A randomized controlled trial on the effectiveness of a rumination-focused group treatment for residual depression

Treatments for partial remission of major depressive disorder: a systematic review and meta-analysis

QUESTION

Partial remission of major depressive disorder (MDD) is a debilitating and distressing clinical state related to chronicity, morbidity and relapse. Although one-third of patients remit partially, evidence for treatment efficacy is unclear. We provide an overview of treatment options and their efficacy.

STUDY SELECTION AND ANALYSIS

Embase, PsycINFO, Medline and SCOPUS were systematically searched through February 2023. Included were randomised controlled trials (RCTs) examining any treatment in patients with partially remitted MDD aged 13-65 years, reporting data on severity, remission or relapse.

FINDINGS

Seven RCTs examining psychotherapy including 1024 patients were eligible. There were not enough RCTs to examine effects of pharmacotherapy. Psychotherapy was associated with lower depressive symptom severity at post-treatment (Hedges' g=0.50; 95% CI 0.23 to 0.76), but not at follow-up up to 1 year (Hedges' g=0.36; 95% CI -0.30 to 1.02) or longer (Hedges' g=0.02; 95% CI -0.09 to 0.12). Psychotherapy was associated with superior remission rates at post-treatment (OR 2.57; 95% CI 1.71 to 3.87) and follow-up 6 months or longer (OR 1.75; 95% CI 1.21 to 2.53), although not with improved relapse rates at post-treatment (OR 0.17; 95% CI 0.01 to 4.83) or follow-up 6 months or longer (OR 0.46; 95% CI 0.21 to 1.03). Overall methodological quality was poor.

CONCLUSIONS

Psychotherapy targeting partial remission may be effective in lowering depressive symptom severity and patients may potentially achieve full remission twice as likely. Yet, long-term and prophylactic effects are lacking. Given the risk of chronicity, more high-quality RCTs are needed.

PROSPERO REGISTRATION NUMBER

CRD42020188451.

Effects of abstract versus concrete rumination about anger on affect

BACKGROUND

The processing-mode theory of rumination proposes that an abstract mode of rumination results in more maladaptive consequences than a concrete ruminative mode. It is supported by evidence mostly from the area of depression and little is known of the relative consequences of abstract versus concrete rumination for anger.

AIMS

We investigated the differential effects of abstract versus concrete rumination about anger on individuals' current affect. We hypothesized that abstract rumination would increase current anger and negative affect, and decrease positive affect, to a greater extent than concrete rumination.

METHOD

In a within-subject design, 120 participants were instructed to focus on a past social event that resulted in intense anger and then to ruminate about the event in both an abstract and a concrete mode, in a randomly assigned order. Current anger, negative and positive affect were assessed before and after each rumination phase.

RESULTS

Anger and negative affect increased and positive affect decreased from pre- to post-rumination. Contrary to expectations, these patterns were observed irrespective of the ruminative mode induced.

CONCLUSIONS

This initial study does not support the hypothesis that abstract and concrete rumination about anger have different consequences for current affect. Replications and more extensive designs are needed.

The influence of childhood emotional maltreatment on cognitive symptoms, rumination, and hopelessness in adulthood depression

Childhood emotional maltreatment (CEM) is a risk factor for the pathogenesis of depressive disorders. However, it is not clear whether CEM is more strongly related to specific symptoms of depression and whether specific traits or cognitive states may mediate the association between CEM and depressive symptoms. In our cross-sectional study, including 72 patients with a current depressive episode, we investigated if CEM is specifically related to cognitive symptoms of depression. In addition, we evaluated whether CEM also influences the extent of rumination and hopelessness in adult depression. Using multiple regression analyses, we tested if CEM and rumination could predict cognitive symptoms and hopelessness. A structural equation model (SEM) was used to examine if rumination mediates the relationship between CEM and cognitive symptoms. Correlational analyses revealed that CEM was related to cognitive symptoms, rumination, and hopelessness. The regression analyses showed that only rumination was a significant predictor for cognitive symptoms and hopelessness, whereas CEM could not significantly predict the two constructs. SEM revealed that the association between CEM and cognitive symptoms in adult depression was mediated by rumination. Our results thereby suggest that CEM is a risk factor particularly for the development of cognitive symptoms as well as rumination and hopelessness in adult depression. However, the influence on cognitive symptomatology seems to be indirectly regulated by rumination. These findings may contribute to a better understanding of processes that promote depression, as well as provide guidance for more targeted treatment options.

The effectiveness of mindfulness-based interventions for ruminative thinking: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To systematically evaluate the effectiveness of mindfulness-based interventions for ruminative thinking.

METHODS

Cochrane Library, Web of Science, Embase, EBSCO, PubMed and Science Direct databases were searched to include randomized controlled trials of mindfulness-based interventions for rumination that met the criteria. The Rumination scale was used as the primary outcome indicator, and the secondary outcome indicator included the Mindfulness scale. An evaluation of bias risk was conducted to identify possible sources of bias based on methodological and clinical factors. Stata 16.0 software was used to perform meta-analysis, subgroup analysis, sensitivity analysis, meta-regression analysis and publication bias detection of the extracted data.

