Cognitive reactivity, self-depressed associations, and the recurrence of depression

Understanding and predicting future relapse in depression from resting state functional connectivity and self-referential processing

BACKGROUND

The recurrent nature of Major Depressive Disorder (MDD) asks for a better understanding of mechanisms underlying relapse. Previously, self-referential processing abnormalities have been linked to vulnerability for relapse. We investigated whether abnormalities in self-referential cognitions and functioning of associated brain-networks persist upon remission and predict relapse.

METHODS

Remitted recurrent MDD patients (n = 48) and never-depressed controls (n = 23) underwent resting-state fMRI scanning at baseline and were additionally assessed for their implicit depressed self-associations and ruminative behaviour. A template-based dual regression approach was used to investigate between-group differences in default mode, cingulo-opercular and frontoparietal network resting-state functional connectivity (RSFC). Additional prediction of relapse status at 18-month follow-up was investigated within patients using both regression analyses and machine learning classifiers.

RESULTS

Remitted patients showed higher rumination, but no implicit depressed self-associations or RSFC abnormalities were observed between patients and controls. Nevertheless, relapse was related to i) baseline RSFC between the ventral default mode network and the precuneus, dorsomedial frontal gyrus, and inferior occipital lobe, ii) implicit self-associations, and iii) uncontrollability of ruminative thinking, when controlled for depressive symptomatology. Moreover, preliminary machine learning classifiers demonstrated that RSFC within the investigated networks predicted relapse on an individual basis.

CONCLUSIONS

Remitted MDD patients seem to be commonly characterized by abnormal rumination, but not by implicit self-associations or abnormalities in relevant brain networks. Nevertheless, relapse was predicted by self-related cognitions and default mode RSFC during remission, suggesting that variations in self-relevant processing play a role in the complex dynamics associated with the vulnerability to developing recurrent depressive episodes.

CLINICAL TRIAL REGISTRATION

Netherlands Trial Register, August 18, 2015, trial number NL53205.042.15.

Factors associated with relapse and recurrence of major depressive disorder in patients starting mindfulness-based cognitive therapy

BACKGROUND

Mindfulness-based cognitive therapy (MBCT) is effective for relapse prevention in major depressive disorder (MDD). It reduces cognitive reactivity (CR) and rumination, and enhances self-compassion and mindfulness. Although rumination and mindfulness after MBCT are associated with relapse, the association of CR, rumination, self-compassion, and mindfulness with relapse before initiation of MBCT has never been investigated.

METHODS

Data were drawn from two randomized controlled trials, including a total of 282 remitted MDD participants (≥3 depressive episodes) who had been using maintenance antidepressant medication (mADM) for at least 6 months before baseline. All participants were offered MBCT while either their mADM was maintained or discontinued after MBCT. CR, rumination, self-compassion, and mindfulness were assessed at baseline by self-rated questionnaires and were used in Cox proportional hazards regression models to investigate their association with relapse.

RESULTS

CR and mindfulness were associated with relapse, independent of residual symptoms, previous depressive episodes, and mADM-use. Higher CR and lower mindfulness increased the risk of relapse. Self-compassion was not associated with relapse. For rumination, a significant interaction with mADM-use was found. Rumination was associated with relapse in patients who discontinued their mADM, while this effect was absent if patients continued mADM.

CONCLUSIONS

These results show that CR, rumination, and mindfulness are associated with relapse in remitted MDD-patients before initiation of MBCT, independent of residual symptoms and previous depressive episodes. This information could improve decisions in treatment planning in remitted individuals with a history of depression.

