = .98 and adjusted GFI = .96). For the prospective model,
overall X2(20, N = 129) = 15.03, p > .70 (GFI = .98 and adjusted
GFI = .94). For both models, all parameter estimates in the measure-
ment models and all hypothesized parameter estimates in the struc-
tural models were significant at the .05 level. The parameter reflecting
correlation between the unique variances for the measures of family
support and social network support was not significant in either model
and was not retained.
 DEPRESSIVE SYMPTOMS AND CARDIAC ILLNESS 159

t e
i I

»-
ThM2
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

»- D«pr«Mlv*
This document is copyrighted by the American Psychological Association or one of its allied publishers.

SVMptOM*

s-

Figure 2. Results of the LISREL test (standardized estimates) of the structural equation and
measurement models for the time-lag model with the combined cardiac samples (n = 396). Latent
constructs are shown in ellipses, and observed variables are shown in rectangles. A superscript f indicates a
parameter set to 1.0 in the unstandardized solution. **p < .01.

Discussion depressive symptoms at follow-up than did men. Thus, wom-

These findings integrate central psychosocial factors identi-
fied in previous research on cardiac illness in a 1-year prospec-
tive framework to predict depressive symptoms in a late-middle-
aged sample of patients reporting diagnoses of cardiac illness.
Consistent with previous research (Havik & Maelands, 1990;
Schleifer et al., 1989; Waltz et al., 1988) and extending our
cross-sectional findings (Holahan et al., in press), individuals
with both chronic and acute cardiac illness reported more
depressive symptoms at a 1-year follow-up than did persons
free of illness.
Consistent with their experiencing new heart problems,
acutely ill individuals scored somewhat higher on both indexes
of depressive symptoms; however, the two illness groups did
not differ significantly on either index. The high level of
depressive symptoms among chronically ill individuals is consis-
tent with other research with cardiac patients (Fielding, 1991)
and their spouses (Coyne & Smith, 1991) as well as with
broader evidence of the psychologically debilitating effects of
chronic stressors more generally (Avison & Turner, 1988).
Moreover, because chronic cardiac illness often gives rise to
new negative life events, like rehospitalization and financial
reverses (Waltz et al., 1988), such illness typically involves a
configuration of adaptive demands deriving from both endur-
ing stressors and associated acute events (see Pearlin, 1989).
In support of emerging findings by other investigators on the
psychosocial functioning of women with cardiac disease (see
Shumaker & Czajkowski, 1993) and extending our cross-
sectional results (Holahan et al., in press), cardiac illness
related more closely to poorer adjustment among women than
among men. Compared with men, women in the cardiac
samples experienced particularly high levels of heart-related
physical symptoms. Moreover, women overall showed more
en's general vulnerability to depressive symptoms (see Soren-
son, Rutter, & Aneshensel, 1991) remains apparent in the
context of cardiac illness.
In addition, women with cardiac illness were particularly
vulnerable to behavioral manifestations of depressive symp-
toms in comparison with both men with cardiac illness and
healthy persons. This external expression of distress among
women with cardiac illness may reflect the fact that they
experience themselves as more sick than do men with cardiac
illness. Overall, these results encourage broadening the emerg-
ing interest in improving the medical treatment of women who
are cardiac patients (Kitler, 1992; Maynard et al., 1992) to
encompass concern about enhancing resources and interven-
tion efforts that can facilitate their psychosocial rehabilitation
(see S. J. Blumenthal & Matthews, 1993).
The level of depressive symptoms in the cardiac samples
varied dramatically. Although some individuals with cardiac
illness reported marked depressive symptoms, others experi-
enced no depressive symptoms at all. Psychosocial factors were
central to understanding this individual variability—both so-
cial support and adaptive coping strategies predicted fewer
depressive symptoms.
These results are consistent with earlier research indicating
that social support, such as confiding in family members and
friends, is associated with better psychosocial adjustment
among persons with cardiac illness (King et al., 1993; Waltz et
al., 1988). They also support earlier research suggesting that
active coping efforts are beneficial (Scheier et al., 1989) and
avoidant forms of coping harmful (Levine et al., 1987; Mayou
& Bryant, 1987) to psychosocial functioning after cardiac
illness. Moreover, the results extend earlier research with
cardiac patients by demonstrating that comparable protective
 160 HOLAHAN, MOOS, HOLAHAN, AND BRENNAN