RESULTS

A total of 61 studies with 4229 patients were included. Meta-analysis results revealed a significant intervention effect on ruminative thinking (SMD = -0.534, 95 % CI = [-0.675, -0.394], z = -7.449, P < 0.001). However, there was no significant difference between mindfulness-based interventions and CBT (SMD = 0.009, 95%CI = [-0.239, 0.258], z = 0.073, P = 0.941). Meta-analysis showed that mindfulness-based interventions significantly enhanced the level of mindfulness (SMD = 0.495, 95 % CI = [0.343, 0.647], z = 6.388, P < 0.001), while it was not significant compared to CBT (SMD = 0.158, 95%CI = [-0.087, 0.403], z = 1.266, P = 0.205). The two subgroups with >65 % (SMD = -0.534, 95%CI = [-0.681, -0.386], z = -7.081, P < 0.001) and 80 % (SMD = -0.462, 95%CI = [-0.590, -0.334], z = -7.071, P < 0.001) of females showed significant improvement in ruminative thinking. There were significant intervention effects for depression, students, cancer, healthy adults, and clinical patients. Significant intervention effects were demonstrated for various participant ages and intervention periods.

CONCLUSION

This study confirmed the feasibility of mindfulness-based interventions in improving ruminative thinking and enhancing the level of mindfulness. However, the effectiveness of mindfulness-based interventions was not significant compared to CBT. The two subgroups with a higher proportion of females showed a more significant improvement in ruminative thinking, whereas there were no significant differences in participant characteristics, age, and the duration of intervention.

Understanding the experience of rumination and worry: A descriptive qualitative survey study

OBJECTIVES

Rumination and worry have been implicated in the onset, severity, maintenance and relapse risk of depression and anxiety disorders. Despite this, little research has examined individuals' personal experiences of these processes. This study investigates how individuals experience these processes, which will provide insight into these common features of mental disorders and inform the development of an online intervention specifically targeting rumination and worry.

DESIGN

An online qualitative survey was conducted to gain insight into people's personal definitions, experiences with and understandings of rumination and worry.

METHODS

Participants answered open- and close-ended questions about their personal understanding of rumination and worry, typical thought content, triggers, frequency, duration and coping strategies. Participant responses were coded into themes. Participants also completed self-report questionnaires of depression, anxiety and stress and repetitive negative thinking.

RESULTS

Two hundred and seven adults completed the online survey (76% female; mean age = 28.2 years, range = 17-71), 51% of whom reported previously experiencing depression and anxiety. All participants were familiar with the concept of worry, whereas 28% of participants indicated they had never heard of rumination. Participants reported most commonly ruminating and/or worrying about personal relationships, past mistakes, negative experiences and conversations/social interactions. The most commonly reported triggers for rumination and/or worry were social situations/interpersonal interactions (25%) and negative events/experiences (24%). Distraction was the most common coping strategy (48%); however, 21% reported being unable to stop themselves from ruminating and/or worrying.

CONCLUSIONS

The results provide a unique insight into the personal experiences and understandings of rumination and worry of potential end users of treatment programs targeting these processes.

A Psychoeducational CBT-based Group Intervention ("Drop It") for Repetitive Negative Thinking: Theoretical Concepts and Treatment Processes

Repetitive negative thinking (RNT)-such as worry and rumination-is an important transdiagnostic factor in the onset, course, and recurrence of depressive and anxiety disorders. This article describes a psychoeducational cognitive behavioral therapy (CBT)-based group intervention entitled "Drop It" that focuses exclusively on treating RNT in patients with major depressive disorder and/or generalized anxiety disorder. The theoretical concepts and treatment goals of the intervention are outlined. The organization and therapeutic processes of the different sessions are described and illustrated with statements of participants. Special attention is given to how the intervention capitalizes on the group structure and process to maximize the effectiveness of psychoeducation and CBT-based techniques. We also provide practical guidelines for clinicians treating patients with RNT.

Augmenting neurocognitive remediation therapy to Preventive Cognitive Therapy for partially remitted depressed patients: protocol of a pragmatic multicentre randomised controlled trial

INTRODUCTION

Major depressive disorder (MDD) affects 163 million people globally every year. Individuals who experience subsyndromal depressive symptoms during remission (ie, partial remission of MDD) are especially at risk for a return to a depressive episode within an average of 4 months. Simultaneously, partial remission of MDD is associated with work and (psycho)social impairment and a lower quality of life. Brief psychological interventions such as preventive cognitive therapy (PCT) can reduce depressive symptoms or relapse for patients in partial remission, although achieving full remission with treatment is still a clinical challenge. Treatment might be more effective if cognitive functioning of patients is targeted as well since cognitive problems are the most persisting symptom in partial remission and predict poor treatment response and worse functioning. Studies show that cognitive functioning of patients with (remitted) MDD can be improved by online neurocognitive remediation therapy (oNCRT). Augmenting oNCRT to PCT might improve treatment effects for these patients by strengthening their cognitive functioning alongside a psychological intervention.

METHODS AND ANALYSIS

This study will examine the effectiveness of augmenting oNCRT to PCT in a pragmatic national multicentre superiority randomised controlled trial. We will include 115 adults partially remitted from MDD with subsyndromal depressive symptoms defined as a Hamilton Depression Rating Scale score between 8 and 15. Participants will be randomly allocated to PCT with oNCRT, or PCT only. Primary outcome measure is the effect on depressive symptomatology over 1 year. Secondary outcomes include time to relapse, cognitive functioning, quality of life and healthcare costs. This first dual approach study of augmenting oNCRT to PCT might facilitate full remission in partially remitted individuals as well as prevent relapse over time.

