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J Nerv Ment Dis. Author manuscript; available in PMC 2022 May 01.
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Published in final edited form as:

J Nerv Ment Dis. 2021 May 01; 209(5): 370–377. doi:10.1097/NMD.0000000000001306.

Differential Association of Spirituality and Religiosity with

Rumination: Implications for the Treatment of Depression
David Saunders, MD PhD1,2,3, Connie Svob, PhD1,4, Lifang Pan, PhD4, Eyal Abraham, PhD4,
Jonathan Posner, MD1,2, Myrna Weissman, PhD1,4,5, Priya Wickramaratne, PhD1,4,5
1Columbia University College of Physicians and Surgeons, Department of Psychiatry; 1051
Riverside Drive, Unit 24, New York, NY, USA 10032
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2New York State Psychiatric Institute, Division of Child Psychiatry; 1051 Riverside Drive, New
York, NY 10032
3Yale Child Study Center; 230 South Frontage Road, New Haven, CT, 10620
4New York State Psychiatric Institute, Division of Translational Epidemiology; 1051 Riverside
Drive, Unit 24, New York, NY, USA 10032
5Mailman School of Public Health; 722 West 168th Street, New York, NY 10032

Introduction:
Rumination and depression are associated across a robust evidence base (Miranda and
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Nolen-Hoeksema, 2007; Monnart et al., 2016; Smith and Alloy, 2009). Emerging evidence
suggests that those who identify as spiritual have higher rates of depression, while those who
identify as religious have lower rates of depression (Braam and Koenig, 2019; Dein et al.,
2012; Goncąlves et al., 2015; Koenig, 2009; Seybold and Hill, 2001; Unterrainer et al.,
2014; Wong et al., 2006). Some authors have speculated that rumination might mediate the
association between spirituality and depression, an intriguing hypothesis given that
contemporary notions of spirituality tend to emphasize an internal and solitary search for
meaning, akin to the cognitive process of rumination, a psychopathologic hallmark of
depression (Vittengl, 2018). However, to our knowledge, the association between rumination
and religiosity/spirituality (R/S) with depression, has not been studied. Nor has the
combined or interacting effect of generation, which merits further study given increasing
rates of spirituality among young persons, especially Millennials (those born between 1981–
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1996; Lipka & Gecewicz, 2017). This study aims to fill those gaps in the literature. From a
clinical perspective, the material presented here might be of particular interest to cognitive-
behavioral and mindfulness-oriented therapists, given that these treatment modalities often
directly target rumination.

Corresponding Author: Priya Wickramaratne, Priya.Wickramaratne@nyspi.columbia.edu, Phone: 646-774-6427, Address: Columbia

University, Department of Psychiatry, 1051 Riverside Drive, Unit 24, New York NY USA 10032.
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Rumination: definition and depression

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Rumination refers to passively and repeatedly going over the same matter in one’s mind –
often negative thoughts and feelings (Treynor et al., 2003). It is often implicated in the onset
and development of depressive symptoms because individuals who ruminate can perpetuate
their depressive symptoms by thinking continuously about the causes, meanings, and
consequences of their negative mood (Nolen-Hoeksema, 2000; Nolen-Hoeksema et al.,
1993). Indeed, multiple studies have shown that when rumination predicts adverse clinical
outcomes (Miranda and Nolen-Hoeksema, 2007; Monnart et al., 2016). Specifically, Nolen-
Hoeksema and colleagues (1999) identified three different types of rumination – brooding,
reflection, and depression-related – which have been found to predict depressive symptoms,
with slightly different patterns of association (Nolen-Hoeksema et al., 1999). For example,
brooding is positively correlated with both current and long-term depressive symptoms
(Nolen-Hoeksema et al., 2008) while reflection is positively correlated with only current
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depression, and negatively correlated with depression in the long-term (Treynor et al., 2003).

Religiosity & Spirituality: definitions, demographics and depression

“Religiosity” and “spirituality” are multifaceted concepts that evade facile attempts to define
them (Seybold and Hill, 2001). Nevertheless, certain definitions have come to be used
widely in the literature. Religion involves beliefs, practices, and rituals that associate with
God and/or ultimate truth or reality (Koenig, 2009; Saucier and Skrzypińska, 2006). It is
thought to “arise out of a group of people with common beliefs and practices concerning the
sacred” (Koenig, 2009). In contrast, spirituality is typically considered more personal – “a
subjective experience of the sacred” (Vaughan, 1991). Koenig asserts that spirituality frees
one from “the rules, regulations, and responsibilities associated with religion”, and can be
understood entirely in individualistic and secular terms (2009). One key difference is thus
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that religiosity is more communal than spirituality (Greenfield et al., 2009; Hastings, 2016;
Saucier and Skrzypińska, 2006). Interestingly, according to the Pew Research Center,
spirituality is increasing, while religiosity is decreasing in the United States (Lipka and
Gecewicz, 2017). This is perhaps truest among Millennials – those born between 1980 and
1996 – as only 41% believe religion is very important, and only 27% attend religious
services weekly, both of which are significantly less than the four prior generations which
preceded them (Alper, 2015).

