A learning theory account of depression

Brief scales for the measurement of target variables and processes of change in cognitive behaviour therapy for major depression, panic disorder and social anxiety disorder

BACKGROUND

The measurement of process variables derived from cognitive behavioural theory can aid treatment development and support the clinician in following treatment progress. Self-report process measures are ideally brief, which reduces the burden on patients and facilitates the implementation of repeated measurements.

AIMS

To develop 13 brief versions (3-6 items) of existing cognitive behavioural process scales for three common mental disorders: major depression, panic disorder, and social anxiety disorder.

METHOD

Using data from a real-world teaching clinic offering internet-delivered cognitive behavior therapy (n=370), we drafted brief process scales and then validated these scales in later cohorts (n=293).

RESULTS

In the validation data, change in the brief process scales significantly mediated change in the corresponding domain outcomes, with standardized coefficient point estimates in the range of -0.53 to -0.21. Correlations with the original process scales were substantial (r=.83-.96), internal consistency was mostly adequate (α=0.65-0.86), and change scores were moderate to large (|d|=0.51-1.18). For depression, the brief Behavioral Activation for Depression Scale-Activation subscale was especially promising. For panic disorder, the brief Agoraphobic Cognitions Questionnaire-Physical Consequences subscale was especially promising. For social anxiety disorder, the Social Cognitions Questionnaire, the Social Probability and Cost Questionnaire, and the Social Behavior Questionnaire-Avoidance and Impression Management subscales were all promising.

CONCLUSIONS

Several brief process scales showed promise as measures of treatment processes in cognitive behaviour therapy. There is a need for replication and further evaluation using experimental designs, in other clinical settings, and preferably in larger samples.

Promoting appetitive learning of consensual, empowered vulnerability: a contextual behavioral conceptualization of intimacy

Vulnerability is emphasized in a number of theoretical models of intimacy (e.g., Intimacy Process Model), including from behavioral and contextual behavioral perspectives. Vulnerability is generally defined as susceptibility to harm and involves behaviors that have been historically met with aversive social consequences. From these perspectives, intimacy is fostered when vulnerable behavior is met with reinforcement. For example, interventions have trained intimacy by building skills in emotional expression and responsiveness with promising results. Vulnerability has divergent functions, however, depending on the interpersonal context in which it occurs. Functional intimacy is explored through the lens of functional relations, which play a key role in interpersonal processes of power, privilege, and consent. This conceptualization suggests that vulnerability must be under appetitive functional relations, consensual, and empowered for safe intimacy to emerge. The responsibility to promote appetitive learning of consensual, empowered vulnerability to foster intimacy falls to the person with more power in a particular interaction and relationship. Recommendations are offered for guiding this process.

Engagement with Activity Monitoring During a Behavioral Activation Intervention: A Randomized Test of Monitoring Format and Qualitative Evaluation of Participant Experiences

Behavioural activation (BA) is an efficacious treatment approach. Activity monitoring is a key component of brief BA treatments; however, no studies have examined the most efficacious format for monitoring. The present pilot study tested brief versus intensive activity monitoring approaches during a BA intervention administered in a college orientation course. Outcomes characterised (1) engagement with the treatment protocol via activity monitoring and (2) participant qualitative experiences with monitoring and the intervention as reported during focus group interviews. Four course sections were randomly assigned to receive monitoring forms that were brief (assessed activities three times daily) or intensive (assessed activities hourly). Forms were provided electronically to students via a web-based platform which tracked completion. There were no significant differences in monitoring frequency (38.0 vs. 23.0 days; p = .154) or the duration of monitoring engagement (62.0 vs. 36.0 days; p = .054) between the brief and intensive conditions. Qualitative findings suggested that participants in both conditions found utility in activity monitoring, particularly during the first month as they transitioned to college. Overall, findings indicated that participants may find utility in monitoring during the first month of a BA intervention using either brief or intensive monitoring forms.

"Don't [ruminate], be happy": A cognitive perspective linking depression and anhedonia

Anhedonia, a lack of pleasure in things an individual once enjoyed, and rumination, the process of perseverative and repetitive attention to specific thoughts, are hallmark features of depression. Though these both contribute to the same debilitating disorder, they have often been studied independently and through different theoretical lenses (e.g., biological vs. cognitive). Cognitive theories and research on rumination have largely focused on understanding negative affect in depression with much less focus on the etiology and maintenance of anhedonia. In this paper, we argue that by examining the relation between cognitive constructs and deficits in positive affect, we may better understand anhedonia in depression thereby improving prevention and intervention efforts. We review the extant literature on cognitive deficits in depression and discuss how these dysfunctions may not only lead to sustained negative affect but, importantly, interfere with an ability to attend to social and environmental cues that could restore positive affect. Specifically, we discuss how rumination is associated to deficits in working memory and propose that these deficits in working memory may contribute to anhedonia in depression. We further argue that analytical approaches such as computational modeling are needed to study these questions and, finally, discuss implications for treatment.