FarolySuppoit 57

Wortc Support

Support!
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Tim* 1 Tim. 2
D*pr***lv* D*pr***lv*
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Symptom* Symptom*

.57

t t t
Figure 3. Results of the LISREL test (standardized estimates) of the structural equation and
measurement models for the prospective model with the combined cardiac samples (n = 396). Latent
constructs are shown in ellipses, and observed variables are shown in rectangles. A superscript f indicates a
parameter set to 1.0 in the unstandardized solution. *p < .05; **p < .01.

processes operate for both chronically and acutely ill individu-
als.
Although our findings indicate that women with cardiac
illness are at particular psychological risk, the pattern of
intercorrelations among the study variables demonstrated that
the protective benefits of social support and adaptive coping
strategies were as advantageous to women as to men with
cardiac illness. Women's use of a lower percentage of behav-
ioral approach coping strategies compared with men's may
partially explain their poorer psychosocial adjustment to car-
diac illness. Although women reported relatively more interper-
sonal coping problems than men, there was no evidence that
the types of coping problems faced by women required less
behavioral approach coping than those experienced by men.
Women's psychological risk in the context of cardiac illness
also may be linked to factors outside of our predictive
framework, such as gender-related social role demands (see
Verbrugge, 1985).
Bolstering the view that various sources of social support
relate to psychosocial adjustment during cardiac rehabilitation
(Davidson, 1987; Roberts et al., 1986), the pattern of correla-
tions showed that all three components of social support
tapped here—family, work, and broader social network—were
comparably related to adjustment. Furthermore, consistent
with the idea that the benefits of social resources in cardiac
rehabilitation derive from reduced interpersonal strains as
well as emotional support (Badura & Waltz, 1984; Waltz,
1986), negative aspects of relationships, such as conflict and
criticism from family and friends, were as damaging to adjust-
ment as positive aspects of support were beneficial. This latter
finding reinforces more general reconceptualizations of social
support that emphasize the adverse influence of negative
aspects of social ties on the overall perception of support and
psychological well-being (see Coyne & DeLongis, 1986; Pierce,
Sarason, & Sarason, 1991; Rook, 1984).
In addition, congruent with Holahan and Moos's (1987,
1990, 1991) resources model of coping and extending our
cross-sectional research with chronic cardiac patients (Hola-
han et al., in press), the predictive link of social support with
fewer subsequent depressive symptoms operated in part
through adaptive coping strategies. This result is consistent
with conceptualizations of resources as preceding and influenc-
ing coping (Lazarus & Folkman, 1984) and of social support as
assisting coping (Thoits, 1986). This finding also is conceptu-
ally important because it identifies a key mechanism through
which social support relates to adjustment (see Williams,
Wiebe, & Smith, 1992). More practically, it suggests a point of
intervention for enhancing coping efforts. Advice from a
confidant can provide a context for exploring coping options
after cardiac surgery (Kulik & Mahler, 1989), and encourage-
ment from a loved one can foster less debilitating appraisals of
threat when one is faced with cardiac symptoms (Fontana,
Kerns, Rosenberg, & Colonese, 1989).
Some limitations should be noted in interpreting and gener-
alizing these results. Common method (i.e., questionnaire) or
agent (i.e., self-report) variance across measures, or both could