The neuroprogressive nature of major depressive disorder: evidence from an intrinsic connectome analysis

Major depressive disorder (MDD) is a prevailing chronic mental disorder with lifetime recurring episodes. Recurrent depression (RD) has been reported to be associated with greater severity of depression, higher relapse rate and prominent functioning impairments than first-episode depression (FED), suggesting the progressive nature of depression. However, there is still little evidence regarding brain functional connectome. In this study, 95 medication-free MDD patients (35 with FED and 60 with RD) and 111 matched healthy controls (HCs) underwent resting-state functional magnetic resonance imaging (fMRI) scanning. After six months of treatment with paroxetine, 56 patients achieved clinical remission and finished their second scan. Network-based statistics analysis was used to explore the changes in functional connectivity. The results revealed that, compared with HCs, patients with FED exhibited hypoconnectivity in the somatomotor, default mode and dorsal attention networks, and RD exhibited hyperconnectivity in the somatomotor, salience, executive control, default mode and dorsal attention networks, as well as within and between salience and executive control networks. Moreover, the disrupted components in patients with current MDD did not change significantly when the patients achieved remission after treatment, and sub-hyperconnectivity and sub-hypoconnectivity were still found in those with remitted RD. Additionally, the hypoconnectivity in FED and hyperconnectivity in RD were associated with the number of episodes and total illness duration. This study provides initial evidence supporting that impairment of intrinsic functional connectivity across the course of depression is a progressive process.

Cognitive reactivity among high-risk individuals at the first and recurrent episode of depression symptomology: A structural equation modelling analysis

Understanding the particular mechanisms by which vulnerability and capability factors influence cognitive reactivity (CR) can contribute to an enhanced capacity to adequately react to depression. However, few studies have explored the CR model. The main aim of the present study was to develop a model that specifies the predictive effects of CR for depression among individuals at high risk for first-episode and recurrent depression. A national cross-sectional, online study using convenience sampling was conducted among 587 vulnerable healthy individuals and 224 depressed patients in China. A battery of indices, including measures of CR, social support, resilience, self-compassion, life events, neuroticism, sleep condition, and negative emotion, were collected. A structural equation model was applied to analyse the data. The final first-episode and recurrent depressive symptoms of the CR models showed good model fit. According to the models, 45%-52% of the variance in depressive symptom was predicted by CR. Social support, self-compassion, resilience, and positive life events directly influenced CR, with β values ranging from -0.18 to -0.24 (P < 0.01). Neuroticism, negative emotion, poor sleep conditions, and negative life events also directly and positively influenced CR (P < 0.01). The relationship between these negative or positive contributing factors and depression was also indirectly influenced by CR (P < 0.01). Our findings demonstrate the role of CR in the prevention and treatment of depression. The first-episode and recurrent depressive symptoms of the CR models considering both vulnerabilities and capabilities of CR in the psychopathology of depression provide a theoretical basis for interventions that reduce CR in high-risk populations.

Factors influencing cognitive reactivity among young adults at high risk for depression in China: a cross-sectional study

Background

Understanding the factors influencing cognitive reactivity (CR) may help identify individuals at risk for first episode depression and relapse and facilitate routine access to preventative treatments. However, few studies have examined the relationship between CR and depression in Asian countries. This study was performed to assess the current status of CR among Chinese young adults and explore influencing factors.

Methods

A national cross-sectional online study using convenience sampling was conducted among 1597 healthy young adults in China (response rate: 93.94%) with a mean age of 24.34 (SD = 5.76) years.

Results

The mean CR score was 51.36 ± 18.97 (range 0–130). Binary logistic regression showed that a low level of CR was associated with the following factors: high self-compassion, high social support, high resilience, high monthly household income, and living in a rural area, with odds ratios (ORs) ranging from 0.14 to 0.70. Young adults in full-time employment, experiencing poor sleep, with high neuroticism, who reported frequent sad mood, and who had a high intensity of negative life events had increased CR to depression, with ORs ranging from 1.18 to 6.66. The prediction probability of these factors was 75.40%. Causal relationships among the influencing factors and CR could not be explored.

Conclusions

The self-reported CR levels among Chinese young adults were moderate. Enhancing self-compassion, resilience, and social support for young adults and reducing negative life events, neuroticism, and poor sleep may help decrease CR. These findings may help healthcare providers or researchers determine how to cultivate and improve the CR of young adults by establishing documented policies and/or improving intervention efficacies.