ETHICS AND DISSEMINATION

Ethical approval was obtained by Academic Medical Center, Amsterdam. Outcomes will be made publicly available.

TRIAL REGISTRATION NUMBER

NL9582.

Treatment experiences during a cognitive behaviour therapy group intervention targeting repetitive negative thinking: A qualitative study

OBJECTIVES

Treatment of repetitive negative thinking (RNT) focuses rather on individual than group cognitive behaviour therapy (CBT) treatment. Additionally, little is known on how clients experienced these interventions. This study investigates clients' experiences on participating in a CBT group intervention targeting RNT (RNT-G).

DESIGN

Of the 80 participants, 11 were randomly selected for an in-depth, semi-structured interview after treatment. Interviews focused on what participants experienced as important on group aspects, offered interventions, homework tasks, and possible changes.

METHODS

All participants were adults, diagnosed with major depressive disorder and/or generalized anxiety disorder and being currently in mental health care treatment. After transcribing the interviews, analyses were performed according to the guidelines of thematic analysis.

RESULTS

Four major themes were identified. First, the group format itself was experienced as an important factor of change. The experiences about the different offered interventions during the group formed a second theme. A third theme related to changes in family or professional life and dealing with RNT as a result of the intervention. Finally, group participation, social interactions, and mental health care treatment were experienced as mutually influencing during the intervention.

CONCLUSIONS

The results of this study shed some light on which treatment interventions were perceived as beneficial during the RNT-G and should therefore be emphasized in treatment. Further, they indicate that the treatment in a group format was experienced as helpful by the participants. Finally, a positive mutual influence between the group intervention and the ongoing individual treatment was experienced.

Mechanisms of rumination change in adolescent depression (RuMeChange): study protocol for a randomised controlled trial of rumination-focused cognitive behavioural therapy to reduce ruminative habit and risk of depressive relapse in high-ruminating adolescents

BACKGROUND

Adolescent-onset depression often results in a chronic and recurrent course, and is associated with worse outcomes relative to adult-onset depression. Targeting habitual depressive rumination, a specific known risk factor for relapse, may improve clinical outcomes for adolescents who have experienced a depressive episode. Randomized controlled trials (RCTs) thus far have demonstrated that rumination-focused cognitive behavioral therapy (RFCBT) reduces depressive symptoms and relapse rates in patients with residual depression and adolescents and young adults with elevated rumination. This was also observed in a pilot RCT of adolescents at risk for depressive relapse. Rumination can be measured at the self-report, behavioral, and neural levels- using patterns of connectivity between the Default Mode Network (DMN) and Cognitive Control Network (CCN). Disrupted connectivity is a putative important mechanism for understanding reduced rumination via RFCBT. A feasibility trial in adolescents found that reductions in connectivity between DMN and CCN regions following RFCBT were correlated with change in rumination and depressive symptoms.

METHOD

This is a phase III two-arm, two-stage, RCT of depression prevention. The trial tests whether RFCBT reduces identified risk factors for depressive relapse (rumination, patterns of neural connectivity, and depressive symptoms) in adolescents with partially or fully remitted depression and elevated rumination. In the first stage, RFCBT is compared to treatment as usual within the community. In the second stage, the comparator condition is relaxation therapy. Primary outcomes will be (a) reductions in depressive rumination, assessed using the Rumination Response Scale, and (b) reductions in resting state functional magnetic resonance imaging connectivity of DMN (posterior cingulate cortex) to CCN (inferior frontal gyrus), at 16 weeks post-randomization. Secondary outcomes include change in symptoms of depression following treatment, recurrence of depression over 12 months post-intervention period, and whether engagement with therapy homework (as a dose measure) is related to changes in the primary outcomes.

DISCUSSION

RFCBT will be evaluated as a putative preventive therapy to reduce the risk of depressive relapse in adolescents, and influence the identified self-report, behavioral, and neural mechanisms of change. Understanding mechanisms that underlie change in rumination is necessary to improve and further disseminate preventive interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03859297 , registered 01 March 2019.

Meaning-making as a mediator of anxiety and depression reduction during cognitive behavioral therapy intervention in participants with adjustment disorders

There is a consensus among researchers about the link between low meaning in life and anxiety and depressive symptoms. One unanswered question is whether meaning-making is a mediator of the change in anxiety and depression symptoms in participants with adjustment disorders during cognitive behavioural therapy (CBT) treatment. The aims of this study were (a) to analyse whether there was meaning-making during the application of the CBT, (b) to analyse whether meaning-making was a mediator of anxiety psychopathology and (c) to analyse whether meaning-making was a mediator of depressive symptoms. The sample was composed of 115 patients who satisfied the full Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criteria for adjustment disorder as their primary diagnosis and completed CBT treatment in a primary care mental health service: 74.78% women, n = 86, and 25.22% men, n = 29, with a mean age of 41.89 (standard deviation [SD] = 10.39) years. The diagnosis was established using the Structured Clinical Interview for DSM-5 (SCID-5), and participants filled out the Beck Anxiety Inventory, the Beck Depression Inventory and Purpose in Life questionnaires. The therapists were clinical psychologists with experience in clinical assessment. A repeated-measures analysis of variance (ANOVA) and two mediation analyses using the bootstrap method were performed. The results indicated that (a) There was meaning-making during the CBT because the treated sample showed a statistically significant improvement in meaning in life, and (b) meaning-making during the CBT was a partial mediator between anxiety symptoms and depressive symptoms before and after the treatment. The present study suggests that meaning in life could be an important variable in the psychopathology of adjustment disorders.