have contributed to the linkages we found. For example,
depressed individuals may have a general negative bias in their
perceptions of themselves, their physical health, and other
persons (see Stokes & McKirnan, 1989). Moreover, some
 DEPRESSIVE SYMPTOMS AND CARDIAC ILLNESS
patients with cardiac symptoms suffer from panic disorder
(Chignon, Lepine, & Ades, 1993; Kushner, Thomas, Barrels, &
Beitman, 1992), and because depression is often comorbid
with panic disorder, such patients may inflate the rate of
reported depression. These concerns are diminished some-
what by the use of prospective analyses that control for initial
depressive symptoms. Nevertheless, future research is needed
to extend these findings to include objective indexes of health
and functioning.
Additional caution is appropriate concerning our findings
with women because our criterion-related validity data apply
essentially only to men. There is evidence, for example, that
women report atypical chest pain with angiographically normal
arteries more often than men (Wenger et al., 1993). However,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
in a state of the issue report on gender and health, Verbrugge
(1985) concluded, "Comparing medical records with interview
reports, shows no difference in how often women and men
report their diagnosed chronic conditions" (p. 171).
A further limitation of the present study is that we did not
control for personality factors, such as neuroticism. Some
investigators have argued that the relationship between coping
and psychological adjustment is based on an underlying
influence of neuroticism (see Bolger, 1990). This concern is
alleviated somewhat in that the prospective design used here
controls for initial functioning and thus for the influence of
neuroticism as a nuisance variable associated with a stable
component in functioning. As Carver et al. (1993) explained,
"If neuroticism acts to predispose people to distress, it follows
that the best proxy for neuroticism is distress itself (p. 387).
However, as Carver et al. pointed out, neuroticism also may
operate as a dynamic variable, such as by affecting reactivity to
events (see Bolger & Schilling, 1991). Future research in this
area could strengthen the present design by controlling for
relevant personality characteristics such as neuroticism.
Finally, the present findings are specific to late-middle-aged
men and women. However, because the prevalence of heart
disease is relatively high for this age group (Vital and Health
Statistics, 1986) and because most of these individuals can
anticipate many well years of life (see Kaplan, 1988), these
findings are of particular relevance to cardiac rehabilitation.
Fielding (1991) argued that in cardiac care "depression is
arguably the key obstacle to effective and full recovery" (p.
1021). Moreover, there is some evidence that depression
(Anda et al., 1993), social isolation (Case, Moss, Case, McDer-
mott, & Eberly, 1992; Williams et al., 1992), and negative
cognitive coping responses (Affleck et al., 1987) may predict
increased risk for reinfarction and cardiac death after myocar-
dial infarction.
The predictive model examined here can be applied to
psychological treatment and prevention efforts related to
cardiac rehabilitation (for a discussion of psychological inter-
ventions in cardiac rehabilitation, see J. A. Blumenthal &
Emery, 1988). Supplementing more traditional medical and
functional concerns, psychosocial goals for an individual recov-
ering from cardiac illness also might address the social support
available to the patient and the patient's coping strategies.
Because women may be at particular psychological risk in the
context of cardiac disease, the inclusion of such indexes may be
especially relevant to managing the psychosocial rehabilitation
161