Neurocognitive working mechanisms of the prevention of relapse in remitted recurrent depression (NEWPRIDE): protocol of a randomized controlled neuroimaging trial of preventive cognitive therapy

BACKGROUND

Major Depressive Disorder (MDD) is a psychiatric disorder with a highly recurrent character, making prevention of relapse an important clinical goal. Preventive Cognitive Therapy (PCT) has been proven effective in preventing relapse, though not for every patient. A better understanding of relapse vulnerability and working mechanisms of preventive treatment may inform effective personalized intervention strategies. Neurocognitive models of MDD suggest that abnormalities in prefrontal control over limbic emotion-processing areas during emotional processing and regulation are important in understanding relapse vulnerability. Whether changes in these neurocognitive abnormalities are induced by PCT and thus play an important role in mediating the risk for recurrent depression, is currently unclear. In the Neurocognitive Working Mechanisms of the Prevention of Relapse In Depression (NEWPRIDE) study, we aim to 1) study neurocognitive factors underpinning the vulnerability for relapse, 2) understand the neurocognitive working mechanisms of PCT, 3) predict longitudinal treatment effects based on pre-treatment neurocognitive characteristics, and 4) validate the pupil dilation response as a marker for prefrontal activity, reflecting emotion regulation capacity and therapy success.

METHODS

In this randomized controlled trial, 75 remitted recurrent MDD (rrMDD) patients will be included. Detailed clinical and cognitive measurements, fMRI scanning and pupillometry will be performed at baseline and three-month follow-up. In the interval, 50 rrMDD patients will be randomized to eight sessions of PCT and 25 rrMDD patients to a waiting list. At baseline, 25 healthy control participants will be additionally included to objectify cross-sectional residual neurocognitive abnormalities in rrMDD. After 18 months, clinical assessments of relapse status are performed to investigate which therapy induced changes predict relapse in the 50 patients allocated to PCT.

DISCUSSION

The present trial is the first to study the neurocognitive vulnerability factors underlying relapse and mediating relapse prevention, their value for predicting PCT success and whether pupil dilation acts as a valuable marker in this regard. Ultimately, a deeper understanding of relapse prevention could contribute to the development of better targeted preventive interventions.

TRIAL REGISTRATION

Trial registration: Netherlands Trial Register, August 18, 2015, trial number NL5219.

For Whom Does Cognitively Based Compassion Training (CBCT) Work? An Analysis of Predictors and Moderators among African American Suicide Attempters

OBJECTIVES

Both Cognitively-Based Compassion Training (CBCT) and support-based group intervention have been found to be effective for African American suicide attempters in reducing suicidal ideation and depression, as well as enhancing self-compassion. This study aims to further our understanding of effective interventions by exploring participants' responses to both interventions.

METHODS

Exploratory analyses were conducted in a sample of low-income African Americans who had attempted suicide (n=82) to determine how baseline demographic and psychological characteristics would (1) predict outcomes (i.e., suicidal ideation, depression, and self-compassion) regardless of intervention conditions, and (2) moderate outcomes in interaction with intervention condition.

RESULTS

Non-reactivity, a mindfulness facet, was identified as an intervention moderator for suicidal ideation and depressive symptoms, suggesting that CBCT outperformed the support group for African American suicide attempters who had low baseline non-reactivity (or high reactivity). Individuals who had high non-reactivity at baseline appeared to benefit more from both conditions in self-compassion as an outcome. There was a pattern that homeless individuals benefited less in terms of their levels of depressive symptoms and self-compassion as outcomes regardless of the assigned condition. When applying Bonferroni corrections, only non-reactivity as an intervention moderator for depressive symptoms was significant.

CONCLUSIONS

Findings reveal the relevance of mindfulness and to a lesser extent socioeconomic status in informing compassion-based intervention outcomes with this underserved population and the importance of intervention matching and tailoring to maximize treatment effects. Future large trials are needed to replicate findings and directions indicated from the current pilot study.

Adaptation and validation of the Chinese version of the modified Leiden index of depression sensitivity

BACKGROUND

The revised Leiden index of depression sensitivity (LEIDS-RR) is commonly used worldwide to measure a marker of depression vulnerability termed cognitive reactivity (CR). However, the optimal cut-off scores for this scale and for the Chinese version of LEIDS-RR (LEIDS-RR-CV) are unknown.