There is emerging evidence to suggest that spirituality is associated with worse depression
outcomes, while religiosity is associated with beneficial outcomes (King et al., 2013;
Vittengl, 2018). For example, Vittengl found that those who identify with spirituality more
than religiosity were more likely to be depressed (Vittengl, 2018). However, the mechanism
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underlying this association is not well understood. He speculates that different rumination
styles in spiritual versus religious individuals may explain their differing association with
depressive symptoms. Similarly, Currier and Eriksson (2017) argue that engagement in
religious communities – which the religious, but not spiritual are more likely to do, from
their perspective – could reduce self-focused, unproductive rumination, and therefore
depressive symptoms (Currier and Eriksson, 2017). Religiosity has often been considered a
social determinant of health and has been associate with positive social relationships and
overall well-being (Idler et al., 2017). The social support derived from communal religious

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gatherings, such as religious service attendance, has been inversely related to various forms
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of psychopathology, including depression (Braam and Koenig, 2019), suicidality

(VanderWeele et al., 2016) and substance abuse (Chen and VanderWeele, 2018). On the
other hand, some propose that spiritual practices (i.e., affirmation, meditation, exercise, and
art) may harness potentially protective aspects of rumination, facilitating the assimilation of
new information and helping to construct ways to understand the world, the self, and
relationships (Vis and Marie Boynton, 2008). Such internalized personal reflections may
help to provide meaning and purpose in times of suffering and provide a sense of hope, but
without a structured religious community framework, may also lead to recurring ruminative
cycles that become associated with depression. In any case, the role of rumination in the
association of religiosity/spirituality (R/S) and depression has yet to be empirically tested,
and remains unclear.

Objectives
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Using data derived from a 3-generation study in which both R/S and rumination are reported
(Weissman et al., 2016a, 2016b) – this study seeks to characterize the association between
religiosity, spirituality, rumination, and depression. Based on previous studies, we
hypothesize that: (1) religiosity and spirituality will be negatively and positively related to
depression, respectively; (2) rumination will be positively related to depression; and (3)
religiosity and spirituality will be negatively and positively associated with rumination.
Together, these hypotheses suggest that the potential effects of religiosity and spirituality on
depression may be mediated in part by rumination. Given the multi-generational sample, an
exploratory objective of this study is to examine the moderating effects of generation. See
Figure 1 for a schematic of the study hypotheses.

Methods:
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Sample and Study Design: The sample consisted of participants 18 or older drawn from
three generations of families: probands (1st generation, G1); their offspring (2nd generation,
G2); and G2’s offspring (3rd generation, G3). Probands (G1) were European Caucasians.
See Weissman, et al., 2016, and Weissman, Wickramaratne, et al., 2016 for details of the
study design. All participants provided written consent and all interviews were approved by
the Institutional Review Board at Columbia University.

At Time 1 (start of study) we had N=90 probands that constituted Generation 1 (G1) and
their respective spouses, as well as N=215 of their offspring, Generation 2 (G2), aged 6–24
years. Probands and their offspring (G1 and G2) were assessed at Years 10, 20, 25, 30, 35
and 40 years after the start of the study. Offspring (G2) who were under age 6 at the start of
the study were allowed to enter the study as they aged in (i.e., as they reached age 6).
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Similarly, as the study continued, the grandchildren (Generation 3; G3) of the probands (G1)
were also eligible to participate in the study as they reached the age of 6, resulting in a
staggered entry into the study.

The relevant assessments for the present study are Years 30, 35, and 40 and include
Generations 2 and 3 (G1s were excluded as they were the defining generation for risk status
– i.e., high vs. low risk for major depressive disorder). Because Religious/Spiritual (R/S)

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Identity and Rumination assessments were collected only at Year 35, assessments at Year 35
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were used for the cross-sectional analyses. For the longitudinal analysis, assessments at
Years 30 and 40 were used as baseline and follow-up assessments, respectively. That is, R/S
Identity and Rumination at Year 35 served as predictors of depression at Year 40. We’ve
included the Ns by Generation for each of the assessment timepoints in Table 1 (see below).