Long-Term Effectiveness of Cognitive Behavioral Therapy in Routine Outpatient Care: A 5- to 20-Year Follow-Up Study

OBJECTIVE

Long-term follow-ups several years after receiving cognitive behavioral therapy (CBT) are scarce and most of the existing literature describes follow-up data of randomized-controlled trials. Thus, very little is known about the long-term effects of CBT in routine care.

METHODS

We investigated psychological functioning in a sample of 263 former outpatients who had received CBT for a variety of mental disorders such as depression, anxiety-, eating- or somatoform disorders 8.06 (SD 5.08) years after treatment termination. All participants completed a diagnostic interview as well as the Brief-Symptom Inventory (BSI) and the Beck Depression Inventory (BDI). Effect sizes and response rates according to Jacobson and Truax [J Consult Clin Psychol 1991;59:12-9] were calculated from pre- to posttreatment and from pretreatment to follow-up assessment.

RESULTS

Pre- to posttreatment effect sizes ranged between 0.75 (BDI) and 0.63 (BSI) and pretreatment to follow-up effect sizes were 0.92 (BDI) and 0.75 (BSI). Of all patients, 29% (BDI) and 17% (BSI) experienced clinically significant change at posttreatment and 42% (BDI) and 24% (BSI) at follow-up.

CONCLUSION

The results point to the long-term effectiveness of CBT under routine conditions for a wide array of problems, especially when compared to the long-term effects of medical treatment. It is noteworthy that the results at follow-up were even better than at posttreatment, indicating further improvement. However, about a quarter of the patients did not respond sufficiently to therapy, neither concerning short-term nor long-term effects.

Sleep quality and emotional reactivity cluster in bipolar disorders and impact on functioning

Objective:

Bipolar disorders (BD) are characterized by sleep disturbances and emotional dysregulation both during acute episodes and remission periods. We hypothesized that sleep quality (SQ) and emotional reactivity (ER) defined clusters of patients with no or abnormal SQ and ER and we studied the association with functioning.

Method:

We performed a bi-dimensional cluster analysis using SQ and ER measures in a sample of 533 outpatients patients with BD (in remission or with subsyndromal mood symptoms). Clusters were compared for mood symptoms, sleep profile and functioning.

Results:

We identified three clusters of patients: C1 (normal ER and SQ, 54%), C2 (hypo-ER and low SQ, 22%) and C3 (hyper-ER and low SQ, 24%). C1 was characterized by minimal mood symptoms, better sleep profile and higher functioning than other clusters. Although highly different for ER, C2 and C3 had similar levels of subsyndromal mood symptoms as assessed using classical mood scales. When exploring sleep domains, C2 showed poor sleep efficiency and a trend for longer sleep latency as compared to C3. Interestingly, alterations in functioning were similar in C2 and C3, with no difference in any of the sub-domains.

Conclusion:

Abnormalities in ER and SQ delineated three clusters of patients with BD and significantly impacted on functioning.

Group rumination-focused cognitive-behavioural therapy (CBT) v. group CBT for depression: phase II trial

BACKGROUND

Although cognitive-behavioural therapy (CBT) is an effective treatment for depression, less than half of patients achieve satisfactory symptom reduction during treatment. Targeting known psychopathological processes such as rumination may increase treatment efficacy. The aim of this study was to test whether adding group rumination-focused CBT (RFCBT) that explicitly targets rumination to routine medical management is superior to adding group CBT to routine medical management in treating major depression.

METHODS

A total of 131 outpatients with major depression were randomly allocated to 12 sessions group RFCBT v. group CBT, each in addition to routine medical management. The primary outcome was observer-rated symptoms of depression at the end of treatment measured on the Hamilton Rating Scale for Depression. Secondary outcomes were rumination at post-treatment and depressive symptoms at 6 months follow-up (Trial registered: NCT02278224).

RESULTS

RFCBT significantly improved observer-rated depressive symptoms (Cohen's d 0.38; 95% CI 0.03-0.73) relative to group CBT at post-treatment on the primary outcome. No post-treatment differences were found in rumination or in depressive symptoms at 6 months follow-up, although these secondary analyses may have been underpowered.

CONCLUSIONS

This is the first randomized controlled trial providing evidence of benefits of RFCBT in major depression compared with CBT. Group RFCBT may be a beneficial alternative to group CBT for major depression.