OBJECTIVES

The main aims were to examine the psychometric properties of the LEIDS-RR and establish appropriate cut-off scores for the Chinese population.

METHODS

Psychometric evaluation was performed for 330 healthy individuals and 330 depression patients in remission, by incorporating classical test theory and item response theory (IRT) methods. Receiver operating characteristic curve analysis was used to determine the optimal LEIDS-RR-CV cut-off.

RESULTS

Cronbach's α, two-week test-retest reliability, and marginal reliability for the LEIDS-RR-CV were 0.92, 0.40, and 0.96, respectively. Confirmatory factor analysis validated the five-factor model, and the cut-off values to screen a population at risk of depression were 60 and 55 for the healthy individuals and patients, respectively. Patients had higher CR than healthy individuals (t = 6.10, p = 0.00), and this was positively correlated with the total CES-D Scale score (r = 0.52, p = 0.00), also confirmed by IRT analysis, indicating the discriminative and concurrent validity of the scale.

LIMITATIONS

The generalizability of these findings may be limited given the sampling method and the fact that all patients were recruited from a tertiary hospital.

CONCLUSIONS

The 26-item LEIDS-RR-CV is a reliable and valid instrument to assess CR in Chinese populations. It can be used for screening at-risk populations and in epidemiological studies to guide the development of tailored intervention strategies.

Predictors of recurrence in a sample of 508 outpatients with major depressive disorder

OBJECTIVE

Specific predictors of relapse/recurrence in major depressive disorder (MDD) have been identified but evidence across studies are inconsistent. This study aimed to identify the most relevant socio-demographic/clinical predictors of MDD recurrence in a sample of 508 outpatients.

METHODS

This naturalistic cohort study included 508 currently euthymic MDD patients (mean age = 54.1 ± 16.2) of which 53.9% had a single and 46.1% recurrent depressive episodes. A detailed data collection was performed and illness histories were retraced through clinical files and lifetime computerized medical records.

RESULTS

Compared to patients with single episode, MDD patients with recurrent episodes significantly differ regarding current age, gender, working status, positive history of psychiatric disorders in family, first-lifetime illness episode characteristics, first-episode and current psychotic symptoms, current melancholic features and seasonality, age at first treatment, duration of untreated illness, and comorbid cardiovascular/endocrinological conditions. However, after multivariate analyses controlling for current age, gender, educational level, working status differences, psychiatric conditions in family, and age of illness episode, recurrence was associated with older age (p ≤ .001), younger age at first treatment (p ≤ .005), being treated with previous psychoactive treatments (p .001), and longer duration of untreated illness (p .001).

CONCLUSIONS

The variables associated with MDD recurrence identified in the current study may aid in the stratification of patients who could benefit from more intensive maintenance treatments for MDD. However, clinicians should rapidly identify cases that are not likely to recur in order to avoid unnecessary treatments which are commonly considered as the standard of care.

The association between the number of previous episodes and modifiable vulnerability factors in remitted patients with recurrent depression

Objective

Remitted patients with a history of several previous major depressive episodes have a higher risk of relapse/recurrence than patients with fewer previous episodes, and the probability of another episode increases progressively with each successive episode. This study examines the association between the number of previous episodes and modifiable vulnerability factors in remitted patients with recurrent depression.

Methods

Patients with recurrent depression (DSM-IV-diagnosed) who were in remission (N = 214) were recruited between September 2011 and July 2016. The association was examined between the number of previous episodes and the following factors: i.e. interpersonal functioning, daily stress, sense of mastery, coping and dysfunctional beliefs.

Results

A history of more previous episodes was associated with higher levels of interpersonal problems (P < .001), daily stress (P = .04) and a lower sense of mastery (P = .05). Interpersonal problems were most strongly associated with more previous episodes in a Generalized Linear Regression model. In the domain of interpersonal problems, the subscales that showed the strongest relationship were domineering/controlling, vindictive/self-centred, socially inhibited and self-sacrificing.