Measures
Depression status was assessed at years 35 and 40 by PHQ-9 total score, a canonical
measure of depressive symptoms over the past two weeks (Kroenke et al., 2009). At year 40
depression was also assessed by MDD diagnosis in the five year interval between years 35
and 40, as measured by the Schedule for Affective Disorders and Schizophrenia (SADS-L;
23).

Religiosity and spirituality were measured by a categorical, self-report variable, with four
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choices: “I am spiritual and religious”, “I am spiritual but not religious”, “I am religious but
not spiritual”, “I am neither spiritual nor religious.” This four category variable was then re-
parameterized as two separate but non-mutually exclusive binary variables (spirituality and
religiosity), such that participants who identified as “spiritual and religious” or “spiritual but
not religious” were characterized as “spiritual with or without religiosity (hereafter,
“spiritual” or “spirituality”). All others were categorized as “not spiritual”. Participants who
identified as “spiritual and religious” or “religious but not spiritual” were categorized as
“religiosity with or without spirituality”, (hereafter, “religious” or “religiosity”). All others
were categorized as “not religious”. These classifications allow one to determine if
rumination and depression are differentially associated with spirituality versus religiosity.

Rumination was assessed at year 35 by the Ruminative Responses Scale (RRS), a

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standardized and validated assessment of rumination (Nolen-Hoeksema, 1991). Multiple

numerical variables from the RRS, including three subscales of rumination – brooding,
reflection, and depression – and rumination total were used in the analysis. Scores were
calculated based on the mean score of corresponding RRS items, with scores ranging
between 1–4, with 1 being “almost never” and 4 being “almost always”.

See Table 2 for a matrix of cross-sectional correlations among the variables used in
hypothesis testing at year 35 analyses.

Analysis
To accurately reflect the original study design all analyses were adjusted for risk status and
generation when analyzing the total sample. In addition, age and sex were considered a
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priori confounding variables and were included in all statistical models. Married-in
participants and G1 individuals, who defined risk level at the study’s beginning, were
excluded from analyses. Group differences in demographic characteristics across each
generations (G2, and G3) were examined. Analysis consisted of Kruskal-Wallis chi-square
tests (for gender and religious affiliation) and two sample t-tests (for age). With a total
sample size of 215 the study had 80 % power to detect a correlation coefficient of 0.19,
which is considered a small correlation. However, our analyses did not consist of merely

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testing correlation coefficients. Since this was an observational study, and we included
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several potential confounding variables in the regression analyses, we expect that the power
is less than 80 % (Hulley et al., 2013).

Cross-sectional Analysis: We first examined cross-sectionally at year 35 1) the

association between depression (PHQ9 scores) with both religiosity and spirituality
simultaneously in a linear regression model with PHQ9 as the dependent variable, and both
R/S as independent variables, while adjusting for potentially confounding demographic
variables as covariates. 2) We then examined the association between PHQ9 scores and each
of the rumination subscales. Four separate linear regressions with the PHQ9 score as the
dependent variable were performed, with brooding, reflection, (rumination) depression, and
rumination total scores, in turn, as the independent variable. 3) Models containing both R/S
as independent variables and rumination as the dependent variable were then examined to
assess whether R/S were both associated simultaneously with rumination. If religiosity in the
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presence of spirituality was found to be significantly associated with rumination and vice
versa, then we can conclude that both spirituality adjusted for religiosity, and religiosity
adjusted for spirituality had independent effects on rumination. All models were adjusted for
potential confounding variables of age, generation, gender and risk status.

Longitudinal Analysis: A similar approach was used to examine the association between
R/S and PHQ9 scores, and rumination and PHQ9 scores for the longitudinal analysis, the
only difference being that we included PHQ9 scores at year 35 as a covariate, so that the
directionality of the association could be more clearly modeled. To examine the association
between R/S and MDD, and rumination and MDD respectively, we performed logistic
regression analyses with MDD as the dependent binary variable, and religion and spirituality
included simultaneously as the independent variables, respectively, while controlling for
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potential confounding variables as well at year 30 MDD (“baseline” depression ). Similar

analyses were performed to examine the association between MDD and each of the four
rumination scales.

Exploratory Analysis: The moderating effect of generation was explored by first

repeating these analyses stratified by generation and subsequently conducting formal tests of
interaction between generation and the relevant independent variables. All analyses applied a
generalized estimating equations approach by means of the GENMOD procedure in the SAS
software package, so as to estimate parameters while adjusting for potential non-
independence of outcomes for off-spring from the same family.