Depressive symptoms and persistent negative self-referent thinking among adolescents: A learning account

Learning theories of depression propose that negative thinking is acquired through subsequent rewarding experiences and is often resistant to change even when it becomes associated with punishment. We examined whether this persistency of negative thinking is related to current and future levels of depressive symptoms among adolescents. Persistency of negative self-referent thinking was assessed by means of a decision-making task, namely the emotional reversal learning task. This task offers participants the choice between thinking about negative and positive self-related aspects. Their choice for negative self-referent thinking is initially rewarded but is later punished. Therefore, participants were expected to efficiently switch between negative and positive self-referent thinking, and to internally update their reward expectancy for these thinking options. Results showed that persistency of negative self-referent thinking was related to concurrent levels of depressive symptoms, replicating earlier findings in adults. However, persistency of negative thinking was unrelated to future levels of depressive symptoms. These findings suggest that adolescents with depressive symptoms tend to hold on to the belief that negative self-referent thinking has beneficial consequences, even when it is no longer being rewarded. This tendency should be seen as a concurrent feature of depression, as the predictive value is still in question.

PhDepression: Examining How Graduate Research and Teaching Affect Depression in Life Sciences PhD Students

Graduate students are more than six times as likely to experience depression compared with the general population. However, few studies have examined how graduate school specifically affects depression. In this qualitative interview study of 50 life sciences PhD students from 28 institutions, we examined how research and teaching affect depression in PhD students and how depression in turn affects students' experiences teaching and researching. Using inductive coding, we identified factors that either positively or negatively affected student depression. Graduate students more commonly mentioned factors related to research that negatively affected their depression and factors related to teaching that positively affected their depression. We identified four overarching aspects of graduate school that influenced student depression: the amount of structure in teaching and research, positive and negative reinforcement, success and failure, and social support and isolation. Graduate students reported that depression had an exclusively negative effect on their research, primarily hindering their motivation and self-confidence, but that it helped them to be more compassionate teachers. This work pinpoints specific aspects of graduate school that PhD programs can target to improve mental health among life sciences graduate students.

Blending group-based psychoeducation with a smartphone intervention for the reduction of depressive symptoms: results of a randomized controlled pilot study

Background

Given their ubiquity and technological facilities, smartphone-based interventions (SBIs) hold potential to support the cost-effective dissemination of evidence-based treatments for depression. As technologically enriched, blended approach–avoidance modification trainings (AAMTs) have recently been shown effective for symptom reduction in various mental health problems, we developed a blended SBI combining group-based psychoeducation and 14 days of app training utilizing principles from AAMT to reduce depressive symptoms.

Methods

In this pilot trial, N = 16 individuals with heightened depression scores were randomized to either an intervention group using the mentalis Phoenix app or a wait list control condition. As outcomes, we descriptively explored usability of the app, engagement with the intervention, and possible reductions of depressive symptoms.

Results

Data analyses suggest that the SBI tested in this pilot trial possesses high usability, is frequently engaged with, and reduces depressive symptoms in participants in the intervention group when compared to wait list controls.

Conclusions

This pilot study provides preliminary evidence that an SBI utilizing AAMT can reduce depressive symptoms. Future studies should replicate these findings using larger samples and disentangle possible mechanisms of change.

Trial registration

DRKS-ID: DRKS00021613 (retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00799-y.

Remembering happy times instead of sticking to negative memories after social exclusion

BACKGROUND & OBJECTIVES

Previous research shows that difficulty disengaging from negative (self-related) stimuli (i.e. negative self-referential processing; NSP) is a vulnerability factor for depression (Gotlib & Joormann, 2010) and contributes to its recurrence (LeMoult, Kircanski, Prasad, & Gotlib, 2017). The Emotional Reversal Learning Task (ERLT) was designed to investigate this, and we examined its construct validity by inducing social rejection, an etiological process of depression, within the ERLT model. We expected excluded participants to have difficulty disengaging from NSP.

METHODS

We administered Cyberball to 130 participants randomly assigned to the excluded or included condition. Participants then completed the ERLT: They chose a valence option (positive or negative), retrieved a memory of the same valence, and then were rewarded or punished for their valence choice. For the first phase, retrieving a negative memory was probabilistically rewarded, and this action-outcome contingency was twice reversed during the task. We used Q-learning models to analyze learning rates.

RESULTS

Excluded participants had no more difficulty disengaging from NSP than included participants: Bayesian computational modeling identified no difference between conditions regarding learning that retrieving negative memories was punished. Exploratory analyses found that excluded participants learned the association between retrieving positive memories and reward quicker than included participants, however.

LIMITATIONS

Doubts remain regarding whether participants fully understood action-outcome contingencies, and we did not explicitly check whether participants truly retrieved memories, which could have affected results.

CONCLUSIONS

We did not find support for the construct validity of the ERLT when using social exclusion to model depressogenic development within the ERLT.