Conclusions

Patients with a history of more depressive episodes reported higher levels of interpersonal problems, daily stress and a lower sense of mastery. Future studies should examine these factors in a longitudinal cohort and look at whether the effect of interventions to prevent relapse can be explained by targeting these psychological factors.

Trial registration

Netherlands Trial Register: 2599.

Why some obese people become depressed whilst others do not: exploring links between cognitive reactivity, depression and obesity

Obesity and depression are two major public health concerns, particularly when they co-occur. To date, mechanisms underlying this association have not been established and it is unclear why some obese people become depressed whilst others do not. However, considering the strong association between depression and cognitive reactivity (CR), the present study explores possible associations between obesity, depression and CR in light of the scarce and conflicting nature of past literature. 254 participants were included for measures of depression, CR and obesity. Multivariate analyses of covariance examined the effects of depression and obesity as well as interaction effects of depression x obesity controlling for age and gender. Directions of effects were analysed by means of regression analyses and group contrasts. Linear analyses revealed (1) a significant effect of obesity on the rumination (RUM) and control/perfectionism subscales of CR, (2) a significant effect of depression on CR and all of its subscales, and (3) a significant interaction effect between obesity x depression on RUM. Results may support the 'Jolly Fat Hypothesis' and the existence of a psychologically protected subgroup of obese patients characterised by a lower ruminative thinking style and fewer depressive symptoms. Thus, incorporating anti-rumination therapy into treatment for obese individuals may be beneficial to prevent the development of comorbid depression.

The measurement of cognitive reactivity to sad mood in patients remitted from major depressive disorder

OBJECTIVES

Cognitive reactivity (CR) to sad mood is a risk factor for major depressive disorder (MDD). CR is usually measured by assessing change on the Dysfunctional Attitudes Scale (DAS-change) after sad mood-induction. It has, however, been suggested that the versions of the DAS (A/B) are not interchangeable, impacting the reliability and validity of the change score. The Leiden Index of Depression Sensitivity-Revised (LEIDS-R) is an alternative self-report measure of CR. Studies examining the relationship between LEIDS-R and DAS-change have shown mixed results. We examined whether scores of these CR measures differed between remitted MDD and controls, the relationship between these CR measures, and the effect of order of DAS administration on DAS-change.

DESIGN

Cross-sectional design with two groups (remitted MDD and controls).

METHODS

Sixty-eight MDD patients remitted from ≥2 previous episodes, not taking antidepressants, and 43 never-depressed controls participated in a mood-induction and filled in the DAS-A/B in randomized order before and after mood-induction, and LEIDS-R separately.

RESULTS

LEIDS-R scores and pre-mood-induction DAS scores were significantly higher in remitted MDD than controls (p < .001, Cohen's d = 1.48; p = .001, Cohen's d = 0.66, respectively). DAS-change did not differ between these groups (p = .67, Cohen's d = 0.08). LEIDS-R correlated with DAS-change (r = .30, p = .042), but only in the group that filled in DAS-B before DAS-A. In remitted MDD, DAS-change was dependent on the order of DAS versions before and after mood-induction (10.6 ± 19.0 vs. -1.2 ± 10.5, for order B-A and A-B, respectively), with a significant group × order interaction (p = .012).

CONCLUSIONS

Existing DAS versions are not interchangeable, which compromises the usefulness of mood-inductions in clinical practice. The LEIDS-R seems a valid measure of cognitive vulnerability to depression.

PRACTITIONER POINTS

Clinical implications: Cognitive reactivity (CR) is a risk factor of depressive recurrence. The current measurement of CR, by assessing change on the Dysfunctional Attitudes Scale (DAS) after mood-induction, is not reliable. The Leiden Index Depression Sensitivity-Revised (LEIDS-R) is an alternative CR measure. In contrast to mood-induction, it reliably assesses depression vulnerability. The use of mood-inductions for clinical/research purposes is unnecessary.

LIMITATIONS OF THE STUDY

We were not able to examine the effect of previous treatment, which could have affected results as psychological treatments probably have differential effects on CR. Examining un-medicated patients may have led to selection of a sample not completely representative for the general MDD population. We did not administer both parallel versions of the DAS (A/B) before and after mood-induction. This might have provided better understanding of their differential sensitivity to change.