Meditation effect in changing functional integrations across large-scale brain networks: Preliminary evidence from a meta-analysis of seed-based functional connectivity

Meditation is a type of mental training commonly applied in clinical settings and also practiced for general well-being. Brain functional connectivity (FC) patterns associated with meditation have revealed its brain mechanisms. However, the variety of FC methods applied has made it difficult to identify brain communication patterns associated with meditation. Here we carried out a coordinate-based meta-analysis to get preliminary evidence of meditation effects on changing brain network interactions. Fourteen seed-based, voxel-wise FC studies reported in 13 publications were reviewed; 10 studies with seeds in the default mode network (DMN) were meta-analyzed. Seed coordinates and the effect sizes in statistically significant regions were extracted, based on 170 subjects in meditation groups and 163 subjects in control groups. Seed-based d-mapping was used to analyze meditation versus control FC differences with DMN seeds. Meditation was associated with increased connectivity within DMN and between DMN and somatomotor network and with decreased connectivity between DMN and frontoparietal network (FPN) as well as ventral attention network (VAN). The pattern of decreased within-DMN FC and increased between-network FC (FPN and DAN with DMN) was more robust in highly experienced meditators compared to less experienced individuals. The identified neural network interactions may also promote meditation’s effectiveness in clinical interventions for treating physical and mental disorders.

Moment-to-moment interaction between affectivity and coping behaviours in bipolar disorder and the role of cognitive appraisals

BACKGROUND

Individuals with bipolar disorder respond to affective symptoms with a range of coping behaviours, which may further maintain the symptoms.

AIMS

To examine moment-to-moment dynamics between affective states and coping behaviours, and to evaluate the role of cognitive appraisals of internal states as moderators.

METHOD

Forty-six individuals with bipolar disorder completed a clinical interview and an experience sampling assessment over 6 days. Time-lagged analyses were conducted by multilevel regression modelling.

RESULTS

A total of 1807 momentary entries were analysed. Negative affect predicted an increase in rumination at the subsequent time point (β = 0.21, s.e. = 0.08, P = 0.009, 95% CI 0.05-0.36), and vice versa (β = 0.03, s.e. = 0.01, P = 0.009, 95% CI 0.01-0.05). Positive affect predicted an increase in adaptive coping (β = 0.26, s.e. = 0.11, P = 0.018, 95% CI 0.04-0.47), and vice versa (β = 0.02, s.e. = 0.01, P = 0.019, 95% CI 0.00-0.03). Positive affect also predicted a decrease in rumination (β = -0.15, s.e. = 0.06, P = 0.014, 95% CI -0.26 to -0.03), and vice versa (β = -0.03, s.e. = 0.01, P = 0.016, 95% CI -0.06 to -0.01). Extreme cognitive appraisals predicted stronger associations between affective states and coping behaviours.

CONCLUSIONS

Feedback loops between affective states and coping behaviours were revealed in the daily life of individuals with bipolar disorder, which were moderated by extreme cognitive appraisals.

DECLARATION OF INTEREST

None.

[Depressed, biased, forgetful: The interaction of emotional and cognitive dysfunctions in depression]

Major depressive disorder is characterized by changes in the emotional state, e. g. the diminished experience of positive emotions, as well as cognitive impairments such as concentration and memory difficulties. These emotional and cognitive dysfunctions are closely interrelated and play a key role for the development and maintenance of depressive symptoms. For instance, patients with depression show negatively biased information processing that affects attention and memory as well as their reaction to feedback. In addition, there is an increased motivation to avoid negatively evaluated conditions and at the same time a reduced motivation to approach positive goals. Furthermore, depressed patients often show a specific style of thinking, called rumination, which involves repeated, intensive thinking about the causes, consequences and symptoms of one's own negative feelings. In this review, the different relationships between emotional, motivational and cognitive symptoms of depressive patients will be presented and the influence of their interaction on cognitive performance will be discussed. The highlighted clinical relevance of emotional-cognitive dysfunctions should be considered more often in therapeutic interventions for depressed patients.

Psychological therapies for treatment-resistant depression in adults

BACKGROUND

Antidepressants are a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression don't respond fully to such medication, and little evidence is available to inform the most appropriate 'next step' treatment for such patients, who may be referred to as having treatment-resistant depression (TRD). National Institute for Health and Care Excellence (NICE) guidance suggests that the 'next step' for those who do not respond to antidepressants may include a change in the dose or type of antidepressant medication, the addition of another medication, or the start of psychotherapy. Different types of psychotherapies may be used for TRD; evidence on these treatments is available but has not been collated to date.Along with the sister review of pharmacological therapies for TRD, this review summarises available evidence for the effectiveness of psychotherapies for adults (18 to 74 years) with TRD with the goal of establishing the best 'next step' for this group.

OBJECTIVES

To assess the effectiveness of psychotherapies for adults with TRD.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (until May 2016), along with CENTRAL, MEDLINE, Embase, and PsycINFO via OVID (until 16 May 2017). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. There were no date or language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with participants aged 18 to 74 years diagnosed with unipolar depression that had not responded to minimum four weeks of antidepressant treatment at a recommended dose. We excluded studies of drug intolerance. Acceptable diagnoses of unipolar depression were based onthe Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria, or Research Diagnostic Criteria. We included the following comparisons.1. Any psychological therapy versus antidepressant treatment alone, or another psychological therapy.2. Any psychological therapy given in addition to antidepressant medication versus antidepressant treatment alone, or a psychological therapy alone.Primary outcomes required were change in depressive symptoms and number of dropouts from study or treatment (as a measure of acceptability).

DATA COLLECTION AND ANALYSIS

We extracted data, assessed risk of bias in duplicate, and resolved disagreements through discussion or consultation with a third person. We conducted random-effects meta-analyses when appropriate. We summarised continuous outcomes using mean differences (MDs) or standardised mean differences (SMDs), and dichotomous outcomes using risk ratios (RRs).