Results:
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Demographics:
At year 35, data were collected from 215 participants with mean age (SD) of 40.5 (14) and
59.5% identifying as female. Forty-six percent drew from G3, or the “Millennial”
generation, with mean age of 27.3 (5.9) and 58% being female. At year 40, data were
collected from 187 participants, with mean age 42.7 (14.2) and 58.29% female. Forty-six
percent were Millennials, with 58% being female.

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Descriptive Statistics:
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Mean scores (SD) of rumination total and all three rumination subscales on the Rumination
Response Scale collected at year 35 are displayed in Table 3. Significantly different
distributions were observed across generations (p values between <0.002 and 0.043).
Assessment of religiosity/spirituality at year 35, also displayed in Table 3, showed that
73.7% of participants identified as spiritual, and 46% identified as religious, with no
statistically significant difference between generation.

Full Sample Analyses:

Rumination and Depression—Table 4a displays results from cross-sectional and
longitudinal analyses of the full sample, with depression (measured by PHQ9) as the
dependent variable, and rumination and its subscales as independent variables. In the cross-
sectional analyses of rumination and depression, rumination total and all subscales were
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significantly positively associated with depression (p < 0.001) after controlling for age,
gender, and risk group. These results were replicated in the longitudinal analyses, save for
rumination reflection was not significantly associated with depression. Table 5 displays full
sample longitudinal associations of the rumination and its subscales with MDD diagnosis (in
lieu of PHQ9 score) within the full sample. Rumination and all three subscales were
associated with MDD diagnosis (p < 0.004), similar to the cross-sectional and longitudinal
analyses with PHQ9 as the dependent variable.

Religiosity/Spirituality and Depression—Table 4b displays cross-sectional and

longitudinal analyses of the full sample, with depression (PHQ9) as dependent variable, and
religiosity and spirituality as independent variables. In the cross-sectional analysis, neither
religiosity or spirituality were significantly associated with PHQ9. Longitudinally,
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religiosity predicted a significant reduction in PHQ9 scores (p = 0.045), while spirituality

was not significantly associated with PHQ9 score. Table 5 shows that, in contrast to PHQ9,
neither religiosity nor spirituality were associated with MDD.

Religiosity/Spirituality and Rumination—Table 6 displays results from a cross-

sectional analysis in which religiosity and spirituality are included simultaneously as
independent variables, and rumination (and its subscales) are dependent variables.
Spirituality was significantly associated with reflection and rumination total (p = 0.025 and
0.058, respectively), and marginally associated with brooding (p = 0.073) while religiosity
was not significantly associated with any rumination subscale.

Exploratory Analysis: Generation Effects

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Rumination and Depression—In the cross-sectional analysis, all rumination subscales

were significantly associated with depression as measured by PHQ9 for both G2 and G3 (not
displayed). In the longitudinal analysis, no rumination subscales were associated with PHQ9
score in G3, while two were significantly associated with PHQ9 score in G2 (rumination
total and rumination depression, p = 0.012 and 0.003, respectively; Table 7). All rumination
subscales in both generations were significantly associated longitudinally with MDD
diagnosis in both G2 and G3 (Table 7), with the exception of G2 reflection, which was
marginally significant (p=0.064).

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Religiosity/Spirituality and Depression—In both cross-sectional and longitudinal

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analysis, neither religiosity nor spirituality was significantly associated with either PHQ9 or
MDD diagnosis in either generation. However, religiosity and spirituality were associated
with PHQ9 scores and MDD in opposite directions in G3 (Table 8) and a test of difference in
direction/magnitude between the beta coefficients for religiosity and spirituality was found
to be marginally significant (p = .062).

Religiosity/Spirituality and Rumination: Table 9 displays the cross-sectional

association of religiosity and spirituality with rumination, stratified by generation. Among
G3 – that is, Millennials – spirituality was either significantly or marginally associated with
all rumination subscales; brooding was most significant (p = 0.027), with depression,
reflection and total displaying marginal significance. In contrast, religiosity was not
associated with rumination or its subscales in G3. In G2, no significant associations were
found, though religiosity was marginally associated with brooding, and spirituality was
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marginally associated with reflection.

Of note, formal tests of interaction to determine if generation moderated the associations

observed in the full sample failed to reach significance.

Discussion
Primary Analysis
The first hypothesis, that spirituality and religiosity will be positively and negatively
associated with depression, respectively, was partially supported by the data. Specifically,
religiosity was marginally associated with lower PHQ9 scores in the longitudinal analysis
(standardized beta = −0.3, p=0.045), which is consistent with the emerging literature on
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the inverse association between religiosity and depression. However, the cross-sectional
analysis did not reach significance, nor did spirituality and depression in either cross-
sectional or longitudinal analyses, probably due to lack of power.