of female cardiac patients (S. J. Blumenthal & Matthews,
1993; Shumaker & Czajkowski, 1993). Intervention goals
consistent with the present findings might include helping
patients learn how to reduce conflict with loved ones and
educating patients about the long-term costs of avoidant forms
of coping.
More broadly, the predictive framework examined here also
may be relevant to understanding psychosocial adjustment to
other physical illnesses (see Kaplan, 1990). Gatchel, Baum,
and Krantz (1989) argued that rehabilitation among patients
with cardiac disease is emblematic of psychosocial issues
involved in coping with physical illness more generally. Espe-
cially important, an emphasis on adaptive processes and
resources in managing physical illness can help to promote a
more optimistic and self-enhancing view of medically ill
persons.
References
Affleck, G., Tennen, H., & Croog, S. (1987). Causal attribution,
perceived benefits, and morbidity after a heart attack: An 8-year
study. Journal of Consulting and Clinical Psychology, 55, 29-35.
Allen, J. K., Fitzgerald, S. T., Swank, R. T., & Becker, D. M. (1990).
Functional status after coronary artery bypass grafting and percuta-
neous transluminal coronary angioplasty. American Journal of Cardi-
ology, 65, 921-925.
Anda, R., Williamson, D., Jones, D., Macera, C, Eaker, E., Classman,
A., & Marks, J. (1993). Depressed affect, hopelessness, and the risk
of ischemic heart disease in a cohort of U.S. adults. Epidemiology, 4,
285-294.
Avison, W. R., & Turner, R. J. (1988). Stressful life events and
depressive symptoms: Disaggregating the effects of acute stressors
and chronic strains. Journal of Health and Social Behavior, 29,
253-264.
Badura, B., & Waltz, M. (1984). Social support and the quality of life
following myocardial infarction. Social Indicators Research, 14,
295-311.
Billings, A. G., Cronkite, R. C., & Moos, R. H. (1983). Social-
environmental factors in unipolar depression: Comparisons of
depressed patients and nondepressed controls. Journal of Abnormal
Psychology, 92, 119-133.
Billings, A. G., & Moos, R. H. (1985). Psychosocial processes of
remission in unipolar depression: Comparing depressed patients
with matched community controls. Journal of Consulting and Clinical
Psychology, 53, 314-325.
Blumenthal, J. A., & Emery, C. F. (1988). Rehabilitation of patients
following myocardial infarction. Journal of Consulting and Clinical
Psychology, 56, 374-381.
Blumenthal, S. J., & Matthews, K. A. (1993). Psychosocial aspects of
cardiovascular disease in women: Introduction and overview. Annals
of Behavioral Medicine, 15, 109-111.
Bolger, N. (1990). Coping as a personality process: A prospective
study. Journal of Personality and Social Psychology, 59, 525-537.
Bolger, N., & Schilling, E. A. (1991). Personality and the problems of
everyday life: The role of neuroticism in exposure and reactivity to
daily stressors. Journal of Personality, 59, 355-386.
Brennan, P. L., & Moos, R. H. (1990). Life stressors, social resources,
and late-life problem drinking. Psychology and Aging, 5, 491-501.
Carver, C. S., Pozo, C., Harris, S. D., Noriega, V., Scheier, M. F.,
Robinson, D. S., Ketcham, A. S., Moffat, Jr., F. L., & Clark, K. C.
(1993). How coping mediates the effect of optimism on distress: A
study of women with early stage breast cancer. Journal of Personality
and Social Psychology, 65, 375-390.
 162 HOLAHAN, MOOS, HOLAHAN, AND BRENNAN
Case, R. B., Moss, A. J., Case, N., McDermott, M., & Eberly, S. (1992).
Living alone after myocardial infarction: Impact on prognosis.
Journal of the American Medical Association, 267, 515-519.
Chignon, J. M., Lepine, J. P., & Ades, J. (1993). Panic disorder in
cardiac outpatients. American Journal of Psychiatry, 150, 780-785.
Commission on Professional and Hospital Activities. (1986). Interna-