MAIN RESULTS

We included six trials (n = 698; most participants were women approximately 40 years of age). All studies evaluated psychotherapy plus usual care (with antidepressants) versus usual care (with antidepressants). Three studies addressed the addition of cognitive-behavioural therapy (CBT) to usual care (n = 522), and one each evaluated intensive short-term dynamic psychotherapy (ISTDP) (n = 60), interpersonal therapy (IPT) (n = 34), or group dialectical behavioural therapy (DBT) (n = 19) as the intervention. Most studies were small (except one trial of CBT was large), and all studies were at high risk of detection bias for the main outcome of self-reported depressive symptoms.A random-effects meta-analysis of five trials (n = 575) showed that psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self-reported depressive symptoms (MD -4.07 points, 95% confidence interval (CI) -7.07 to -1.07 on the Beck Depression Inventory (BDI) scale) over the short term (up to six months). Effects were similar when data from all six studies were combined for self-reported depressive symptoms (SMD -0.40, 95% CI -0.65 to -0.14; n = 635). The quality of this evidence was moderate. Similar moderate-quality evidence of benefit was seen on the Patient Health Questionnaire-9 Scale (PHQ-9) from two studies (MD -4.66, 95% CI 8.72 to -0.59; n = 482) and on the Hamilton Depression Rating Scale (HAMD) from four studies (MD -3.28, 95% CI -5.71 to -0.85; n = 193).High-quality evidence shows no differential dropout (a measure of acceptability) between intervention and comparator groups over the short term (RR 0.85, 95% CI 0.58 to 1.24; six studies; n = 698).Moderate-quality evidence for remission from six studies (RR 1.92, 95% CI 1.46 to 2.52; n = 635) and low-quality evidence for response from four studies (RR 1.80, 95% CI 1.2 to 2.7; n = 556) indicate that psychotherapy was beneficial as an adjunct to usual care over the short term.With the addition of CBT, low-quality evidence suggests lower depression scores on the BDI scale over the medium term (12 months) (RR -3.40, 95% CI -7.21 to 0.40; two studies; n = 475) and over the long term (46 months) (RR -1.90, 95% CI -3.22 to -0.58; one study; n = 248). Moderate-quality evidence for adjunctive CBT suggests no difference in acceptability (dropout) over the medium term (RR 0.98, 95% CI 0.66 to 1.47; two studies; n = 549) and lower dropout over long term (RR 0.80, 95% CI 0.66 to 0.97; one study; n = 248).Two studies reported serious adverse events (one suicide, two hospitalisations, and two exacerbations of depression) in 4.2% of the total sample, which occurred only in the usual care group (no events in the intervention group).An economic analysis (conducted as part of an included study) from the UK healthcare perspective (National Health Service (NHS)) revealed that adjunctive CBT was cost-effective over nearly four years.

AUTHORS' CONCLUSIONS

Moderate-quality evidence shows that psychotherapy added to usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD. Medium- and long-term effects seem similarly beneficial, although most evidence was derived from a single large trial. Psychotherapy added to usual care seems as acceptable as usual care alone.Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD. No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regimen. Addressing this evidence gap is an important goal for researchers.

A Lonely Search?: Risk for Depression When Spirituality Exceeds Religiosity

This study clarified longitudinal relations of spirituality and religiosity with depression. Spirituality's potential emphasis on internal (e.g., intrapsychic search for meaning) versus religiosity's potential emphasis on external (e.g., engagement in socially-sanctioned belief systems) processes may parallel depression-linked cognitive-behavioral phenomena (e.g., rumination and loneliness) conceptually. Thus, this study tested the hypothesis that greater spirituality than religiosity, separate from the overall level of spirituality and religiosity, predicts longitudinal increases in depression. A national sample of midlife adults completed diagnostic interviews and questionnaires of spiritual and religious intensity up to three times over 18 years. In time-lagged multilevel models, overall spirituality plus religiosity did not predict depression. However, in support of the hypothesis, greater spirituality than religiosity significantly predicted subsequent increases in depressive symptoms and risk for major depressive disorder (odds ratio = 1.34). If replicated, the relative balance of spirituality and religiosity may inform depression assessment and prevention efforts.

The effect of CBT and its modifications for relapse prevention in major depressive disorder: a systematic review and meta-analysis

BACKGROUND

The risk of relapse in major depressive disorder (MDD) is associated with high worldwide disease burden. Cognitive behavioral therapy (CBT) and its modifications might be effective in relapse prevention. The aim of this review was to evaluate the efficacy of these treatments for reducing relapse of MDD.

METHODS

The retrieval was performed in the databases of MEDLINE via Pubmed, EMBASE and PsycINFO via OVID, The Cochrane Library and four Chinese databases. Clinical trials registry platforms and references of relevant articles were retrieved as well. Hazard ratio (HR) and corresponding 95% confidence interval (CI) were used to pool evidences.