The second hypothesis, that rumination would be positively associated with depressive
symptoms, was supported in both the cross-sectional and longitudinal analyses, and
consistent with the literature across several decades of research. The lone exception was
rumination reflection, which was not predictive of depressive symptoms at follow-up.
Interestingly, this is consistent with the literature which suggests that reflection predicts
depressive symptoms in the short term, but not over time, suggesting that reflective
rumination is less foreboding in the long-term than brooding and depressive rumination.
These findings extend the well-established association between rumination and depression
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into a novel sample, and justify continued clinical efforts at addressing ruminative
tendencies in the treatment of depression in psychotherapeutic interventions such as
cognitive-behavioral and mindfulness-based therapies.

The most novel contribution of the paper pertains to hypothesis three, in that spirituality was
found to be positively associated with rumination, including two of three subscales. The
findings suggest that the association between spirituality and depression that others have
found is partially explained by increased rumination in those who are spiritual. While

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significant associations between spirituality or religiosity and depression was not observed
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in this sample, the patterns of association are present, but the study appeared to be
insufficiently powered. Notably, the data support Vittengl (2018), who proposed that
increased rumination in spiritual individuals might moderate increases in depressive
symptoms among those who identify as more spiritual than religious. To our knowledge, we
are the first group to empirically demonstrate an association between spirituality and
rumination.

Exploratory Analysis: Generation Effects

The data suggest that the respective associations of religiosity and spirituality with
depression are more pronounced among Millennials than in G2 (Table 8). Given decreasing
rates of religiosity among Millennials (Alper, 2015), this finding leads to several intriguing
questions. If religiosity might benefit mood, and spirituality might not, why are young
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people becoming less religious? And why are the effects of religiosity and spirituality more
pronounced in Millennials than other generations? Interestingly, the proportion of religious
and spiritual individuals are almost identical across generations (see Table 3), meaning that
the terms “spiritual” and “religious” might be interpreted differently across generations.
Alternatively, if the terms are interpreted in the same way across generations, perhaps recent
historical stressors uniquely impacted Millennials more than other generations – i.e., the
financial crisis of 2008 – thus widening the gap between Millennials who are protected from
depression via religiosity, and those who are less protected via spirituality. In any case,
multi-disciplinary investigation is necessary to more fully understand these results, from
religious studies and anthropology, to sociology and the health sciences.

In terms of rumination and depression, despite the fact that Millennials have higher scores
on all rumination subscales than G2 (Table 3), the well-established association between
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rumination and depression does not hold in Millennials, whereas it held in two of four
rumination subscales in G2. Additionally, in data not presented in this paper, we found that
Millennial women and men in this sample are equally likely to ruminate, contradicting the
literature (Johnson and Whisman, 2013) – and in contrast to our G2 data – which shows that
women ruminate more than men.

Together, these exploratory analyses suggest that patterns of rumination might vary based on
generation. One interpretation for the lack of association between rumination and depression
in Millennials, and equivalent rates of rumination among men and women, might be that
rumination is ubiquitous in Millennials (G3), so an association with depressive symptoms, if
one exists, is more difficult to detect. These discrepancies of generation and gender might
suggest that there is something unique to Millennials that disrupts the otherwise tight and
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longstanding associations between rumination and depression. Alternatively, it is possible

that social (or other) changes have reversed the rumination-depression association.

Finally, not only do spiritual people ruminate more than religious people, but spiritual
Millennials ruminate more than anyone else. Additionally, the rumination gap, as it were,
between religious and spiritual individuals is greater in Millennials than it is in G2, raising
the possibility that the difference between religious and spiritual individuals in Millennials
might hinge on ruminative tendencies far more than in other generations.

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These findings merit further study from clinical and mechanistic perspectives. One might
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study whether targeting rumination in CBT or mindfulness-based therapies is as, more, or

less effective in Millennials than other generations; or investigate mechanistically how
rumination is transmitted across generations, including genetic, environmental, and/or other
means, given that the youngest generation (Millennials) ruminates the most.

There were several limitations. First, the original probands were selected from an
ambulatory depression clinic (the Yale Depression Research Unit, in New Haven,
Connecticut) and may not be generalizable to community samples. Furthermore, the sample
was almost exclusively Christian, and of Italian descent, thus further reducing
generalizability. Additionally, since the number of religious-only participants was much
smaller than that of spiritual-only participants, the religiosity category is dominated by those
who report that they are both religious and spiritual. Mitigating this concern, the distribution
of the four R/S categories was identical in both generations. Finally, there were 13.0% fewer
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participants at year 40 than 35. However, as displayed in Table 3, demographics of

participants assessed at years 35 and 40 are relatively similar, with the only significant
change being the sample is older at year 40 than year 35, which is to be expected.