The predictive specificity of psychological vulnerability markers for the course of affective disorders

High scores on markers of psychological vulnerability have been associated with a worse course of affective disorders. However, little is known about the specificity of those associations in predicting the course of different depressive and anxiety disorders. We examined the impact of psychological vulnerability on the short- and long-term course of depressive and anxiety disorders. Participants from the Netherlands Study of Depression and Anxiety with a current diagnosis of depression or anxiety (n = 1256) were reassessed after 2 and 6 years. Diagnostic status and chronic duration (>85% of the time) of symptoms were the outcomes. Predictors were neuroticism, extraversion, locus of control, cognitive reactivity (rumination and hopelessness reactivity), worry and anxiety sensitivity. High neuroticism, low extraversion and external locus of control predicted chronicity of various affective disorders. Rumination, however, predicted chronicity of depressive but not anxiety disorders. Worry specifically predicted chronicity of GAD and anxiety sensitivity predicted chronicity of panic disorder and social anxiety disorder. These patterns were present both at short-term and at long-term, without losing predictive accuracy. Psychological vulnerabilities that are theoretically specific to certain disorders indeed selectively predict the course of these disorders. General markers of vulnerability predicted the course of multiple affective disorders. This pattern of results supports the notion of specific as well as transdiagnostic predictors of the course of affective disorders and is consistent with hierarchical models of psychopathology.

Associations between chronotypes and psychological vulnerability factors of depression

Chronotypes have been associated with psychopathology. The eveningness chronotype has been consistently linked with depressed states or depressive disorder, but the underlying mechanism remains unclear. Prior studies have shown associations between chronotype and personality traits that are linked to depression (e.g. neuroticism), but other psychological vulnerability factors have not been previously investigated in relation to chronotypes. The aim of this study was to examine the association between chronotypes, depression and psychological risk factors of depression (namely, cognitive reactivity and worry), in a large cohort of depressed patients and healthy individuals. We used data from the Netherlands Study of Depression and Anxiety (n = 1654), which includes 1227 clinically diagnosed individuals with a lifetime diagnosis of depression and 427 healthy controls. We assessed cognitive reactivity (Leiden Index of Depression Sensitivity-Revised) and trait worry (Penn State Worry Questionnaire). We controlled for sociodemographic factors as well as for insomnia and neuroticism. We found that the evening type is associated with higher cognitive reactivity scores, especially with increased rumination. Cognitive reactivity also mediated the relationship between chronotype and depression status, even when controlling for neuroticism and insomnia. Trait worry was not associated with chronotype. Our findings show that depressogenic cognitions are more prevalent in evening types and perhaps mediate the association between chronotype and depression. Further prospective research is needed to determine the timeline of the association. Nevertheless, results imply that targeting depressogenic cognitive processes, perhaps in combination with chronotherapeutic treatments, may be particularly useful in evening types.

Leiden Index of Depression Sensitivity-Revised (LEIDS-R): Spanish validation proposal

To adapt and validate the Leiden Index of Depression Sensitivity-Revised for evaluating cognitive reactivity to depressive mood to Spanish and validate this Spanish version. To find the scale's factor structure and psychometric properties. The sample consisted of 600 participants (103 patients and 497 subjects from the general population). A four-factor structure was found, a general factor evaluating cognitive reactivity was proposed and ten items were eliminated. A brief version of the (LEIDS-R24) scale is proposed. The factors and the overall scale have adequate internal consistency, and the results of validation show that all the factors on the scale predict depressive symptomatology (BDI-II) adequately, and are highly correlated with the Dysfunctional Attitudes Scale and BDI-II scales. The complete scale adequately discriminated depressive symptomatology in general population subjects and patients with anxiety and depressive disorders. No significant differences were found in the LEIDS-R24 measurement between subjects with anxiety and depressive disorder. The LEIDS-R24 scale may be a useful brief measure for evaluating cognitive reactivity to depressive mood and analyzing the vulnerability which could be common to persons with anxiety and depressive disorders.