tional classification of diseases: 9th Revision, Clinical Modification
ICD-9-CM (Vols. 1-3). Ann Arbor, MI.
Coyne, J. C., & DeLongis, A. (1986). Going beyond social support:
The role of social relationships in adaptation. Journal of Consulting
and Clinical Psychology, 54, 454-460.
Coyne, J. C., & Smith, D. A. F. (1991). Couples coping with a
myocardial infarction: A contextual perspective on wives' distress.
Journal of Personality and Social Psychology, 61, 404-412.
Davidson, D. M. (1987). Social support and cardiac rehabilitation: A
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
review. Journal of Cardiopulmonary Rehabilitation, 7, 196-200.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Fielding, R. (1991). Depression and acute myocardial infarction: A
review and reinterpretation. Social Science and Medicine, 32, 1017-
1027.
Follick, M. J., Gorkin, L., Smith, T. W., Capone, R. J., Visco, J., &
Stablein, D. (1988). Quality of life post-myocardial infarction:
Effects of a transtelephonic coronary intervention system. Health
Psychology, 7, 169-182.
Fontana, A. F., Kerns, R. D., Rosenberg, R. L., & Colonese, K. L.
(1989). Support, stress, and recovery from coronary heart disease: A
longitudinal causal model. Health Psychology, 8, 175-193.
Forrester, A. W., Lipsey, J. R., Teitelbaum, M. L., DePaulo, J. R.,
Andrzejewski, P. L., & Robinson, R. G. (1992). Depression follow-
ing myocardial infarction. International Journal of Psychiatry in
Medicine, 22, 33-46.
Gatchel, R. J., Baum, A., & Krantz, D. S. (1989). An introduction to
health psychology. New York: Random House.
Havik, O. E., & Maelands, J. G. (1990). Patterns of emotional
reactions after a myocardial infarction. Journal of Psychosomatic
Research, 34, 271-285.
Holahan, C. J., & Moos, R. H. (1987). Personal and contextual
determinants of coping strategies. Journal of Personality and Social
Psychology, 52, 946-955.
Holahan, C. J., & Moos, R. H. (1990). Life stressors, resistance factors,
and psychological health: An extension of the stress-resistance
paradigm. Journal of Personality and Social Psychology, 58, 909-917.
Holahan, C. J., & Moos, R. H. (1991). Life stressors, personal and
social resources, and depression: A 4-year structural model. Journal
of Abnormal Psychology, 100, 31-39.
Holahan, C. J., & Moos, R. H. (1994). Life stressors and mental
health: Advances in conceptualizing stress resistance. In W. R.
Avison & I. H. Gotlib (Eds.), Stress and mental health: Contemporary
issues and prospects for the future (pp. 213-238). New York: Plenum
Press.
Holahan, C. J., Moos, R. H., Holahan, C. K., & Brennan, P. L. (in
press). Depression in cardiac illness: The predictive roles of social
support and coping. Psychology and Health.
Jenkins, C. D., Jono, R. T., Stanton, B. A., & Stroup-Benham, C. A.
(1990). The measurement of health-related quality of life: Major
dimensions identified by factor analysis. Social Science and Medicine,
31, 925-931.
Joreskog, K. G., & Sorbom, D. (1989). LISREL 7: A guide to the
program and applications (2nd ed.). Chicago, IL: SPSS, Inc.
Kaplan, R. M. (1988). Health-related quality of life in cardiovascular
disease.. Journal of Consulting and Clinical Psychology, 56, 382-392.
Kaplan, R. M. (1990). Behavior as the central outcome in health care.
American Psychologist, 45, 1211-1220.
King, K. B., Reis, H. T., Porter, L. A., & Norsen, L. H. (1993). Social
support and long-term recovery from coronary artery surgery:
Effects on patients and spouses. Health Psychology, 12, 56-63.
Kitler, M. E. (1992). Differences in men and women in coronary artery
disease, systematic hypertension and their treatment. American
Journal of Cardiology, 70, 1077-1080.
Kolar, J. A., & Dracup, K. (1990). Psychosocial adjustment of patients
with ventricular dysrythmias. Journal of Cardiovascular Nursing, 4,
44-55.