Furthermore, limitations in measurement are apparent. Specifically, all variables were

measured via self-report items or questionnaires which can result in reporting biases.
Additionally, a better tool than the PHQ-9 could be used to assess for depression, especially
given that it is specifically designed for use in primary care settings, and to assess only
current symptoms of depression. Although the PHQ-9 has been validated for use in clinical
practice (Kroenke et al., 2001; Löwe et al., 2004; Watnick et al., 2005), it has not been
validated for use as a screening instrument for depression in non-clinical populations
(Adewuya et al., 2006). Additionally, the PHQ9 is an assessment tool for depressive
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symptoms from the past two weeks, a relatively short amount of time if seeking to
understand depressive history. However, in order to compare cross-sectional results with
longitudinal results it was logical to use the same outcome measure for each of the analyses.
We addressed this issue in two ways. First, at year 40 we also collected data on MDD
diagnosis over the past five years. The associations between religiosity, spirituality,
rumination and PHQ9 were not significantly different from their associations with MDD
diagnosis – in fact they are almost identical across the full sample; we elected to present
PHQ9 rather than MDD diagnosis to facilitate comparisons between cross-sectional and
longitudinal analyses and because the former is a continuous variable, and thus more capable
of generating a statistically significant effect. Additionally, in the longitudinal analysis, we
controlled for PHQ9 baseline scores at year 35, thus mitigating some of the risk inherent in
assessing for long-term history of depressive symptoms with a short-term questionnaire.
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Finally, religiosity and spirituality are difficult to define and multi-dimensional terms with
complex histories, and mean different things to different people; thus, any study seeking to
empirically investigate these phenomena should be interpreted with caution. As the field
advances, and religiosity and spirituality become more consistently defined and
operationalized, with more objective measures, the data will become increasingly reliable,
replicable, and valid.

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Conclusion:
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This study is the first to demonstrate that spirituality is associated with rumination, and
religiosity is not, and that the association is strongest among Millennials. These findings
further support psychotherapeutic strategies that target rumination, such as CBT and
mindfulness-based interventions, especially among those who identify as spiritual, perhaps
especially Millennials.

Acknowledgments:
We would like to thank Ziqi Wu, as some of the work in this manuscript was based on her Master’s Thesis. This
work was supported by grant funding from The John Templeton Foundation (#54679 and #61330, PI: Weissman)
and the National Institutes of Mental Health (R01MH36197, Co-PIs: Weissman and Posner).

Disclosures:
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Drs. Saunders, Svob, Pan, Abraham, and Wickramaratne have no conflicts of interest to disclose. Dr. Posner has
received research support from Takeda (formerly Shire) and Aevi Genomics and consultancy fees from Innovative
Science. Dr. Weissman has in the past three years received funding from the Sackler Foundation, and the John
Templeton Foundation, and receives royalties from the Oxford University Press, Perseus Press, the American
Psychiatric Association Press, and MultiHealth Systems; none of these pose conflicts of interest.

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Figure 1: Schematic of Study Hypotheses

Figure 1 displays a schematic of the three study hypotheses: 1) spirituality and religiosity are
positively and negatively associated with depression, respectively; 2) rumination predicts
depression; and 3) spirituality and religiosity are positively and negatively associated with
rumination, respectively.
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Table 1.

Schedule of Assessments and Sample Size by Timepoint

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Year 30 Year 35 Year 40

Assessment
G2 G3 G2 G3 G2 G3

Major Depressive Disorder (SADS) 116 99 112 93

Depressive Symptoms (PHQ-9) 116 99 92 86
Rumination (RRS) 116 99
Religious/Spiritual Identity 114 99

Abbrev: G – Generation; SADS - Schedule of Affective Disorders Scale; PHQ-9 – Patient Health Questionnaire 9; RRS – Ruminative Response
Scale
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Table 2:

Pearson Correlation Matrix for Cross-Sectional Variables

Religiosity Spirituality R-Depression R-Reflection R-Brooding R-Total PHQ Total

Religiosity 1.000
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Spirituality 0.209** 1.000

R-Depression −0.045 0.068 1.000

R-Reflection −0.012 0.118 0.791*** 1.000

R-Brooding 0.064 0.107 0.852*** 0.758*** 1.000

R-Total −0.012 0.095 0.975*** 0.883*** 0.921*** 1.000

PHQ Total −0.042 0.039 0.769*** 0.558*** 0.624*** 0.729*** 1.000

1.
There were 2 missing values in variables Religiosity and Spirituality
2.*
p≤0.05, **p≤0.01, ***p≤0.001
3.
Abbrev: R – Rumination; PHQ – Patient Health Questionnaire

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Table 3.