RESULTS

A total of 16 eligible trials involving 1945 participants were included. In the first 12 months, CBT was more efficacious than control in reducing the risk of developing a new episode of depression for MDD patients in remission (HR:0.50, 95%CI:0.35-0.72, I² = 11%). Mindfulness-based cognitive therapy (MBCT) was more efficacious than control only among patients with 3 or more previous depressive episodes (HR:0.46, 95%CI:0.31-0.70, I² = 38%). Besides, compared with maintenance antidepressant medication (m-ADM), MBCT was a more effective intervention (HR:0.76, 95%CI:0.58-0.98, I² = 0%). These positive effects might be only maintained at two and nearly 6 years follow up for CBT.

CONCLUSION

The use of CBT for MDD patients in remission might reduce risk of relapse. Besides, the effect of MBCT was moderated by number of prior episodes and MBCT might only be effective for MDD patients with 3 or more previous episodes. Further exploration for the influence of previous psychological intervention is required.

Efficacy of antidepressants on measures of workplace functioning in major depressive disorder: A systematic review

INTRODUCTION

Work-related disability and productivity loss in Major Depressive Disorder (MDD) are critical determinants of patient quality of life and contribute significantly to the human and economic costs of MDD. Notwithstanding the return to work and pre-morbid levels of functioning as a critical therapeutic objective among individuals with MDD, it is unclear whether antidepressant treatment significantly and reliably improves measures of workplace functioning. Herein, we investigate to what extent antidepressant treatment improves workplace functioning among adults with MDD.

METHODS

We conducted a systematic review of randomized, double-blind, placebo-controlled or active comparator clinical trials primarily or secondarily investigating the efficacy of antidepressant agents on subjective ratings of workplace functioning and/or measures of work absence.

RESULTS

Thirteen placebo-controlled and four active comparator clinical trials reported on the efficacy of agomelatine, bupropion, desvenlafaxine, duloxetine, fluoxetine, levomilnacipran, paroxetine, sertraline, venlafaxine, or vortioxetine on subjective measures of workplace impairment. Overall, antidepressant treatment improved standardized measures of workplace functioning (e.g., Sheehan Disability Scale-work item). One placebo-controlled trial of agomelatine and one clinical trial comparing the efficacy of vortioxetine to that of venlafaxine had mixed results on measures of work absence.

LIMITATIONS

Included interventional trials evaluated work-related disability as a secondary outcome using subjective rating scales.

CONCLUSION

Extant data suggest that antidepressant treatment improves workplace outcomes in MDD. The capability of antidepressants in improving measures of workplace functioning should be considered in cost-benefit analyses to better inform cost-modelling studies pertaining to antidepressant therapy.

Understanding Dysregulated Behaviors and Compulsions: An Extension of the Emotional Cascade Model and the Mediating Role of Intrusive Thoughts

Objective: The Emotional Cascade Model (ECM) by Selby et al. (2008) proposes that people often engage in dysregulated behaviors to end extreme, aversive emotional states triggered by a self-perpetuating vicious cycle of (excessive) rumination, negative affect, and attempts to suppress negative thoughts.

Method: Besides replicating the ECM, we introduced intrusions as a mediator between rumination and behavioral dysregulation and tested this extended ECM for compulsions as part of obsessive–compulsive disorders. A structural equation modeling approach was used to test this in a sample of N = 414, randomly recruited from the general population.

Results: Intrusions were found to fully mediate the effect of rumination on a broad array of dysregulated behaviors and compulsions. This mediation endured when controlling for symptoms of depression.

Conclusion: These findings support the idea that rumination fuels intrusions, which in turn foster dysregulated behaviors. Therefore, addressing rumination as well as intrusions may improve psychotherapeutic interventions for mental disorders characterized by dysregulated behaviors and/or extreme aversive emotional states.

Partially nested designs in psychotherapy trials: A review of modeling developments

OBJECTIVE

Individually-randomized psychotherapy trials are often partially nested. For instance, individuals assigned to a treatment arm may be clustered into therapy groups for purposes of treatment administration, whereas individuals assigned to a wait-list control are unclustered. The past several years have seen rapid expansion and investigation of methods for analyzing partially nested data. Yet partial nesting often remains ignored in psychotherapy trials.

METHODS

This review integrates and disseminates developments in the analysis of partially nested data that are particularly relevant for psychotherapy researchers.

RESULTS

First, we differentiate among alternative partially nested designs. Then, we present adaptations of multilevel model specifications that accommodate each design. Next, we address how moderation by treatment as well as mediation of the treatment effect can be investigated in partially nested designs. Model fitting results, annotated software syntax, and illustrative data sets are provided and key methodological issues are discussed.

CONCLUSIONS

We emphasize that cluster-level variability in the treatment arm need not be considered a nuisance; it can be modeled to yield insights about the treatment process.