Kulik, J. A., & Mahler, H. I. M. (1989). Social support and recovery
from surgery. Health Psychology, 8, 221-238.
Kushner, M. G., Thomas, A. M., Bartels, K. M., & Beitman, B. D.
(1992). Panic disorder history in the families of patients with
angiographically normal coronary arteries. American Journal of
Psychiatry, 149, 1563-1567.
Langeluddecke, P., Fulcher, G., Baird, D., Hughes, C., & Tennant, C.
(1989). A prospective evaluation of the psychosocial effects of
coronary artery bypass surgery. Journal of Psychosomatic Research,
33, 37-45.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New
York: Springer.
Levenson, J. L., Mishra, A., Hamer, R. M., & Hastillo, A. (1989).
Denial and medical outcome in unstable angina. Psychosomatic
Medicine, 51, 27-35.
Levine, J., Warrenburg, S., Kerns, R., Schwartz, G., Delaney, R.,
Fontana, A., Gradman, A., Smith, S., Allen, S., & Cascione, R.
(1987). The role of denial in recovery from coronary heart disease.
Psychosomatic Medicine, 49, 109-117.
Link, B., & Dohrenwend, B. P. (1980). Formulation of hypotheses
about the true prevalence of demoralization in the United States. In
B. P. Dohrenwend, M. S. Gould, B. Link, R. Neugebauer, & R.
Ulursch-Hitzig (Eds.), Mental illness in the United States: Epidemio-
logical estimates (pp. 133-149). New York: Praeger.
Magni, G., Unger, H. P., Valfre, C., Polesel, E., Cesari, F., Rizzardo,
R., Paruzzolo, P., & Gallucci, V. (1987). Psychosocial outcome one
year after heart surgery: A prospective study. Archives of Internal
Medicine, 147, 473-477.
Maynard, C., Litwin, P. E., Martin, J. S., & Weaver, W. D. (1992).
Gender differences in the treatment and outcome of acute myocar-
dial infarction: Results from the myocardial infarction triage and
intervention registry. Archives of Internal Medicine, 152, 972-976.
Mayou, R., & Bryant, B. (1987). Quality of life after coronary artery
surgery. Quarterly Journal of Medicine, 62, 239-248.
Moos, R. H. (1993). Coping Responses Inventory: Adult Form manual.
Odessa, FL: Psychological Assessment Resources.
Moos, R. H., Brennan, P. L., Fondacaro, M. R., & Moos, B. S. (1990).
Approach and avoidance coping responses among older problem
drinkers. Psychology and Aging, 5, 31-40.
Moos, R. H., Cronkite, R. C., & Finney, J. W. (1990). Health and Daily
Living Form manual (2nd ed.). Palo Alto, CA: Consulting Psycholo-
gists Press.
Moos, R. H., & Moos, B. S. (1994). Life Stressors and Social Resources
Inventory: Adult Form manual. Odessa, FL: Psychological Assess-
ment Resources.
Moos, R. H., & Schaefer, J. A. (1993). Coping resources and
processes: Current concepts and measures. In L. Goldberger & S.
Breznitz (Eds.), Handbook of stress: Theoretical and clinical aspects
(2nd ed., pp. 234-257). New York: Free Press.
Neill, W. A., Branch, L. G., DeJong, G., Smith, N. E., Hogan, C. A.,
Corcoran, P. J., Jette, A. M., Balasco, E. M., & Osberg, S. (1985).
Cardiac disability: The impact of coronary heart disease on patients'
daily activities. Archives of Internal Medicine, 145, 1642-1647.
Pearlin, L. I. (1989). The sociological study of stress. Journal of Health
and Social Behavior, 30, 241-256.
Peterson, L. (1989). Special series: Coping with medical illness and
medical procedures. Journal of Consulting and Clinical Psychology,
57, 331-332.
 DEPRESSIVE SYMPTOMS AND CARDIAC ILLNESS
Pierce, G. R., Sarason, I. G., & Sarason, B. R. (1991). General and
relationship-based perceptions of social support: Are two constructs
better than one? Journal of Personality and Social Psychology, 61,
1028-1039.
Roberts, R. W., Coombs, D. W., Whitlow, P., Wayne, J. B., Charles, E.
D., Bynum, K., Stanton, P., Crist, D., & Cabrera, C. (1986).
Psychosocial profile of patients following coronary artery bypass
graft surgery (CABGS). Journal of the American College of Cardiol-
ogy, 7, 41A.
Rook, K. S. (1984). The negative side of social interaction: Impact on