Rumination Scores (RRS), and Percent of Participants Identifying as Spiritual/Religious by Generation

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Variable Total (n=215) G2 (n=116) G3 (n=99) T value P value

R-Depression 1.81 1.73 1.92 −2.04 0.043

SD 0.69 0.64 0.74
R-Reflection 1.77 1.63 1.92 −3.09 0.002
SD 0.70 0.63 0.74
R-Brooding 1.96 1.86 2.08 −2.16 0.032
SD 0.76 0.72 0.79
R-Total 1.84 1.73 1.96 −2.45 0.015
SD 0.67 0.61 0.71

Variable Total (n=215) G2 (n=116) G3 (n=99) z score P value

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Religiosity 98 50 48 0.45 0.49

% 46 43.9 48.5
Spirituality 157 85 72 0.09 0.76
% 73.7 74.6 72.7

1.
The t-tests and z-score tests are to comparing means between generation 2 and 3
2.
Abbrev: R – Rumination; SD – Standard Deviation; G – Generation
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Table 4.

Cross-Sectional and Longitudinal Association of Rumination (RRS) and Religiosity/Spirituality with Depression (PHQ9)

A. Rumination (RRS) with Depression (PHQ9)

Cross-Sectional Longitudinal
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Scale CI CI
Beta Beta
n Beta (95%) P-value n Beta (95%) P-value
(std) (std)
(std) (std)

R-Depression 215 5.72 0.78 [ 0.69, 0.86] < 0.001 178 3.76 0.54 [ 0.41, 0.66] < 0.001
R-Reflection 215 4.09 0.56 [0.44, 0.68] < 0.001 178 2.84 0.4 [ 0.27, 0.54] < 0.001
R-Brooding 215 4.22 0.62 [ 0.52, 0.73] < 0.001 178 3.04 0.47 [ 0.34, 0.61] < 0.001
R-Total 215 5.68 0.74 [ 0.65, 0.84] < 0.001 178 3.85 0.53 [ 0.40, 0.66] < 0.001

B. Religiosity and Spirituality with Depression (PHQ9)

Religiosity −0.42 −0.08 [−0.36, 0.19] 0.5518 −1.46 −0.3 [−0.58, −0.01] 0.045**
213 176
Spirituality 0.70 0.14 [−0.17, 0.45] 0.3849 0.95 0.19 [−0.14, 0.52] 0.255

1.
** - p < 0.05
2.
Abbrev: R – rumination; CI – Confidence Interval; std – Standardized; PHQ9 – Patient Health Questionnaire – 9; RRS – Ruminative Response Style

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Table 5:

Longitudinal Association of Rumination (RRS) and Religiosity/Spirituality with MDD Diagnosis

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Scale N Beta OR CI (95%) Chi-sq p-value

R-Depression 1.12 3.08 [1.67, 5.66] 13.01 < 0.001***

R-Reflection 0.83 2.30 [1.30, 4.09] 8.12 0.004**

170
R-Brooding 0.91 2.50 [1.46, 4.27] 11.16 0.001**

R-Total 1.18 3.26 [1.72, 6.18] 13.07 < 0.001***

Religiosity −0.39 0.68 [0.31, 1.48] 0.96 0.326

168
Spirituality 0.19 1.21 [0.49, 2.96] 0.17 0.677

1.
Controlled for gender, risk status, generation, age at wave 6.5 and baseline MDD year 30 (MDD not assessed at year 35)
2.
Independent variable data collected at year 35, MDD diagnosis assessed at year 40
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3.
* p≤0.05, **p≤0.01, ***p≤0.001
4.
Abbrev: R – Rumination; CI – Confidence Interval; OR – Odds Ratio; RRS – Ruminative Response Style
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Table 6.

Cross-Sectional Association of Religiosity and Spirituality with Rumination (RRS)

Predictors Religiosity Spirituality

Outcome n Beta Beta (std) CI (95%) (std) P-value Beta Beta (std) CI (95%) (std) P-value
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R-depression 213 −0.05 −0.04 [−0.17, 0.10] 0.583 0.17 0.11 [−0.03, 0.24] 0.119
R-reflection 213 −0.03 −0.02 [−0.15, 0.11] 0.760 0.24 0.15 [0.02, 0.29] 0.025
R-brooding 213 0.10 0.07 [−0.06, 0.20] 0.315 0.21 0.12 [−0.01, 0.26] 0.073
R-total 213 −0.01 −0.01 [−0.14, 0.12] 0.896 0.20 0.13 [0.00, 0.26] 0.058