Me, myself, and I: self-referent word use as an indicator of self-focused attention in relation to depression and anxiety

Self-focused attention (SFA) is considered a cognitive bias that is closely related to depression. However, it is not yet well understood whether it represents a disorder-specific or a trans-diagnostic phenomenon and which role the valence of a given context is playing in this regard. Computerized quantitative text-analysis offers an integrative psycho-linguistic approach that may help to provide new insights into these complex relationships. The relative frequency of first-person singular pronouns in natural language is regarded as an objective, linguistic marker of SFA. Here we present two studies that examined the associations between SFA and symptoms of depression and anxiety in two different contexts (positive vs. negative valence), as well as the convergence between pronoun-use and self-reported aspects of SFA. In the first study, we found that the use of first-person singular pronouns during negative but not during positive memory recall was positively related to symptoms of depression and anxiety in patients with anorexia nervosa with varying levels of co-morbid depression and anxiety. In the second study, we found the same pattern of results in non-depressed individuals. In addition, use of first-person singular pronouns during negative memory recall was positively related to brooding (i.e., the assumed maladaptive sub-component of rumination) but not to reflection. These findings could not be replicated in two samples of depressed patients. However, non-chronically depressed patients used more first-person singular pronouns than healthy controls, irrespective of context. Taken together, the findings lend partial support to theoretical models that emphasize the effects of context on self-focus and consider SFA as a relevant trans-diagnostic phenomenon. In addition, the present findings point to the construct validity of pronoun-use as a linguistic marker of maladaptive self-focus.

The Perseverative Thinking Questionnaire in Patients with Persecutory Delusions

BACKGROUND

Ruminative negative thinking has typically been considered as a factor maintaining common emotional disorders and has recently been shown to maintain persecutory delusions in psychosis. The Perseverative Thinking Questionnaire (PTQ) (Ehring et al., 2011) is a transdiagnostic measure of ruminative negative thinking that shows promise as a "content-free" measure of ruminative negative thinking.

AIMS

The PTQ has not previously been studied in a psychosis patient group. In this study we report for the first time on the psychometric properties of Ehring et al.'s PTQ in such a group.

METHOD

The PTQ was completed by 142 patients with current persecutory delusions and 273 non-clinical participants. Participants also completed measures of worry and paranoia. A confirmatory factor analysis was performed on the clinical group's PTQ responses to assess the factor structure of the measure. Differences between groups were used to assess criterion reliability.

RESULTS

A three lower-order factor structure of the PTQ (core characteristics of ruminative negative thinking, perceived unproductiveness, and capturing mental capacity) was replicated in the clinical sample. Patients with persecutory delusions were shown to experience significantly higher levels of ruminative negative thinking on the PTQ than the general population sample. The PTQ demonstrated high internal reliability.

CONCLUSIONS

This study did not include test-retest data, and did not compare the PTQ against a measure of depressive rumination but, nevertheless, lends support for the validity of the PTQ as a measure of negative ruminative thinking in patients with psychosis.

Rumination-focused cognitive behaviour therapy vs. cognitive behaviour therapy for depression: study protocol for a randomised controlled superiority trial

Background

Cognitive behavioural therapy is an effective treatment for depression. However, one third of the patients do not respond satisfactorily, and relapse rates of around 30 % within the first post-treatment year were reported in a recent meta-analysis. In total, 30–50 % of remitted patients present with residual symptoms by the end of treatment. A common residual symptom is rumination, a process of recurrent negative thinking and dwelling on negative affect. Rumination has been demonstrated as a major factor in vulnerability to depression, predicting the onset, severity, and duration of future depression. Rumination-focused cognitive behavioural therapy is a psychotherapeutic treatment targeting rumination. Because rumination plays a major role in the initiation and maintenance of depression, targeting rumination with rumination-focused cognitive behavioural therapy may be more effective in treating depression and reducing relapse than standard cognitive behavioural therapy.

Method/design

This study is a two-arm pragmatic randomised controlled superiority trial comparing the effectiveness of group-based rumination-focused cognitive behaviour therapy with the effectiveness of group-based cognitive behavioural therapy for treatment of depression. One hundred twenty-eight patients with depression will be recruited from and given treatment in an outpatient service at a psychiatric hospital in Denmark. Our primary outcome will be severity of depressive symptoms (Hamilton Rating Scale for Depression) at completion of treatment. Secondary outcomes will be level of rumination, worry, anxiety, quality of life, behavioural activation, experimental measures of cognitive flexibility, and emotional attentional bias. A 6-month follow-up is planned and will include the primary outcome measure and assessment of relapse.

Discussion

The clinical outcome of this trial may guide clinicians to decide on the merits of including rumination-focused cognitive behavioural therapy in the treatment of depression in outpatient services.

Trial registration

ClinicalTrials.gov Identifier: NCT02278224, registered 28 Oct. 2014.

The German Version of the Behavioral Activation for Depression Scale (BADS): A Psychometric and Clinical Investigation

The Behavioral Activation for Depression Scale (BADS) was developed to measure core concepts of behavioural activation for depression. A number of studies, mostly based on analogue samples, have provided initial support for the BADS. In the present study, we examined the psychometric properties of the German version of the scale more broadly, including change sensitivity and clinical treatment data. A mixed sample of students (N = 312) and depressed outpatients in partial remission undergoing cognitive-behavioural group treatment for depressive rumination (N = 59) was examined. To analyze construct validity, a set of theoretically relevant constructs such as perseverative thinking, distraction and mindfulness was also assessed. Results indicated good psychometric properties, additional evidence for construct validity of the total scale and subscales, and adequate fit of the data to the original factor structure. Furthermore, the BADS proved to be sensitive to changes in participants undergoing treatment for depression. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Behavioural activation (BA) is an effective treatment for patients suffering from unipolar depression. The Behavioral Activation for Depression Scale (BADS) can be used to measure core elements of the BA treatment rationale. It is useful to track changes in activation within treatment. The BADS is available in different languages and has shown to possess good psychometric properties.