psychological well-being. Journal of Personality and Social Psychol-
ogy, 46, 1097-1108.
Scheier, M. F., Matthews, K. A., Owens, J. F., Magovern, G. J.,
Lefebvre, R. C., Abbott, R. A., & Carver, C. S. (1989). Dispositional
optimism and recovery from coronary artery bypass surgery: The
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
beneficial effects on physical and psychological well-being. Journal of
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Personality and Social Psychology, 57, 1024-1040.
Scherck, K. A. (1992). Coping with acute myocardial infarction. Heart
& Lung, 21, 327-334.
Schleifer, S., Macari-Hinson, M., Coyle, D., Slater, W., Kahn, M.,
Gorlin, R., & Zucker, H. (1989). The nature and course of
depression following myocardial infarction. Archives of Internal
Medicine, 149, 1785-1789.
Shumaker, S. A., & Czajkowski, S. M. (1993). A review of health-
related quality-of-life and psychosocial factors in women with
cardiovascular disease. Annals of Behavioral Medicine, 15, 149-155.
Sorenson, S. B., Rutter, C. M., & Aneshensel, C. S. (1991). Depression
in the community: An investigation into age of onset. Journal of
Consulting and Clinical Psychology, 59, 541-546.
Spitzer, R. L., Endicott, J., & Robins, E. (1978). Research diagnostic
criteria: Rationale and reliability. Archives of General Psychiatry, 25,
773-782.
Stokes, J. P., & McKirnan, D. J. (1989). Affect and social environment:
The role of social support in depression and anxiety. In P. C.
Kendall & D. Watson (Eds.), Anxiety and depression: Distinctive and
overlapping features (pp. 253-284). San Diego, CA: Academic Press.
Suls, J., & Fletcher, B. (1985). The relative efficacy of avoidant and
nonavoidant coping strategies: A meta-analysis. Health Psychology,
4, 249-288.
163
Thoits, P. A. (1986). Social support as coping assistance. Journal of
Consulting and Clinical Psychology, 54, 416-423.
Valentiner, D. P., Holahan, C. J., & Moos, R. H. (1994). Social
support, appraisals of event controllability, and coping: An integra-
tive model. Journal of Personality and Social Psychology, 66, 1094-
1102.
Verbrugge, L. M. (1985). Gender and health: An update on hypoth-
eses and evidence. Journal of Health and Social Behavior, 26,
156-182.
Vital and Health Statistics. (1986). Current estimates from the National
Health Survey: United States, 1985 (DHHS Publication No. 86-1588).
Washington, DC: U.S. Government Printing Office.
Vitaliano, P. P., Maiuro, R. D., & Russo, J. (1987). Raw versus relative
scores in the assessment of coping strategies. Journal of Behavioral
Medicine, 10, 1-19.
Waltz, M. (1986). Marital context and post-infarction quality of life: Is
it social support or something more? Social Science and Medicine, 22,
791-805.
Waltz, M., Badura, B., Pfaff, H., & Schott, T. (1988). Marriage and the
psychological consequences of a heart attack: A longitudinal study
of adaptation to chronic illness after 3 years. Social Science and
Medicine, 27, 149-158.
Wenger, N. K., Speroff, L., & Packard, B. (1993). Cardiovascular
health and disease in women. New England Journal of Medicine, 329,
247-256.
Wiklund, I., Sanne, H., Vedin, A., & Wilhelmsson, C. (1984). Psycho-
social outcome one year after a first myocardial infarction. Journal of
Psychosomatic Research, 28, 309-321.
Williams, P. G., Wiebe, D. J., & Smith, T. W. (1992). Coping processes
as mediators of the relationship between hardiness and health.
Journal of Behavioral Medicine, 15, 237-255.
Williams, R. B., Barefoot, J. C, Califf, R. M., Haney, T. L., Saunders,
W. B., Pryor, D. B., Hlatky, M. A., Siegler, I. C., & Mark, D. B.
(1992). Prognostic importance of social and economic resources
among medically treated patients with angiographically documented
coronary artery disease. Journal of the American Medical Association,
267, 520-524.