1.
Controlled for age, gender, generation and risk status
2.
N = 215
3.
Abbrev: R – rumination; CI – Confidence Interval; std – Standardized; RRS – Ruminative Responses Style

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Table 7:

Longitudinal Association of Rumination (RRS) with Depression Outcomes by Generation

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A. Rumination and Depression as Measured by PHQ9

Generation Scale Estimate Standard Error t-value P-value

R-Depression 2.47 0.80 3.10 0.003**

R-Reflection 0.86 0.65 1.32 0.191
G2
(N=92) R-Brooding 0.94 0.61 1.55 0.125

R-Total 2.09 0.81 2.57 0.012*

R-Depression 0.89 1.07 0.84 0.406

G3 R-Reflection 0.65 0.86 0.76 0.452

(N=86) R-Brooding 1.32 0.81 1.62 0.108
R-Total 1.18 1.04 1.13 0.263
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Rumination data collected at year 35; PHQ9 score collected at year 40; adjusted for age, gender, risk, and baseline PHQ9 score year
35

B. Rumination and Depression as Measured by MDD Diagnosis

Generation Scale Estimate OR CI (95%) Chi Sq P-value

R-Depression 1.79 6.00 [0.65, 2.94] 9.42 0.002**

R-Reflection 0.96 2.61 [−0.06, 1.98] 3.43 0.064
G2
(N=88) R-Brooding 1.26 3.51 [0.31, 2.20] 6.78 0.009**

R-Total 1.84 6.30 [0.64, 3.05] 8.97 0.003**

R-Depression 0.85 2.35 [0.11, 1.59] 5.08 0.024*

G3
R-Reflection 0.81 2.24 [0.09, 1.53] 4.80 0.028*
(N=82)
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R-Brooding 0.76 2.14 [0.08, 1.44] 4.76 0.029*

R-Total 0.93 2.53 [0.15, 1.70] 5.50 0.019*

1.
Rumination data collected at year 35; MDD diagnosis collected at year 40; adjusted for age, gender, risk and baseline MDD year 30
2.*
p≤0.05, **p≤0.01, ***p≤0.001
3.
Abbrev: R – Rumination; G – Generation; CI – Confidence Interval; OR – Odds Ratio; PHQ9 – Patient Health Questionnaire 9; MDD – Major
Depressive Disorder
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Table 8:

Longitudinal Association of Religiosity/Spirituality with Depression (PHQ9) by Generation

G2 (N=90) G3 (N=86)
Scale Beta CI (95%) Beta CI (95%)
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Beta P-value Beta P-value

(std) (std) (std) (std)

Religiosity −0.62 −0.15 [−0.57, 0.26] 0.467 −1.85 −0.33 [−0.76, 0.09] 0.131
Spirituality 0.22 0.05 [−0.40, 0.51] 0.817 1.98 0.35 [−0.14, 0.85] 0.168

1.
Controlled for age, gender and risk status
2.
Abbrev: G – Generation; CI – Confidence Interval; std – Standardized

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Table 9.

Cross-Sectional Association of Religiosity/Spirituality with Rumination (RRS) by Generation

Predictors

Sample Outcome Religiosity Spirituality

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Beta Beta (std) CI (95%) (std) P-value Beta Beta (std) CI (95%) (std) P-value

R-depression 0.08 0.06 [−0.13, 0.25] 0.532 0.11 0.08 [−0.11, 0.26] 0.423
R-reflection 0.06 0.05 [−0.14, 0.24] 0.609 0.23 0.16 [−0.02, 0.34] 0.085
G2*
(N=116) R-brooding 0.23 0.16 [−0.02, 0.35] 0.085 0.07 0.04 [−0.13, 0.22] 0.626
R-total 0.11 0.09 [−0.10, 0.27] 0.345 0.13 0.09 [−0.09, 0.27] 0.312

R-depression −0.16 −0.11 [−0.31, 0.09] 0.296 0.27 0.16 [−0.04, 0.37] 0.114

G3 R-reflection −0.09 −0.06 [−0.27, 0.14] 0.540 0.27 0.17 [−0.04, 0.37] 0.119
(N=99) R-brooding 0.02 0.01 [−0.19, 0.21] 0.898 0.41 0.23 [0.03, 0.43] 0.027
R-total −0.10 −0.07 [−0.27, 0.13] 0.475 0.31 0.19 [−0.01, 0.39] 0.067

1.
*114 subjects applied in this sample, given 2 missing values
2.
Controlled for age, gender and risk status
3.
N = 215
4.
Abbrev: R – rumination; G – Generation; CI – Confidence Interval; std – Standardized

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