How to Treat Depression With Low-Intensity Virtual Reality Interventions: Perspectives on Translating Cognitive Behavioral Techniques Into the Virtual Reality Modality and How to Make Anti-Depressive Use of Virtual Reality-Unique Experiences

Depression is a common mental disorder with a large treatment gap. Low-intensity, automated virtual reality (VR) interventions (not requiring a therapist) is a scalable and promising solution now that VR is an accessible and mature, consumer technology. Yet unlike with phobias, there have been few attempts at translating evidence-based cognitive behavioral therapeutic (CBT) techniques for depression into the VR modality. In this paper, we discuss how specific CBT techniques can be made into VR experiences, including psychoeducation, behavioral activation, cognitive restructuring, and social skills training. We also discuss how VR-unique experiences, such as alternative embodiment and virtual pet interactions, can be made therapeutic. Creating a pre-clinical and clinical evidence base for these types of novel interventions should be considered a research priority, and high-quality development on par with other consumer VR applications will be essential to the success of any consumer-targeted intervention. If this is achieved, low-intensity VR interventions for depression have great potential to make an impact on public mental health.

Difficulty in updating positive beliefs about negative cognition is associated with increased depressed mood

BACKGROUND AND OBJECTIVES

Depressed people hold positive beliefs about negative cognition (e.g., rumination is useful to find a solution), which may motivate those individuals to engage in sustained negative thinking. However, in reality, rumination often leads to unfavorable outcomes. Thus, such beliefs create a large discrepancy between one's expectations and the actual outcome. Therefore, we hypothesized that this prediction error would be associated with increased depressed mood.

METHODS

We observed how people update their positive beliefs about negative cognition within a volatile environment, in which negative cognition does not always result in a beneficial outcome. Forty-six participants were offered two response options (retrieving a negative or positive personal memory) and subsequently provided either an economic reward or punishment. Retrieving a negative (rather than positive) memory was initially reinforced, although this action-outcome contingency was reversed during the task. In the control condition, positive memory retrieval was initially reinforced, although a contingency reversal was employed to encourage negative memory retrieval.

RESULTS

Model-based computational modeling revealed that participants who showed a delay in switching from negative to positive (but not from positive to negative) responses experienced increased levels of depressed mood. This delay in switching was also found to be associated with depressive symptoms and trait rumination.

LIMITATIONS

The non-clinical nature of the sample may limit the clinical implications of the results.

CONCLUSIONS

Difficulty in updating positive beliefs (or outcome predictions) for negative cognition may play an important role in depressive symptomatology.

The relationship between neuroticism and appetitive conditioning

Appetitive conditioning is considered a central mechanism for the vulnerability to psychiatric disorders. However, the investigation of individual differences that are related to altered appetitive learning has been almost neglected so far. The aim of this study was to investigate the link between neuroticism and appetitive conditioning processes. 79 subjects participated in a differential conditioning procedure in which a conditioned stimulus (CS+) was paired with a reward (money) after a fast behavioral response, while a second conditioned stimulus (CS-) was never followed by a reward, irrespective of the behavioral response. As a main result, neuroticism correlated negatively with the underlying neural processes of appetitive conditioning in females, but not in males. In detail, higher levels of neuroticism were associated with decreased neural responses in the left (p = .001) and right amygdala (p = .011), left (p = .063) and right (p = .019) nucleus accumbens, and left (p = .002) and right (p = .021) orbitofrontal cortex (all results are family-wise-error-corrected). The present results support previous findings, which also showed an inverse sex-specific effect in the context of neuroticism and emotional processing in females. In addition, the findings suggest that neuroticism is not solely linked to increased amygdala sensitivity during the processing of negative stimuli but also to decreased neural responses when processing rewarding stimuli. Possible explanations for the sex differences and implications are discussed.

Stuttering Thoughts: Negative Self-Referent Thinking Is Less Sensitive to Aversive Outcomes in People with Higher Levels of Depressive Symptoms

Learning theories of depression have proposed that depressive cognitions, such as negative thoughts with reference to oneself, can develop through a reinforcement learning mechanism. This negative self-reference is considered to be positively reinforced by rewarding experiences such as genuine support from others after negative self-disclosure, and negatively reinforced by avoidance of potential aversive situations. The learning account additionally predicts that negative self-reference would be maintained by an inability to adjust one’s behavior when negative self-reference no longer leads to such reward. To test this prediction, we designed an adapted version of the reversal-learning task. In this task, participants were reinforced to choose and engage in either negative or positive self-reference by probabilistic economic reward and punishment. Although participants were initially trained to choose negative self-reference, the stimulus-reward contingencies were reversed to prompt a shift toward positive self-reference (Study 1) and a further shift toward negative self-reference (Study 2). Model-based computational analyses showed that depressive symptoms were associated with a low learning rate of negative self-reference, indicating a high level of reward expectancy for negative self-reference even after the contingency reversal. Furthermore, the difficulty in updating outcome predictions of negative self-reference was significantly associated with the extent to which one possesses negative self-images. These results suggest that difficulty in adjusting action-outcome estimates for negative self-reference increases the chance to be faced with negative aspects of self, which may result in depressive symptoms.